Getting to 80% ART coverage Dr Francois Venter Reproductive Health and HIV Research Unit University of the Witwatersrand January 2010 Thanks to: Robin Wood

HIV and South Africa 5 million people

Eastern & Southern Africa 1.5 million (57% Rest of the world 1.2 million (43%) Global new infections, 2.7 million ESA new infections, Prov. estimate 1.5m Estimates of New Infections in Eastern and Southern Africa, 2007

South Africa: Why is it important? Size of the country; size of the epidemic; size of ART programme Rich country! De Cock: If South Africa fails, we all fail

The proportion of deaths due to AIDS has shown a staggering increase in the last decade 97% 3% 28% 54% 46%AIDS implicated % Source: ASSA2003 Model Stats SA 2009: 43% directly due to AIDS Common, preventable, treatable… How is it not a public health priority?

 Review of data from from 176 sites in 42 countries (N = 33,008) When Is Antiretroviral Therapy Started? Egger M, et al. CROI Abstract 62.

High death rate while waiting for ART Arch Intern Med 2008;1678:86 Braitstein, P et al. High Risk Express Care: a novel care model to reduce early mortality among high risk HIV- infected patients initiating combination antiretroviral treatment. HIV Implementers Meeting, Namibia, abstract 1556, June Expedited care decreased mortality by 60%

“"There is a need for honesty and peer review in situations that impact public health policy. When AIDS denialism enters public health practice, the consequences are tragic. The implications start in honest science but extend to the need for accountability and, perhaps, public health reform." Chigwedere P, Essex M. AIDS Denialism and Public Health Practice. AIDS and Behavior, 2010; DOI: /s

Outcomes of ART 5 year survival on ART in Botswana 88.6% (88.1 – 89.2) Puvimanasinghe JPA et al. Mexico 2008 (MOAB0204) ART recipients do well!

How are we doing?

Somewhere around 45% in 2009… (NOT retention in care!)

Who did we NOT reach? Proportion of children reached probably similar

need ARV’s EACH year well on ARV’s dead

Our models: 1 hospitalisation, 2-3 clinic visits per person put on ART “Test and treat” modellers – 2-9 days hospitalisation averted per person on ART Hugely cost saving in SA WHATEVER CD4 you use (in Kenya, not so)

Can we achieve scale-up?

RHRU programme? Urban and rural: Initiation CD since 2004 Johannesburg inner city – average CD4 106, despite 70% coverage, and massive escalation of HIV testing ¼ of all South Africans had an HIV test in 2008 (Shisana, HSRC Mandela survey, 2009)

Number of Patients initiated on to RHRU Supported Sites within Region F

The famous cascade… 50% loss to follow up at EVERY step

Target setting Not even done at a provincial level Starts with HIV testing – but EVERY step needs to be counted

Paediatrics Decent maternal ART=unemployed HIV paediatricians BUT hard to identify, hard to treat Suffer the most in poor health systems Prevention is better than treatment

Task shifting Cost of SA health care workers is very high Excuse for not scaling up, despite relatively high staffing levels Paradoxically, meant that task shifting has not happened

TB… Thanks: Braamie Variava

Highest TB incident and prevalence % ,000 1,100 1, Incidence of TB per 100,000 population MDG 2015 Target 56 Source: Health Systems Trust reported 722 number; WHO: Global Tuberculosis Control, Surveillance, Planning, Financing reported 940 TB-HIV co-infection was approximately 55% in 2002 The number of people diagnosed with TB trebled between 1996 and 2006 (from 269 to 720 cases of TB per ) 900 cases of Extensive Drug Resistant TB were reported between 2004 and 2007

ART best way to prevent TB IPT very hard to implement

The role of donors History – confrontational Patch up the gaping holes in the programme Now: sustainability and technical ability – ESPECIALLY critical reviews of data and resource usage

In summary: We’re still treating HIV as an acute illness Mortality is driven by late diagnosis, poor referral, and delayed ART – we aren’t acting urgently post diagnosis People who get ART, generally stay on it DESPITE the system (commonest reason for LTFU – changing jobs) Adherence is good, but failures are costly

What would I do? Quick and (relatively) easy: TDF, FDC’s, use tender process to get better deals on drug packaging, PMTCT ANC and TB clinics to test and start ART Programmatically hard: Targets for every step – starting with the provinces, down to a clinical level Creative and expensive: Chronic disease grants, medicine pick ups Expand HIV testing in health facilities Critically review certain programmes for LTFU – ‘know your status’ not good enough Review SANAC

The two elephants in the room Health systems and retention in care The average South African does not want to attend a state health facility (for good reason!) Retention in care affects – OI prophylaxis, IPT, ‘prevention for positives’, discordant couple interventions, etc etc ? A chronic care system is the silo we need Finally: Public health leadership – tough choices, tough priority setting – focus on using existing resources more intelligently