1. Scaling Up Treatment in Zimbabwe: The path to high coverage IAS Conference Dr. Tsitsi Mutasa-Apollo ART Programme Coordinator, Zimbabwe 30 th June, 2013 Kuala Lumpur, Malaysia

2. Outline IntroductionBackgroundAchievementsTreatment CascadeChallengesOpportunities

3. Zimbabwe Country Context Population: 12,9m 1.2 million PLHIV HIV Prevalence (ZDHS 2010/11) – 15-49 yrs. 15% – Female 18% – Males 12% 41% of the U5 Mortality Rate is attributed to HIV/AIDS as the underlying cause 26% of MMR is attributable to HIV/AIDS

4. The Zimbabwe National Response Multi-sectoral response with broad stakeholder involvements Zimbabwe introduced a 3% tax on income to increase domestic resources for the national AIDS response in 1999 – 26% contribution towards ARV procurements 5-year 2011 to 2015 strategy – National response towards achieving zero new infections, zero discrimination and zero AIDS related deaths by 2015

5. Zimbabwe HIV IncidenceZimbabwe Annual AIDS Deaths 2010 UNAIDS Report - Attributed to successful implementation of prevention strategies, especially behavior change, high condom use and reduction in multiple sexual partners - AIDS-related mortality has also fallen HIV incidence peaked in 1993 and has fallen significantly

6. Identification of major policy, health systems and structural bottlenecks in paediatric ART A multi-country paediatric HIV assessment with support from UNICEF and WHO in 2012 What hampered access to Early Infant Diagnosis (EID), ART and retention to paediatric HIV treatment and care? Major findings: – Limited linkage between EID and ART – Centralized PCR testing and a long turnaround times – The median time from diagnosis to ART initiation was 61 days for children <2 years of age while the median age at ART initiation was above 7 years. – The proportion of children remaining in care 12 months after initiation was below 75% and high rate of lost to follow-up was more observed among the under-fives The country is working towards addressing the uptake of EID and linkages to, and retention in care in order to improve child survival

7. Progress in implementing 2010 ART guidelines MOHCW adapted the 2010 WHO Guidelines with a 3-year phased approach to phase in TDF-based regimens and phase out D4T- based regimens Due to limited resources the adaptation committee prioritized the following groups: – HIV-infected Pregnant women – TB/HIV co-infected people – Patients presenting with side effects stavudine-related side effects – Patients on ART for over 3 years By April 2012; 66% of adults receiving TDF-based regimens; while 34% on D4T- regimens (phasing out by Dec 2013) All children were prioritized for transitioning to AZT-based regimens unless medically contraindicated

8. Step 1: HIV Testing to enrolment into care Step 1 HIV Testing to enrolment into care Step 2 HIV Enrollment to eligibility Step 3 Eligibility to initiation Step 4 Initiation to long- term ART HIV Testing An increase in proportion of people reported ever tested & received results from 22% percent to 57% among women resp. from 16% to 36% among men (from 2005 to 2010) A discordance rate of 12 % among couples (2010-11, ZDHS) Challenges Poor links between testing & services; Lack of post-test support Currently 96% of Primary Care Facilities offer Provider Initiated Testing & Counselling 79% of facilities offer Early Infant Diagnosis using Dried Blood Spots for PCR Couple counselling to be rollout out in 2014

9. Step 2: Enrolment to Eligibility Step 1 HIV Testing to enrolment into care Step 2 HIV Enrollment to eligibility Step 3 Eligibility to initiation Step 4 Initiation to long-term ART Congestion at many clinics Long distance to nearest clinic/high transport costs Limited CD4 testing including Point of care technology Competing life priorities e.g. seeking food Inadequate referral information Strategies: Mobilized resources for additional CD4 POC machines Decentralization of ART services

10. Decentralization of HIV Care and Treatment Services The aim of decentralization is to bring ART services closest to where people live. By end of 2007, only 9 ART sites open By March 2013, 1006 (64%) ART sites Target is to reach 1,560 health facilities offering ART services by 2015

11. Step 3: Eligibility to Initiation Step 1 HIV Testing to enrolment into care Step 2 HIV Enrollment to eligibility Step 3 Eligibility to initiation Step 4 Initiation to long-term ART  Males poorer clinical and immunological status prior to initiating ART when compared to females  Males generally presenting late for HIV treatment and care when compared with their female counterparts  Currently no waiting lists for ART initiation

12. Zimbabwe ART Programme Scale Up

13. Step 4: Initiation to long-term ART Step 1 HIV Testing to enrolment into care Step 2 HIV Enrollment to eligibility Step 3 Eligibility to initiation Step 4 Initiation to long-term ART Too many appointments when ARV supply is insecure Challenges with migrant workers resulting in high defaulters and loss to follow Nurse led ART initiations have bolstered ART scale up particularly in remote areas At 12 months after initiation of ART; 89.8% participants achieved viral suppression of below 1000 copies/ml Strategies: Introduced an E-Patient Tracking System; Secured ARV commitments under the Global Fund NFM; Community support groups

14. Retention of Patients Initiating ART during 2007-2009, Zimbabwe Good retention in care observed in a retrospective cohort study in a nationally representative sample of patients initiating ART between 2007 and 2009 69% of patients were continuing ART treatment at 24 months, whereas 7% had died and 24% were lost to follow-up (MOHCW, 2012)

15. Zimbabwe ART coverage AIDS mortality & new HIV infections Source: Zimbabwe HIV Estimates, 2013

16. Recent modelling exercise has shown substantial impact of the ART programme with 71,970 deaths averted by ART in 2012 alone Analysis of ART Programme Impact

17. Challenges while Scaling Up Mismatch between numbers of HIV care providers and patient volume Need to review staff establishment Insufficient counsellors for adherence counselling & support Expensive to run in-service trainings Need to strengthen pre-service curriculum and internship Lack of adequate competencies for Paediatric ART and counselling skills When to switch patients to 2 nd lines; management of co-morbidities Limited viral load capacity for patient monitoring; long TAT for Early Infant Diagnosis using PCRDifficulties in linking patients to care, adherence, and viral suppressionThe paper-based system for M & E is difficult to implement in a large programme

18. Opportunities Zimbabwe an early applicant for the Global Fund New Funding Model GF board recently approved USD 311m for HIV Anticipation of additional USD 244m from GF replenishment funding to support new initiatives: - ART initiation at CD4 < 500 and ART for children < 5 yrs Planned development of a 3-year Strategic Plan for the National ART programme starting July 2013 Large and diverse private sector Particularly vibrant health insurance industry for possible private-public partnerships

19. Implications for the 2013 HIV Guidelines CD4 500 threshold – Estimated 28% annual increase in number of PLHIV in need for ART – ART Coverage will drop from 85% (2012) to below 70% Triple ARVs for HIV+ pregnant women – Support the e-MTCT country agenda Treatment for the Under 5s – Help overcome treatment eligibility challenges experienced by health workers – Support scale up Efavirenz-based regimens – Increment of US$ 1-50 to 2 per patient per month compared to NVP- based regimens – Improve adherence

20. I Thank You