1. Fast-track to ending AIDS in Zimbabwe: 90.90.90 opportunities
Michael Bartos
UZ-UCSF Annual Research Day 17 April 2015

2. Outline
1. Why the TARGETS? 2. TESTING – SHIFTING TO YIELDS 3. TREATMENT ACHEIVEMENTS AND CHALLENGES 4. SUSTAINING VIRAL SUPPRESSION 5. FINANCING THE RESPONSE 6. CONCLUSION

4. New HIV infections in low- and middle-income countries, 2010–2030, with achievement of ambitious Fast-Track Targets, compared to maintaining 2013 coverage

5. AIDS-related deaths in low- and middle-income countries, 2010–2030, with achievement of ambitious Fast-Track Targets, compared to maintaining 2013 coverage

6. Ending the AIDS epidemic: A working definition
‘Ending the AIDS epidemic as a public health threat by 2030’ is provisionally defined as ‘reducing new HIV infections, stigma and discrimination experienced by people living with HIV and key populations, and AIDS-related deaths by 90% from 2010 levels, such that AIDS no longer represents a major threat to any population or country’

7. Global targets for ending the AIDS epidemic

8. Ambitious but achievable treatment target

9. of all people living with HIV will know their HIV status
By 2020…
90%
of all people living with HIV will know their HIV status
90%
of all people diagnosed with HIV will receive sustained antiretroviral therapy.
90%
of all people receiving antiretroviral therapy will have durable suppression.

10. What would ending AIDS targets look like for Zimbabwe – 2030 results ?
New infections down 13% year on year
100,000 in 2010
currently (2013) 69,000
to 63,000 in 2015 (current projection)
to 25,000 in 2020
and 10,000 in 2030
AIDS deaths down from
90,000 in 2010
currently (2013) 64,000
to 27,000 in 2015 (current projection)
to 9,000 in 2030

11. Outline
1. Why the TARGETS? 2. TESTING – SHIFTING TO YIELDS 3. TREATMENT ACHEIVEMENTS AND CHALLENGES 4. SUSTAINING VIRAL SUPPRESSION 5. FINANCING THE RESPONSE 6. CONCLUSION

12. Testing: volume or yield?
13m total population
40% under 15 (5.2m)
Over 15 infected or at risk (7.8m)
Already tested +
about 1m
Pool of potential unknowns around 6m
Current test volume 2.5m, 2018 target 3m annually

13. Testing – results from the 2013 MICS
% of sexually active young people tested in past 12 months
All – ever tested
Tested past 12 mths

14. Korenromp and Stover, Democratizing Testing, UNAIDS April 2015

15. HIVST market intervention
Country
# Tests
Phase 1
Phase 2
Malawi
172,754
420,466
South Africa
36,000
Zambia
200,478
404,522
Zimbabwe
359,190
1,069,810
Total
732,422
1,930,798

16. Outline
1. Why the TARGETS? 2. TESTING – SHIFTING TO YIELDS 3. TREATMENT ACHEIVEMENTS AND CHALLENGES 4. SUSTAINING VIRAL SUPPRESSION 5. FINANCING THE RESPONSE 6. CONCLUSION

18. Zimbabwe ART coverage targets 2014-2016
Ending AIDS 81% coverage target

19. Outline
1. Why the TARGETS? 2. TESTING – SHIFTING TO YIELDS 3. TREATMENT ACHEIVEMENTS AND CHALLENGES 4. SUSTAINING VIRAL SUPPRESSION 5. FINANCING THE RESPONSE 6. CONCLUSION

20. 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)

21. 90% of those on ART virally suppressed: trade offs?
Initiation vs. retention
Routine viral load vs. ‘on demand’
Maximally effective regimen vs. maximally forgiving regimen

22. Community ART refill groups
Model
self-selecting patient groups (7-14)
one representative picks up  ARVs for the group on quarterly basis
group contribute money for transport/ lunch/in kind support (eg work their fields)
Results: 9 months pilot evaluation (n=207)
100% retention, 99% virally suppressed
Time saving: normally 45mins waiting, 50 mins with staff (nurse, counsellor, pharmacist); ART refill groups: 30 mins to serve 8 patients – saving >10 person/hours per day in a busy 3 person clinic
Cost savings to patients from $14 per month to $48 (more remote areas)
Secondary benefits in increased resilience, reduced stigma, more participation in health governance.

23. Outline
1. Why the TARGETS? 2. TESTING – SHIFTING TO YIELDS 3. TREATMENT ACHEIVEMENTS AND CHALLENGES 4. SUSTAINING VIRAL SUPPRESSION 5. FINANCING THE RESPONSE 6. CONCLUSION

24. Building on past achievements: funds invested in AIDS programmes in
PEPFAR: The United States President’s Emergency Plan
for AIDS Relief
Sources: UNAIDS estimates, UNAIDS–Kaiser Family Foundation reports on financing the response to HIV in low- and middle-income countries, GARPR 2014, philanthropic resource tracking reports from Funders Concerned About AIDS, reports from the Global Fund and UNITAID.
Building on past achievements: funds invested in AIDS programmes in
low- and middle-income countries, 1986–2013

25. Potential room for expansion: per capita health assistance, selected countries
Zimbabwe

26. Public resource Availability for AIDS in Zimbabwe, 2009-2016, US $ million

27. Resource needs for AIDS in two different scenarios: current coverage and enhanced, more efficient coverage

29. Additional impact: infections averted

30. Additional impact: deaths averted

31. conclusion Sustainability will require much more community delivery
Patient-driven diagnostics and regimen switching
Testing – shift from undifferentiated to targeted yield
No one turned away
More money will be needed (also to turn off the tap)
conclusion