1. Dr. Yogan Pillay Deputy Director General National Department of Health, South Africa Monday 1 July 2013 OPERATIONAL AND PROGRAMMATIC CONSIDERATIONS IN SCALING UP ART

2. Major progress in scaling up ART 15 million on ART by 2015 within reach 2

3. Elimination of MTCT (UNAIDS) 3

4. Some South African Data 6.4 million people living with HIV and AIDS HIV associated with 50% of maternal mortality 55% of under 5 mortality HIV Prevalence: 30% amongst pregnant women 2.1 million on ART ART Coverage: 80% of women, 65% of children and men MTCT: 8% in 2009 2.7% in 2011 All this in a relatively weak health system 4

5. MTCT rate at 6 weeks in South Africa 5 Thousands

6. Total annual AIDS deaths EPP ClassicSpline 2011 2012 270 000316390221770

7. 7 Rising life expectancy associated with ART scale up Bor et al, Science 2013

8. But considerable operational challenges 8

9. Too few take a test and get their result Staveteig et al, DHS Comparative Reports, 2013 13% - 76% 8% - 69% 9

10. Retention is a challenge as programmes expand Western Cape Provincial Dept. of Health, South Africa, 2013 50% lost to care After 5 years 50% lost to care After 5 years Mugglin et al, Trop Med Int Health, 2013 15-30% drop out of care at each step from testing to ART

11. Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Expanded testing scenarios Task shifting and decentralization Service integration Adherence support Key WHO Operational Recommendations

12. Expanded testing in South Africa 2009 VCT rates 2m testing per year in health facilities April 2010 National HIV Counselling and Testing Campaign led by the President Stigma reduction Know your status HIV, TB, other chronic diseases screening 20 million tested in 20 months 1/3 men! 2011/12 Return to PICT: 9m tested in HCT Campaign to be reactivated with MMC in August Target every SA to test annually 12

13. Task shifting WHO 2013 Recommendations: Trained non-physician clinicians, midwives and nurses can initiate and maintain ART Trained and supervised community health workers can dispense ART WHO 2013 Recommendations: Trained non-physician clinicians, midwives and nurses can initiate and maintain ART Trained and supervised community health workers can dispense ART Sanne et al, Lancet 2010; Fairall et al, Lancet 2012 13

14. Task shifting in South Africa Nurse initiation of ART (2009) 23 000 nurses trained in initiation of FDCs Prescribing and dispensing Lay counselors trained to conduct counseling and testing (rapid tests) – 2010 Ward based outreach teams trained in HIV, TB and MCH 10 000 reoriented during 2011/12 14

15. Decentralization and integration Kerstenberger et al, PlosOne, 2013 15

16. Adherence support WHO 2013 Recommendations: Minimizing out of pocket payments Use of fixed-dose combinations Strengthening drug supply Patient counselling and education Mobile phone text messages WHO 2013 Recommendations: Minimizing out of pocket payments Use of fixed-dose combinations Strengthening drug supply Patient counselling and education Mobile phone text messages Wilkinson, SAJHIV Med, 2013 16 Lester et al, Lancet 2010

17. Examples of integration 60% co-infection rate (HIV and TB) 50% of deaths in pregnant women and children associated with HIV Need for integration is obvious Since 2010 all PHC facilities that provide TB, sexual & reproductive, ANC and child health services, including school health services, also targeted for HIV services Currently most public health facilities and over 3500 of 4200 public health facilities offer ART Many challenges to integration still exist, including infection control! 17

18. HIV and TB – school health programme 18

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20. A record 10 million PLHIV now have access to antiretroviral treatment, June 2013, UNAIDS Press Release “ Significant successes in reducing costs have been achieved in recent years. For example the price of medicines to prevent mother to child transmission of HIV was reduced from US$ 800 in 2011 to below US$ 100 in 2013. Through a more competitive bidding process, South Africa has reduced the cost of procurement of antiretrovirals to the lowest price anywhere in the world at US$ 127 per person per year for the fixed dose combination recommended in the new guidelines. This has resulted in a 53% reduction in expenditure on antiretroviral treatment for South Africa”. 20

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22. Conclusions Guidelines by the WHO are based on the best possible evidence Some operational research evidence is available BUT there are many gaps – need more operational research/implementation science Expertise to model resources required to implement new guidelines exists but need data for modeling Each country should carefully assess what is needed to implement new treatment guidelines 22

23. Acknowledgements WHO working group on operational guidelines Health Economics and Epidemiology Research Organisation (HERO) “Modelling Group” Country Team 23