Post on 27-Jun-2018
OPTIONSCountrySituationAnalysisInterimFindings:Zimbabwe
FSGinpartnershipwithPangaeaGlobal
DECEMBER2016
2DECEMBER2016
OPTIONSIntroductionOneoffivecooperativeagreementsawardedbyUSAIDwithPEPFARfundingthroughRoundThreeoftheAnnualProgramStatement(APS)forMicrobicideResearch,Development,andIntroduction.
OPTIONSObjectiveDevelopastreamlined,adaptableproductdeliveryplatformforcurrentandfuturemicrobicideandARV-basedHIVpreventionoptions.
OPTIONSConsortiumMembers
KENYA
SOUTHAFRICA
ZIMBABWE
3DECEMBER2016
OPTIONS ConsortiumAims
Developevidence-basedbusinesscasesandacoordinatedinvestmentstrategy forARV-basedpreventionproductintroductiontoensuretimelyglobal,nationalandprivatesectoractiononpriorityareas
AIM1 AIM2 AIM3 AIM4
Providetechnicalassistanceandsupportforhealthsystemsstrengthening(HSS) withrapiduseofdatatoidentifyandaddressimplementationbottlenecksthroughoutthevaluechain
Supportcountrylevel regulatoryapproval,policydevelopment,programplanning,marketingandimplementationstrategiesforARV-basedpreventionproductintroduction
Facilitateandconductimplementationscience(IS)toadvancetheintroductionofandaccesstomicrobicidesandARV-basedpreventiontechnologies
OPTIONShasfourmajorgoalsoverthenextfiveyears:
4DECEMBER2016
OPTIONSHowWeWork
• OPTIONSisnotaservicedelivery project;weapplysystemsthinkingtosupportandaccelerateproductintroduction
• Oursupportisflexibleandisdesignedtoberesponsivetonationalcountryprioritiesandplans
• InadditiontoPangaea,whohassignificantexperienceworkingonHIVpreventionandtreatmentinZimbabwe,ourconsortiumbringsmulti-disciplinaryexpertisetotheefforttointroducefemale-controlledHIVpreventionproductsinZimbabwe
• Wearetakingsignificantstepstoensurewedonotreplicateexistingorongoingwork– ourmissionistofillgapsandhelpanswerkeyquestionsasoutlinedbythenationalgovernment,theUSAIDcountrymission,andotherkeylocalstakeholders
5DECEMBER2016
AbouttheSituationAnalysis• This document includes a summary of preliminary findings from the
OPTIONS situation analysis for oral PrEP in Zimbabwe, completed by FSGwith significant input and consultation from Pangaea Global AIDS
• The situation analysis aims to take a comprehensive and robust approachto assessing the “state of the field” for oral PrEP in Zimbabwe, includingopportunities and resources as well as gaps and expected challenges
• This document reflects findings from secondary research and in-countryconsultations with key stakeholders
• This is designed as a “living document,” to be updated on an ongoing basiswith additional information and stakeholder feedback to inform ongoingplanning and decision-making around oral PrEP
• Ifyouhaveanyupdates,additionalinformation,orfollow-upquestionsregardingthissituationanalysis,pleaseemailNeerajaBhavarajuatneeraja.bhavaraju@fsg.org
6
ExecutiveSummary• Zimbabwehasbeencreatingtheconditions,policies,andpracticesneededtosuccessfullyroll-outandscale-upPrEP.The
country’sHIVresponsehashistoricallybeenontheleadingedgeamongpeersandgenerallyresponsivetoglobalguidelines.
• InMarch2016,theMinistryofHealthandChildCare(MOHCC)convenedanationalworkinggrouptoadapttheWHO“testandstart”guidelinesissuedinNovember2015.Aspartofthateffort,asub-committeeonPrEPhasbeenestablished.Thissub-committeehasbeenmeetingtodevelopnationalguidelinesonPrEPandaplanforrollout.
• PrEPguidelineshavebeenreleasedaspartofcountry’sARTguidelines,andimplementationplanningisexpectedtobegininearly2017.Therolloutisexpectedtobephased,beginningwithtargetpopulations.
• ThekeychallengesforPrEPinZimbabwearesecuringfundingforPrEP,identifyingandagreeingonexacttargetgeographiesandpopulations,deployinganeffectivecommunicationsstrategy,andnavigatingthehealthsystemcapacitylimitationsinherentinclosingZimbabwe’sexistingtreatmentgapwhileinvestingin“new”preventionmethods.
– Zimbabwe’sHIVstrategicplanfocusesonkeypopulationsandcombinationprevention,andnowincludesPrEP.MOHCCofficialshaveexpressedinterestinintroducingPrEPforabroaderrangeofpopulationsbeyondkeypopulations(MSM,femalesexworkers),includingadolescentgirlsandyoungwomen(AGYW)andthoseinsero-discordantrelationships.
– TherearesignificantlegalandculturalbarrierstoquantifyingandreachingthekeygroupsforwhomPrEPwouldbewell-suited,particularlySWandMSM,whosepracticesareillegal,andAGYW,whofacestigmaandopposingculturalnormsrelatedtoHIVprevention.
– ZimbabwehasmadesolidprogressinexpandingcoverageofARTandHTCsites,buttreatmentgapsremain;inaddition,healthcareworkerknowledgeandattitudesandenduserawarenessanddemandhavecontinuedtobecriticalfactorsdeterminingthesuccessofHIVpreventionandtreatmentinterventions.
• Despitethesechallenges,PrEProlloutinZimbabwewillbefacilitatedbythecountry’smanystrengths,includingincreasinglyharmonizedprocurement,distribution,andM&Esystems,anactivecivilsociety,thepresenceoftheDREAMSinitiative,andanearlycompletePrEPdemonstrationproject(SAPPH-IRe).
• Inthenear-term,decisionsonPrEPinZimbabwerevolvearoundthequestion:“HowmuchshouldbeinvestedinPrEP,forwhom,how,andinwhichareas?”
7DECEMBER2016
CurrentStateofHIVinZimbabweContext• ZimbabwehasoneofthelargestHIVburdensinSouthernAfrica,with1.4MpeoplelivingwithHIV(PLHIV)andaprevalencerate
~14.7%.Therewereanestimate~64,000newinfectionsin2015• TheHIVepidemicexhibitsgrowingratesamongwomen – HIVprevalenceisnow1.5xhigheramongwomenthanmen• Keydriversoftheepidemicincludemultipleandconcurrentpartnerships,inter-generationalsex,discordantcouplesandlow(but
rising)VMMCrates;severalkeygeographiesandpopulationslistedbelowremaindisproportionatelyaffectedbytheepidemic
Demographics• Sourceofnewinfections(not
mutuallyexclusive):– 55%amongpeopleinstableunions– 36%amongyoungpeople– 12%amongsexworkersandclients– 4-7%amongMSMandpartners
• Prevalence(notmutuallyexclusive):– 17%amongwomeningeneral– 12%amongmeningeneral– 5-6%amongwomen15-24years– 50-70%amongFSW– 14%inprisons
• Incidencebyageandgender(2013):
Geography• Geographichotspots:
– Threeprovinces:MatabelelandNorth,Bulawayo,MatabelelandSouth– 14additionaldistrictsrecentlynamedashotpots
• HIVprevalencebyprovince:%ofpeople15-49yearsold
Male Female
• HIVincidencebyprovince:Newinfections,people15-49years
201420152016
Characteristics• TheHIVepidemicinZimbabweis
generalized,feminizedandgenerallyhomogenous,thoughnotablehotspotsofhighHIVtransmissionhavebeenidentifiedthroughoutthecountryincities,bordertowns,andminingandfishingareas
• TheHIVprevalenceratehasdecreasedto~14.7%in2015from~20%in2005
• From2011-2015:• NationalHIVincidencehas
decreasedfrom1.29to0.74• AIDSdeathshavedecreased
from115,117to31,217• ARTcoverageforadultsand
childrenhasincreasedfrom31.3%to72%
0k5k
10k15k20k
0-14 15-24 25-49 50+
Male
Female
Sources:(1)ZimbabweNationalHIVandAIDSEstimates:2013.MinistryofHealthandChildCare.2013;(2)ZimbabweNationalHIVandAIDSStrategicPlan2011-2015(ZNASPII).MinistryofHealthandChildCareandNationalAIDSCouncil.March2015;(3)ZimbabweNationalHIVandAIDSStrategicPlan2015-2018(ZNASPIII),MinistryofHealthandChildCareandNationalAIDSCouncil.March2015;(4)ZimbabweProgressReport,GlobalAIDSResponse,NationalAIDSCouncil,2016;(5)2015Spectrumdataestimates
8DECEMBER2016
HIVPreventionandTreatmentContext• Improvementsinprevalenceandincidenceratesprimarilyduetosuccessfulpreventioneffortsandreductioninpersonalrisk-taking
behavior,while HIV-relateddeathshavebeenreducedbyover60%duetoZimbabwe’streatmentandsupportprogram• Forprevention,thegovernmenthasprioritizedsocialandbehaviorchangeinterventions,condom promotionanddistribution
(coupledwithintensifiedawareness oncorrectandconsistentuseofcondoms),andvoluntarymedicalmalecircumcision• ARTscaleupiskeytoZimbabwe’sHIVstrategy.HIVtestingandcounselling(HTC) hasbeenidentifiedasakeyentrypointforART,
andprovider-initiatedHTC(whichcomprises80%ofallcurrenttestinginZimbabwe)isbeingscaledup• 80%ofallhealthfacilitiesofferART.Therewere879,271peopleonARTby2015,with73%reachingdurableviralsuppression• NationalHIVresponseisguidedbythethirdandmostadvancedstage(ZNASPIII),focusedonkeypopulationsandgeographies
CurrentEfforts• Sustainingcurrenttreatmentandcareinvestment,including
throughthecountry’sin1460HTCcenters• RapidlyscalingupVMMC to80%by2018usingWHO
guidelines/standards• Comprehensivepreventionprogramsforsexworkers,
adolescentandyoungpeople,sero-discordantcouples• ScalingupinnovativecommunityHIVtestinginitiatives,
includingself-testingkitsviaaPSIinMberengwa andBuhera• RollingoutPITC to94%ofhealthfacilities• Integratingsocialnormandbehaviorchangeinterventions
intodeliveryofsocialandHIV-relatedservices• Communitysystemstrengthening• Preventing secondaryincreasesintheepidemicduetolower
levelsoffunding• Zimbabwehasallowedtheexistenceofinformallobby
groupsforFSW,prisoners,andMSM
RemainingNeeds• Coveragegaps:Zimbabweisbehindby55%inproviding
treatmentforHIV+children;mostcommitmentsforARTendin2016,whichwillcreateadditionalgapsforHTC
• Datagaps: datagapsexistgenerallyandparticularlyforkeypopulations
• Keypopulations:Currentstrategiesareinequitabletokeypopulations(e.g.,needformorefemale-controlledoptions,as27%ofZimbabwe’swomenhaveexperiencedsexualviolenceintheirlifetime;irregularcondomuseamongMSM)andlegalcodesandstigmaposechallengesforkeypopulations
• Healthsystem:Zimbabwe’shealthsystemhasbeenweakened byeconomiccrisisandisoftenseenasnot“friendly”towomenandadolescents;communityorganizationshaveoftenlackeddefinition,cohesion,prioritization,andfunding
Sources:(1) ZimbabweNationalHIVandAIDSEstimates:2013.MinistryofHealthandChildCare.2013;(2)ZimbabweNationalHIVandAIDSStrategicPlan2011-2015(ZNASPII).MinistryofHealthandChildCareandNationalAIDSCouncil.March2015;(3)ZimbabweNationalHIVandAIDSStrategicPlan2015-2018(ZNASPIII)[Notofficiallylaunched].MinistryofHealthandChildCareandNationalAIDSCouncil.March2015.
9DECEMBER2016
KeyConsiderationsforPrEP• Achieving national targets: Zimbabwe has demonstrated strong political will
by adopting the global 90-90-90 goals and committing to reducing newinfections by 75%. However, this target may be difficult to meet withoutreducing infection among high-incidence populations (e.g., sero-discordantcouples, AGYW, FSW, and MSM) through prevention methods appropriate forthese populations. As one MOHCC representative noted, “There is no way tomove towards zero new infections unless we have PrEP as part of theinterventions package.”
• Protecting human rights and upholding zero discrimination: Several of thehigh-risk populations for whom PrEP is most appropriate are also thepopulations most discriminated against by Zimbabwean society and legalframeworks (e.g., FSW, MSM). Excluding PrEP from the prevention strategyruns contrary to Zimbabwe’s vision for “zero discrimination.”
• Promoting equity: Zimbabwe promises to “uphold equity-orientedinterventions that promote allocation of resources preferentially to the needyso as to address challenges related to unfair differences” in outcomes. PrEP isappropriate for those most left behind by the country’s HIV response.
• Enabling a gender-sensitive response: Zimbabwe’s strategic plan commits to"promoting and implementing a gender responsive national AIDs response inthe next five years,” but the dominant HIV prevention strategiesrecommended and prioritized are male-controlled (e.g., condoms, VMMC)
• Ensuring truly “comprehensive” prevention: Zimbabwe’s plan calls for a“comprehensive prevention program for sex workers and adolescent girls.”The current package for FSW includes HIV testing and treatment, condompromotion, solidarity programs, violence and abuse support, and protectivepolicing, but excludes health education, skills training, PrEP, and others.
WhyPrEPisunderconsiderationinZimbabwe CurrentPrEPContext• Zimbabweconvenedanationalworking
grouptoadapttheWHO“testandstart”guidelinesinMarch2016,includingasub-committeeonPrEP. Thecountry’sARTguidelinesnowincludeachapteronPrEP
• Truvada hasbeenregisteredforprevention,butiscurrentlyapprovedonlyfortreatment;nogenericsorotheralternativeformsoforalPrEPareapprovedforprevention.Itappearsthatanpreventionindicationmaynotbeneeded
• PrEPdemonstrationprojectledbyCeSHHAR concludedin2016;DREAMSprogramfocusedonAGYWlaunchedin2016withaPrEPcomponent.OthersincludeHPTN082andIMPACT
• NewHIVstrategicplan launchedin2016includescomprehensivepreventionincludingoralPrEP
• WhileFSWandAGYWareprioritizedforHIVprevention,notallkeypopulationsaremeaningfullyincluded(e.g.,MSM)
• SignificantlegalandculturalfactorscontinuetomarginalizeMSMandFSWandobscureabilitytoquantifythesizeandHIVratesofthesepopulations
Sources:(1) AchievinganAIDS-FreeGenerationforGayMenandOtherMSMinSouthernAfrica.amfAR,TheFoundationforAIDSResearchandJohnsHopkinsBloombergSchoolofPublicHealth.May2013;(2)FSGinterviewwithPangaeaGlobal.December16,2015;(3)ZimbabweNationalHIVandAIDSStrategicPlan2015-2018(ZNASPIII)[Notofficiallylaunched].MOHCCandNationalAIDSCouncil.March2015.
10DECEMBER2016
PlandevelopedtoimplementWHOPrEPguidelinesfortargeted
populations
PrEPproduced,purchased,anddistributedin
sufficientquantitytomeetprojecteddemand
PrEPservicesdeliveredbyappropriatechannelswithaccesstotarget
populations
TargetpopulationsseekandareabletoaccessPrEPandbeginuse
TargetpopulationadherestoPrEPatrecommendedfrequencyand forideal
timeperiod
PLANNINGANDBUDGETING
SUPPLYCHAINMANAGEMENT
PREPDELIVERYPLATFORMS
INDIVIDUALUPTAKE
EFFECTIVEUSE&MONITORING
What’sNeededtoIntroducePrEPOPTIONSaimstotakearobustandcomprehensiveapproachtoanalyzingthesituationaroundPrEP. ThegoalofthisexerciseistoidentifykeybottlenecksandopportunitiestointroduceandscalePrEPeffectively,particularlyforwomenandgirls,ineachOPTIONScountry.Thisinformationwilleventuallyfeedintotheinvestmentcasesandwillbeusedtoinformandcapturecountryprogress.
Toidentifywhat’sneededforPrEPintroduction,wehaveorganizedtherestofthesituationanalysisalongthePrEPvaluechain,introducedbelow.
ValueChainforPrEP
11DECEMBER2016
ValueChainAnalysesThefollowingslidesholdthreeanalysesalongthevaluechain
• Resourcesthatexistin-countrytosupportandacceleratePrEPintroduction
• GapsinresourcesthatcouldactasbarrierstoeffectivePrEPintroduction
• Keyconsiderations toinformcomprehensivein-countryplanningforPrEPintroduction
• Alistofspecificfactorsthatneedtobein-placetoeffectivelyintroducePrEPforeachcomponentofthevaluechainalongwithprogressto-dateforeachfactor
• Detailsoncurrentsituation,keyactors,responsibilities,timelinesandprogresstowardseachactivityareincludedintheappendix
• Remainingquestionstoinformin-countrydiscussionsandplanning
• Remainingquestionstoinformongoingmodelling,researchandanalysisefforts
• OpportunitiesforotherpartnerstosupportaccelerationofPrEPintroduction
12DECEMBER2016
ResourcesandGapsforPrEPinZimbabwe
PLANNING&BUDGETING
SUPPLYCHAINMANAGEMENT
PREPDELIVERYPLATFORMS
INDIVIDUALUPTAKE
EFFECTIVEUSE&MONITORING
EmergingKeyConsiderations
• Notallkeypopulationsfully representedinnewplan
• Noclearfundingsources forPrEPbeyondDREAMS
• Truvada registeredastreatmentbutnotprevention
• Demandforecastactivitieswillinvolvepopulationsforwhichlittledataexists
• Access ofkeypopulationstoHTC
• Negative/stigmatizinghealthcareworkerattitudestowardstargetpopulations
• Capacitylimitations insomeHIVchannels
• Low(butrising)ratesofHTCusage
• Demandgenerationplans stillearly-stage
• StigmaandlawsinhibitaccesstoHIVservicestohigh-riskpopulations
• LittleisknownaboutPrEPadherenceingeneralandamongkeypopulations
• OngoingtestingofPrEPuserscouldplacestrainontheexistingHIVtestingcapacity
ExpectedStrengths
• Newplan callsforHIVinvestmentinchildren,adolescents,youngpeople,women,girls,keypopulations
• Innovativedomesticfinancingmechanism
• Well-coordinatedprocurementanddistributionsystemthatservespublicandNGOchannels
• CoordinationchallengesinARVscale-upresolved
• VarietyofHIVservicechannelswithstrongcoverage(e.g.,ARTsites,CBHC,HTCcentres,civilsociety,mobileclinics)
• Widedisseminationoftreatmentguidelines
• GoodHTCcoverage• RecentpositivelegalchangerelevanttoFSWs
• PITCisbeingpushed• Civilsocietypresenceadvocatingforkeypops(e.g.,FSW,MSM)
• Singleharmonizedmonitoringandevaluationsystem
• Newplan(ZNASPIII)mentionsM&Eplantobedevelopedandupholdsimportanceofmonitoring
13DECEMBER2016
Impact, costandcost-effectivenessanalysesforPrEP aspartofcomprehensiveHIVpreventionportfolio
IdentificationandquantificationoftargetpopulationsforPrEP
InclusionofPrEPandfemale-controlledmethodsincurrentorupcomingnationalHIVpreventionplans
Timelineandplan forPrEPintroductionandscale-up
Abudget forPrEProll-outtotargetpopulations
Sufficientfunding toachievetargets
Regulatoryapprovalofform(s)oforalPrEPbyauthorities
EffectivedemandandsupplyforecastingmechanismsforPrEP
ManufactureridentificationandcontractnegotiationtopurchasePrEP
Productandpackagingdesigntomeettargetpopulation needsandpreferences
DevelopmentofdistributionplanforPrEPtoreachtargetpopulations
Effectivedistributionmechanisms toavoidPrEPstock-outsinpriorityfacilities
TowardsIntroductionofPrEPinZimbabwe
Issuanceofstandardclinicalguidelinesforprescription anduseofPrEP
Sufficientinfrastructure andhumanresourcestoconductinitialHIVtestsandprescribePrEPinprioritychannels
Plantoengagehealthcareworkers onPrEPanddeliverytotargetpopulations(includingmitigatingstigma)
ToolstohelppotentialclientsandHCWunderstandwhoshouldusePrEP
Sufficientresourcestoroll-outplansforhealthcareworkerengagement
ClearandinformativecommunicationsonPrEPforgeneralpublicaudiences
Developmentofdemandgenerationstrategiestargetedtouniqueneedsofdifferentpopulations
Linkages betweenHTC,PrEPprescription,andPrEPaccesstoenablePrEPuptake
Information forclientsonhowtoeffectivelyusePrEPforalltargetpopulations
Sufficientresources toroll-outplansfordemandgeneration
EstablishedplanstosupporteffectiveuseandregularHIV,creatininetestingthatreflecttheuniqueneedsoftargetpopulations
CapacitytoprovideongoingHIV andcreatinineleveltestingforPrEPusersaccessibletotargetpopulations
Monitoringsystemtosupportdatacollectionforongoinglearning(e.g.,rateofpatientsreturningfor2ndvisit,non-HIVSTIrates)
PLANNING&BUDGETING
SUPPLYCHAINMANAGEMENT
PREPDELIVERYPLATFORMS
INDIVIDUALUPTAKE
EFFECTIVEUSE&MONITORING
Significantprogressand/ormomentum
Earlyprogress
Initialconversationsongoing
COLORKEY
14DECEMBER2016
KeyQuestionsforPrEPinZimbabwe
PLANNING&BUDGETING
SUPPLYCHAINMANAGEMENT
PREPDELIVERYPLATFORMS
INDIVIDUALUPTAKE
EFFECTIVEUSE&MONITORING
• WhataretheincrementalbenefitsandcostsofPrEPfortargetpopulations?
• WhenwillPrEPbemeaningfullyincludedinnationalplan?
• Whatpopulationsandsub-segments,andwhere,willreceivePrEPbeyonddemoprojectsandDREAMS?
• HowwillPrEPbefundedbeyondcurrentlevels?
• WhenwillTruvada,oralternatives,beapproved forprevention?
• WhatisthetotalforecastedneedforPrEP,andhowwilleffectiveforecastsbedevelopedgivendatalimitations?
• Howwillthesupplychainbemanagedtoavoidstock-outsorperceivedcompetitionwithtreatment?
• Whichdeliverychannels willbeusedtodeliverPrEPtokeypopulations,inwhatsequence?
• Howcannon-publicfacilities(e.g.NGO,private)beleveragedforPrEP?
• HowandwhenwillhealthcareworkerengagementforPrEPbedelivered?Whatareexpectedopportunitiesorchallenges?
• Towhatextent,how,andwithwhatfundingwillthechallengesofstigma,access,anddemandgenerationbeaddressed?Who willaddressthese?
• Whowillcoordinatethe communicationscampaignforPrEPandwhen?Whatarethemosteffectivemessagestoreachpopulationsatrisk,includingthoseincities,commercialfarming,mining,borders,etc.?
• Whatinvestmentand/orcapacity-buildingneedstobedonetomitigatestrainonthesystemfromongoingtesting(HIVandcreatininelevels)ofPrEPusers?
• WillusersadheretoeffectiveuseofPrEP?Howcanadherence/effectiveusebeencouragedandsupported?
• Howwillservicesbelinkedacrossfacilitieswhennotavailableon-site?
15DECEMBER2016
PLANNING&BUDGETING
SUPPLYCHAINMANAGEMENT
PREPDELIVERYPLATFORMS
INDIVIDUALUPTAKE
EFFECTIVEUSE&MONITORING
KeyStakeholdersforPrEP
MOHCCdevelopsnationalstrategicplan,identifiesdrugneeds,doesforecasts,specifiesdeliverytimelines,createstreatmentguidelines,M&Eplans
NACprovideslogisticalandtechnicalassistanceduringplanpreparation...
NACisresponsibleforoverseeingmonitoring&evaluation
Technicalworkinggroupsfocusedonkeythemesareinvolvedinplanning
Civilsocietygroups(e.g.,CeSSHAR,Katswe Sisterhood,GALZ,ZNNP+,ZAN,WAG,WASN)advocateforkeypopulationinclusioninplan,equitableaccess,anddemandgeneration
Nationa
lstakeho
lders
LocalImplem
enters
Dono
rs
Pangaeacanhelpensureinclusionofkeypopulationsinitssecretariatrole
Keypopulationsareincludedintechnicalworkinggroupsbutmoreeffortsareneededtoensuremeaningfulrepresentation
CCMoverseesGlobalFundproposalsandgrants
NatPharm quantifiesdrugneedsandoverseesstorage
MCAZperformsqualityassuranceandregistration
SPBregulatesandmanagespublicprocurement
LocalmanufacturershavehadsomeinvolvementinARVproductioninthepast
HealthcarefacilitiesalreadydeliveringARTlikelytobethefirsttodeliverPrEP
OtherpublicHIVservicechannels couldpotentiallydeliverPrEP(e.g.,CBHCs,HTCcenters,ARTsites,mobileclinics)
Specificorganizationswillbedetermineduponnationallevel
implementationplans
GeneralHTCandHIVpreventionpartnersmayplayaroleinPrEPdeliverypendingnationalimplementationplans(e.g.,FHI,PSI,OPHID,ZAPSO,ZACH,ZNFPC,PSZclinics)
Otherstakeholders(e.g.,youthcenters,sexworkerclinics,andcivilsocietyorganizations)mayplayaroleinensuringPrEPaccessamongkeypopulations
CESHHARconductingonlyPrEPimpactstudyinZimbabwe(amongFSW)
Internationalbilateralfundersanddomesticpublicfundingsources(e.g.,PEPFAR,DFID,CIFF,CIDA,ZimbabweNationalAIDSTrustFund)
Multilateraldonors(e.g.,GlobalFund,WHO,UNITAID)
UNAIDSsupportscivilsocietycoordination
17DECEMBER2016
AppendixA: ValueChainDetail
ThefollowingslidesprovideadditionaldetailoneachsectionofthePrEPvaluechaininZimbabwe
18DECEMBER2016
PlanningforPrEPKeyStakeholders• MOHCC isresponsiblefordevelopingnationalstrategicplanaswellas
conveningatheguidelineadaptationTWGforWHOguidelinesonUTTandPrEP,andthePrEPsub-committee
• CountryCoordinatingMechanismoverseesGFproposalsandgrants• Technicalworkinggroupsfocusedonkeythemesareinvolvedinplanning• Keypopulationsareincludedinthesegroups,butmoreeffortsareneeded
toensuremeaningfulrepresentation• NAC provideslogisticalandtechnicalassistanceinthepreparationofplan• Advocacygroups forkeypopulations(e.g.,GALZ,ZNNP+,WASN,etc.)• PrEPimplementingpartners- DREAMS (CeSHHAR,PSI)&HPTN(UZ-UCSF)
KeyStrengthsandOpportunities• ZNASPIIIidentifieskeypopulationsas,adolescents,AGYW,keyFSW,
MSM,andpeopleinstableunionsandsero-discordantcouples• ZNASPIIIcallsforprioritizationofspecificgeographichotspots• Technicalworkinggroupsincludesomekeypopulationsinplanning• NationalAIDSLevydraws3%ofprivateincome(totaling~$19M),ofwhich
10%goestoHIVprevention• HIVpolicyenvironmentappearstobewelldeveloped,supportedby
strongtechnicalexpertise,andresponsive toWHOguidelines
KeyEmergingConsiderations• Notallkeypopulationsmeaningfullyrepresentedinworkinggroupsor
nationalplan(e.g.,planstatesthatnotenoughdataexistsonMSM,butit’sunclearifMSMhaveinputoriftheyaredeemed“priority”)
• ConcernthatPrEPwillbefocusedprimarilyonFSW,whichcouldstigmatizetheuseofPrEP forotherpopulations(e.g.,AGYW)
• PrEPnotmeaningfullyincluded inZNASPIII• RecentsuccesseswithVMMChavemadeitakeypreventionstrategy,but
government’sinvestmentinscalingitupmaypreventadditionalfocusonPrEPscale-up
• Nationalleadersremainconcernedabout ARVresistanceresultingfromPrEP
ReadinessforPrEPIntroductionReadinessFactor Progress
Impact, costandcost-effectivenessanalysesforPrEP aspartofcomprehensiveHIVpreventionportfolio
• CESSHAR, IMPACCT,HTPN082demoprojects underway;potentialforadditionalstudies
• BMGFcompilingcostdatafromPrEPdemoprojectstocreatestandardizedcostingmodel
IdentificationandquantificationoftargetpopulationsforPrEP
• PrioritiesincludecomprehensivepreventionprogramsforSW,adolescentandyoungpeople,peopleinstableunions,anddiscordantcouples,withafocusongeographichotspots.TargetpopulationsforPrEPspecificallyhavenotbeenidentified
InclusionofPrEPandfemale-controlledmethodsincurrentorupcomingnationalHIVpreventionplans
• PrEP hasbeenincorporatedintotheZimbabweNationalStrategicPlan
Timelineandplan forPrEPintroductionandscale-up
• ATWGon WHOTestandStartGuidelines,aswellasasub-committeeonPrEP, developedoralPrEPguidelines. Implementationplanningissettobeginin2017
• ZIMPHIAstudyresultssharedinDecember2016.InsightsfromdatasettoinformPrEProllout
Abudget forPrEProll-outtotargetpopulations
• A costed implementationplan,tobedevelopedin2017,willbeusedasaresourcemobilizationtool.Nobudgethasbeencreatedasofyet
Sufficientfunding toachievetargets
• Available fundinglimitedtoDREAMSandCeSHHAR
19DECEMBER2016
KeyPopulationsforPrEPAdolescentgirlsandyoungwomen(AGYW)
Sero-discordant couples Menwhohavesexwithmen(MSM)
FemaleSexWorkers(FSW)
KeyIndicators
• ~1.7Mtotaladolescentgirls(ages10-19),ofwhich61,000livingwithHIVand~1.6MwithoutHIV
• 4-6%prevalence(ages15-19)• 14,000 newlyinfectedadolescent
girls(ages15-24)in2015=66%ofnewinfectionsinthatagerange
• 18% ofadolescentgirls(ages15-19)haveexperiencedsexualviolence
• 45%havetestedforHIV
• Heterosexualpeopleinstableunionsorpeopleengaginginlowriskheterosexualsexaccountforaround54.8% ofallnewHIVinfections
• 11.3%ofmarried/cohabitingcouplesaresero-discordant
• In6.7%ofcouplesthemanistheHIVpositiveandin4.5%thewomanisHIV-positive
• Unknown numberoftotalMSM
• ~24%prevalenceamongMSM(basedonresearchincludingZimbabweandothercountries)
• 4% oftotalnewinfectionsand7% includingtheirpartnersareamongMSM
• 40,000-80,000totalFSWinZimbabwe
• 20% prevalenceoverallbasedonCESSHARestimate,but50-70%insmallerstudies
• 12% ofZimbabwe’stotalincidenceisamongsexworkersandtheirclients
• ~30%of HIV+FSWareonART
Prioritiza
tion • Innewnationalplan,AGYWare
includedasaprioritypopulationforcomprehensivepreventionbutnotPrEP
• AGYWwillbethefocusoftheDREAMSinitiativeinsixdistrictsthroughoutZimbabwe
• Innewnationalplan,peopleinstableunionsandsero-discordantcouplesareacknowledgedtobeamongkeypopulations
• OneofthePriorityAreasofFocusistoreduceacquisitionfromortolong-termsexualpartners
• MSMindirectlylistedaskeypopulationinnationalplan(e.g.,“moredataneeded”)
• MSMincludedinGlobalFund’sKP-REACHinitiative($11MforHIVresponseacrossmultiplesub-SaharanAfricancountries)
• Strongcivilsocietyadvocates(e.g.,GALZ)
• Innewnationalplan,FSWincludedasapriorityforcomprehensivepreventionandpossiblyPrEP
• Zimbabwe’sonlyongoingPrEPimpactstudy(SAPPH-IRe)seekstodemonstrateacceptabilityandfeasibilityofPrEPandmaximizeadherenceamongasubsetof28,000highway-basedFSW
Questions • Whichchannelswouldbemost
appropriatefordeliveringPrEPtoAGYW?
• WilltherebefundingspecificallyforPrEPforAGYW?
• WhichchannelswouldbemostappropriatefordeliveringPrEPtopeopleinstableunionsandsero-discordantcouples?
• WhatisthesizeandHIVprevalenceofthepopulation?
• WhichchannelswouldbemostappropriatefordeliveringPrEPtoMSM?
• WhatwillbetheresultsofSAPPH-IRe study,andtheirimpactonPrEPpolicy?
Sources:AdolescentGirls– (1)HIVandAIDSinZimbabwe.AVERT.May1,2015;(2)RethinkingHIVPreventiontoPrepareforOralPrEPImplementationforYoungAfricanWomen.Celum,etal;JournaloftheInternationalAIDSSociety.2015;(3)SexualandReproductiveHealthNeedsOfAdolescentsinZimbabwe.Guttmacher Institute.2014;(4)ZimbabweNationalHIVandAIDSEstimates:2013.MinistryofHealthandChildCare.2013.ZimbabweNationalHIVandAIDSStrategicPlan2015-2018(ZNASPIII)[Notofficiallylaunched].MinistryofHealthandChildCareandNationalAIDSCouncil.March2015.MSM– (1)Fosteringevidence-basedHIVprogrammingformenwhohavesexwithmen(MSM)insub-SaharanAfrica.TheGlobalFund,WHO,andANOVAInstitute.April24,2013:(2)PSAf StudytoCharacterizeSexualMinoritiesinZambia[PartofresearchthatincludesZimbabwe]. TheCommunicationInitiativeNetwork:(3)ZimbabweNationalHIVandAIDSStrategicPlan2015-2018(ZNASPIII)[Notofficiallylaunched].MinistryofHealthandChildCareandNationalAIDSCouncil.March2015.FSW– (1)EngagementwithHIVPreventionTreatmentandCareamongFemaleSexWorkersinZimbabwe:aRespondentDrivenSamplingSurvey.Cowan,etal;PLOSOne.October2013;(2)Truvada asPrEP:ANewHIVPreventionOptionontheTableforZimbabwe?ICASAYouthFront.October19,2015;(3)“Youarewastingourdrugs:”HealthServiceBarrierstoHIVTreatmentforSexWorkersinZimbabwe.Mtetwa,etal,ofBMCPublicHealth.2013.;Cowan FM,Mtetwa S,Davey C,Fearon E,Dirawo J,etal.(2013) EngagementwithHIVPreventionTreatmentandCareamongFemaleSexWorkersinZimbabwe:aRespondentDrivenSamplingSurvey.PLOSONE8(10):e77080.doi:10.1371/journal.pone.0077080
20DECEMBER2016
BudgetingforPrEP
CurrentFundingforHIV• 85%isfrominternational sources• 15%isfromdomestic resources,
largelytheNationalAIDSTrustFundlevy(thuslinkedtoeconomicgrowth)
• Levyhasdrawn~$20-50M.TheLevywasextendedtotheminingsectorwhichwilladdsignificantadditionalresourcestotheFund
• FundingforHIVinZimbabwe (publicdomesticandinternational,‘09-’16):
RemainingGapsandChallenges• OffundingfromNationalAIDSLevy,
only10%isallocatedtoprevention• Onaper-PLHIVbasis,Zimbabwe
receivesoneofthelowestpercapitaallocationsgloballyfromcombinedfundingofGlobalFundandPEPFAR
• WorldBank2011expenditurereviewshowedpercapitadevelopmentassistanceforhealthinZimbabwetobewellbelowneighboringcountries
• HIVcosts,commitments,andgap:
PotentialNewFunding• PEPFAR,GlobalFund,andZimbabwe
governmentrecentlyjointfundedthenew$3MZIMPHIAstudy
• GlobalFundgiving$11MtoKP-REACH(KeyPopulations:Representation,Evidence,andAttitudeChange)effort
• Zimbabwesubmitteda$40.2MrequestforincentivefundingonMay18th,2015,fromtheGlobalFund (ontopofits~$145averageannualcommittedallocationthrough2016):
Summary:• Stronggrowthinfundingoverpast5yearsduetoPEPFARfundsdoublingto$95M
andnewfundingmodelincreasingaverageGFannualgrantsfrom$67Mto$145M• Zimbabwe’sHIVfundingneedsareprojectedtogrowto~$600Mby2018and
~$700Mby2023,butcurrentannualfundingcommitmentsare<$400M• HIVtreatmenttakinglargershareofresourcesasmorepeopleareputonART
$525MtotalHIVcosts$183Mofwhichisprevention$41M* committedtoPrEP*AmountonlyavailableforDREAMS
Year TotalCost Available Gap2013 $330M $223M 32%2014 $401M $279M 30%2015 $466M $304M 35%2016 $525M $264M 50%2017 $567M $238M 58%2018 $591M $238M 60%
IncentiveFundingArea RequestedLaboratoryandPharmaceuticals $19.5MYouthandAdolescents $10.0MCommunityandKeyPopulations $2.9MMonitoringandEvaluation $4.2MGrantManagement $3.6MTOTAL $40.2M
Sources:(1)126MillionAdditionalFundingAnnouncedtoFightHIVinZimbabwe.UnitedNationsDevelopmentProgram.January20,2015;(2)GlobalAIDSResponseReport:ZimbabweCountryReport.UNAIDS.December2014:(3)GlobalFundapproves$17millionfornewHIVprogrammes inAfrica.InternationalHIV/AIDSAlliance.July6,2015;(4)GlobalFundCountryAllocations:2014-2016.TheGlobalFundtoFightAIDS,Tuberculosis,andMalaria.March12,2014;(5)NationalAIDSCouncil:Funding.NationalAIDSCouncilofZimbabwe.2011;(6)Zimbabwe:MinistryofHealthandChildCaretoLaunchNewHealthSurvey– ZimbabwePopulation-BasedHIVImpactAssessment.AllAfrica.September17,2015.;(7)ZimbabweNationalHIVandAIDSStrategicPlan2011-2015(ZNASPII).MinistryofHealthandChildCareandNationalAIDSCouncil.March2015:(8)ZimbabweNationalHIVandAIDSStrategicPlan2015-2018(ZNASPIII)[Notofficiallylaunched].MOHCCandNationalAIDSCouncil.March2015;(9)ZimbabwePlannedFunding.PEPFAR.2014.
21DECEMBER2016
SupplyChainManagementKeyStakeholders• MOHCC identifiesdrugneeds,specifiesdeliverytimelines,oversees
developmentoftreatmentguidelines• GileadfilesforpreventionindicationofTruvadainZimbabwetoMCAZ• NatPharm conductsquantificationstoforecastdemandbasedon
programneeds,runscentralmedicalstore,publicwarehouses,andlocalbranches
• MCAZperformsqualityassuranceandproductregistrationforalldrugs• StateProcurementBoardregulatesandmanagesallpublicprocurement
KeyStrengthsandOpportunities• Zimbabwehaswell-coordinated procurementanddistributionsystemto
whichPrEPcanbeadded;coordinationsystemisflexibletodeliverPrEPtospecifiedgeographiesandchannels(NGOorpublic)
• ZimbabweisoneofAfrica’spioneerprocurementreformcountries,withWorldBanksupportingSPBtraining,assessment,andcapacity-building
• WidedisseminationoftreatmentguidelinesamongpublichealthfacilitiesbodeswellforpotentialPrEP-relatedguidance
• PotentialforPrEPtobedonatedbyGilead(althoughthiscouldbebothanopportunityandachallenge)
• Truvada iscurrentlyapprovedfortreatmentbutnotprevention,yetMCAZhassignaledthatthisindicationissufficient touseTruvada forprevention
KeyEmergingConsiderations• ForARVscale-up,thereweresomecoordinationchallenges,as
procurementhappenedindividuallybydonoragenciesandwasn’talwaysharmonized,thoughsomeofthishasbeenresolved/streamlined
• QuantificationprocessinformingNatPharm procurementreliessolelyonprogramtargets.Processmaynotbeadequate forPrEPforecasting
ReadinessforPrEPIntroductionReadinessFactor Progress
Regulatoryapprovalofform(s)oforalPrEPbyauthorities
• PrEP(Truvada)isnotregisteredfor treatment, whichMCAZhasindicatedissufficientforuseofthemedicationforpreventionpurposes
EffectivedemandandsupplyforecastingmechanismsforPrEP
• StrongsupplychaininplaceforARVs,whichwilllikelytranslatetoPrEPreadiness– butnoPrEPspecificplanningconductedto-date
ManufactureridentificationandcontractnegotiationtopurchasePrEP
• PulsepharmaceuticalshasbeenidentifiedasthedistributorofPrEP
Productandpackagingdesigntomeettargetpopulation needsandpreferences
• Unclear todateandlikelytodependonchosenPrEPmanufacturer
DevelopmentofdistributionplanforPrEPtoreachtargetpopulations
• Nodistributionplanisyetinplace butwillbedevelopedin2016/2017
Effectivedistributionmechanisms toavoidPrEPstock-outsinpriorityfacilities
• Zimbabwe hasa robustdrugprocurementanddistributionmechanismthat iscentrallycoordinatedforpublicandNGOsites; ARVstock-outs arerare.
• NatPharm doesnotanticipatemajorobstaclesinaddingPrEPtocurrentdistribution
22DECEMBER2016
PrEPDeliveryPlatformsKeyStakeholders• GeneralHIVservicechannels:community-and-home-basedcareproviders
(CHBC),HTCcenters,ARTsites(includingcentral,district,local,andmissionhospitals),mobileclinics
• GeneralHIVpreventionpartners:ZNFPC,PSI,PSZclinics• GeneralHTCimplementingpartners: PSI,OPHID,ZAPSO,ZACH,WHO• Youth/AGYW:youthcenters,healthfacilityyouth-friendlycorners;FSW:
networkofsexworkclinics;MSM:civilsocietyandadvocacyorganizations(e.g.,GALZ)
KeyStrengthsandOpportunities• DespitesomecapacityissuesduringARVscale-up,thereappearstobecapacity
forPrEPdeliveryaslongaspolicyclarifiestargetpopulations• CHBCshavesignificantreach(e.g.,theyreached700kpeoplein2011)• 1,460HTCcentersidentifiedaskeychannelforARVsandHIVprevention• ARTsitestripledfrom‘10to’14,and>85%livewithin3kminmostdistricts• StrongNGOprogramsandpoliticalwilltosupportFSW• GALZhasHCWcontactsacrossthecountry;couldprovidePrEPtoMSM• Earlysuccessesinaddressingnurses’negativeFSWattitudeswithtraining
KeyEmergingConsiderations• CHBCshavelimited skills andexperience,lower quality assurance,andweaker
referral systems• Community-basedHTCisnotrobust,andHTCisparticularlylaggingfortarget
populationsincludingAGYW• Civilsocietyorgsaccessibleinurbanareasbutnotperi-urbanorrural• OfficialclinicaltrainingonPrEPneededfromMOHCC.Trainingsoftenreach
staffatprovincialhospitals,butnotlocallevelfacilitieswherepopulationswithhighHIVriskarelikelytogo
• Trainingneededfromgroupswhounderstandandrepresentkeypopulations(GALZ,CESHAAR,AFRICAID)onhowtodeliverPrEPtokeypopulations(GALZtrained500HCWsin2015inMSMsensitization)
ReadinessforPrEPIntroductionReadinessFactor ProgressIssuanceofstandardclinicalguidelinesforprescription anduseofPrEP
• ConsolidatedPrEPguidelineswerereleasedinNovember2016
Sufficientinfrastructure andhumanresourcestoconductinitialHIVtestsandprescribePrEPinprioritychannels
• Network of1,460HTCcentersidentifiedaskeychannelforARVsandHIVprevention.ThesearelikelytoserveaskeyinfrastructureforPrEProll-out,but outreachwillbeneeded
• Humanresources needtobedeterminedbyroll-outplan
Plantoengagehealthcareworkers onPrEPanddeliverytotargetpopulations(includingmitigatingstigma)
• GALZconductinghealthcareworkertrainingproject–demonstratingresultsofreducedstigma
• OralPrEPisexpectedtobeincludedinhealthcareworkerstrainingmanuals
ToolstohelppotentialclientsandHCWunderstandwhoshouldusePrEP havebeencreated
• OralPrEPhasbeenincludedontheOperationalServiceDeliveryManual
• PrEPfactsheetisbeingfinalized• HPTN082willbetestingascreeningtool thatcouldpotentiallybeusedforscaleup
Sufficientresourcestoroll-outplansforhealthcareworkerengagement
• Neededresources willbedeterminedalongwithhealthcareworkerengagementplansandidentificationofPrEPdeliverychannels.
23DECEMBER2016
CurrentPrEPDeliveryChannelsDemoprojectsandOpenLabel Extensions DREAMS
Backgrou
nd
• TheSAPPH-IreDemonstrationProjectinZimbabwehasbeenimplementedat14outreachsitesthatofferHIVservicestofemalesexworkers.ThestudybeganinJuly2014withenrollmentof2,800women.• HPTNtoinitiatethreestudiesin2016,includingHPTN082andIMPACT
• TheDREAMS initiative(Determined, Resilient, Empowered,AIDS-free, Mentored,and Safewomen)hasbegunprovidingPrEPtoyoungwomen(18-24)inthree(Chipinge,Mutare,andBulawayo) ofthesixDREAMSdistricts(Bulawayo,Gweru,Mazowe,Makoni,Mutare,Chipinge)beginningin2016.PrEPisbeingrolledoutusingthePSINewStartCentres• PrEPintheformofTruvada isdonatedbyGileadforusebyDREAMS
KeyStreng
ths
• DemoprojectreachingtargetpopulationsathighriskofHIVtransmission• ExistingaccesstoPrEPandassociatedtesting,monitoring,andcounsellingservices• ExperiencedstaffhighlyknowledgeableaboutPrEP• APrEPdemoproject/researchtaskforcewillbeconvenedtosharevaluableinsightsfromrecruitmentandretentioneffortsthusfar,includingdemandcreationandmessaging,andmodelsofservicedelivery• LowlevelsofstigmaamongstaffworkingwithPrEPusers
• Targetedprogramreachinghigh-risk(asidentifiedbycommunity-ledcriteria)adolescentgirls• Districtlevelmicroplanning andhotspotanalysisisunderwaytoeffectivelytargetprogramactivities• ZimbabweisbenefitingfromsupplementaryTest&StartandVMMCfundingtorapidlyexpandaccessofmalesexualpartnersofAGYWtohighimpactHIVservicesintheDREAMSdistricts• PrEPdeliverycoupledwithHTC,behaviorchangeactivities,extensivecounseling,communitymobilization,andinitiativestostrengthenfamilies• PotentialtoexpandPrEPdistrict-widegivenotherinvestmentstomakePrEPavailabletoDREAMSparticipants,includinglogistics,procurement,demandgeneration,andcommunitybuy-inefforts
Key
Challeng
es • PerceptionofPrEPaspartofan“experiment”deterspotentialusersfearingpoorsafetyandefficacyofdrug• Highercostsofdeliveryindemonstrationprojectcontext
• DREAMSPrEPtoreachadolescentgirlsonlyincommunitieswheremanyotherpopulationscouldbenefitfromPrEP• Reachlimitedto1,451youngwomeninDREAMSdistricts(53,654youngwomenwillbetargetedwithHTC)
24DECEMBER2016
ComprehensiveCareCenters &otherARTsites SexualandReproductiveHealth(SRH)careproviders
Backgrou
nd
Public(Gov’t) NGO Private
• Publichospitals,clinics,andotherhealthcarecenters(e.g.,VMMCclinics)
• NGO-runclinics,carecenters,otherHIV serviceprogramssuchasPSINewStartCenters,FHI’snewprograms,andkeypopulationclinics(SistersClinic)
• Private fee-for-serviceproviders
• ArangeofSRHcareincludingfamilyplanning,post-abortioncareclinics,pre-natalcare&otherSRHproviders
KeyStreng
ths
• Mostvisibletogeneralpopulations
• Systemsguidedandlinkedwithcountyandnationalstandards/agendas
• Canprovidegreateraccesstokeypopulations(FSW,MSM,PWID)
• Effectivelyreachhigh-riskindividualswithlow/nostigmapresentincentersoramongstaff
• Frequentuseofpeer-educatorprograms,whichmightbecriticaltoeffectiveuseandincreaseddemandgeneration
• Opportunitiestodeliverthroughprivatechannelsaccessingkeypopulationssuch
• DiscreteaccesstoPrEPwithoutstigmaforthosewhocanaffordit
• Notdependentonaid
• Providegreateraccesstosero-discordantwomenandAGYWinfemale-friendlyandtrustedsettings
• StaffhavelowerlevelsofstigmaagainstAGYWwhoseekfamilyplanningandHTCservices
• Post-abortioncareclinicshavethepotentialtoreachwomenwithveryhighriskofHIVinfection
• PotentiallyprovidelowcostofdemandgenerationsincewomenarealreadyvisitingSRHservices
• ~1500ARTsitesthroughoutZimbabwe• Well-integratedprocurementanddeliverysystems• LaboratorycapacityfornecessaryPrEPmonitoringinplaceatmanyofthesesites• HTC-trainedstaff
Key
Challeng
es • HCWstigmaagainsttargetpopulations,ifpresent,candetermanyfromaccessingcarethroughthesesites
• Staffandresourcesperceivedtobestretchedthin,resultinginsuboptimalcare• Nosingleoutleteffectivelyreachesalltargetpopulations
• PotentiallylimitedexperienceandtraininginHTClinkages
• Limited/nolaboratorycapacityfornecessaryPrEPmonitoring
• AGYWmayhavetroubleaccessing
PotentialPrEPDeliveryChannelsThisisacontinuedareaoffocus.Additionaldetails
expectedtoemerge
25DECEMBER2016
IndividualUptakeKeyStakeholders:• NGOgroups,includingCHAI,areinearlystagesofdemandgeneration
researchandpromotion• Networks (ZNPP+,ZAN)mayhelpwithdemandgenerationactivities• FHI360 iscominginasanewpartnerunderPEPFARonHTCandmay
introducenewplansformobilizingtestingandcarelinkagesthatcouldbeleveragedforPrEPdelivery
• PEPFARandGlobalFundmaybekeyfundersofdemandgeneration• PSI deploying354,000HIVself-testingkits,whichmightbecriticalin
providingHTCtohighriskpopulationsnotalreadyaccessingtestingservices
KeyStrengthsandOpportunities:• GoodHTCcoverage,butactualHTCusageislessfavorable:91%ofwomen
and88%ofmenknowwheretoaccessHTC,but57%ofwomen(45%ofyoungwomen)and36%ofmen(24%ofyoungmen)haveeverbeentestedandreceivedresults
• PITCisbeingpushedbyMOHCCandscaledupto94%ofhealthfacilities• TrackrecordofsuccesswithVMMC,aswellasrecognitionthatgapsin
consistentcondomusepersist,particularlyamongkeypopulations• GALZ,CESHAAR,SAFAIDS,andothersareworkingtoadvocateforlegal
reformforFSWandMSM• Recentpositivelegalchangearound“loiteringlaws”showthatthingsmaybe
movingpositivelyforFSW
KeyEmergingConsiderations• FSW:sexworkillegal,highratesofabuse/violence,highopportunityand
transportationcostskeepFSWfromchoosingtoaccessHIVservices• MSM:practicesareillegal(unlikelytochange),facilitiesrefusetreatment• AGYW:uptakechallengeswithotherproducts(e.g.,forculturalreasons,only
1/4ofadolescentgirlsusethepill,whichaccountsformajorityoftheirmoderncontraceptiveuse),lowHTCuptake
• General:directadvertisingofRxmedicinestothepublicisprohibited,concernsaboutPrEP’s unintendedconsequences(e.g.,resistance,undetectedHIVinfections,riskierbehavior,increasedabuse/violence)
ReadinessforPrEPIntroductionReadinessFactor ProgressClearandinformativecommunicationsonPrEPforgeneralpublicaudiences
• Nocommunicationsstrategy orplanningforonehasbeeninitiateddodate
Developmentofdemandgenerationstrategiestargetedtouniqueneedsofdifferentpopulations
• Demandgenerationactivitiesarenotinplace beyondthoseattachedtospecificdemoprojects,butthesehaven’tbeenresearchedorvetted
Linkages betweenHTC,PrEPprescription,andPrEPaccesstoenablePrEPuptake
• Necessary linkageswillbeunknownuntilPrEPguidelinesoutliningchannels,populations,andprescriptiondetailsarecompleted.IfPrEPisdeliveredthroughARVchannels,thelinkagesarelikelytoenablePrEPuptakeatleastinthosepopulationsalreadyaccessingsuchchannels
Information forclientsonhowtoeffectivelyusePrEPforalltargetpopulations
• Informationexistsforthoseparticipatingindemoprojects.
• APrEPfactsheetisunderdevelopment
Sufficientresourcestoroll-outplansfordemandgeneration
• Resources notyetsecured.Neededresources willbedeterminedandultimatelysecuredonceZimbabwedeterminesdemandgenerationneedsandplans
26DECEMBER2016
KeyConsiderations
Stigma
• Earlystigmalingers:makingPrEPwidelyavailablebeyondkeypopulationswouldhelpmitigatepreconceptionsofPrEPasanoptiononlyforFSWandMSM.ThisisimportantbecauseonlydemoprojecttodateinZimbabweisworkingwithFSW.AnyPrEPcommunicationscampaignwillneedtodirectlyaddressthestigmaassociatedwiththispopulation
• Amonghealthworkers:thechallengesaretwofold- healthcareworkershavetheirownbiasesaboutwhoshouldbeaccessingbirthcontroloptionsandHIVpreventionservices,andtheyoftenlacktheappropriateinformationandtrainingtoeffectivelyprovidearangeofoptionsforindividualstomakeinformeddecisions
• Youthandfemale-friendlyspacesarecriticalandneeded:centersthatarestigma-free,youthandfemale-friendlywillfacilitateuptake,butchangestofacilitieshavebeenslowandinsufficient
DrugPreconceptions
• TherearefearsaboutdevelopingresistancetoARVswhileonPrEP,anddevelopingphysicalsideeffectsassociatedwithARVs
• PeoplerecognizeTruvadaasanARVanddonotwanttobeseentakingitiftheyareHIVnegative
Messengers• MessagesaroundPrEPneedtobeproactive,consistent,andcomefrommultipledirections.Importantmessengersinclude:nationalandcountygovernments,ministries,CBOs,celebrities,religiousleaders,healthcareworkers,peersandvariousformsofmedia(e.g.print,radio,online)
Messages
• PrEPaspower: PrEPcouldbeframedasanoptiontoprotectoneself and thecommunity. Alsoassomethingthatisempoweringandpositiveasopposedtoshamefulandincriminating.Ideasformessagingincluded statementssuchas:“Ourownchoice,ourownpower”
• Risk inrelationships:potential toappealtolikely PrEPusersbyhighlightingtheriskassociatedbytheirownconduct andalsothatoftheirpartners whomayhavemultiplesexualpartners
• Riskperception:youngwomeninKenyagenerallydonotseethemselvesathighriskforHIVtransmission.Theyaremorefocusedoneconomicopportunityandeducation
• PrEPforall: ideasfor inclusivemessaging includedstatementssuchas“PrEPisforyou,PrEPisforme”and“PrEPisforallofus”
KeyEnd-userThemesforPrEP
27DECEMBER2016
EffectiveUse&MonitoringKeyStakeholders:• MOHCCisresponsibleforvettingtheM&Eindicatorsandoverseeing
theworkofthePrEPandM&ETWGs,whichwillworktodevelopandapproveoralPrEPM&Erecommendations
• NACisresponsibleforoverseeingthegeneralnationalM&Eplan• USAIDanditsSIteamisinvolvedintherefinementofM&Eindicators
andreviewinganddevelopingtoolstosupporttheprocess• NGOs havebeenparticularlyimportantinprovidingpost-testsupport
servicesforHIV-negativeandHIV-positivepeoplethataddressriskreduction,disclosure,andtreatmentadherence
KeyEmergingConsiderations• Whileadatasystem(DHIS2)exists,onlysomeoffacility/patientdata
ispulledintoDHIS.Additionally,facilityregistersandreportingtoolsdonot(yet)reflectneedstotracktheroll-outofPrEP.Therefore,M&EtoolswillneedtoberevisedtobeabletoreportonPrEProllout
• LittleisknownaboutPrEPadherenceingeneral,andevenlessonhowitmaydifferamongtargetpopulationsinZimbabwe
• WhileitseemslikethereissufficientcapacityforHIVtesting,ongoingtestingofPrEPuserscouldplacestrainontheexistingsystem
ReadinessforPrEPIntroductionReadinessFactor Progress
EstablishedplanstosupporteffectiveuseandregularHIV,creatininetestingthatreflecttheuniqueneedsoftargetpopulations
• Earlyconsiderationsforencouragingandsupportingeffectiveuseandadherencetoregulartestingarebeingdiscussed
• However,specificstrategies fortargetpopulationsarenotyetbeingcreated
CapacitytoprovideongoingHIV andcreatinineleveltestingforPrEPusersaccessibletotargetpopulations
• While thereisincreasinglysufficientHTCcapacityforcurrentefforts,gapsremainandresourcesmaycontinuetobeachallenge.Additionally,exacttestingneedsforPrEPareyettobedetermined.Countrytreatmentguidelinesshouldoutlinethesespecificneeds
Monitoringsystemtosupportdatacollectionforongoinglearning(e.g.,rateofpatientsreturningfor2ndvisit,non-HIVSTIrates)
• Toolsandindicatorsformonitoringarecurrentlybeingreviewed
• M&EforPrEPlikelytobeintegratedwithexistingARVM&Esystem.PrEPguidelineswillneedtodictatemonitoringand trainingneeds
KeyStrengthsandOpportunities:• Zimbabwehasasinglemonitoringandevaluationsystem.This
systemislinkedtoindividualproject/programM&EsystemsbeingusedbyHIV/AIDSserviceorganizations;thissystemappearstobeintheprocessofbecomingmoreintegratedandharmonized
• M&EforPrEPlikelytobeintegratedwithexistingARVM&Esystem• ZNASPIIIstatesthat“acontextualNationalM&EPlanwillbe
developedtoguidetheimplementationofthestrategicplananditspartnersystems”
28
NationalM&EStructure/Process:
Steps Who
DeveloprecommendedoralPrEPM&Eindicators OralPrEPTWGVetrecommendedindicatorsandmakerefinements asneeded MOHCCandUSAID
Approverefinedindicators M&ETWGNecessarydatacollectiontoolsreviewedanddeveloped OPTIONS andUSAID
Integrate indicatorsintoDHIS_2andelectronicpatientmedicalrecordsystem MOHCC
Possibly:monitor earlyrollouttopilotpopulations,includingtrackingclientscyclingonandofforalPrEP
TBD,withtechnicalsupportfromCHAI/PMM
29DECEMBER2016
AppendixB:ExpectedPrEPActivitiesQ1|16 Q2|16 Q3|16 Q4|16 Q1|17 Q2|17 Q3|17 Q4|17 2018 2019 2020
Research
SaPPHIRe results expectedforPrEPamongFSWinZimbabwe
ZIMPHIA survey datacollectionamong15kZimbabwehouseholds Results
HTPN082andIMPACTdemoprojectsbegin
Plan
ning/Im
plem
entatio
n
GuidelineAdaptationCommitteemeets,incl.PrEP workinggroup
New nationalstrategicplan for2016-2018(ZNASPIII)ineffect
MOHCC-directedPrEPimplementationplanningperiod
DREAMS activitiestotakeplaceinZimbabweinidentifiedhotspotdistricts
ZNASP IIImid-termreview;opportunitytopushforPrEPinclusioninplan
CHAIdemandgenerationresearchinitialresultsexpected
GatesresearchoncostofPrEPdeliveryacrossdemoprojectsinitialresultsexpected
Policy
Zimbabwe releasesPrEPguidelines
Gilead licensureprocessapprovalexpected(Pulseasdistributor)
TBD
30DECEMBER2016
AppendixC:References• 126MillionAdditionalFundingAnnouncedtoFightHIVinZimbabwe.UnitedNationsDevelopmentProgram.January20,2015.• AchievinganAIDS-FreeGenerationforGayMenandOtherMSMinSouthernAfrica.amfAR,TheFoundationforAIDSResearchandJohnsHopkinsBloomberg
SchoolofPublicHealth.May2013.• CountryUpdates:Zimbabwe.PrEPWatch.2015.• EngagementwithHIVPreventionTreatmentandCareamongFemaleSexWorkersinZimbabwe:aRespondentDrivenSamplingSurvey.Cowan,etal;PLOSOne.
October2013.• EvaluationsandRegistration andHowWeRegulate.MedicinesControlAuthorityofZimbabwe.2012.• GlobalAIDSResponseReport:ZimbabweCountryReport.UNAIDS.December2014.• GlobalFundCountryAllocations:2014-2016.TheGlobalFundtoFightAIDS,Tuberculosis,andMalaria.March12,2014.• HIVandAIDSinZimbabwe.AVERT.May1,2015.• ManagementofHIV&AIDSCommoditiesinZimbabwe:ACapacityAssessmentofNatPharm andMinistryofHealthandChildWelfare .DELIVER,forUSAID.
July2006.• NationalAIDSCouncil:Funding.NationalAIDSCouncilofZimbabwe.2011.• ProcurementandSupplyChainManagementinZimbabwe.UNDPandGlobalFund.March4,2015.• ProcurementChallengesintheZimbabweanPublicSector:APreliminaryStudy.JournalofTransportandSupplyChainManagement.2015.• RethinkingHIVPreventiontoPrepareforOralPrEPImplementationforYoungAfricanWomen.Celum,etal;JournaloftheInternationalAIDSSociety.2015.• SexualandReproductiveHealthNeedsOfAdolescentsinZimbabwe.Guttmacher Institute.2014.• SuccesswithPrEP:NextStepstoSupportPolicyDecisionsinSouthernandEastAfrica.AVAC,UNAIDS,andWHO.October26,2014.• TruvadaasPrEP:ANewHIVPreventionOptionontheTableforZimbabwe? ICASAYouthFront.October19, 2015.• “Youarewastingourdrugs:”HealthServiceBarrierstoHIVTreatmentforSexWorkersinZimbabwe.Mtetwa,etal,ofBMCPublicHealth.2013.• ZimbabweBeginsPublicProcurementModernization.TheWorldBank.May13,2015.• ZimbabweFailstoCapitalizeon$4bnARVsMarket.RobinMuchetu ofTheSundayNews.April12,2015.• Zimbabwe:MinistryofHealthandChildCaretoLaunchNewHealthSurvey– ZimbabwePopulation-BasedHIVImpactAssessment.AllAfrica.September17,
2015.• ZimbabweNationalHIVandAIDSEstimates:2013.MinistryofHealthandChildCare.2013.• ZimbabweNationalHIVandAIDSStrategicPlan2011-2015(ZNASPII).MinistryofHealthandChildCareandNationalAIDSCouncil.March2015.• ZimbabweNationalHIVandAIDSStrategicPlan2015-2018(ZNASPIII)[Notofficiallylaunched].MinistryofHealthandChildCareandNationalAIDSCouncil.
March2015.• ZimbabweProgressReport, GlobalAIDSResponse,NationalAIDSCouncil,2016.• ZimbabwePharmaceuticalCountryProfile.MinistryofHealthandChildWelfare,DirectorateofPharmacyServices,incollaborationwiththeWorldHealth
Organization.June2011.• ZimbabwePlannedFunding.PEPFAR.2014.