Overview of the Society Presented at the Regional Workshop on HIV, AIDS and Housing Lauren...

Overview of the Society

Presented at the Regional Workshop on HIV, AIDS and Housing

Lauren Jankelowitz 15 September 2014

HIV/AIDS Within the Southern African Context

Presented September 2014By Lauren Jankelowitz

Non-profit membership organisation of HIV health care workers

Formed in 1997 by Prof Des Martin to help coordinate response to HIV/AIDS epidemic

Governed by an eight member elected Board of Directors

Secretariat in Johannesburg – 6 FTEs, network of consultants and clinical volunteers

WHO ARE WE?

Presented September 2014By Lauren Jankelowitz

Society membership is inclusive of all health care workers in HIV: doctors, related professionals, nurses and emerging focus on lay HCWs as well

Approximately 3 000 members 58% doctors; 50% public sector 50% private sector28% nurse; 5% pharmacist85% South African, remaining largely Southern African (Botswana, Namibia, Zimbabwe, Zambia)37% reside in Gauteng; ~15% KZN, Western Cape and Eastern Cape each Paediatrics is the largest reported specialty

WHO DO WE SERVE?

To promote quality comprehensive, evidence-based HIV healthcare in Southern Africa

Objectives:To partner with governments to implement optimal HIV programmes and policies

To foster evidence-based HIV related education for healthcare workers

To produce evidence-based guidelines

To facilitate interactions amongst HIV healthcare workers to optimise patient care

To expand access to the activities of the Society

To advocate for the best possible HIV treatment, care and prevention

To improve TB diagnosis, care and prevention within the context of the HIV epidemic

MISSION & OBJECTIVES

AIDS-related deaths 1.7 millionHIV+ 34 million

50% know their statusNew HIV infections 2.5 millionEligible for treatment 14.8 millionOn treatment 8 million

(UNAIDS Global Report, 2012) deaths among PLHIV by 50%children

Intensify HIV prevention educe TB deaths among PLHIV by 50%

Eliminate new HIV infections in children

Intensify HIV prevention

HIV Globally: The Facts

HIV+ 23.5 million (70% global total)SA 5.6 millionNigeria 3 millionKenya & Tanzania 1.6 million eachUganda & Mozambique 1.4 million eachZimbabwe 1.2 millionZambia 970 000Ethiopia 790 000Botswana 340 000

(UNAIDS Global Report, 2012) deaths among PLHIV by 50%children




HIV in Southern Africa: The Facts

HIV Global Health Targets:

Place 15 million people on ART

Reduce TB deaths among PLHIV by 50%



(United Nations General Assembly High Level Meeting on AIDS, 2011) deaths among PLHIV by 50%children




Current HIV/AIDS Related Knowledge: The Way Forward In Dealing with the Current State of Health in Southern Africa

The WHO/UNAIDS Treatment 2.0 Initiative

Achieve and sustain universal access & maximize the preventive benefits of ART

The five pillars to re-energize the

HIV response:

I – Optimize drug regimens

II – Promote diagnostics using point of care and other simplified technologies

III – Reduce costs

IV – Adapt delivery systems

V – Mobilise communities, protect human rights

TREATMENT2.0

Adapt delivery systems

Mobilize communities

POC and other

simplified monitoring

Optimize drug regimens

Reduce costs

Several countries are implementing or considering PMTCT Option B+ in Sub-Saharan Africa…

Country Current Option

Transition Status

Malawi B+ Currently implementing B+ at national level. Revised treatment guidelines were approved in July 2011 and implementation began in September 2011.

Kenya Mixed Phased roll out of B+ beginning with high volume facilities. Most (60%) of the country receives Option A, with 40% receiving Option B. Revised PMTCT include B+, with a goal of 50% of HIV+ pregnant women on ART by Dec 2012.

Rwanda B Will begin implementing Option B+ in July 2012; already treating all pregnant women CD4<500.

Uganda Mixed Will conduct a phased rollout of B+ over a 14 month period, beginning in regions with high HIV prevalence. Aim is to transition all sites by March 2013.

Haiti B MOH is considering transition to Option B+ in 2012.

Namibia A Has had preliminary discussions about B/B+ and will be conducting a cost and benefit/feasibility analysis, although no timeframe has been set.

Zambia A+ (treatment of

discordant couples)

TWG recommended transition to B/B+ in early 2010, but has not been implemented due to lack of funding and HR challenges.

Mozambique A MOH endorsed piloting B+ at 241 PEPFAR PMTCT facilities with ART facilities if ARV availability can be secured.

Swaziland A B+ pilot studies planned; Discussions of a phased implementation are ongoing.

Cameroon A Planned pilot of B+ in 2 districts.

B+

Impl

emen

tatio

n St

rate

gy in

Pla

ce

TWG

has

re

com

men

ded

B+

or

unde

r con

side

ratio

n by

MO

H

Con

duct

ing

B+

pilo

t stu

dies

PEPFAR, Feb,2012

How to use ARVs most strategically in a Public Health framework?

Treatment 2.0

Strategic Use of ARVs

Consolidated ARV Guidelines

Key Populations

PMTCT

Countries will have to make programmatic decisions how best to use ARVs-based interventions

Further simplification and optimisation of HIV treatment is needed to reach global targets

New evidence on the effectiveness of ARVs for both HIV treatment and HIV prevention, requires new guidance on the strategic use of ARVs.

PMTCT success directly linked with integration, service delivery and health systems strengthening

Exploring the use of antiretrovirals for prevention plays an important role in key populations

The architecture of WHO's normative guidance will be modified, with inclusion of operational and programmatic dimensions, and a shift towards consolidation for different populations and interventions.

Cannot be done without Treatment 2.0

11

Interventions

HIV testing & counselling Adults, adolescents and

children, age > 50 HIV+ with TB, HBV, HCV,

HIV-2 co-infections, HIV+ pregnant women and

their exposed children Key populations ARTp PrEP for specific

populations PEP

Different dimensions of consolidated ARV guidance (2013)

Clinical Operational Programmatic

Ad

ults / A

do

lesP

regn

ancy

Ch

ildren

How?

What?

Where and when?

(Prioritization)

Tx 2.0 normative pillars: Overview of short-, and medium/long-term objectives

Drug Regimen Optimisation:– Short term: Improve currently available drugs and formulations – Medium/long term: Stimulate the research pipeline towards development of

better drugs, regimens and strategies

Diagnostics Optimisation:– Short term: Establish priority areas for optimisation (EID, CD4 and VL)– Medium/long term: Stimulate the PoC diagnostics´ pipeline and promote the

development of QA/QC & prequalification frameworks on those areas

Adapting System Delivery:– Short term: Establish operational/programmatic guidance on system delivery (task

shifting, decentralisation & integration– Medium/long term: Technical assistance to treatment 2.0 pilot countries, review

implementation experience and inform policy and programmes.

Optimizing Drug RegimensMajor Strategies

Co-formulation (use FDCs or co-blister pack)

Reformulation (use extended release formulation; improve drug bioavailability)

Dose adjustment (improve toxicity, reduce pill burden/size)

New drugs (substitution to improve toxicity or increase efficacy)

New strategies (eg: induction-maintenance; intensification)

Drug manufacturing process (improve API route synthesis and reduce cost)

Globally and in Southern Africa there has been a 50% reduction in new infections

WHY? Political leadership; sustained investment; scale-up of treatment programmes; scale-up of some prevention programmes

BUT: international investment dwindling and where stable, very fragile; behavioural prevention has largely failed; structural factors continue to drive the epidemic

among PLHIV by 50%children




The Southern African Context

HIV communication programmes, condom distribution and condom use in SA

0%

10%

20%

30%

40%

50%

60%

70%

80%

0

50

100

150

200

250

300

350

400

450

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

% of women aged 15-24 who used

condom at last sex

Numbers of male condoms

distributed (millions)

Condoms distributed Condom use

Start of Soul

City series

Start of loveLife &

Siyayinqoba

Start of Khomanani

Start of TAC condom

distribution campaign

Start of HIV lifeskills

programmes in schools

• Gender inequalities: relationship between men and women BUT why Southern Africa?

• Poverty: can’t afford, food, shelter, transport to collect meds• Mobility and migration: lack of stability=lack of adherence if

migration is unplanned BUT studies show similar adherence• Economic well-being: focus on work and income vs. on healthy

living and costs associated• Stigma and discrimination: fear, lack of disclosure, lack of

support; may equal criminalization for key pops• Education: children running households, missing school• Social capital: community relationships, citizenship BUT TAC

Structural Factors Driving Epidemic

Structural Interventions

• Build social, legal & physical environments that enable risk reduction behaviours & encourage use of essential health & supportive services

• Address the factors that undermine healthy living, thereby fostering individual agency to reduce risk, adhere to prescribed regimens & remain engaged in continuous HIV care.

• Create & support AIDS-competent communities that prioritise community engagement & communication to promote better health outcomes.

HIV=Death!Stigma & discriminationDeath vs. testingNo/limited treatmentLots of behavioural prevention programmesExceptionalising HIVLack of political willActivism: a role for civil societyMassive injection of funding to support any HIV work





The Way We Were

HIV=chronic illnessStill stigma & discrimination (less?)Reduced mortality….still not enough testingMass treatment programmes…treatment as prevention BUT now linked services/ issues the focus (PoC, labs, adherence, resistance)Behavioural prevention programmes failing: what now?Still exceptionalising HIV while simultaneously trying to integrate/mainstreamPolitical will present mostly, except for key popsChanging role for activism: failings in health systems (stock outs, nurse attitudes, training, transport, medicine delivery, patient access) vs. treatmentFunding reducing, threatening to reduce further; limited funding for prevention/ social programmes





Now, where are we?!

How are poverty issues (nutrition; access to water, sanitation and decent housing) impacting on ARV roll out and adherence in Southern Africa?• Transport issues, distances to clinics (even logistics for labs, medicine supply),

incorrect nutrition linked to increased lypodystrophy, lack of access to clean water for formula feeding & increased infections, mobility and lack of appropriate housing leading to difficulties in adherence

How are capacity constraints impacting on ARV roll out and adherence in Southern Africa?• Lack of HR capacity and expertise, clinics without refrigeration, lack of

education, high unemployment…among PLHIV by 50%children




Now, where are we?!

1. Treatment as prevention2. Knowing your status3. Reaching HIV+ mothers and children; women; youth4. MMC5. Changing sexual behaviour (BUT new research shows

no/contrary link to ‘sugar daddies’, polygamy, concurrent partners)

6. Consistent condom use7. Key populations8. Adherence support programmes: cash transfers, housing

subsidies, NHI, keeping children in school, food assistance, legal reform





Where to?

Due to social drivers need 3-pronged combination prevention approach:1. Behavioural (communications)…Prevention2. Structural (law)…Policy3. Technological (tools)…Treatment

How do we get all 3 right?among PLHIV by 50%children




Social Drivers

Department of HealthVarious NGO and private sector ART programmesFrancois VenterLeigh JohnsonGottfried HirnschallUNAIDSWHO

Questions?among PLHIV by 50%children




Acknowledgements

Overview of the Society Presented at the Regional Workshop on HIV, AIDS and Housing Lauren...

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