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
Intensify HIV prevention educe TB deaths among PLHIV by 50%
Eliminate new HIV infections in children
Intensify HIV prevention
HIV in Southern Africa: The Facts
HIV Global Health Targets:
Place 15 million people on ART
Reduce TB deaths among PLHIV by 50%
Eliminate new HIV infections in children
Intensify HIV prevention
(United Nations General Assembly High Level Meeting on AIDS, 2011) 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
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
Intensify HIV prevention educe TB deaths among PLHIV by 50%
Eliminate new HIV infections in children
Intensify HIV prevention
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
among PLHIV by 50%children
Intensify HIV prevention educe TB deaths among PLHIV by 50%
Eliminate new HIV infections in children
Intensify HIV prevention
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
among PLHIV by 50%children
Intensify HIV prevention educe TB deaths among PLHIV by 50%
Eliminate new HIV infections in children
Intensify HIV prevention
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
Intensify HIV prevention educe TB deaths among PLHIV by 50%
Eliminate new HIV infections in children
Intensify HIV prevention
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
among PLHIV by 50%children
Intensify HIV prevention educe TB deaths among PLHIV by 50%
Eliminate new HIV infections in children
Intensify HIV prevention
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
Intensify HIV prevention educe TB deaths among PLHIV by 50%
Eliminate new HIV infections in children
Intensify HIV prevention
Social Drivers
Department of HealthVarious NGO and private sector ART programmesFrancois VenterLeigh JohnsonGottfried HirnschallUNAIDSWHO
Questions?among PLHIV by 50%children
Intensify HIV prevention educe TB deaths among PLHIV by 50%
Eliminate new HIV infections in children
Intensify HIV prevention
Acknowledgements
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