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Overview of lessons learned from previous biomedical HIV prevention interventions in South Africa

Overview of lessons learned from previous biomedical HIV prevention interventions in South Africa. Presented by: Elizabeth T. Montgomery, Ph.D February 7,2012. Background.

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Overview of lessons learned from previous biomedical HIV prevention interventions in South Africa

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  1. Overview of lessons learned from previous biomedical HIV prevention interventions in South Africa Presented by: Elizabeth T. Montgomery, Ph.D February 7,2012

  2. Background • The history of other biomedical HIV prevention methods introduced in South Africa may offer insights relevant to the introduction of oral PrEP and vaginal microbicides • Case studies to consider: • PMTCT • Male circumcision

  3. Case Study 1: PMTCT, timeline • HIVNET 012 results published in 1999 • First SAG policy drafted in 2001 • Original Department of Health plan was to implement single dose Nevirapine (NVP) at 18 pilot sites (1 urban, 1 rural, per province) • July 2002: “lobby groups” won a case against the NDOH in the Constitutional Court. National expansion of PMTCT mandated • August 2005: ~2525 sites offering PMTCT

  4. PMTCT Timeline continued • SAG published new PMTCT guidelines in 2008 to include provision of dual therapy • 2008 PEPFAR estimates of ARV coverage for HIV+ pregnant women in South Africa just under 60% • 2010 Updated Guidelines published

  5. PMTCT Programme Intervention

  6. h

  7. PMTCT Analysis – one perspective

  8. PMTCT Programme in South Africa Strengths • Policy drafted in 2001 • New guidelines published in 2008 • Wide consultation on policies and plans • PLWHA and disability sector involved in the social mobilization plan for PMTCT Weaknesses • Protocol does not fully match international best practice standards • Men not sufficiently involved • Adolescent mothers not included in PMTCT planning • Inadequate human resources • Poor quality counseling • Infant formula supply problems • Inaccurate M & E

  9. PMTCT Programme – another perspective PMTCT: A Winnable Battle in South Africa • National cross-sectional facility-based survey of infant-caregiver pairs attending the 1st infant immunization visit • Dried blood spot (DBS) specimens from 4-8 week old infants were tested for HIV antibodies • Exposed infants further tested using DNA PCR

  10. PMTCT Programme results • 9610 enrolled infant-caregiver pairs, 2888 (30%) HIV-exposed infants were identified. • National MTCT rate at 4-8 week postpartum was estimated to be 4.0% (95%CI 3.3%-4.8%). • Unplanned pregnancy (AOR=1.7; 95%CI 0.9-2.9) associated with MTCT. • Exclusive breast-feeding (AOR=0.6; 95%CI 0.4-0.9); and maternal triple antiretroviral treatment (AOR=0.4; 95%CI 0.2-0.8) were protective factors.

  11. PMTCT – important lessons • Civil society keeps up with research and will hold SAG accountable to all citizens, not just those in “pilot” areas • Early preparation needed • More than just a pill • Prevention interventions complex and rely on a series of interventions and a holistic approach of how the pills fit in • Importance of ongoing and evidence-based evaluation

  12. Case Study 2: Male circumcision OVERVIEW • 2005-2006 Clinical trial results: ~60% reduction in HIV acquisition • 2007 WHO/ UNAIDS recommendations issued • South Africa identified as a priority country • March 2011 South African National Implementation Guidelines for Medical Male Circumcision

  13. National and multinational goals • South African Guidelines goal: to make accessible, safe MMC services available to all South African men. The priority age group is young men aged between 15 and 49. • WHO/ UNAIDS Strategic Framework seeks to achieve the following goal: By 2016 countries with generalized HIV epidemics and low prevalence of MC have: • a) VMMC prevalence of at least 80% among 15–49 year old males, and • b) Established a sustainable national programme that provides VMMC services to all infants up to 2 months old and at least 80% of male adolescents.

  14. VMMC Considerations • Goal(s) • Guiding principles, e.g. supportive leadership, safe and effective practice, human rights, gender sensitivity, socio-cultural sensitivity, comprehensive HIV prevention • Implementation Activities • Management at different levels • Service Delivery • Clinical Guidelines • Communication • Leadership and partnerships • HR, Financing, Costing, Supplies, etc etc etc

  15. South Africa Estimates of VMMC • 130,000 VMMC in South Africa by end of 2010 (UNAIDS) • To date: Catey and Carlos? • Successes and Weaknesses of VMMC programme

  16. Summary and Conclusions • Issues of potential relevance to Oral PrEP/ Vaginal Microbicides • Political Leadership • Role of civil society • Costs of intervention/ opportunity costs • Degree of integration with other RH activities and HIV prevention efforts • related impact on capacity of service delivery • Training and human resources • Supply/ commodity demands • Marketing and communications • Counseling needs, issue of partial efficacy • Need for ongoing monitoring and evaluation

  17. And finally • What have we learned from implementation of other (non HIV-related) interventions that could be useful?

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