HCT Campaign and ARV Expansion programme

1. HCT Campaign and ARV Expansion programme Business sectors leaders 29 March 2010

2. Goals • Implement the new treatment guidelines and Presidential mandates • Train health workers on the new guidelines and policies • Implement the HCT campaign strategy • Expand availability of ART sites, decentralize to PHC, implement nurse initiated ART • Plan for scale up of services, increase drug, commodities, labs and HR

3. Strategy • Implement the business plans, monitor patient uptake, monitor drugs stock levels, support nurse initiated services • Provide support to new sites, use out reach treatment initiating teams, team up with partners and local practitioners • Mobilize civil society, work with provincial, district and local AIDS council • Monitor and track progress, capture data, communicate problems, challenges to the Nerve center for rapid responses

4. Patient profile • 84% of public sector patients are on d4T, 3TC, EFV • 8% of patients are d4T, 3TC, NVP • 2% of patients are d4T, 3TC, LPV/r • 2/3 of patient are women • 11 % are pregnant women

5. Patient profile • Mean age of patient is 35,4 years for women and 38,7 years for men • 1/3 of patient present with cd4 cell count below of less than 50 cells • Most patient present with advance disease with cd4 cell count of 87 cells • 20% of patients are under nourished

6. Adherence • undiagnosed and untreated depression • Active substance abuse • Poor counseling leading to lack of insights • Failure to disclose HIV status close family • Adolescents and young adults • Lack of support from support groups and DOTs • Co morbidities, pill burden, unmanaged drug toxicity and stigma

7. High risk of mortality • Men presented at old age, advance diseases, lower cd4 cell count and compare to non pregnant women • Non pregnant women presented with more advance diseases than pregnant women • 39% of death occurred in the first six months • Risk of death was almost five times higher in among patient with cd4 < 50 cells compared to cd4 > 200 cells

8. Challenges • Over a third of the patients present with advanced disease with median cd4 count of less than 87 cells count • Rapid expansion of the ART services needing a change in the service platform • High rate of single drug substitution • High death rate at the first six months compared to deaths at 1 year • More than half of patient at ART initiation are employed, need nutritional support

9. Presidential Mandates • Urgent cases in needs, patients with cd4 less than 200 • Pregnant women who are HIV positive with cd4 equal and less than 350 start HAAR at 14 weeks • TB/HIV co infection with cd4 equal and less than 350 • Infants exposed to HIV pregnant women do PCR if positive start treatment at once • Infants that are breast feeding to have NVP syrup for the duration of breast feeding

10. Impact of Policy shift

11. Nerve Center • Establish provincial Nerve center to coordinate, monitor, direct and problems solve the HCT Campaign and Expansion of ART • Provincial nerve center must provide daily update on the issues, challenges and progress to National Nerve Center • All Hospital to establish local nerve center to monitor, validate and support health facility readiness and new site establishment • Provincial AIDS council, civil society, local sectors of SANAC must participate, provide leadership and strategic direction on the social mobilization

12. New Patients • All new patients must be put on the new regimes from 1 April, TDF, 3TC and EFV based on the national guidelines • Nationally we have limited stock of Tenofovir/emtricitabine, abacavir, NVP syrup, provinces are asked to put their orders early for the first three months • Truvada (TDF/emtricitabine) single dose replace NVP for women exposed to sdNVP • TB/HIV patients, pregnant women and children must be strictly managed according to new guidelines

13. Drug availability • National policy is that all patients that are eligible for ARV are put on treatment based on the new guidelines • Patients who are stable on the old regime of d4T, FTC, EFV/NVP must be maintain on the same treatment • The switch from d4T is based on clinical judgment and is related to adverse events • Mono therapy switching for D4T for TDF must be kept within the national norms of less than 10% on establish patients

14. Prevention Programme • Implement mix of package of effective intervention strategy to reduce new infections • Implement and rapidly expand medical male circumcision • Increase substantial the availability and distribution of male and female condoms • Implement the biomedical prevention strategies include PEP and microbicide • Attain high ART coverage to achieve secondary prevention • Eliminate or reduce to less than 5% MTCT and transmission through breast milk

15. Enhanced Prevention Strategy Differential Communication for target groups and social mobilization ( Leadership of SANAC) Scale up of condom distribution and access Implement Medical Male Circumcision Increased access to syndromic management of STI Monitoring and evaluation and tracking of epidemic Population based study to access cost effectiveness

16. Screening and early detection of PHLWV HCT screening linked to care , provider initiated at public health facilities Screening for TB linked to IPT, scaling up TST implementation Screening for HIV in all pregnant women for early detection and access to care in ANC services l Screening for STI, and linked care Expand to access to access ANC to modern contraceptive service

17. Early Access to Treatment • Set optimal patient eligibility criteria to achieve improved clinical interventions and reduce progression of disease to stage3, 4 and death • Select cost effectiveness ART drug combinations to improve clinical outcome, reduce toxicity and pill burden • Set optimal criteria for judicious use of laboratory services to improve patient care, quality of care and toxicity monitoring • Set policy guideline for optimal human resources generation, task shifting and right mix, numbers and distribution

18. Early Access to Treatment • Set guidelines for appropriate service delivery platform that is fit for purpose for prevention, screening, treatment, care and support and mitigation of impact • Provide supportive supervision to provinces to strengthen the institutional capacity, strategy planning and management to support PHC service delivery • Achieving synergies between communicable disease program and health system strengthening • Strengthening leadership role of the health sector supply side to support multsectoral response, to priority district based on their epidemiological profile and disease burden

19. Social Mobilization Avert early death due to AIDS related diseases Mitigate impact of HIV and AIDS to targeted groups Mobilize and support AIDS competent communities Provide integrated services for affected and infected individuals, communities Mobilize community against stigma, gender violence and discrimination

20. ART Programme NEED Results Base 2011

21. Antenatal prevalence 33% • Reduced from 30% to 20% PMTCT • 50% sdNVP 21% • 50% sdNVP + 50% ZDV+sdNVP 35% 42% • 100% ZDV+sdNVP Infant feeding 33% • 100% BF for only 6 mths • 50% FF and 50% 6m BF 39% Reduce MTCT to below 5% Newell ML. IAS 2005. Abstract WePl102.

22. TB/HIV Control Courtesy of R. Chaisson.

23. Prophylaxis • All patients who are HIV positive must be assessed for active TB if not must be put on INH prophylaxis • All patients who HIV positive with cd4 less than 200 including children must be put on cotrim • All patients who are exposed to HIV infection must assessed and provided with PEP at once • All children exposed to HIV in pregnancy or whose status is unknown must be provide with NVP until their status is know

24. Clinical outcomes • Reduce mortality especially in the first six months • Reduce loss to follow up • Improve cd4 cell count gains • Increase and maintain viral suppression • Achieve long term durability of the first line regimes

25. Patient Retention

26. Information and SPHC • The need for specific epidemiological information to identify those conditions causing the most severe public health problems • The data is used to indicate priorities, determine unit costs of interventions and cost effectiveness basis for decision making • Priorities cannot be read off the results or based only on technical considerations 'priority setting involves political judgment • Over emphasizing the immediate and spectacular may draw attention away from the other necessary conditions required for the successful reduction of ill health

27. Remolding health information System • We need a system to provide data necessary for monitoring intersectoral action of health and for feedback • We need a set of simple cross sectoral analytical tabulation to link health to more important determinants of heath from other sectors

28. Inadequacy o f health information systems • Overload imposed on health workers by demand for over sophisticated information systems • Over centralization of information system • failure to analyst the available information adequately or use for planning or feedback • The aggregation of data at higher level which masks inequalities on which action Should be taken • The failure to build bridges to otter sectors • The failure to analyze information or to use Information for planning process

29. Weaknesses of information Systems • Breakdown in the key processes required to produce useful automation • the unresolved tension between the demand for uniform data and the requirement to have automaton at local level that is relevant and specific to the needs and resource availability • Information used to check on achievements four above • Targets that are unrealistic or irrelevant • Targets set for outputs of health services give no indication by themselves of the extent to which interventions have achieved the desired impact • Community health coulee can be used to monitor the extent to which heeds that have been (developed are met I tastes accepted Are achieved, resource promised made available

30. Achieve Scaling Up • Advocacy and social mobilization • Decentralization & integration using the district approach • Integration of procurement & monitoring & evaluation into existing health system • Partner public/private sectors • Multisectorial coordination mechanism • National and international leadership and support Tsague L, et al. IAS 2005. Abstract TuOa0302.