OPERATIONAL AND PROGRAMMATIC
CONSIDERATIONS
IN SCALING UP ART
Dr. Yogan Pillay
Deputy Director General
National Department of Health, South Africa
Monday 1 July 2013

2
Major progress in scaling up ART
15 million on ART by 2015 within reach

3
Elimination of MTCT (UNAIDS)

Some South African Data
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 6.4 million people living with HIV and AIDS
 HIV associated with
 50% of maternal mortality
 55% of under 5 mortality
 HIV Prevalence: 30% amongst pregnant women
 2.1 million on ART
 ART Coverage:
80% of women, 65% of children and men
 MTCT: 8% in 2009
2.7% in 2011
All this in a relatively weak health system

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MTCT rate at 6 weeks in South Africa
Thousands

Total annual AIDS deaths
EPP Classic
2011
270 000
Spline
2011
316390
2012
221770

7
Rising life expectancy associated with
ART scale up
Bor et al, Science 2013

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But considerable operational challenges

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Too few take a test and get their result
8% - 69% 13% - 76%
Staveteig et al, DHS Comparative Reports, 2013

Retention is a challenge as programmes expand
15-30% drop out of care at each step from testing to ART
50% lost to care
After 5 years
Mugglin et al, Trop Med Int Health, 2013
Western Cape Provincial Dept. of Health,
South Africa, 2013

Key WHO
Operational Recommendations
• Expanded testing scenarios
• Task shifting and decentralization
• Service integration
• Adherence support
Kuala Lumpur, Malaysia , 30 June - 3 July 2013

Expanded testing in South Africa
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


2009
 VCT rates 2m testing per year in health facilities
April 2010


National HIV Counselling and Testing Campaign led by the
President



Stigma reduction
Know your status
HIV, TB, other chronic diseases screening
20 million tested in 20 months
 1/3 men!
2011/12
 Return to PICT: 9m tested in HCT


Campaign to be reactivated with MMC in August
Target every SA to test annually

Task shifting
WHO 2013 Recommendations:
• Trained non-physician clinicians, midwives and nurses can initiate and maintain ART
•
Trained and supervised community health workers can dispense ART
13
Sanne et al, Lancet 2010; Fairall et al, Lancet 2012

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Task shifting in South Africa
 Nurse initiation of ART (2009)
 23 000 nurses trained in initiation of FDCs
 Prescribing and dispensing
 Lay counselors trained to conduct counseling and testing (rapid tests) – 2010
 Ward based outreach teams trained in HIV, TB and
MCH
 10 000 reoriented during 2011/12

Decentralization and integration
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Kerstenberger et al, PlosOne, 2013

Adherence support
WHO 2013 Recommendations:
• Minimizing out of pocket payments
• Use of fixed-dose combinations
• Strengthening drug supply
• Patient counselling and education
• Mobile phone text messages
16
Wilkinson, SAJHIV Med, 2013 Lester et al, Lancet 2010

Examples of integration
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 60% co-infection rate (HIV and TB)
 50% of deaths in pregnant women and children associated with HIV
 Need for integration is obvious
 Since 2010 all PHC facilities that provide TB, sexual & reproductive, ANC and child health services, including school health services, also targeted for HIV services
 Currently most public health facilities and over 3500 of 4200 public health facilities offer ART
 Many challenges to integration still exist, including infection control!

HIV and TB – school health programme
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A record 10 million PLHIV now have access to antiretroviral treatment, June 2013, UNAIDS Press Release
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 “ Significant successes in reducing costs have been achieved in recent years. For example the price of medicines to prevent mother to child transmission of HIV was reduced from US$ 800 in 2011 to below US$ 100 in
2013.
 Through a more competitive bidding process, South
Africa has reduced the cost of procurement of antiretrovirals to the lowest price anywhere in the world at US$ 127 per person per year for the fixed dose combination recommended in the new guidelines.
 This has resulted in a 53% reduction in expenditure on antiretroviral treatment for South Africa”.

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Conclusions
 Guidelines by the WHO are based on the best possible evidence
 Some operational research evidence is available
BUT there are many gaps – need more operational research/implementation science
 Expertise to model resources required to implement new guidelines exists but need data for modeling
 Each country should carefully assess what is needed to implement new treatment guidelines

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Acknowledgements
 WHO working group on operational guidelines
 Health Economics and Epidemiology Research
Organisation (HERO)

“Modelling Group” Country Team