Overview of lessons learned from previous
biomedical HIV prevention interventions in
South Africa
Presented by:
Elizabeth T. Montgomery, Ph.D
February 7,2012
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RTI International is a trade name of Research Triangle Institute
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
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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
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PMTCT Timeline continued
•
SAG published new PMTCT guidelines in 2008 to
include provision of dual therapy
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•
2008 PEPFAR estimates of ARV coverage for HIV+
pregnant women in South Africa just under 60%
2010 Updated Guidelines published
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PMTCT Programme Intervention
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PMTCT Analysis – one perspective
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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
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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
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
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PMTCT Programme results
• 9610 enrolled infant-caregiver pairs, 2888 (30%) HIVexposed 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 0.20.8) were protective factors.
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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
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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
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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.
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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
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Management at different levels
Service Delivery
Clinical Guidelines
Communication
Leadership and partnerships
HR, Financing, Costing, Supplies, etc etc etc
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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
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Summary and Conclusions
• Issues of potential relevance to Oral PrEP/ Vaginal
Microbicides
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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
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And finally
• What have we
learned from
implementation of
other (non HIVrelated)
interventions that
could be useful?
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