Prevention of new infections by
reducing Viral transmission –VL monitoring in ART
cohorts
19/11/15
AWACC
Towards the 90/90/90 goals of the National programme for HIV/TB
services
DOH-CAPRISA –UKZN- NHLS PROJECT
Dr. Henry Sunpath
Ethekwini District DOH
Antiretroviral Therapy Program
• To date (June 2014), a total of 949 339 patients are receiving Antiretroviral Therapy
(ART) from 618 facilities in the province- (now I miI on ART)
• Of the 618 facilities, 545 are Primary Health Care (PHC) facilities and services are
mainly Nurse driven
• Since 2010, close to 3 000 Nurses that have been trained on Nurse Initiated and
Managed Antiretroviral Therapy (NIMART)
• Since the roll out of Fixed Dose Combination Drugs (FDCs),
408 495 patients initiated or switched
• FDC: a single pill containing three drugs replacing three single ARV medicines
• FDCs aim to reduce the pill burden
and improve adherence for ART patients
including TB/HIV co-infected patients
2
TB & HIV Burden
• HIV burden
•
•
•
•
People living with HIV = 6,4 million
Prevalence [15 – 49 yrs] = 19.1%
Incidence [15 – 49 yrs] = 1.36%
AIDS related Deaths = 200,000
• TB burden
•
•
•
•
People infected with TB = 360,000
Incidence = 860/100,000 population
Prevalence = 715/100,000 population
Statistician General reported that, TB is the Number ONE
leading cause of death among South Africans (8.8%)
3
Ageing faster with AIDS in Resourceconstrained settings
…the proportion of elderly people in Africa
infected with HIV/AIDS is increasing.
This increase brings both good and bad news:
good news because increased access to treatments means
that patients are living with longer life expectancy;
bad news because meeting the complexities of geriatric care for
HIV-infected adults will further challenge overwhelmed health systems
Edward J Mills, Anu Rammohan, Niyi Awofeso; Lancet 2010
How many HIV tests were done in KZN over
one year
• 1. 2.5 MILLION
• 2. 1. 8 MILLION
• 3. 4.5 MILLION
• 4. 1.2 MILLION
Dashboard: Number of HIV tests conducted 2014/2015 per quarter (by district & province)
Q1
(Apr-June 2014)
Q2
(July –
Sept.2014)
Q3
(Oct- Dec 2014)
Q4
(Jan - March
2015)
Total tested
2014/ 2015
HIV testing
Target
2014/15
Amajuba
33598
36414
35761
37559
143332
125141
EThekwini
169956
197018
221965
255792
844731
890662
Harry Gwala
32440
35417
21902
33943
156142
116645
iLembe
34982
40024
28420
30448
133874
151346
Ugu
47184
55824
47977
54553
205538
181416
uMgungundlovu
47618
68337
62751
82060
260766
261459
uMkhanyakude
39826
39348
34061
16775
130010
148330
uMzinyathi
44767
51075
50612
44074
190528
115231
uThukela
37993
34970
31528
32754
137245
164023
uThungulu
55952
69018
59099
54100
184069
232733
Zululand
40661
44679
52214
137554
197444
584977
672124
646290
2577889
2584430
PROVINCE
642058
Achieved
Target
6
Graphical: % of positive cases 2014/2015 per quarter (by district)
20.00%
18.00%
16.00%
14.00%
12.00%
10.00%
8.00%
6.00%
4.00%
2.00%
0.00%
Q1 (April - June 2014) % tested HIV +ve
Q2 (July - Sept. 2014) % tested HIV +ve
Q3 (Oct - Dec 2014) % tested HIV +ve
Q4 (Jan - March 2015) % tested HIV +ve
7
How many patients on average are started on
ART per quarter in KZN • 1. 7500
• 2.25 000
• 3. 15 000
• 4. 10 000
Dashboard: Total number of clients receiving ART per quarter(District and Province)
Q1
(Apr-June 2014)
Q2
(July - Sept 2014)
Q3
(Oct - Dec 2014)
Q4
(Jan - March 2015)
Amajuba
35804
38176
38901
41272
EThekwini
299877
289729
297530
309119
Harry Gwala
37121
38307
39423
41540
iLembe
48955
45221
47908
51406
Ugu
66657
65382
67132
67432
uMgungundlovu
99546
111691
113777
122135
uMkhanyakude
58909
59746
62355
36472
uMzinyathi
37320
41063
42423
44194
uThukela
47357
49026
51829
51829
uThungulu
90185
87102
89508
Zululand
59024
66912
68916
PROVINCE
880755
892355
919703
765399
9
Graphical: Total number of clients receiving ART
350000
300000
250000
200000
150000
100000
50000
0
Q1FY2014/2015(April - June 2014)
Q2FY2014/2015 July - Sept. 2014)
Q3FY2014/2015 (Oct. - Dec. 2014)
Q4FY2014/2015 (Jan. - March. 2015)
10
Dashboard: Number of ART clients lost to follow up
5 districts: Amajuba, eThekwini, Ugu, uMgungundlovu, uMzinyathi recorded increases in numbers lost to follow up between
2014/2015.
Q1fy2014/2015
Q2FY2014/2015
Q3FY2014/2015
Q42014/2015
TOTAL
(Apr-June 2014) (July – Sept. 2014) (Oct. - Dec.2014)
(Jan. – March
2014/2015
2015)
Amajuba
176
181
114
314
eThekwini
4766
3966
3992
4252
614
718
552
269
1627
1432
1127
767
Ugu
306
379
458
744
uMgungundlovu
452
367
279
318
uMkhanyakude
753
859
363
uMzinyathi
483
399
2470
3508
Harry Gwala
iLembe
uThukela
16976
2153
4953
1887
1 416
1 975
453
3662
uThungulu
839
Zululand
990
821
898
13476
15864
12595
PROVINCE
785
1 407
3662
13302
582
1421
2709
11142
53077
11
Fast Track 90 90 90
Global 90-90-90 HIV Targets
UNAIDS 90-90-90 targets for 2020 are summarized below:
• 90% of all people living with HIV will know their HIV status
• 90% of people with diagnosed HIV infection will receive sustained ART
• 90% of all people receiving ART will have viral suppression
What does 90 90 90 for HIV mean for
South Africa
6.4 million
PLHIV
90%
of PLHIV know
their status
90% x 6.4m =
5.7m
90%
of people with
diagnosed HIV
infection will receive
sustained ART
90%
of all people
receiving ART will
have viral
suppression
90% of 5.7m
(UTT)
CD<500 eligible for
ART:
80% x 5.7m =
4.6m x 90% = 4.1m
90% x 4.1m =
3.7m
HIV Treatment Cascade
SA 2012 vs 90-90-90
90-90-90 for HIV
7,000,000
• 5.7 million People living with
HIV knowing their HIV status
6,420,000
5,778,000
6,000,000
• 4.1 million People who know
their status who are eligible
are on treatment
• 3.7 million People on
treatment with suppressed
viral loads
Reduce the annual number of
new HIV infections by 150,000
5,000,000
4,237,859
4,160,160
4,000,000
3,744,144
3,000,000
2,185,000
2,000,000
1,600,000
1,000,000
People Living with HIV
PLHIV who know their
status
SA at 2012
On antiretroviral
treatment
90-90-90
Virally suppressed
90-90-90 TB Targets
• 90% of vulnerable groups/key populations screened for TB
 PHC headcount; Inmates in correctional service facilities; Miners;
People living in informal settlements/peri-mining communities
o screen contacts of index cases
• 90% of people with TB diagnosed & treated
• 90% treatment success
90%
90%
90%
of vulnerable people
screened for TB
of People with TB
diagnosed and
treated
TB treatment
success rate
90 90 90 Tracer Indicators
Phase 2- FY 2016/17
90 90 90 tracer indicators
specified health indicator chosen to represent a broader
programme area
measures key element of programme
90 90 90 strategy tracer indicator programme areas:
• HIV
• TB
• PMTCT
• PAEDS
Programme area- TB (1)
Old Ref New Ref
TB-1
TB-2
TB-1
TB-2
TB-3
TB-3
TB-4
TB-4
TB-5
TB-5
TB-6
TB-7
TB-8
Indicator Name
TB sputum 5 years and older test rate
TB symptom 5 years and older screened rate
TB/HIV co-infected client on ART rate
TB client 5 years and older initiated on
treatment rate
TB client lost to follow up rate
Initial LTFU rate
MDR treatment success rate
XDR treatment success rate
Programme area- PMTCT (1)
Old Ref
New Ref
PMTCT-2
PMTCT-1
PMTCT-3
PMTCT-4
PMTCT-5
PMTCT-6
PMTCT-1
PMTCT-2
PMTCT-3
PMTCT-4
PMTCT-5
PMTCT-6
Indicator Name
Antenatal 1st visit before 20 weeks rate
Antenatal client HIV re-test rate
Antenatal client start on ART rate
Mother postnatal visit within 6 days rate
Infant 1st PCR test positive around 6 weeks rate
Child rapid HIV test around 18 months uptake rate
Child rapid HIV test around 18 months positive
PMTCT-7
rate
Programme area- PAEDS (1)
Old Ref
New Ref
Indicator Name
Paeds-1
Paeds-1
HIV test positive child 19-59 months
Paeds-2
Paeds-2
HIV test positive child 5-14 years
Paeds-3
Paeds-3
Child under 1 year naïve started ART
Paeds-4
Paeds-4
Child 12-59 months naïve started ART
Paeds-5
Paeds-5
Child 5-14 years naïve started ART
Paeds-6
Paeds-6
Child under 15 years remaining on ART - total
Programme area- HIV (1)
Old Ref
New Ref
Indicator Name
HIV-1
HIV test client 15 years and older (incl ANC)
HIV-1
HIV-2
HIV test positive client 15 years and older (incl ANC)
HIV-2
HIV-3
HIV-3
HIV-4
Male condom distribution coverage
Medical male circumcision performed
HIV-4
HIV-5
Adult started on ART during this month - naïve
HIV-5
HIV-6
Adult remaining on ART – total
HIV-6
HIV-7
Adult lost to follow up (LTF) rate at 12 months
HIV-7
HIV-8
HIV-8
HIV-9
HIV-10
Adult with Viral load completion (VLD) rate at 12
months
Adult with Viral load suppressed (VLS) rate at 12
months
Number enrolled in Pre-ART
Programme area- HIV (1)
INDICATOR
Medical male circumcision performed (HIV - 4)
Adult lost to follow up (LTF) rate (HIV - 7) (12 months)
Adult with Viral load completion (VLD) rate (HIV -8)
Adult with Viral load completion (VLD) rate (HIV -8)
Definition:
• Proportion of adults in the 12 month cohort, still on treatment
who had Viral load test done in the last year
Numerator:
• Adult viral load done (VLD) at 12 months
Denominator:
• Adult first line regimen + Adult second line regimen at intervals
in 12 month cohort
2016/17 Target (Proposed):
• 95% VLD rate at 12 months
Which of these statements is false.
An undectectable viral load will –
• 1.Halt disease progression
• 2.Reduce incidence of Ois
• 3.Promote immunological recovery
• 4.Prevent drug resistance
• 5.Eradicate the virus
Goal of HAART
Durable Viral Suppression
Undetectable Levels
Halt disease
progression
Reduce OIs
Immunological
recovery
Prevent drug
resistance
Reduce viral
transmission
Ideal vs. poor engagement in HIV care
Adherence monitoring:
Use the viral load.
• WHO recommends VL monitoring with other
adherence measures.
• Raised viral load indicates a risk of failure, so DO
something.
• 56-68% can re-suppress with an adherence
intervention.
Long-term 2nd-line outcomes
Proportion with VL <50 c/mL
Murphy-Sunpath
Virologic outcome according to adherence level over time
Categories of HIV Viral Load per District
ZULULAND
in KZN
DISTRICT
UTHUNGULU
UTHUKELA
UMZINYATHI
UMKHANYAKUDE
UMGUNGUNDLOVU
UGU
SISONKE
ILEMBE
ETHEKWINI
AMAJUBA
0
50000
100000
150000
200000
HIV VIRAL41LOAD
CATEGORY
to 1000
>1000
Undetectable
250000
300000
Categories of HIV Viral Load Total in KZN
18.30%
18.05%
63.65%
HIV Viral Load Category Undetectable %
HIV Viral Load Category 41 to 1000 %
HIV Viral Load Category >1000 %
Categories of HIV VL Total in Ethekwini
District
44996
47852
190892
Viral Load Category Undetectable n
Viral Load Category 41 to 1000 n
Viral Load Category >1000 n
How many adult patients on ART have a
viral load at 6 months in KZN
• 1.19.3%
• 2. 25 %
• 3. 30%
Adult with Viral load suppressed rate at
6 months
Target
FY 2014/15
FY 2011/12
FY 2012/13
Amajuba District Municipality
96.5
92.5
94.5
94.1
1,108
eThekwini Metropolitan Municipality
96.5
90.2
92.9
92.8
4,535
Harry Gwala District Municipality
96.5
74.4
78.9
83.5
1,577
iLembe District Municipality
96.5
90.3
91.7
0.0
0
Ugu District Municipality
96.5
92.1
93.2
91.3
3,941
uMgungundlovu District Municipality
96.5
80.2
80.9
84.5
915
Umkhanyakude District Municipality
96.5
92.5
90.5
91.3
1,884
Umzinyathi District Municipality
96.5
82.7
94.5
92.9
369
Uthukela District Municipality
96.5
87.6
89.7
93.1
1,676
Uthungulu District Municipality
96.5
67.5
78.2
83.9
4,250
Zululand District Municipality
96.5
83.3
87.1
92.6
718
KwaZulu-Natal
96.5
84.9
87.7
89.4
20,973
District
FY 2013/14 Progress Q3
VLS at 6m
FY 2013/14
Adult with Viral load completion rate at
6 months
NDoH Target
FY 2014/15
FY 2011/12
FY 2012/13
Amajuba District Municipality
80
54.0
47.9
48.4
11,678
eThekwini Metropolitan Municipality
80
64.6
64.4
67.4
4,872
Harry Gwala District Municipality
80
65.1
55.3
44.1
1,148
iLembe District Municipality
80
50.2
44.0
42.6
23,041
Ugu District Municipality
80
38.6
36.2
32.4
1,178
uMgungundlovu District Municipality
80
26.5
30.6
29.6
4,888
Umkhanyakude District Municipality
80
41.4
39.4
35.4
1,888
Umzinyathi District Municipality
80
33.0
43.8
0.0
0
Uthukela District Municipality
80
37.7
42.9
53.4
4,318
Uthungulu District Municipality
80
38.6
35.2
28.4
1,083
Zululand District Municipality
80
43.4
37.6
32.0
2,064
KwaZulu-Natal
80
17.4
15.4
19.3
397
District
FY 2013/14 Progress Q3
VLD at 6m
FY 2013/14
How many children have undectectable VL in
KZN
• 1. 60 %
• 2.70 %
• 3.80%
• 4. 90 %
Child under 15 years with Viral load
suppressed rate at 6 months
Target
FY 2014/15
FY 2011/12
FY 2012/13
FY 2013/14
Amajuba District Municipality
80.5
90.5
100.0
85.7
12
eThekwini Metropolitan Municipality
80.5
65.4
76.3
72.7
165
Harry Gwala District Municipality
80.5
60.7
62.1
67.1
51
iLembe District Municipality
80.5
81.8
80.0
0.0
0
Ugu District Municipality
80.5
71.3
81.1
75.8
122
uMgungundlovu District Municipality
80.5
60.3
71.1
71.7
33
Umkhanyakude District Municipality
80.5
76.4
78.6
64.0
87
Umzinyathi District Municipality
80.5
100.0
91.7
77.8
7
Uthukela District Municipality
80.5
72.4
78.2
76.2
48
Uthungulu District Municipality
80.5
41.7
51.2
62.8
71
Zululand District Municipality
80.5
70.0
81.5
91.7
22
KwaZulu-Natal
80.5
68.1
73.2
71.1
618
District
Progress Q3
VLS at 6m
FY 2013/14
Child under 15 years with Viral load
completion rate at 6 months
NDoH Target
FY 2014/15
FY 2011/12
FY 2012/13
FY 2013/14
Amajuba District Municipality
80
31.3
29.2
23.7
14
eThekwini Metropolitan Municipality
80
20.9
32.8
30.5
227
Harry Gwala District Municipality
80
29.2
29.2
26.7
76
iLembe District Municipality
80
36.7
16.7
0.0
0
Ugu District Municipality
80
43.9
39.6
52.6
161
uMgungundlovu District Municipality
80
36.0
35.5
26.6
46
Umkhanyakude District Municipality
80
32.0
29.2
37.0
136
Umzinyathi District Municipality
80
16.7
26.1
10.5
9
Uthukela District Municipality
80
31.1
25.3
17.1
63
Uthungulu District Municipality
80
32.3
46.5
58.9
113
Zululand District Municipality
80
31.0
21.1
21.6
24
KwaZulu-Natal
80
30.0
32.0
32.3
869
District
Progress Q3
VLD at 6m
FY 2013/14
VL July Group 3
17%
1200
1000
189
VL
9%
800
16%
600
111
71
53
159
200
11%
20%
498
685
36
34
56
30
36%
23%
0%
0
1
0%
332
34
18
97
75
17
119
0
15%
> 40 <= 1000
>1000
0%
0
HOSPITALS
<= 40
800
511
396
267
92
13%
80
53
26
181
0
14%
99
65
400
121
25%
% > 1000
23%
33
23
61
23
161
183
Definitions of virologic failure - antiretroviral treatment guidelines1
• Virologic suppression:
• A confirmed HIV RNA level below the limit of assay detection (e.g., <48
copies/mL).
• Virologic failure: (lab report for close follow up)
• The inability to achieve or maintain suppression of viral replication (to an
HIV RNA level <400copies/mL).
• Virologic failure (clinical guide for change of regimen)
-The inability to achieve or maintain viral suppression (to an HIVRNA level <1000
copies/ml )
• Incomplete virologic response:
• Two consecutive plasma HIV RNA levels >400 copies/mL after 24 weeks on
an ARV regimen.
• Virologic rebound:
• Confirmed detectable HIV RNA (to >400 copies/mL) after virologic
suppression.
• Persistent low-level viremia:
• Confirmed detectable HIV RNA levels that are <1,000 copies/mL.
• Virologic blip:
• After virologic suppression, an isolated detectable HIV RNA level that is
followed by a return to virologic suppression.
DHHS Antiretroviral Treatment Guidelines, January 10, 2011 Available at:
http://aidsinfo.nih.gov/guidelines. -adapted
DRK/Canberra/26.9.11
When should you check a viral load?
SA Dept. Health
SA HIV Clin. Soc.
DHHS (USA)
At initiation
✗
✓
✓
Before 6 months
✗
3 months
At 2-8 weeks, then every 4-8 weeks
until suppressed
6 months
✓
✓
✓
12 months
✓
✓
✓
Thereafter
Every 12 months
Every 6-12 months
Every 3-6 months
Why check viral loads before 6 months?
•
•
Enables early detection of virological failure (usually due to poor adherence), before
resistance develops, or worsens.
At 3 months, most patients will be virally suppressed, but a small group of people who
started with a very high viral load may still have detectable viraemia… although they’ll
still show at least a 2 log10 drop from their initiation viral loads.
What should you do if you find
a high viral load?
SA National Department of Health
• < 400: no specific action
• 400-1000: adherence counselling & repeat VL 6 monthly
• > 1000: adherence counselling, repeat VL 2-3 months
• If repeat < 1000, repeat VL in 6 months
• If repeat > 1000, switch therapy
SA HIV Clinicians Society
• > 50: adherence counselling & repeat VL in 2-3 months
• > 1000 on 2 occasions 2-3 months apart: switch therapy
• > 200 for more than 1 year: switch therapy
Programme area- HIV (1)
INDICATOR
Medical male circumcision performed (HIV - 4)
Adult lost to follow up (LTF) rate (HIV - 7) (12 months)
Adult with Viral load completion (VLD) rate (HIV -8)
Adult with Viral load completion (VLD) rate (HIV -8)
Definition:
• Proportion of adults in the 12 month cohort, still on treatment
who had Viral load test done in the last year
Numerator:
• Adult viral load done (VLD) at 12 months
Denominator:
• Adult first line regimen + Adult second line regimen at intervals
in 12 month cohort
2016/17 Target (Proposed):
• 95% VLD rate at 12 months
Bottleneck Analysis
1. Know your
indicator, track your
response,
accountability
2. Target setting and
targeting
3. Data management
4. Communication
(ACSM, demand
creation strategy)
5. Get the basics right
then innovate
6. Infrastructure,
medicines, PSCM,
equipment
7. Human resources
8. Service delivery
platforms defined
and linkages with
communities
9. Connecting the
dots (linkage to care,
integration)
10. Cascades and
11. Referrals and
pathways (continuum transport (mapped,
of care)
available and skilled)
12. Inter-sectoral
coordination (social
development, private
sector, schools)
KZN VL monitoring
ENSURE THAT VL IS DONE ON TIME
USE OF VL REGISTERS MONTHLY TO ASSESS 6 AND 12 MONTHLY VL COMPLETION RATES
PATIENT EDUCATION AT INITIATION AND EACH FOLLOW UP VISIT
USE REMINDERS USING APPOINTMENT CARDS , COMMUNITY WORKERS ,ADHERENCE CLUBS ,
GRADUAL IMPLEMENTATION OF ICSM MODEL AT ALL PHCs
ENSURE THAT TEST IS DONE LAB AND RESULTS AVAILABLE
ENSURE THAT RESULTS ARE RECEIVED AND FOLLOWED UP IN THE CLINIC
DATA ELEMENTS- WITH VL REGISTER
• HOW MANY PER MONTH HAD THEIR 6 MONTHS VL DONE ?
• HOW MAY DID NOT HAVE THE VL DONE ?
• WHAT HAPPENED TO THE RESULTS?
LATER MONITOR 12 MONTHLY SO THAT CLINIC SPECEFIC DATA CAN BE
WORKED OUR
IMPORTANT!!!
• How many who had a high VL > 1000 copies/ml had a repeat blood
after 2- 3 months adherence intervention?
• This must also Be reflected in the VL register.
• Could NHLS develop a patient linked Vl data longitudinally???
OTHER QUICK WINS
• GET PHARMACY INVOLVED
• CREATION OF STANDARDISED CLINICAL RECORDS –FACE SHEET FOR
FOLLOW UP
TWG plans
• Report from NHLS – review by District task team
for QI HAST SERVICES –meet monthly on first
Wednesday
• Input into monthly TWG meeting at District office
on Monday
• Quarterly meeting with all HAST clinical managers
and ONM of ART clinics –including NGOs
• Achieve >90 %VC rate at 12 months and >90
suppression rates at 12 months
• What is needed to get more useful data for appropriate follow up?
All our labs have a list of rejection criteria so we are strict about it.
But we will still do the HIV VL even if we have no clinical details
FORM MUST INDICATE
• Whether it is a 6/12,12/12,18/12,24/12 etc test
• Whether px is on Reg 1,Reg 2 or Reg 3
• MRN=MEDICAL RECORD NUMBER – this is a unique number which we put on
every result – this number should be used whenever any lab test is requested so
that when HIV VL are downloaded then
I
ART Program Use of EWI Results
1.
Strengthened record keeping systems
•
•
•
•
•
2.
3.
4.
5.
Formation of clinic specific care optimizing committees1
Validation of existing electronic record keeping systems1, 2,3
Adjustments in pharmacy record keeping to permit on time pill pick up assessments 3
Pilot of enhanced defaulter tracing to identify patients missing drug pick-ups with the
goal of reengaging in care within 48 hours1
General strengthening of records4,5,6,7,8
Seek funding support from partners to scale-up EWI9
District teams to support adherence and trace patients LTFU1,10,11
Scale-up viral load testing5
Regular review of patient pill pick-up and establishment of formal
referral system to document transfers-in/out6
1Hong
et al. JAIDS 2010; 2 Anna Jonas, MoHSS Namibia, personal communication; 3Dawn Pereko, MSH Namibia,
personal communication; 4Jack N et al. CID (in press); 5Ye M et al. CID (in press); 6Daonie e et al. CID (in pres); 7Nhan DT
el al. CID (in press); Hedt BL et al., Anti Viral Ther 2008; 9Paula Mundari, Uganda National ART Programme, IAS 2010,
Vienna; 10Evelyne B, National ART Program, Burundi, personal communication; 11Anna Jonas, MoHSS Namibia,
personal communication.
Acknowledgements
• Desmond Tutu HIV Centre team
• Melanie Thompson and IAPAC guideline team
• Catherine Orrell
• AWACC -2014
• NDOH presentation -2015
90 90 90 Tracer Indicators
Phase 2- FY 2016/17
Harsha Somaroo
PHM MO
Ethekwini District Office
Analysis
District AIDS Councils Response to the HIV& AIDS,STIs & TB Multi-Sectoral Response
Quarter 4 2014/2015
Presentation made at the DAC & LAC Secretariat Meeting
23/07/2015
HIV & AIDS Directorate
Office of the Premier, Province of KwaZulu-Natal