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Achieving epidemic control in South Africa: A PEPFAR Perspective 1
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Page 1: Achieving epidemic control in South Africa · PEPFAR in South Africa: Current Context • Place: PEPFAR SA is currently operating in 100% (52/52) of districts • Time: Decreasing

Achieving epidemic control in South

Africa: A PEPFAR Perspective

1

Page 2: Achieving epidemic control in South Africa · PEPFAR in South Africa: Current Context • Place: PEPFAR SA is currently operating in 100% (52/52) of districts • Time: Decreasing

New HIV Infections & AIDS-related deaths: Fast Track vs. Current Coverage (Eastern & Southern Africa)

Page 3: Achieving epidemic control in South Africa · PEPFAR in South Africa: Current Context • Place: PEPFAR SA is currently operating in 100% (52/52) of districts • Time: Decreasing

New HIV infections Estimated new HIV infections in 2030 in LMIC with achievement of Fast Track Targets compared to continuation of 2013 coverage

Page 4: Achieving epidemic control in South Africa · PEPFAR in South Africa: Current Context • Place: PEPFAR SA is currently operating in 100% (52/52) of districts • Time: Decreasing

35M PLWHA

52M PLWHA

44M PLWHA

79M PLWHA

48M PLWHA

Ending AIDS Scenario: New and Current HIV Infections

$8B in additional

Tx cost/year

$31B in additional Tx

cost/year

Source: UNAIDS 2014 GAP Report

Page 5: Achieving epidemic control in South Africa · PEPFAR in South Africa: Current Context • Place: PEPFAR SA is currently operating in 100% (52/52) of districts • Time: Decreasing

2013 Disability-Adjusted Life Years (DALYs): South Africa

5

Page 6: Achieving epidemic control in South Africa · PEPFAR in South Africa: Current Context • Place: PEPFAR SA is currently operating in 100% (52/52) of districts • Time: Decreasing

Investment Case: The objective was to calculate the cost, impact and cost-

effectiveness of HIV and TB interventions

6  

1

2

3

Baseline  scenario  Keeps  coverage  of  all  interven5ons  constant  at  2014  levels    Government  targets  scenario  Projects  the  epidemic  under  the  current  government  targets  

Op3misa3on  Op5misa5on  rou5ne  scales  up  interven5ons  in  order  of  their  cost  effec8veness  (cost  per  life  year  saved)    

A)  un5l  current  budget  envelope  is  reached  B)  un5l  HIV  90/90/90  targets  are  reached  

Impact  and  cost  is  being  considered  over  20  years  (2015  to  2034),  under  6  scenarios:  

1 Baseline  scenario  Keeps  coverage  of  all  interven5ons  constant  at  2014  levels    

2 TB  90/90/90  Announced  by  Minister  Motsoaledi  at  the  World  Lung  Conference  in  Barcelona,  November  2014    

•  Screen  90%  of  vulnerable  popula5ons  •  Diagnose  and  treat  90%  of  TB  cases  •  Treat  90%  of  cases  successfully    

HIV   TB  

Page 7: Achieving epidemic control in South Africa · PEPFAR in South Africa: Current Context • Place: PEPFAR SA is currently operating in 100% (52/52) of districts • Time: Decreasing

South Africa has passed peak incidence- the choice is how rapidly to further reduce it going forward

NSP:  50%  reduc5on  in  2012  incidence  by  2016  

UNAIDS:  Elimina5on  (=Incidence  <0.1%)  

7  

The  introduc5on  of  ART  has  already  done  much  to  reduce  incidence  

Page 8: Achieving epidemic control in South Africa · PEPFAR in South Africa: Current Context • Place: PEPFAR SA is currently operating in 100% (52/52) of districts • Time: Decreasing

How has Epidemic Control Been Defined for PEPFAR and how does this Relate to UNAIDS 2020 Goals?

•  PEPFAR Defines Epidemic Control as the point at which new HIV infections and AIDS related deaths have decreased and new infections have fallen below the number of AIDS-related deaths

•  Countries are on different paths towards achieving this goal

•  UNAIDS* has set a 90:90:90 target for 2020 to accelerate reaching epidemic control

–  90% of PLHIV know their status –  90% of those that know their status are adherent on ART –  90% of those on ART are virally suppressed

•  Prioritization is critical and PEPFAR programs should coordinate with country programs to focus on the locations and populations with the highest burden of disease

*Published Oct 2014: (http://www.unaids.org/sites/default/files/media_asset/90-90-90_en_0.pdf)

8

Page 9: Achieving epidemic control in South Africa · PEPFAR in South Africa: Current Context • Place: PEPFAR SA is currently operating in 100% (52/52) of districts • Time: Decreasing

So, how is PEPFAR planning to support the implementation & to achieve Epidemic Control in South Africa?

9

Page 10: Achieving epidemic control in South Africa · PEPFAR in South Africa: Current Context • Place: PEPFAR SA is currently operating in 100% (52/52) of districts • Time: Decreasing

Achieving epidemic control will require delivering the

Right Things in the

Right Places at the

Right Time

10

Page 11: Achieving epidemic control in South Africa · PEPFAR in South Africa: Current Context • Place: PEPFAR SA is currently operating in 100% (52/52) of districts • Time: Decreasing

PEPFAR in South Africa: Objectives of Focusing for Impact

Goal: To focus PEPFAR resources so that the program helps South

Africa achieve maximum epidemiologic impact and reach the most people in need of HIV services by 2017 (TIME)

Objectives:

•  Reduce the number of new infections to below the number of AIDS-related deaths

•  Support South Africa’s commitment to the UNAIDS 90-90-90 targets:

•  Contribute to South African Government annual HIV targets •  Improve linkages and planning among prevention,

treatment and OVC programs at the community and facility levels to achieve district level outcomes

11

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PEPFAR in South Africa: Current Context

•  Place: PEPFAR SA is currently operating in 100% (52/52) of districts

•  Time: Decreasing PEPFAR budget as defined by the SAG/USG Partnership Framework Implementation Plan (PFIP)

•  From approximately $500 million in 2012 to $250 million in 2017. •  PEPFAR funding represents about 15-20% of the resources used

for the national response •  Things:

•  Currently supporting a wide range of prevention, care, treatment, health system strengthening areas

•  Transition from direct service delivery to technical assistance for clinical care and treatment services has been underway for years

•  E.g. From >3,000 (2012)->189 seconded staff (June 2015)

12

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1.  Intense  reliance  on  applying  the  best-­‐available  data  in  a  ra5onale  way  to  achieve  90-­‐90-­‐90  in  select  geographic  loca5ons  

2.  COP  Development:  burden  based  on  PLHIV  a)  Geographic  &  Site  Priori5za5on  

i.  Scale  up,  Long-­‐Term  Transi5on,  Short-­‐Term  Transi5on  ii.  Site  Selec5on  

3.  Does  it  Make  Sense?  a)  Affordable  b)  Cost  Realignment  c)  Achievable  

PEPFAR  2015  Country  Opera3onal  Plan  (COP)  Development  

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Es3mated  PLHIV  by  District  (2014)  

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•  Iden5fied  and  ranked-­‐ordered  district-­‐specific  PLHIV  burden  –  ~80%  of  PLHIV  burden  is  in  27  districts  

•  Costs  for  ART  coverage  calculated    –  Per  pa5ent  budget  analysis  (ART  &  HTC)  based  on  PEPFAR  unit  

expenditure  (UE),  partner  survey  (ART),  enhanced  ac5vi5es  –  80%  of  ART  need  matched  COP15  (and  expected  COP16)  budget  envelope  

and  was  represented  in  27  districts  based  on  HIV  burden  (i.e.  90  90  90/district);  9  addi5onal  districts  included  for  5me-­‐  and  program  limited  support  [LONG-­‐TERM  TRANSITION]  

–  District-­‐specific  HTC  targets  es5mated  based  on  CARE_New  target/district  posi5vity  

Current  Geographic  Priori3za3on  District  &  Site  ranking  by  PLHIV  (1/2)  

 

Page 16: Achieving epidemic control in South Africa · PEPFAR in South Africa: Current Context • Place: PEPFAR SA is currently operating in 100% (52/52) of districts • Time: Decreasing

PLHIV  &  Treatment  Coverage*:    Scale-­‐up,  Long-­‐,  and  Short-­‐term  Transi5on  Districts    

0,0%  

10,0%  

20,0%  

30,0%  

40,0%  

50,0%  

60,0%  

70,0%  

80,0%  

90,0%  

100,0%  

0  

100  000  

200  000  

300  000  

400  000  

500  000  

On  ART  2014   Not  on  ART   Cummula3ve  PLHIV  (%)  

*Treatment  coverage=  Current  on  ART/Es5mated  PLHIV  

Treatment  coverage  (range):  •  Guidelines  (median):  62%  •  PLHIV:  12-­‐>100%  

Page 17: Achieving epidemic control in South Africa · PEPFAR in South Africa: Current Context • Place: PEPFAR SA is currently operating in 100% (52/52) of districts • Time: Decreasing

Currently on ART (#, cumulative %) by Site (APR14)

17

0,0%

20,0%

40,0%

60,0%

80,0%

100,0%

120,0%

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

20000

1 68

135

202

269

336

403

470

537

604

671

738

805

872

939

1006

10

73

1140

12

07

1274

13

41

1408

14

75

1542

16

09

1676

17

43

1810

18

77

1944

20

11

2078

21

45

2212

22

79

2346

24

13

2480

25

47

2614

26

81

2748

28

15

2882

29

49

3016

30

83

3150

32

17

3284

33

51

# adults and children currently on treatment Cumulative %

80% of achievements at 1141/3411 (34%) sites.

Page 18: Achieving epidemic control in South Africa · PEPFAR in South Africa: Current Context • Place: PEPFAR SA is currently operating in 100% (52/52) of districts • Time: Decreasing

•  Within  district  site  analysis  &  selec5on  •  Scale-­‐up  (n=27):  EPIDEMIC  CONTROL;  Based  on  sites  with  

contribu5ng  to  90%  of  ART,  PMTCT  or  HTC  OR  least  500  ART  pa5ents  

•  Long-­‐term  transi3on  (n=9):  MAINTENANCE;  high  volume  facili5es  (i.e.  80%  na5onal  ART  by  site  and  within  top  25k  ART  coverage  within  district)      

•  COP15  site  targets  allocated  propor5onally  based  on  2014  results  

 Data  sources:  HSRC  2012,  2012  EPP/Spectrum,  StatsSA  popula5on  data,  2014  District  Health  Info  System  (DHIS)    

 

Current  Geographic  Priori3za3on:  District  &  Site  ranking  by  PLHIV  (2/2)  

 

Page 19: Achieving epidemic control in South Africa · PEPFAR in South Africa: Current Context • Place: PEPFAR SA is currently operating in 100% (52/52) of districts • Time: Decreasing

Within  District  Facility  Selec3on  

90%  ART  

90%  HTC    

90%  PMTCT  

•  Began  with  2014  DHIS  site  list  for  SA  •  Filtered  based  on  priority  districts  •  Calculated  within  district  rank-­‐sum  

values  for  ART,  PMTCT,  and  HTC  –  Selected  sites  that  where  in  top  90%  of  results  for  ART,  PMTCT,  or  HTC  

•  Allocated  district-­‐level  targets  to  sites  propor5onal  to  their  2014  results  

5,037  facili5es  (DHIS,  2014)  

2,202  facili5es  in  27  ‘Scale-­‐up’  Districts  

1,969  facili5es  in  27  ‘Scale-­‐up’  Districts  

198  Long-­‐term  transi5on  facili5es  

(9  districts)    

2,167  PEPFAR-­‐supported  facili5es  

(36  districts)    

Page 20: Achieving epidemic control in South Africa · PEPFAR in South Africa: Current Context • Place: PEPFAR SA is currently operating in 100% (52/52) of districts • Time: Decreasing

Site  level  HIV  Treatment  Targets  (COP15)  within  Scale-­‐Up  &  Long-­‐Term  Transi3on  

Districts    

0  

5000  

10000  

15000  

20000  

25000  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Scale-­‐Up  

Long  Term  Transi3on

 Long  Term  Transi3on

 Long  Term  Transi3on

 Long  Term  Transi3on

 Long  Term  Transi3on

 

Scale-­‐up  district  ART  sites  (n=1969)   LTT  district  sites  

(n=198)  

Scale-­‐up:    •  27  districts  •  Ave.  #  Pa5ents/site:  1600  •  3.04  million  pa5ents  •  80%  in  831  (42%)  sites  

Long-­‐term  transi3on:    •  9  districts  •  Ave.  #  Pa5ents/site  :  1700  •  333,000  pa5ents  •  80%  in  123  (62%)  sites  

Page 21: Achieving epidemic control in South Africa · PEPFAR in South Africa: Current Context • Place: PEPFAR SA is currently operating in 100% (52/52) of districts • Time: Decreasing

Geographic  Priori3za3on  

Page 22: Achieving epidemic control in South Africa · PEPFAR in South Africa: Current Context • Place: PEPFAR SA is currently operating in 100% (52/52) of districts • Time: Decreasing

 Geographical Focus Scale-up and Transition Districts

Scale-up (intensified

support)

27 districts 5.6m PLHIV

(83%)

1,969 Sites

Long-term Transition with

exceptions in high volume facilities

9 districts 720,000 PLHIV

(11%)

198 Sites

Central Support

16 districts 424,000 PLHIV

(6%)

TRANSITIONING OUT OF

2,015 SITES

Page 23: Achieving epidemic control in South Africa · PEPFAR in South Africa: Current Context • Place: PEPFAR SA is currently operating in 100% (52/52) of districts • Time: Decreasing

ART:  •  Increases  HIV  recovery,  

survival  •  Reduces  transmission,  

community  viral  load,  drug  resistance  

 

HIV  Counseling  &  Tes3ng:  •  Gateway  to  HIV  preven5on,  

care  services  •  Knowing  (HIV+)  status  can  lead  

to  reduc5on  in  risk  behaviors  •  Specific  focus  on  high-­‐risk  

popula5ons    

 Orphans  &  Vulnerable  

Children:  •  Mi5gates  impact  of  HIV/AIDS  on  

this  priority  popula5on  •  Reduces  risk  and  vulnerability  to  

infec5on      

Volunteer  Medical  Male  Circumcision:  

•  Reduces  males’  risk  of  HIV  hetero-­‐sexual  acquisi5on  by  up  to  60%  

•  Decreased  transmission  to  female  partner  

•  Linkage  to  other  services  (e.g.  tes5ng)  

 

Targets:    Right  Things,  Right  Place,  Right  Time  

FY’17  OVC  coverage   FY’17  HTC  coverage  

FY’17  VMMC  coverage   FY’17  ART  coverage  

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Mode  of  Implementa3on  @  sub-­‐na3onal  level  

•  District-­‐level  implementa5on  plan  (DIP)  

•  Led  by  NDoH,  and  supported  by  UNAIDS  and  PEPFAR  implemen5ng  partners:  o  Identify high burden areas,

high volume sites and high risk populations

o  Address particular district context and needs

o  Prioritize activities that will have the highest impact on the epidemic

o  Determine support required per district and align conditional grant allocations

•     

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Tracking 90-90-90 (PEPFAR) •  Analysis at a more ‘granular’ administrative level (e.g. district, facility) •  To coordinate reporting processes and systems with DIP process/systems •  Quarterly indicators

–  Track progress towards reaching 1st 90 •  HIV Testing, PMTCT Status, Early Infant Diagnosis (EID), Medical Male CIRCUMCISION

–  Track progress towards reaching 2nd 90 •  Newly starting CARE •  Newly starting TREATMENT

•  Semi-annual indicators –  Quarterly indicators plus track progress towards 2nd 90 & required indicators

•  PMTCT on TREATMENT •  currently on TREATMENT •  TB patients on TREATMENT •  Priority and Key Population PREVENTION, •  ORPHANS/VULNERABLE children reached

•  Annual review –  Track progress towards 3rd 90

•  Retained on TREATMENT •  VIROL LOAD done •  Undetectable VIRAL LOAD

25

Page 26: Achieving epidemic control in South Africa · PEPFAR in South Africa: Current Context • Place: PEPFAR SA is currently operating in 100% (52/52) of districts • Time: Decreasing

How did we get here? Consultative Process

•  Bilateral portfolio review Nov 2014 •  Stakeholder engagements included:

•  Government of South Africa (GSA) •  Development Partners; UNAIDS •  Global Fund (CCM; Concept Note development)

•  At RSA request, review of proposed analysis by UNAIDS and HE2RO (January, 2014)

•  Meeting with PEPFAR Implementing Partners, April 2015 •  Meetings with Provincial government representatives •  Civil society consultations (November 2014 – May 2015)

•  Civil Society stakeholders meeting April 2015 •  PEPFAR Steering Committee June 2015 •  PEPFAR, GSA, and civil society review June 2015 •  Support to DIP development and implementation

26

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Changes  with  Focusing  for  Impact  

§  RIGHT  TIME:    §  Focusing  for  Impact  will  represent  a  shit  by  end  of  FY17      

§  RIGHT  THINGS:  §  …6  million  to  13.6  million  tested    §  …3.0  to  4.3  million on  ART*  §  …and  include  transi5on  out  of  low  impact  interven5ons  §  Support  quality  data  in  local  info  systems  (e.g.  DHIS,  5er.net)  §  Support  to  District  Implementa5on  Planning  (DIP)  

§  RIGHT  PLACE:  §  …52  to  27  scale-­‐up  (+  9  long-­‐term  transi5on)  districts  (for  care  and  treatment  services)  

§  …4,183  to  2,167  ART  sites*    

*  Further  analysis  during  district  planning  process  is  expected  to  lead  to  addi5onal  focusing  at  the  sub-­‐district  and  site  level  

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Extra Slides

Page 29: Achieving epidemic control in South Africa · PEPFAR in South Africa: Current Context • Place: PEPFAR SA is currently operating in 100% (52/52) of districts • Time: Decreasing

Optimisation results Interven3on  Condom  availability  (90%)  MMC  (90%)  SBCC  campaign  1  (90%)  MMC  age  group  targe5ng    Tes5ng  at  6  weeks  (90%)  ART  at  current  guidelines  (90%)  PMTCT  B+  (60%)  HCT  (90%)  SBCC  campaign  3  (90%)  Universal  test  and  treat  (90%)  Tes5ng  of  adolescents  (90%)  Birth  tes5ng  (90%)  PrEP  for  sex  workers  (90%)  Microbicides  (90%)  PrEP  for  adolescents  (90%)  PrEP  for  discordant  couples  (90%)  Condom  educa5on  (90%)  Early  infant  male  circumcision  (90%)  

ART  at  current  guidelines  (85%)  

         

90/90/90  TARGETS  

AFFORDABLE  UNDER    CURRENT  BUDGET  

Budget  in  2016/17 ZAR  21.7  billion  

Page 30: Achieving epidemic control in South Africa · PEPFAR in South Africa: Current Context • Place: PEPFAR SA is currently operating in 100% (52/52) of districts • Time: Decreasing

HTC  Yield  by  Facility  

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Page 32: Achieving epidemic control in South Africa · PEPFAR in South Africa: Current Context • Place: PEPFAR SA is currently operating in 100% (52/52) of districts • Time: Decreasing

*Ref:  Takuva  S  et  al.  Dispari8es  in  engagement  within  HIV  care  in  South  Africa.  Conference  on  Retroviruses  and  Opportunis5c  Infec5ons,  Seawle,  abstract  154,  2015.    

Page 33: Achieving epidemic control in South Africa · PEPFAR in South Africa: Current Context • Place: PEPFAR SA is currently operating in 100% (52/52) of districts • Time: Decreasing

 

Preliminary  HIPSS  Baseline  Results,  2014–15,  n=8583  

Tes3ng  à  Treatmentà  VL  Suppression  

0  

1000  

2000  

3000  

4000  

5000  

6000  

Total  par5cipants  

Ever  tested  for  HIV  (total)  

HIV                                                                            prevalence  

PLHIV  ever  tested  for  HIV    

PLHIV  who  know  their  status  

PLHIV  advised  to  ini5ate  ART  (any  CD4)  

Diagnosed  PLHIV  on  ART  

Diagnosed  PLHIV  with  

suppressed  VL  (<1000  copies/

ml)  Male   Female  

Ever  tested  for  HIV*:  64.3%  77.6%  

Medically  advised  to  ini5ate  ART*    (any  CD4):  71.5%  72.7%  

On  ART*  66.1%  67.8%  

VL  suppressed  87.5%  89.7%  

*Self  report   JUNE  2015  Version    

PLHIV  ever  tested  for  HIV*:  64.3%  77.6%  

PLHIV  who  know  status*:  49.5%  60.1%  

1st  90  

2nd  90  3rd  90  

28%  

47%  

NOT  FOR  DISTRIBUTION  

Page 34: Achieving epidemic control in South Africa · PEPFAR in South Africa: Current Context • Place: PEPFAR SA is currently operating in 100% (52/52) of districts • Time: Decreasing

Conclusions  (TEMPRANO  and  START)  

The initiation of antiretroviral therapy in HIV-positive adults with a CD4+ count of more than 500 cells per cubic millimeter provided net benefits over starting such therapy in patients after the CD4+ count had declined to 350 cells per cubic millimeter

Page 35: Achieving epidemic control in South Africa · PEPFAR in South Africa: Current Context • Place: PEPFAR SA is currently operating in 100% (52/52) of districts • Time: Decreasing

Provincial Population-HIV Prevalence-PEPFAR Investment*

**Ref: R4D 2013 SA Expenditure Analysis Report (August 2014) 2013 SA Expenditure Analysis Report (August 2014)

Eastern Cape

Free State

Gauteng

KZN

Limpopo

Mpumalanga

North West

Northern Cape

Western Cape

0

100

200

300

400

500

600

700

800

0 5 10 15 20 25 30

2013 PEPFAR Provincial Expenditure*HIV Prevalence*Population

r=0.49, p-value=0.18


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