Achieving epidemic control in South
Africa: A PEPFAR Perspective
1
New HIV Infections & AIDS-related deaths: Fast Track vs. Current Coverage (Eastern & Southern Africa)
New HIV infections Estimated new HIV infections in 2030 in LMIC with achievement of Fast Track Targets compared to continuation of 2013 coverage
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
2013 Disability-Adjusted Life Years (DALYs): South Africa
5
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
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%)
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The introduc5on of ART has already done much to reduce incidence
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)
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So, how is PEPFAR planning to support the implementation & to achieve Epidemic Control in South Africa?
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Achieving epidemic control will require delivering the
Right Things in the
Right Places at the
Right Time
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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
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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)
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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
Es3mated PLHIV by District (2014)
• 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)
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%
Currently on ART (#, cumulative %) by Site (APR14)
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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.
• 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)
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)
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
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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
Geographic Priori3za3on
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
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
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
•
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
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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
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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
Extra Slides
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
HTC Yield by Facility
*Ref: Takuva S et al. Dispari8es in engagement within HIV care in South Africa. Conference on Retroviruses and Opportunis5c Infec5ons, Seawle, abstract 154, 2015.
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
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
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