PEPFAR N

Namibia

COP 2018 Stakeholder Meeting HIV Treatment :

“Treat All” Policy, Differentiated

Service Models

January 31, 2018

PEPFAR

Presentation Outline

I. Program Overview Update of Test and Treat Policy

PEPFAR Country Specific COP18 Guidance :Highlights on Treatment

II. Update on Outcomes for PEPFAR Namibia FY17

– TX New and Tx Curr Results

– Adherence and Retention Outcomes

– Viral Load Suppression Outcomes

III. Differentiated Models of Care

– Updates on implementation during FY17

• Ongoing Evaluations

– Community-Based ART

– Community Adherence Clubs

IV. Questions and Discussion

2

PEPFAR

Status Treat-All Policy and Transitioning from

EFV-based to Dolutegravir-based 1st line regimen

• Treat All Policy in Full Implementation in All Districts since early 2017

• New DTG Formulations – Technical Advisory Committee (TAC) meeting convened

by MoHSS after the IAS2017 to deliberate technical considerations: • Concerns raised regarding missing data for sub-populations (e.g.

Pregnant women, TB patients on Rifampicin)

– TAC considered: • Current ARVs Stock-on-hand as well as Stock already –on-order • Lead times for ordering ARVs

– MOHSS working on a transition plan with the ultimate objective of transitioning patients to new; safer DTG-based regimens in due course

3

COP 2018 COUNTRY SPECIFIC POLICY DIRECTIVES AND TECHNICAL APPROACHES

Same Day Initiation - There are still many districts where same day initiation of ART has not been adequate, including in the capital of Windhoek. PEPFAR Namibia should continue monitoring time to initiation and ensure that implementing partners have plans that utilize efficient linkage methods, following up where progress remains inadequate.

Community Based ART – CBART has proven to be a successful method of treatment provision in Namibia. PEPFAR Namibia should continue to scale up CBART and begin cost/impact analysis of the multiple models; determine which models may be most sustainable with different populations.

TLD Optimization: Submission of a draft TLD transition and supply plan for FY 2019 is required for the Regional Planning Meeting. These plans must be developed in close consultation with host countries and in collaboration with GF and other key stakeholders.

4

PEPFAR

UPDATE ON OUTCOMES FOR

PEPFAR NAMIBIA FY17

5

6

Trends in Total Current on ART (Tx Curr) and New ART initiation (Tx new):

Namibia FY15-FY17

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Rapid Increase in patients Current on ART in districts supported by PEPFAR: (1) During the period FY15-FY17 –Tx Curr number more than tripled the number current on ART. This reflects the highly successful major

pivot (from a Technical Assistance program to Direct Service Delivery Support Model ) implemented by PEPFAR Namibia beginning in FY15

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Day 0 7 Days 30 days 90 Days

43% 47%

52%

61% 60% 63%

68%

78% 82% 81%

83%

89% 90% 89% 90% 93%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 7 days 30 days 90 days

FY17Q1

FY17Q2

FY17Q3

FY17Q4

FY17Q1

FY17Q2

FY17Q3

FY17Q4

FY17Q1

FY17Q2

FY17Q3

FY17Q4

FY17Q1

FY17Q2

FY17Q3

FY17Q4

Cu

mu

lati

ve (

%)

Star

ted

on

AR

T

Namibia: FY17 :Time from HIV Diagnosis to ART initiation,FY17 Q1 –Q4

The proportion of patients initiating ART on Same Day (Day 0) has increased from 43% in FY17 Q1

to 61% by FY17 Q4

APR 2017: PMTCT _ ART and Infants <1 Linked to ART

9122 8092

205

11967 11691

194 188 0

2000

4000

6000

8000

10000

12000

14000

HIV + pregnantwomen Target

HIV + pregnantwomen

receiving ARTtarget

HIV infectedinfants

identified by 12months of age

(target)

HIV infectedinfants New on

ART

PMTCT APR 17: Targets and Achievements

Target Achieved

0%

20%

40%

60%

80%

100%

PMTCT_ART Coverage by District

PMTCT_ART coverage

• FY17 PMTCT targets were achieved except for new HIV infected infants identified

• PMTCT-ART coverage was 98%. Ranging from 84% to 100%

• 188 (96%) of identified HIV infected infants were linked to ART

Challenges

• Shortage and periodic rotations of trained staff affecting service delivery

• Inadequate re-testing of pregnant and breastfeeding women

• Data reporting issues

• Lower target set for PMTCT_ ART (adjusted for FY2018)

• 15 districts had higher ART linkage and 8 districts had lower ART linkage than HIV infected infants identified • Some infants were initiated on ART in clinics

other than where diagnosis was made.

Challenges

• Paeds. ART not decentralized to some clinics • Inadequate re-testing of breastfeeding women and

HEIs beyond 6 weeks , 9months and 18 months • Data reporting issues

0%

100%

200%

300%

400%

500%

600%

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Axis Title

HIV infected infants identified HIV Infected infants new on ART (<1yr)

% HIV infected infants new on ART (<1yr)

HIV infected infants identified and linked to ART by

District

Adherence Estimates based on Pharmacy Pill Count July to September 2017

MOHSS, (November, 2017). Quarterly ART PMIS Feedback Report for the Period July to September 2017. Windhoek: MoHSS –Division: Pharmaceutical Services.

Aggregate national rates for Adults and Pediatrics patients with >75% adherence are 63% and

50% respectively for the period of July to September 2017

63%

50%

56%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% w

ith

>7

5%

Ad

he

ren

ce

Region

#>75% Adherence Adults #>75% Adherence Paeds Sum of National %

77%

91% 91%

83%

74%

84% 84%

79% 78% 78%

87%

81%

87% 86%

81%

86% 87% 87%

81%

86% 89%

74%

91% 89%

84%

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84% 84% 83%

90%

81%

87%

95%

87%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Namibia Viral Load Suppression Oct16 to Sep 17 (N=191,239)

Source: Laboratory Data from the Namibia Institute of Pathology; MEDITECH

74%

80%

72%

64%

89%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<5 Y 5-9Y 10-14Y 15-19Y >20

% V

L Su

pp

ress

ion

Age group

Namibia VLS by Age Group, October 2016 to Sep 2017 : (N=158,632)

N=8,052 N=6,844 N=137,326

N=4,534

N=1,876

Source: Laboratory Data from the Namibia Institute of Pathology; MEDITECH

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0%

10%

20%

30%

40%

50%

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100%

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Nam

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12

Mo

nth

Ret

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n (

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District

Retention by District Namibia ,October 2016 to October 2017

PEPFAR

DIFFERENTIATED MODELS OF

CARE

15

Community Based ART Model & Description

Districts (Est. no. of patients-December 2017)

Community based ART Delivery (CBARTs)- provider managed

Oshakati (300); Engela; Eenhana (800); Outapi (270); Tsandi (250); and Okahao (250)

Community Adherence Clubs (CACs)- patient-self managed with support from CHWs and HEWs

Oshakati (280); Katima Mulilo (90) Windhoek, Andara , and Nyangana(still forming)

Community-Based ART Management

National ART guideline revised and Community based ART delivery models included in the 2016

ART Curriculum revised and include Community based ART models, Training conducted PEPFAR facilitated exchange learning visits & best practices sharing (Omusati,

Ohangwena, Oshana, Kavango West and East and Zambezi region) Used project ECHO platform to share best practices SOPs and reporting tools developed and used in demonstration project- to be adapted

Number of CACS and Patients in CACs by Region: December 2017

17

200 175

37

412

25 29 5

59

0

50

100

150

200

250

300

350

400

450

Oshana Zambezi Khomas Total

Nu

mb

er

of

Pati

ents

Region

Districts (Est. no. of patients) Number of Clubs

Draft COP18 Proposed Activities

Facility-Based Community Adherence Clubs targeting Urban Facilities

Further Expansion of Community-Adherence Clubs

Standardization of Teen Clubs and expansion of use

Support for continued ART decentralization especially for Pediatric access

Use of Technology for Teen Adherence Clubs and others1

1New app helps treatment adherence for people living with HIV http://www.unaids.org/en/resources/presscentre/featurestories/2017/october/20171030_life4me

PEPFAR

QUESTIONS AND DISCUSSION