Transcript HCT Campaign and ARV Expansion

HCT Campaign and ARV
Expansion programme
Business sectors leaders
29 March 2010
Goals
• Implement the new treatment guidelines and
Presidential mandates
• Train health workers on the new guidelines
and policies
• Implement the HCT campaign strategy
• Expand availability of ART sites, decentralize
to PHC, implement nurse initiated ART
• Plan for scale up of services, increase drug,
commodities, labs and HR
Strategy
• Implement the business plans, monitor patient
uptake, monitor drugs stock levels, support nurse
initiated services
• Provide support to new sites, use out reach
treatment initiating teams, team up with partners
and local practitioners
• Mobilize civil society, work with provincial,
district and local AIDS council
• Monitor and track progress, capture data,
communicate problems, challenges to the Nerve
center for rapid responses
Patient profile
• 84% of public sector patients are on d4T,
3TC, EFV
• 8% of patients are d4T, 3TC, NVP
• 2% of patients are d4T, 3TC, LPV/r
• 2/3 of patient are women
• 11 % are pregnant women
Patient profile
• Mean age of patient is 35,4 years for women
and 38,7 years for men
• 1/3 of patient present with cd4 cell count
below of less than 50 cells
• Most patient present with advance disease
with cd4 cell count of 87 cells
• 20% of patients are under nourished
Adherence
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undiagnosed and untreated depression
Active substance abuse
Poor counseling leading to lack of insights
Failure to disclose HIV status close family
Adolescents and young adults
Lack of support from support groups and DOTs
Co morbidities, pill burden, unmanaged drug
toxicity and stigma
High risk of mortality
• Men presented at old age, advance diseases,
lower cd4 cell count and compare to non
pregnant women
• Non pregnant women presented with more
advance diseases than pregnant women
• 39% of death occurred in the first six months
• Risk of death was almost five times higher in
among patient with cd4 < 50 cells compared
to cd4 > 200 cells
Challenges
• Over a third of the patients present with
advanced disease with median cd4 count of less
than 87 cells count
• Rapid expansion of the ART services needing a
change in the service platform
• High rate of single drug substitution
• High death rate at the first six months compared
to deaths at 1 year
• More than half of patient at ART initiation are
employed, need nutritional support
Presidential Mandates
• Urgent cases in needs, patients with cd4 less than
200
• Pregnant women who are HIV positive with cd4
equal and less than 350 start HAAR at 14 weeks
• TB/HIV co infection with cd4 equal and less than
350
• Infants exposed to HIV pregnant women do PCR if
positive start treatment at once
• Infants that are breast feeding to have NVP syrup
for the duration of breast feeding
Impact of Policy shift
Approach
HCT
ART
Opportunist Palliative
ic infections care
Phase 1
Deferred
Treatment
Low (VCT
passive client
driven)
Moderate (
cd4 <200)
symptomatic
High
Opportunistic
infections and
disability
High
Palliative care
and death
Phase 2. Early
Treatment
Moderate
(HCT provider
initiated HCF )
Moderate
Early ART <
350
Low disease
progression
and acute
episode of OIs
Low Palliative
care and AIDS
related death
Phase 3 Test
and Treat
High
(population
based HCT)
High universal Very low
access at cd4 > disease
500
progression
Low death
and palliative
care
Nerve Center
• Establish provincial Nerve center to coordinate,
monitor, direct and problems solve the HCT Campaign
and Expansion of ART
• Provincial nerve center must provide daily update on
the issues, challenges and progress to National Nerve
Center
• All Hospital to establish local nerve center to monitor,
validate and support health facility readiness and new
site establishment
• Provincial AIDS council, civil society, local sectors of
SANAC must participate, provide leadership and
strategic direction on the social mobilization
New Patients
• All new patients must be put on the new regimes from
1 April, TDF, 3TC and EFV based on the national
guidelines
• Nationally we have limited stock of
Tenofovir/emtricitabine, abacavir, NVP syrup, provinces
are asked to put their orders early for the first three
months
• Truvada (TDF/emtricitabine) single dose replace NVP
for women exposed to sdNVP
• TB/HIV patients, pregnant women and children must
be strictly managed according to new guidelines
Drug availability
• National policy is that all patients that are eligible
for ARV are put on treatment based on the new
guidelines
• Patients who are stable on the old regime of d4T,
FTC, EFV/NVP must be maintain on the same
treatment
• The switch from d4T is based on clinical
judgment and is related to adverse events
• Mono therapy switching for D4T for TDF must be
kept within the national norms of less than 10%
on establish patients
Prevention Programme
• Implement mix of package of effective intervention
strategy to reduce new infections
• Implement and rapidly expand medical male
circumcision
• Increase substantial the availability and distribution of
male and female condoms
• Implement the biomedical prevention strategies
include PEP and microbicide
• Attain high ART coverage to achieve secondary
prevention
• Eliminate or reduce to less than 5% MTCT and
transmission through breast milk
Enhanced Prevention Strategy
• Differential Communication for target groups
and social mobilization ( Leadership of
SANAC)
• Scale up of condom distribution and access
• Implement Medical Male Circumcision
• Increased access to syndromic management
of STI
• Monitoring and evaluation and tracking of
epidemic
Screening and early detection of
PHLWV
• HCT screening linked to care , provider
initiated at public health facilities
• Screening for TB linked to IPT, scaling up TST
implementation
• Screening for HIV in all pregnant women for
early detection and access to care in ANC
services l
• Screening for STI, and linked care
• Expand to access to access ANC to modern
contraceptive service
Early Access to Treatment
Set optimal patient eligibility criteria to achieve
improved clinical interventions and reduce
progression of disease to stage3, 4 and death
Select cost effectiveness ART drug combinations
to improve clinical outcome, reduce toxicity and
pill burden
Set optimal criteria for judicious use of laboratory
services to improve patient care, quality of care
and toxicity monitoring
Set policy guideline for optimal human resources
generation, task shifting and right mix, numbers
and distribution
Early Access to Treatment
Set guidelines for appropriate service delivery platform
that is fit for purpose for prevention, screening,
treatment, care and support and mitigation of impact
Provide supportive supervision to provinces to
strengthen the institutional capacity, strategy planning
and management to support PHC service delivery
Achieving synergies between communicable disease
program and health system strengthening
Strengthening leadership role of the health sector
supply side to support multsectoral response, to
priority district based on their epidemiological profile
and disease burden
Social Mobilization
• Avert early death due to AIDS related diseases
• Mitigate impact of HIV and AIDS to targeted
groups
• Mobilize and support AIDS competent
communities
• Provide integrated services for affected and
infected individuals, communities
• Mobilize community against stigma, gender
violence and discrimination
ART Programme
NEED
Results
Benefit
Outcomes
HSS
Reach
100% PHC
New
infection
Quality
Adults
1,350 M
70% adult
ART low
cd4
Early
treatment
Access
HAART
Women
55 000
PMTCT
100%
Disease
progression
Women
Child
Retention
TB/HIV
66000
TB/HIV 70% Disability
and OIs
Benefit
Benefit
Benefit
Benefit
Benefit
Capacity
Resources Testing
Initiation
R 6 billion Referral
Target Target
Base
Coverage
Benefit
TB/HIV Toxicity
Low cd4 Clinical
outcomes
Children Children
22000
PCR + 100%
AIDS
Death
Target
Target
Target
Target
Target
2011
Reduce MTCT to below 5%
Antenatal prevalence
 Reduced from 30% to 20%
33%
PMTCT
 50% sdNVP
21%
 50% sdNVP + 50% ZDV+sdNVP
35%
 100% ZDV+sdNVP
42%
Infant feeding
 100% BF for only 6 mths
33%
 50% FF and 50% 6m BF
39%
Newell ML. IAS 2005. Abstract WePl102.
TB/HIV Control
Tools
Current Strategies
Future Strategies
Diagnostics
 Diagnose symptomatic patients who
present to health services.
 Active case finding
 Rely on test (ZN) with 50% sensitivity
 Algorithm for smear negatives
Treatment
Preventive therapy
(PT)
 Contact evaluations
 Use of new technologies
 Joint TB/HIV case finding
 DOTS with first line drugs
 Shortened treatment
 INH/EMB continuation phase in many
settings
 Intermittent treatment
 Primary INH PT for limited time
 New regimens (eg, RPT)
 Avoid drug interactions
 Continuous INH
 Secondary PT
 Mass PT
Other
Courtesy of R. Chaisson.
 Antiretrovirals for advanced disease
 Earlier antiretrovirals
 No infection control
 Simple infection control
Prophylaxis
• All patients who are HIV positive must be
assessed for active TB if not must be put on INH
prophylaxis
• All patients who HIV positive with cd4 less than
200 including children must be put on cotrim
• All patients who are exposed to HIV infection
must assessed and provided with PEP at once
• All children exposed to HIV in pregnancy or
whose status is unknown must be provide with
NVP until their status is know
Clinical outcomes
• Reduce mortality especially in the first six
months
• Reduce loss to follow up
• Improve cd4 cell count gains
• Increase and maintain viral suppression
• Achieve long term durability of the first line
regimes
Patient Retention
Information and SPHC
• The need for specific epidemiological information to
identify those conditions causing the most severe public
health problems
• The data is used to indicate priorities, determine unit costs
of interventions and cost effectiveness basis for decision
making
• Priorities cannot be read off the results or based only on
technical considerations 'priority setting involves political
judgment
• Over emphasizing the immediate and spectacular may
draw attention away from the other necessary conditions
required for the successful reduction of ill health
Remolding health information System
• We need a system to provide data necessary
for monitoring intersectoral action of health
and for feedback
• We need a set of simple cross sectoral
analytical tabulation to link health to more
important determinants of heath from other
sectors
Inadequacy o f health information
systems
• Overload imposed on health workers by demand for
over sophisticated information systems
• Over centralization of information system
• failure to analyst the available information adequately
or use for planning or feedback
• The aggregation of data at higher level which masks
inequalities on which action Should be taken
• The failure to build bridges to otter sectors
• The failure to analyze information or to use
Information for planning process
Weaknesses of information Systems
• Breakdown in the key processes required to produce useful
automation
• the unresolved tension between the demand for uniform
data and the requirement to have automaton at local level
that is relevant and specific to the needs and resource
availability
• Information used to check on achievements four above
• Targets that are unrealistic or irrelevant
• Targets set for outputs of health services give no indication
by themselves of the extent to which interventions have
achieved the desired impact
• Community health coulee can be used to monitor the
extent to which heeds that have been (developed are met I
tastes accepted Are achieved, resource promised made
available
Achieve Scaling Up
• Advocacy and social mobilization
• Decentralization & integration using the district
approach
• Integration of procurement & monitoring &
evaluation into existing health system
• Partner public/private sectors
• Multisectorial coordination mechanism
• National and international leadership and
support
Tsague L, et al. IAS 2005. Abstract TuOa0302.