Scaling Up Treatment in Zimbabwe: The path to high coverage
IAS Conference
Dr. Tsitsi Mutasa-ApolloART Programme Coordinator, Zimbabwe
30th June, 2013Kuala Lumpur, Malaysia
Outline
Introduction
Background
Achievements
Treatment Cascade
Challenges
Opportunities
Zimbabwe Country Context
• Population: 12,9m • 1.2 million PLHIV• HIV Prevalence (ZDHS 2010/11)
– 15-49 yrs. 15% – Female 18%– Males 12%
• 41% of the U5 Mortality Rate is attributed to HIV/AIDS as the underlying cause
• 26% of MMR is attributable to HIV/AIDS
The Zimbabwe National Response
• Multi-sectoral response with broad stakeholder involvements
• Zimbabwe introduced a 3% tax on income to increase domestic resources for the national AIDS response in 1999– 26% contribution towards ARV procurements
• 5-year 2011 to 2015 strategy– National response towards achieving zero new infections, zero
discrimination and zero AIDS related deaths by 2015
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
2012
2014
0
1
2
3
4
5
6
7
High estimate
HIV incidence (15-49 years old) (%)
Low estimate
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
2012
2014
0
0.2
0.4
0.6
0.8
1
1.2
1.4
High estimate
Annual AIDS Deaths (%)
Low estimate
Zimbabwe HIV Incidence Zimbabwe Annual AIDS Deaths
2010 UNAIDS Report
- Attributed to successful implementation of prevention strategies, especially behavior change, high condom use and reduction in multiple sexual partners- AIDS-related mortality has also fallen
HIV incidence peaked in 1993 and has fallen significantly
Identification of major policy, health systems and structural bottlenecks in paediatric ART
• A multi-country paediatric HIV assessment with support from UNICEF and WHO in 2012
• What hampered access to Early Infant Diagnosis (EID), ART and retention to paediatric HIV treatment and care?
• Major findings:– Limited linkage between EID and ART– Centralized PCR testing and a long turnaround times– The median time from diagnosis to ART initiation was 61 days for children <2
years of age while the median age at ART initiation was above 7 years. – The proportion of children remaining in care 12 months after initiation was
below 75% and high rate of lost to follow-up was more observed among the under-fives
• The country is working towards addressing the uptake of EID and linkages to, and retention in care in order to improve child survival
Progress in implementing 2010 ART guidelines
• MOHCW adapted the 2010 WHO Guidelines with a 3-year phased approach to phase in TDF-based regimens and phase out D4T- based regimens
• Due to limited resources the adaptation committee prioritized the following groups:– HIV-infected Pregnant women– TB/HIV co-infected people – Patients presenting with side effects stavudine-related side effects– Patients on ART for over 3 years
• By April 2012; 66% of adults receiving TDF-based regimens; while 34% on D4T- regimens (phasing out by Dec 2013)
• All children were prioritized for transitioning to AZT-based regimens unless medically contraindicated
Step 1: HIV Testing to enrolment into care
Step 1HIV Testing to
enrolment into care
Step 2 HIV Enrollment to
eligibility
Step 3Eligibility to
initiation
Step 4Initiation to long-
term ART
HIV Testing• An increase in proportion of people reported ever tested & received results from
22% percent to 57% among women resp. from 16% to 36% among men (from 2005 to 2010)
• A discordance rate of 12 % among couples (2010-11, ZDHS)• Challenges
• Poor links between testing & services; Lack of post-test support• Currently
• 96% of Primary Care Facilities offer Provider Initiated Testing & Counselling• 79% of facilities offer Early Infant Diagnosis using Dried Blood Spots for PCR• Couple counselling to be rollout out in 2014
Step 2: Enrolment to Eligibility
Step 1HIV Testing to
enrolment into care
Step 2 HIV Enrollment
to eligibility
Step 3Eligibility to
initiation
Step 4Initiation to
long-term ART
• Congestion at many clinics• Long distance to nearest clinic/high transport costs• Limited CD4 testing including Point of care technology• Competing life priorities e.g. seeking food• Inadequate referral information• Strategies:
• Mobilized resources for additional CD4 POC machines• Decentralization of ART services
Decentralization of HIV Care and Treatment Services
The aim of decentralization is to bring ART services closest to where people live.
By end of 2007, only 9 ART sites open
By March 2013, 1006 (64%) ART sites
Target is to reach 1,560 health facilities offering ART services by 2015
Step 3: Eligibility to Initiation
Step 1HIV Testing to
enrolment into care
Step 2 HIV Enrollment
to eligibility
Step 3Eligibility to
initiation
Step 4Initiation to
long-term ART
Males poorer clinical and immunological status prior to initiating ART when compared to females
Males generally presenting late for HIV treatment and care when compared with their female counterparts
Currently no waiting lists for ART initiation
Zimbabwe ART Programme Scale Up
2004 2005 2006 2007 2008 2009 2010 2011 20120
100
200
300
400
500
600
700
800
900
1000
0
10
20
30
40
50
60
70
80
90
100
5 49 71 80 104 117 128 1412200 5
5 9
27
263
382449
760
ART INITIATING ART FOLLOW-UP SITES ART TREATMENT COVERAGE (%)
Period
Num
ber
of S
ites
ART
Cove
rage
(%)
Step 4: Initiation to long-term ART
Step 1HIV Testing to
enrolment into care
Step 2 HIV Enrollment
to eligibility
Step 3Eligibility to
initiation
Step 4Initiation to
long-term ART
• Too many appointments when ARV supply is insecure• Challenges with migrant workers resulting in high defaulters and loss to follow
• Nurse led ART initiations have bolstered ART scale up particularly in remote areas• At 12 months after initiation of ART; 89.8% participants achieved viral suppression of
below 1000 copies/ml
Strategies: • Introduced an E-Patient Tracking System;• Secured ARV commitments under the Global Fund NFM;• Community support groups
Retention of Patients Initiating ART during 2007-2009, Zimbabwe
• Good retention in care observed in a retrospective cohort study in a nationally representative sample of patients initiating ART between 2007 and 2009
• 69% of patients were continuing ART treatment at 24 months, whereas 7% had died and 24% were lost to follow-up (MOHCW, 2012)
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 -
100,000
200,000
300,000
400,000
500,000
600,000
8,000
565,675
120,000
62,000
160,000
86,000
No of PLHIV receiving ART No of People Newly Infected with HIVNo of people dying from AIDS related causes
Zimbabwe ART coverageAIDS mortality & new HIV infections
Source: Zimbabwe HIV Estimates, 2013
Recent modelling exercise has shown substantial impact of the ART programme with 71,970 deaths averted by ART in 2012 alone
Analysis of ART Programme Impact
Challenges while Scaling UpMismatch between numbers of HIV care providers and patient volumeNeed to review staff establishment
Insufficient counsellors for adherence counselling & support
Expensive to run in-service trainingsNeed to strengthen pre-service curriculum and internship
Lack of adequate competencies for Paediatric ART and counselling skillsWhen to switch patients to 2nd lines; management of co-morbidities
Limited viral load capacity for patient monitoring; long TAT for Early Infant Diagnosis using PCR
Difficulties in linking patients to care, adherence, and viral suppression
The paper-based system for M & E is difficult to implement in a large programme
Opportunities
Zimbabwe an early applicant for the Global Fund New Funding ModelGF board recently approved USD 311m for HIV
Anticipation of additional USD 244m from GF replenishment funding to support new initiatives:- ART initiation at CD4 < 500 and ART for children < 5 yrs
Planned development of a 3-year Strategic Plan for the National ART programme starting July 2013
Large and diverse private sectorParticularly vibrant health insurance industry for possible private-public partnerships
Implications for the 2013 HIV Guidelines
• CD4 500 threshold– Estimated 28% annual increase in number of PLHIV in need for ART– ART Coverage will drop from 85% (2012) to below 70%
• Triple ARVs for HIV+ pregnant women– Support the e-MTCT country agenda
• Treatment for the Under 5s– Help overcome treatment eligibility challenges experienced by health workers – Support scale up
• Efavirenz-based regimens– Increment of US$ 1-50 to 2 per patient per month compared to NVP-based
regimens– Improve adherence
I Thank You