Progress towards ending the HIV epidemic in Zimbabwe

Progress towards ending the HIV epidemic in Zimbabwe

Progress towards ending the HIV epidemic in Zimbabwe Dr R.C Choto, MBChB, MPH (uz) National ART Coordinator AIDS and TB Programmes, Ministry of Health and Child Care Cresta Lodge Msasa, Harare 21 August 2019 Presentation Outline Country HIV Epidemiology Achievements & Challenges Innovations Country Context: Zimbabwe remain one of the countries in the world heavily burdened by HIV/AIDS & TB 1.36m PLHIV 1,25m adults 74,460 adolescents 76, 650 children (2018 HIV estimates) HIV Prevalence: 14.04% among 15-49 yr age group Female 16.7% Male 10.5%

HIV Incidence: 0.49% (down from 1.42% in 2011, 0.98% in 2013) (2018 HIV estimates) MTCT rate 6.74% (2018 HIV estimates) TB/HIV co-infectivity rate of 63% [Global TB Report, 2018] Total Popn ~ 13 million (2012 Census) New HIV infections in Zimbabwe are primarily sexually transmitted among adults. 87% of new infections among adults 15+ IDU 0-1% 13% among children Blood MSM (4%) Abuse Vertical transmission

Heterosexual transmission (94% of adult infections) Co-facilitated by low levels of male circumcision (& other biological factors) Sex work-clients, partners 13% Structural Factors Source: MOT, Preliminary 2018 National HIV estimates Multiple including concurrent partnerships, casual sex (and other partner change due to separation, widowhood etc) Social, cultural, economic environment, gender, stigma Transmission within stable relationships (38%) The Health Sector Response HIV PREVENTION PREVENTION UNIVERSAL PRECAUTIONS FOR BLOOD SCREENING HIV TESTING SERVICES COMPREHENSIVE CONDOM

PROGRAMME STI PREVENTION & MANAGEMENT CARE & TREATMENT VOLUNTARY MEDICAL MALE CIRCUMCISION PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV (PMTCT) ANTI-RETROVIRAL THERAPY (ART) PREVENTION & MANAGEMENT OF OIs Zimbabwe utilizes and promotes a combination approach to HIV prevention to reduce heterosexual transmission Vaccine s The national Response to HIV has been cross cutting and comprehensive to address the complex issues associated with the epidemic Guided, Crosscutting Response Public health Approach Comprehensive context for

implementation -Zimbabwe adopted a multi-sectoral and multidisciplinary response to the HIV epidemic - Implementation is guided by the ZNASP III, eMTCT strategy, Consolidated ARV Guidelines for Preventing and Treating HIV, VMMC Operational Plan etc A public health approach to scale up of HIV prevention, care & treatment - Population based - Evidence based - Simplified tools and guidelines Implementation is undertaken in the context of a comprehensive combination HIV prevention, treatment, care and comprehensive HIV support package that addresses all Combination prevention refers to a systematic approach to implementing a range of HIV prevention interventions: behavioural and biomedical in synergy with structural Infections averted by eMTCT and ART programs (2017 HIV Estimates) In 2017, 11,860 new child infections were averted by In 2017, an estimated 66,600 deaths were averted by ART in both

11 0 2 12 0 2 13 0 2 14 0 2 15 0 2 16 0 2 17 44 0

3 2 43 Number of patients 8 10 0 2 1,169,752 09 0 2 565,675 08 0 2 362,817 07 0

2 139,251 06 0 2 41,905 05 0 2 53,632 04 0 2 25,867 11,000 0 235,440

200,000 486,675 400,000 665,199 600,000 879,271 800,000 787,980 2010 National ART Guidelines 975,667 1,000,000 1 1,200,000

1,119,909 2013 National ART Guidelines 2 Evolution of the OI/ART Programme, 2004 - 2018 0 2016 National ART Guidelines Addendum to the 2016 National ART Guidelines Country introduced OI/ART programme in April 2004 guided by Nationwide Scale-up of ART plans covering periods 2005-2007; 2008 2012 & 2013 2017,

Plan feeds into overarching extended Zimbabwe National AIDS Strategic Plans (ZNASP), coordinated by one coordinating body (NAC) and monitored by one monitoring framework The Three Ones Principle Zimbabwe TB case notifications versus ART coverage, 2000-2013 Zimbabwe has made great progress in controlling the HIV epidemic and is well positioned to achieve & surpass the 9090-90 Fast Track targets 100% 75% 50% 90% 90% 74% 90% 86% 86% 25% 0%

Target by 2020 Current status The biggest gap to achieving the 90-90-90 targets is in HIV testing (16%). The new national HTS Strategy (2016- 2020) shifts focus from testing for coverage to targeted testing for Current identification those living with undiagnosed HIV. Note: status as of of 2016 Source: ZimPHIA, 2015; Spectrum, Zimbabwe National HIV Estimate Despite recording remarkable progress in reducing HIV prevalence & incidence, wide variations still remain across provinces (Left) and districts (Right). HIV burden still high among adolescent girls and young women HIV prevalence among 20- to 24year-olds is three times higher among females (8.5 percent) than males (2.7 percent) which calls for urgent

attention Source: ZIMPHIA, 1 Dec, 2016 Significant gaps remain particularly pronounced among key populations.. Retention in ART care (%) Despite achieving high overall retention rates of at least 88% & 83% at 12 & 24 months respectively, there still remains missed opportunities among adolescents & young people 84 82 80 78.5 78 76 74.6 75.3 74 72 70 68 66 64 62 60 74.6

71.2 70.7 3 months 6 months 70.9 69 67.4 12 months 0-9 years 10-19 years (in months) Time since ART initiation 20+ years NB: Age groups exclude pregnant women at ART initiation Barriers to Retention B. Phelps, Linkage, initiation and retention of children in the antiretroviral therapy cascade: an overview, AIDS. Nov 2013; 27.. ART Outcome Study Report, 2016

Despite routine VL having been scaled up significantly since 2016, VL testing coverage remains low Sample transportation system Extended total Turnaround Time 1200000 Low viral load capacity utilization. Numbers By end of Dec 2018, a total of 508,917 VL tests had been done translating to 44% testing coverage with a suppression rate of 85% Country has adequate VL testing platforms deployed country wide [both conventional (22) & POC (100)] however, with limited capacity utilization Challenges relating to VL testing include: 1000000 800000

600000 400000 200000 0 2014 # ofVL test 2015 2016 PLHIV on Txt Jan - 2017* Sept 2017 VL capacity Source: 2017 ART End Term Programme Review Proportion of active patients enrolled in ART from 2013-2017 with suppressed VL from the first VL test stratified by age at health facilities with ePMS and in ART care for at least 12 months from ART initiation (N=114,857 ) Older age groups tended to have higher

proportions of active patients on ART that were virally suppressed 100 90 VL Suppression rate (%) Adolescents aged 1019 years had the least proportion of active patients that were suppressed (58%) compared to all the other age groups. 80 87.7 75.4 70 60 60.9

58 50 40 30 20 10 0 Source: ePMS 2018 81.7 84.5 <10 yrs 10-19 yrs 20-29 yrs 30-39 yrs 40-49 yrs 55+ yrs Baseline CD4 testing uptake for the 2017 ART Cohort

40000 36067 Number of patients 35000 30000 25000 20000 15000 10000 5000 0 775 757 <50 51-100 1594 2251 1804

2450 101-200 201-350 351-500 >500 Not recorded Baseline CD4 count (cells/mL) Baseline CD4 test done within 3 months after ART initiation. Only 21% of all new patients (2017 Cohort) had a Source: ePMS, MOHCC Paediatric and Adolescent HIV Issues: Sub-optimal integration of HIV services with adolescent sexual and reproductive

health Elevated levels of common mental disorders among ALHIV Stigma and discrimination in health facilities, especially towards ALHIV Long TAT for EID VL results with limited use of POC EID devices; limited access to VL testing services Weak sample transportation system for DBS and VL samples Adolescents experiencing challenges with adherence to medicines

Disclosure of HIV status Increasing call for country to reconsider its 1st line regimen based on periodic HIV Drug Resistance Surveillance being done Country has HIV DR prevention strategy TWG in place to guide implementation Country implementing all components of HIV DR prevention as per WHO Guidance Conducts Early warning Indicator (EWIs) surveys almost on an annual basis Conducted Pre-treatment (2016) and Acquired (2017) HIV DR surveys Results of Pre-treatment HIV DR survey indicates resistance to NNRTIs of 10.9% which is above WHO recommended level and this warrants country to reconsider its 1st line regimen Innovations HIV Testing Services:

Shift from testing from coverage to targeted testing Models and approaches: Facility based (PITC, Index case testing and HIV ST) Community based- outreach, index case and HIV ST Job aid developed to screen children, adolescents and adults for HIV prior to testing aimed at reducing # of re-testing and supporting compliance to testing algorithms 1. HIV Self Testing Expansion of coverage to 44 districts in all the countrys 10 provinces Capacity building - 865 healthcare workers to date Different models used: Community-based Facility based Secondary distribution 2. Birth HIV Testing to support Early Infant Diagnosis

Protocol approved by MRCZ (CHAI/UNICEF) Training of implementing sites done ( Harare & Parirenyatwa Specialist Centres ) Data Collection March until June 30 2019 EGPAF arm Data collection October 2018-April 2019 Outputs will inform Feasibility of roll out of Birth testing in Zimbabwe Care and treatment of HIV+ Neonates Dosing guidance for RAL & dosing charts development Timely ART initiation upon accurate EID WHO Infant testing algorithm 20% MTCT

Positive HIV NAT Infant is HIV infected x 400 True positive False positive 1% MTCT Immediate START ART Repeat NAT to confirm HIV infection x 9,900 Start ART , without delay implemented: and new Confirmatory NAT is poorly

how do we minimize unnecessary specimen collected at the time of ART True negative And lets remember that Infant diagnosis is a process! Moving to a multi-HIV NAT algorithm Birth (where of value) 6 weeks 9 months Any time HIV exposed infants present sick Ensuring confirmatory testing of a positive NAT result is undertaken Diagnosis is not completed without final diagnosis at

I m p le m e P r o p o r tio n o f D is tr ic ts 3. Differentiated Service Delivery: Provision of tailored care that meets the preferences and expectations of the client 82 % of adults and adolescents receiving ARV refills for 3+ months Proportion of Districts that have at least one facility implementing any one DSD model for ART Models, end of 2017 100% 75% 50% 25% 0% OUTREACH CARGs FACILITY CLUB REFILL FAMILY REFILL

FAST TRACK REFILLS 4. Treatment Optimization: Key Considerations Safety Efficacy Minimum adverse events Good adherence Potency of the medicine in achieving viral suppression Affordabili ty/ availabilit y Cost of the ARV medicines

Generic formulations Availability in the market Reduced pill burden/ od vs bd Preferably Fixed-dose combinations Once daily regimes preferred (convenient) Other considerations - simplicity of use/prescribing by lower level requirements, Harmonizati on across different age-groups & populations combination s

Limited number of options used across cadres,populations cold chain DTG Transitioning Roadmap Q3, 2018 Q3 2018 Q4 2018 2019 Q3 2018 2020 Consultations with various stakeholders including WLHIV [ZIMA; MIPA; Media Practitioners etc] Adaptation committee and NMTPAC to provide guidance to DTG Transition Policy Development of Tools- Addendum to the National ARV Guidelines; training materials, Job AIDs Sensitization & training of HCWs Strengthen Pharmacovigilance systems & SRH/HIV linkages

Country adopting a phased in approach in introducing DTG based treatment regimens for 1 st and 2nd line clients All eligible ART nave clients starting from May 2019 5. HIV Case-Based Surveillance (CBS) Country entered a new treatment era with potential to eliminate HIV, MTCT & syphilis Increased focus on prevention in high-risk population groups and geo-locations/ hot spots to reduce and interrupt HIV transmission and end AIDS High need to provide an accurate (unduplicated) measure of the HIV care cascade indicators disaggregated by age, sex, risk population, geography and by individual Increased focus on targeting of resources and evaluation of program impact Increased focus on retention of long term patient follow up and tracking patient outcomes Zimbabwe selected with 3 other countries (Tanzania, Malawi and DRC) for first round of support by WHO to introduce CBS Lessons learnt from implementation to inform subsequent roll out & introduction of CBS in region. *WHO. Consolidated Strategic Information Guidelines for HIV in the Health

Thank You & Acknowledgements NAC Global Fund PEPFAR USAID and CDC UN Family (WHO, UNDP, UNICEF, UNFPA, UNAIDS) PSI, ITECH, OPHID, CHAI, FHI 360, ZACH, EGPAF, KAPNEK, PANGEA, AHF, MSF, SOLIDARMED MOHCC AIDS and TB Programs PMDs, DMOs All levels of health care delivery systems

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