MSF role in Treatment as Prevention
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1 Médecins Sans Frontières Experience in Treatment as Prevention Southern African HIV Clinicians Society Conference, September 2014
2 MSF role in Treatment as Prevention General: demonstrating feasibility/acceptability Test, link, treat, retain, with undetectable viral load Pilot new interventions & models in high coverage settings: Recent evaluations through population surveys
3 Treatment as Prevention Projects Chiradzulu (Malawi) MSF/MOH HIV program MSF support for 13 years Kwazulu-Natal BTC (South Africa) MOH HIV program MSF gradual support since 2011 Shiselweni (Swaziland) MOH with MSF support since 2008 Test & Treat planned for Nhlangano Ndhiwa (Kenya) MOH/Other NGO HIV program No MSF presence yet Recent HIV Impact in Population Survey (incidence, prevalence, coverage)
4 Chiradzulu Southern region of Malawi Population: 288,546 (2008 census) Health services: -1 District Hospital -2 Private Clinics -10 Health Centers
5 Chiradzulu 1997: MSF opens programme 2001: First patients on ART 2003: Decentralisation to 10 health centres 2004: Task-shifting to nurses and counsellors (NiMART) 2008: 6-monthly clinic visits for stable patients 2012: Circumcision project 2013: 27,000 on ART
6 KZN - Mbongolwane and Eshowe Population: 115,000 Rural, urban & farms 2 hospitals & 10 PHC clinics Objectives: Reduce HIV/TB incidence and associated mortality & morbidity Demonstrate successful strategies for testing, treatment and prevention of HIV and TB.
7 KZN - Aim: Bend the Curves Adhere Community Mixed Model of care: Adherence Clubs, Community Adherence Groups Retain Treat Link Decentralization, TB/HIV integration, NiMART Mentoring Support Early ART: <500, PMTCT B+ since July Test Community Testing: Mobile, Fixed Sites, Door to Door (CHW), PITC,
8 Increase in HTC with community testing Fixed sites Door to door Mobile testing Health facilities
9 Community & School Testing to Reach Youth Community tests in Female Male <12 12 to to to to to 59 60
10 Increase in annual ART initiations Aug 2011: - CD Decentralization - Nimart April 2013 PMTCT B MSF support
11 Improve virological monitoring and outcomes Viral loads done Viral load results LDL (<400) 400 to to to > % 75.0% 60.0% 45.0% 30.0% 15.0% 0.0%
12 PMTCT B = B+ 99% of HIV+ pregnant women initiated on ART 6 week PCR+: 2.9% in 2012 to 2.2% in 2013 Increased HIV testing at 18 months Retention on ART at 6 month was 87% in patients with CD4 <350 vs. 63% with CD4 >350 (p<0.001). 68% retained in care at 6 months had a viral load recorded; 89% of these were <400 copies/ml.
13 HIV incidence and cascade of care: findings from three population-based studies
14 Methods Study Procedures Interview head of household Interview eligible individuals HIV rapid test (finger prick) Household questionnaire Individual questionnaire HIV test Positive Discordant Negative Blood collection (phlebotomy) Interview HIV positive Questionnaire HIV care & ART Laboratory tests CD4 count Viral load ARV testing (SA) Incidence testing ELISA HIV test Acute infection testing (NAAT)
15 Results 9,802 HH visited > 21,798 indiv. eligible > 18,999 (87.2%) included - Kenya: 6077/6833 (88.9%) - South Africa: 5649/6688 (84.5%) - Malawi: 7273/8277 (87.9%). Table: Participants socio-demographic characteristics Women, n (%) Age, median years (IQR) Married, n (%) Primary education, n (%) Student/unemployed, n (%)
16 HIV incidence Kenya South Africa Malawi /100 PY 95%CI /100 PY 95%CI /100 PY 95%CI Women 2.7 ( ) 1.6 ( ) 0.7 ( ) Men 1.3 ( ) 0.6 ( ) 0.1 ( ) Overall 2.2 ( ) 1.4 ( ) 0.4 ( ) PY: persons-year Women years: - Kenya: 3.8 /100 PY (95%CI: ) - South Africa: 3.2 /100 PY (95%CI: ) - Malawi: 0.9 /100 PY (95%CI: )
17 HIV incidence Kenya South Africa Malawi /100 PY 95%CI /100 PY 95%CI /100 PY 95%CI Women 2.7 ( ) 1.6 ( ) 0.7 ( ) Men 1.3 ( ) 0.6 ( ) 0.1 ( ) Overall 2.2 ( ) 1.4 ( ) 0.4 ( ) PY: persons-year Women years: - Kenya: 3.8 /100 PY (95%CI: ) - South Africa: 3.2 /100 PY (95%CI: ) - Malawi: 0.9 /100 PY (95%CI: )
18 HIV incidence Kenya South Africa Malawi /100 PY 95%CI /100 PY 95%CI /100 PY 95%CI Women 2.7 ( ) 1.6 ( ) 0.7 ( ) Men 1.3 ( ) 0.6 ( ) 0.1 ( ) Overall 2.2 ( ) 1.4 ( ) 0.4 ( ) PY: persons-year Women years: - Kenya: 3.8 /100 PY (95%CI: ) - South Africa: 3.2 /100 PY (95%CI: ) - Malawi: 0.9 /100 PY (95%CI: )
19 HIV incidence Kenya South Africa Malawi /100 PY 95%CI /100 PY 95%CI /100 PY 95%CI Women 2.7 ( ) 1.6 ( ) 0.7 ( ) Men 1.3 ( ) 0.6 ( ) 0.1 ( ) Overall 2.2 ( ) 1.4 ( ) 0.4 ( ) PY: persons-year Women years: - Kenya: 3.8 /100 PY (95%CI: ) - South Africa: 3.2 /100 PY (95%CI: ) - Malawi: 0.9 /100 PY (95%CI: )
20 HIV prevalence Kenya South Africa Malawi % (95%CI) % (95%CI) % (95%CI) Women 26.8 ( ) 30.9 ( ) 19.6 ( ) Men 19.8 ( ) 15.9 ( ) 13.2 ( ) Overall 24.1 ( ) 25.2 ( ) 17.0 ( )
21 HIV prevalence Kenya South Africa Malawi % (95%CI) % (95%CI) % (95%CI) Women 26.8 ( ) 30.9 ( ) 19.6 ( ) Men 19.8 ( ) 15.9 ( ) 13.2 ( ) Overall 24.1 ( ) 25.2 ( ) 17.0 ( )
22 HIV prevalence Kenya South Africa Malawi % (95%CI) % (95%CI) % (95%CI) Women 26.8 ( ) 30.9 ( ) 19.6 ( ) Men 19.8 ( ) 15.9 ( ) 13.2 ( ) Overall 24.1 ( ) 25.2 ( ) 17.0 ( )
23 % of total population HIV prevalence - Women 60% 50% 40% 30% 20% Kenya South Africa Malawi 10% 0% Age
24 % of total population HIV prevalence - Women 60% 50% 40% 35.7 % 30% 20% Kenya South Africa Malawi 10% 0% Age
25 % of total population HIV prevalence - Women 60% 56.0% 50% 40% 30% 20% Kenya South Africa Malawi 10% 0% Age
26 % of total population HIV prevalence - Women 60% 50% 40% 34.9 % 30% 20% Kenya South Africa Malawi 10% 0% Age
27 ART coverage Kenya HIV+=1457 South Africa HIV+=1493 Malawi HIV+=1190 Current National Guidelines CD4<350 PMTCT A CD4<350 PMTCT B CD4<350 PMTCT B+ Eligible, n (%) 826 (60.0) 988 (69.4) 952 (80.0) ART coverage, n (%) 582 (68.7) 741 (75.0) 766 (80.4)
28 ART coverage Kenya HIV+=1457 South Africa HIV+=1493 Malawi HIV+=1190 Current National Guidelines CD4<350 PMTCT A CD4<350 PMTCT B CD4<350 PMTCT B+ Eligible, n (%) 826 (60.0) 988 (69.4) 952 (80.0) ART coverage, n (%) 582 (68.7) 741 (75.0) 766 (80.4) 2013 WHO Guidelines CD4<500 / PMTCT B+ Eligible, n (%) 1127 (81.0) 1152 (80.9) 1041 (87.5) ART coverage, n (%) 582 (50.5) 741 (64.3) 766 (73.5)
29 Women Men Women Men Women Men Women Men Women Men Women Men Women Men Women Men Women Men Number of ART eligible CD4 <350 ; PMTCT B KZN ART coverage Overall: 75.0% (95%CI: ) Women age 20-24: 42% - Women: 78.5% (95%CI: ) - Men: 63.9% (95%CI: ) No ART ART
30 Women Men Women Men Women Men Women Men Women Men Women Men Women Men Women Men Women Men Number of HIV positive Who was already aware of their HIV infection? Awareness: 75.2% (95%CI: ) Women & men y: 43.1% & 83.3% were unaware of their HIV infection. - Women: 77.7% (95%CI: ) - Men: 67.3% (95%CI: ) Not aware Aware
31 % of total HIV positive Cascade of care 100% 90% 80% 70% 60% 50% 40% 77.7% 74.8% 61.8% 75.0% 73.4% 65.4% 61.1% 57.4% 56.2% 64.7% 57.1% 42.2% Malawi South Africa Kenya 61.9% 49.3% 39.5% 30% 20% 10% 0% Diagnosed Linked to Care Retained in care On ART VL<1000
32 Tipping point «Tipping Point» : When ART initiations go over new infections New infections ART initiations Kenya South Africa Malawi N=76,880 N=61,179 N=139,484 New infections ART initiations 1 1, Tipping point ratio During the 6 months prior to survey date
33 Getting ahead of the wave
34 Conclusions We are already treating our way out of the epidemic. Scale up without messing up Key to develop specific interventions across the cascade: Test, link, treat low coverage groups, especially youth Simplify (FDC, minimal lab, 6-monthly or annual visits ) Community-based & patient centred interventions Adherence support Quality & M&E improvement Huge need for community mobilisation will not be met without investing in civil society.
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36 Acknowledgements Ndhiwa, Chiradzulu, Kwazulu-Natal & Shiselweni communities, patients and healt care teams (DoH & MSF). Kenya/Malawi survey team Sophie Masson Isaac Nabaasa May Atieno Patrick Ochoro Field teams South Africa survey team Malika Bouhenia Radoslav Antonov Nomsa Nzama Godwin Dube Field teams MSF Geneva Roger Teck MSF Kenya William Hennequin Beatrice Kirubi Ali Ouattara MSF Malawi C. Masiku J. Price MSF South Africa Andrew Mews Amir Shroufi Ruggero Guilliani Mathew Reid Emilie Venables Emilie Wang MSF SAMU South Africa Tom Ellman Eric Goemaere Emmanuel Fajardo Carole Metcalf Kemri/CDC Kisumu Clement Zeh Andrea Kim MoH Kenya Irene Mukui Ojwang Lusi MoH Malawi Davie Zolowere Benson Chilima NICD Johannesburg Adrian Puren MSF Paris Elisabeth Szumilin Annette Heinzelman Leon Salumu Pierre Mendiharat MSF Brussels Marc Biot Epicentre Paris Helena Huerga David Maman Jean-François Etard Serge Balandine Jihane Ben Farhat Stephane Crisan Biostastic Unit Lyon Benjamin Riche René Ecochard Stéphanie Blaizot IRD, Montpellier Martine Peeters Eric Delaporte A. Aghokeng SACEMA Stellenbosch Alex Welte University of Cape Town Jennifer Norman Global Laboratory Durban Madurai Lorna Bronwyn Pitam Collin Pillay
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