Ending the AIDS epidemic: Science, Policy and Community Peter Godfrey-Faussett, UNESCO Merck Africa Research Summit 19/10/2015
The cooking pot sits on three stones Science Policy Community
Science 20 May 1983: Vol. 220 no. 4599 pp. 868-871
Catherine Niyrenda and Winstone Zulu 4
Jul-99 Jan- 99 Feb- 99 Mar- 99 Apr- 99 May- 99 Jun- 99 Aug- 99 Sep- 99 Oct- 99 Nov- 99 Dec- 99 Jan- 00 Feb- 00 Mar- 00 Apr- 00 The policy cascade - Question Evidence Recommendation -Policy Practice Impact Is it feasible to administer TB preventive therapy in Lusaka? Helen Ayles, David Mukombo ZAMBART project Aim: To conduct a feasibility study of the provision of isoniazid preventive therapy (IPT) via the voluntary counselling and testing centres (VCTs) in Lusaka, Zambia Methods: 6 counselling centres,all HIV-positive individuals offered IPT. Screening done by counsellors for contraindications and to exclude active TB. Clients reviewed on a monthly basis to monitor adherence and adverse events. Results: 6435 individuals have been tested for HIV, 1761 (27.4%) are positive,1208 recruited into the study and 612 started on IPT. Number HIV tested by month Recruitment Screened 6435 800 700 600 500 400 Positive Negative 1761 4674 Not recruited Recruited 553 1208 The ProTEST Initiative - a combined response to the combined epidemics of TB and HIV 300 200 100 0 Month TB 34 Symptomatic 389 Started PT 96 TB 1 Started PT 516 TB 1 Asymptomatic 817 Not started PT 301 Screening to exclude TB has been a major issue. We have compared the use of chest x-ray and symptom screen alone in terms of specificity and negative predictive value, as well as in terms of cost and feasibility. 30% of clients never managed to get an x-ray done despite x-rays being provided free. Comparisons of Screens Scree n G old Stand ard Sym p&c XR S m ea r/ culture + Sym p alone Smear/ culture + Spe cific ity % (95 % C I) 14 9/25 4 59% (53.1-6 4.9) 22 7/33 7 82% (77.9-8 6.1) Sym p&c XR Clin ic al 14 9/24 2 61.6% (5 5.7-6 7.5) Sym p alone Clinical 275/325 84.6% (8 0.8-8 8.4) N PV % (95 % C I) 14 9/14 9 10 0% 27 7/27 8 99.6% (9 8.9-1 00) 14 9/14 9 10 0% 27 5/27 8 98.9% (9 7.8-1 00) C osts Symptoms and C XR Co u nsello r $0.4 x 346 tim e =$138.40 Clin ic $6.23 x 68 =$423.64 C XR $4.50 x 195 =$877.50 Clinic for $1.73 x 45 C XR =$77.85 T otal $1517.39/ 149clients= $10. 18 S ym p to m s alon e $0.4 x 346 =$138.40 $6.23 x 68 =$423.64 $562.04/ 278 clients =$2.02 WHO/CDS World Health Organisation London School of Hygiene and Tropical Medicine Of 272 clients so far having received IPT for at least 6 months, only 21% have adhered to the full course of treatment. Preliminary analysis reveals no association between age, sex or educational status of client. The time of greatest loss is between the first and second month of IPT. C o m p lia n c e Conclusions: Despite its proven benefit, IPT is difficult to implement via the VCT. Important reasons for not starting IPT include late stage of presentation for HIV test and loss during the screening process. Adherence to therapy is extremely poor. Further studies are underway to identify factors contributing to adherence and to optimise the screening process. Funded by the Wellcome Trust 3 0 0 2 5 0 2 0 0 1 5 0 1 0 0 50 0 1 2 3 4 5 6+ n u m b e r atte nding v is it
Halt and begin to reverse, by 2015, the spread of HIV/AIDS
Figure 3 Number of new HIV infections, global, 1990 2014 30 million new HIV infections averted from 2000-2014 through scale up of HIV treatment and prevention including 1.4 million among children Source: UNAIDS 2014 estimates.
Figure 8 Number of AIDS-related deaths, global, 2000 2014 7.8 million deaths averted from 2000-2014 through scale up of antiretroviral treatment 8.9 million children not orphaned Source: UNAIDS 2014 estimates.
Figure 24 Number of people receiving antiretroviral therapy, 2000 2015 Source: UNAIDS 2014 estimates. Numbers receiving antiretroviral therapy through March 2015 provided by selected countries in sub-saharan Africa.
Figure 9 Adult life expectancy trends, Kyamulibwa general population cohort, Uganda, 1991 2012 Source: Reniers et al, CROI 2015.
Life expectancy at birth, selected countries and regions, 1960 2015 Source: World population prospects: the 2012 revision. The 2012 Revision. New York: United Nations, 2013 (available from hps://data.un.org/data. aspx?q=life+expectancy&d=popdiv&f=variableid%3a68, accessed 2 July 2015).
Estimated number of tuberculosis-related deaths among people living with HIV, globally and in sub-saharan Africa, 2004 2013 Source: WHO 2013 estimates.
The HPTN 071 Study Team, led by: Dr. Richard Hayes Dr. Sarah Fidler Dr. Helen Ayles Dr. Nulda Beyers Government Agencies: PEPFAR Implementing Partners:
PopART Intervention Package Universal testing: annual door-todoor HBT Facilitated by CHiPs Service promotion and referral for - HIV care for HIV +ve including PMTCT - VMMC - TB - STI VMMC facility Follow-up on referral Support for: - Retention in care - Adherence to treatment Universal treatment for HIV +ve irrespective of CD4 count Health centre CHiPs: Community HIV-care Providers PMTCT: Prevention of Mother to Child Transmission VMMC: Voluntary Medical Male Circumcision TB: Tuberculosis STI: Sexually Transmitted Infections
19 July 2010: CAPRISA 04 tenofovir gel trial
July 2011: Oral PrEP prevents HIV transmission in discordant couples (PartnersPrEP) 4,758 HIV discordant couples in Kenya & Uganda Effect of TDF on HIV: 67% (CI: 44% - 81%) Effect of FTC/TDF on HIV: 75% (CI: 55% - 87%)
Figure 14 Number of voluntary medical male circumcisions performed annually, by country, 2008 2014 Source: GARPR 2015.
ARV prophylaxis Microbicides for women AbdoolKarim Q, Science 2010 Male circumcision Auvert B, PloS Med 2005 Gray R, Lancet 2007 Bailey R, Lancet 2007 Treatment of STIs Grosskurth H, Lancet 2000 Female Condoms Oral pre-exposure prophylaxis Grant R, NEJM 2010 (MSM) Baeten J, NEJM 2012 (Couples) Paxton L, NEJM 2012 (Heterosexuals) Choopanya K, Lancet 2013 (IDU) Post Exposure prophylaxis (PEP) Scheckter M, 2002 HIV PREVENTION Treatment for prevention Cohen M, NEJM, 2011 Donnell D, Lancet 2010 Tanser, Science 2013 HIV Counselling and Testing Coates T, Lancet 2000 Sweat M, Lancet 2011 Behavioural Intervention - Abstinence - Be Faithful Male Condoms Note: PMTCT, Screening transfusions, Harm reduction, Universal precautions, etc. have not been included this is on sexual transmission
Total resources for HIV/AIDS in low- and middle-income countries, 2000 2015 Source: UNAIDS estimates June 2015, based on UNAIDS-KFF reports on financing the response to AIDS in low- and middle-income countries until 2014; OECD CRS last accessed June 2015; UNGASS and GARPR reports; FCAA Report on Philanthropic funding Dec 2014.
Figure 34 Global resource availability for HIV, by source, 2000 2015 Source: GARPR 2015.
Domestic public spending in low- and middle-income countries, 2006 2014, in US$ million
SDGs
TARGETS for SDG 3 3.1 By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births 3.2 By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births 3.3 By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases 3.4 By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being 3.5 Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol 3.6 By 2020, halve the number of global deaths and injuries from road traffic accidents 3.7 By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes 3.8 Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all 3.9 By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil pollution and contamination 3.a Strengthen the implementation of the World Health Organization Framework Convention on Tobacco Control in all countries, as appropriate 3.b Support the research and development of vaccines and medicines for the communicable and non-communicable diseases that primarily affect developing countries, provide access to affordable essential medicines and vaccines, in accordance with the Doha Declaration on the TRIPS Agreement and Public Health, which affirms the right of developing countries to use to the full the provisions in the Agreement on Trade-Related Aspects of Intellectual Property Rights regarding flexibilities to protect public health, and, in particular, provide access to medicines for all 3.c Substantially increase health financing and the recruitment, development, training and retention of the health workforce in developing countries, especially in least developed countries and small island developing States 3.d Strengthen the capacity of all countries, in particular developing countries, for early warning, risk reduction and management of national and global health risks
Figure 26 Antiretroviral therapy coverage in adults and children, 2000 2014 Source: UNAIDS 2014 estimates.
Figure 23 Awareness of HIV status among people aged 15 49 living with HIV in sub-saharan Africa Source: Analysis based on DHS and the South African National HIV Prevalence Surveys.
The Fast-Track approach Decline in new adult HIV infections Decline in AIDS-related deaths Source: Fast-Track: ending the AIDS epidemic by 2030. Geneva: UNAIDS; 2014.
Investments for Fast-Track 1 90% of people living with HIV knowing their HIV status, 90% of people who know their HIV status accessing treatment and 90% of people on treatment having suppressed viral loads, so they remain healthy.
What have we learned through the HIV research response? African studies, (African leads) African centres West, East, Central, South People, funding, careers Biomedical, pharmaceutical, epidemiological, social, operational Medical schools, Governmental, Parastatals, Independent Partnership, Collaboration, Networks
Pensilo
Acknowledgements
HIV response extraordinary MDGs-SDGs- end of AIDS Science from Africa key Policy changes unpredictable and quirky Community vital demand, accountability, exceptionalism Research policy environment
Cascades for HIV treatment, policy and research Diagnosis Linkage Treatment Adherence - Success Question Evidence Recommendation - Policy Practice Impact Environment Institutions Individuals - Publications
ZAMSTAR Zambia and South Africa Tuberculosis and AIDS reduction trial Helen Ayles ZAMBART Project, Lusaka; Nulda Beyers Stellenbosch University, South Africa University of Zambia and Central Board of Health, Zambia City of Cape Town and Provincial Department of Health, South Africa London School of Hygiene and Tropical Medicine