Translating the Science to End New HIV Infections in Kenya

Translating the Science to End New HIV Infections in Kenya Perspectives, Practices and Lessons Nairobi, 28-30 May 2017 www.iasociety.org

Scientific Symposium Building Consensus Challenges, Lessons Learnt and Opportunities for the Future in Implementing HIV Prevention Combination Approach in Kenya Nduku Kilonzo, PhD CEO, National AIDS Control Council - Kenya www.iasociety.org

HIV Prevention Challenges We use data selectively We are not ready to invest for prevention results We are not ready to be accountable for results Lessons We must become consistent in action It takes a few to impact change HIV starts and ends with behavior, everthing else is in between Opportunities National and County leadership The Global HIV Prevention Coalition Sustainable financing investments in reducing new infections 3

Where are we at? 16 Counties reduced adult infections by >50% 14 Counties increased new infections by >50% Highest #new infections in high burden areas..

The greatest impact was felt in reduction of mother to child transmission Of 79,000 pregnant women, 6,613 HIV infections among children recorded 49% reduction in mother to child transmission of HIV Technical action: Option B+; free maternity; Bring back mothers initiative Political support: County investments; Beyond Zero Campaign

Where do we need to go? 75% reduction from 2010 levels, Kenya and Zimbabwe

Challenges 7

We use evidence selectively In Kenya, impact of changes in sexual risk behavior, and to a much lesser extent ART, on the course of the epidemic, with their combined impact averting approximately 4,107,000 infections between 1980 and 2015. This was mostly attributed to changes in sexual risk behavior Final Report on Evaluating the Evidence for Historical Interventions Having Reduced HIV Incidence-2016

We use data selectively *widespread micro-financing services IMAGE Study: Testing a structural intervention to address HIV & Gender-base violence After 2 years, risk of physical & sexual intimate partner violence reduced by 55% (arr 0.45 95% CI 0.23-0.91) Among young IMAGE participants (age <35yrs): Reduced unprotected sex & HIV service uptake increased (Pronyk et al. AIDS 22, 2008) 9

Selective application of evidence? Education sector investments Keeping girls in school HIV Indicators for Education system Teacher/matron guidance for health services and support (Prevention & Rx) AYPs approx. 280,000 42% ART coverage? 40% testing; Lowest adherence, lowest viral suppression AIDS leading cause of mortality 10

Embu Kirinyaga Mandera Tana River Baringo Kajiado Kilifi Meru Nyamira Turkana Bungoma Kiambu Machakos Mombasa Nakuru Uasin Gishu Amount in Millions (Ksh) We are not ready to be accountable for results for Kenyans HIPORS Report Baseline 411 NGO s Only 44 (11%) reported in FY15/16 Total expenditure Kshs 14,385,285,158 across the 46 counties for HIV and AIDS programmes 4,000 3,500 3,000 2,500 2,000 1,500 1,000 500-18 16 14 12 10 8 6 4 2 0 Low (1-2 NGOs) Medium (3-5 NGOs) High (>=6 NGOs) Total Amount # of NGOs

Lessons 12

We must become consistent in action Marketing our products what can we learn from the private sector.. Every young person, old person literate or now knows where to get a bamba 20 in Kenya. Why do they not know where to get a condom? (Mukoma 2016) Do not desert what works for the new kid on the block The story of condoms Know your HIV status - HIV testing and counselling Communities of persons living with HIV Deliver 90-90-90 as cascade is still below optimal prevention benefits 13

HIV starts and ends with behaviour. Everything else is in between (Dazon Dialo, 2011) Figure adapted from: Adherence vs. efficacy in PrEP trials (Bekker L-G, Tenofovir based PrEP technologies in women: what do we currently know? IAS 2013, Kuala Lumpur, Malaysia) AIDS mortality for adolescents and young people in Africa and 2 nd globally key issue is stigma and discrimination resulting in ART non-uptake and non-adherence 14

We must become consistent in action Marketing our products what can we learn from the private sector.. Every young person, old person literate or now knows where to get a bamba 20 in Kenya. Why do they not know where to get a condom? (Mukoma 2016) Do not desert what works for the new kid on the block The story of condoms Know your HIV status - HIV testing and counselling Communities of persons living with HIV

Recognize that we need a financing mechanism lay man s language for ARVs only County* (Examples) Estimated PLHIV Annual cost of ARVs only (Ksh 20,000 ) Nairobi 177,552 3,551,040,000 35,510,400.00 Kisumu 134,826 2,696,520,000 26,965,200.00 Nakuru 61,598 1,231,960,000 12,319,600.00 - ART = 200US$ (approx. 300M$ = 30B required) - 40% of annual Ministry of Health budget for FY 2015/16 - Does not include costs of HIV prevention, research Mombasa 54,670 1,093,400,000 10,934,000.00 Total PLHV 1,500,000 30,000,000,000 300,000,000.00 - Life-time cost liability - LMIC status vs TRIPS and public health flexibilities on access to generics - >70% donor funding

Opportunities 17

It takes a few to create change - Kenya s HIV prevention revolution roadmap Who needs HIV Prevention? (populations) What do they need? (risk, perceptions) From national to County clusters High, Medium, Low incidence cluster Timely data on granularity of epidemics Timely incidence surveillance What is available? From interventions to populations By age group By priority populations By bridging populations (evidence based interventions) How will it be delivered? (packaging, settings, delivery ) From biomedical only to combination prevention targeted packages at scale faster research to policy translation coordinated R&D for HIV prevention What will it cost? (cost, effectiveness) From health to HIV prevention as everyone's business Leverage political leadership Leverage social movements Legal and structural reforms 18

National and County leadership and accountability Counties (leadership and investments) County AIDS Strategic Plans Public Sector investments Sector plans and indicators Ministry of Health investments and support The multi-sector role/responsibility of the National AIDS Control Council

Global HIV Prevention Coalition Oct 10 th 11 th 2017 NAIROBI Lessons from the successes of ART and emtct Targets described as numbers Is this the time to re-think measurement From prevalence to incidence? Financing mechanism?? Lets say I have a boyfriend and am against the act, but you can be forced. He will come at night when he knows I am there because he want to do, and to make me to give him. He knows if he rapes me... and when others get to know, they will reject and laugh at me saying I was raped so I will give in (Jane, 16yrs, Thika - 2004) 20

Global Prevention Coaltion: Investing in HIV Prevention systems Products forecasting, quantification, supply & management service delivery (for Jane): Health facilities? VCT sites? pharmacies? Youth sites? Surveillance: indicators? who collects? Community based adherence systems High impact interventions (behavioural/ structural): Standardize application & deliver them uniformly with high levels of Coverage 21

HIV Prevention what is needed? We must invest for prevention results for Kenyans (beyond projects) We must become consistent in action, beyond HIV starts and ends with behavior, everthing else is in between The Global HIV Prevention Coalition is an opportunity Sustainable financing investments in reducing new infections 22