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1 5 th Inter-Agency Meeting on Coordination and Harmonization of HIV/AIDS, TB and Malaria Strategies Universal Access to HIV/AIDS, TB and Malaria Services in Africa; Challenges and Prospects
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1 5 th Inter-Agency Meeting on Coordination and Harmonization of HIV/AIDS, TB and Malaria Strategies Universal Access to HIV/AIDS, TB and Malaria Services.

Dec 25, 2015

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Page 1: 1 5 th Inter-Agency Meeting on Coordination and Harmonization of HIV/AIDS, TB and Malaria Strategies Universal Access to HIV/AIDS, TB and Malaria Services.

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5th Inter-Agency Meeting on Coordination and Harmonization of HIV/AIDS, TB and

Malaria Strategies

5th Inter-Agency Meeting on Coordination and Harmonization of HIV/AIDS, TB and

Malaria Strategies

Universal Access to HIV/AIDS, TB

and Malaria Services in Africa;

Challenges and Prospects

Universal Access to HIV/AIDS, TB

and Malaria Services in Africa;

Challenges and Prospects

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Overview of PresentationOverview of PresentationOverview of PresentationOverview of Presentation

For each of the 3 diseases Situation and Trends Trends in the Response Programmatic Challenges

Prospects for the Future

For each of the 3 diseases Situation and Trends Trends in the Response Programmatic Challenges

Prospects for the Future

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HIV/AIDS Situation -2012HIV/AIDS Situation -2012HIV/AIDS Situation -2012HIV/AIDS Situation -2012 People living with HIV – 25 million (71% of

global burden) Children <15 years living with HIV – 2.9

million (89% of global burden) Regional Prevalence – 4.7% People newly infected with HIV in 2012 –

1.6 million AIDS related deaths in 2012 – 1.2 million

People living with HIV – 25 million (71% of global burden)

Children <15 years living with HIV – 2.9 million (89% of global burden)

Regional Prevalence – 4.7% People newly infected with HIV in 2012 –

1.6 million AIDS related deaths in 2012 – 1.2 million

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HIV Burden in sub-Saharan Africa, 1990-2012

Source: UNAIDS and WHO

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The Health Sector's Contribution to The Health Sector's Contribution to Achieving Universal Access to HIV/AIDS Achieving Universal Access to HIV/AIDS

InterventionsInterventions

Expanding testing and counsellingExpanding testing and counsellingExpanding testing and counsellingExpanding testing and counselling

Accelerating treatment Accelerating treatment scale upscale up

Accelerating treatment Accelerating treatment scale upscale up

Maximising preventionMaximising preventionMaximising preventionMaximising prevention

Strengthening health systemsStrengthening health systems Strengthening health systemsStrengthening health systems

SSTTRRAATTEEGGIICC

IINNFFOORRMMAATTIIOONN

SSTTRRAATTEEGGIICC

IINNFFOORRMMAATTIIOONN

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Clinically relevantClinically relevantEarlier initiation of ART Earlier initiation of ART (CD4 ≤ 500)(CD4 ≤ 500)

Immediate ART for children below 5 Immediate ART for children below 5 yearsyears

Lifelong ART in pregnant women Lifelong ART in pregnant women (option B/B+)(option B/B+)

Harmonization of ART across Harmonization of ART across populations (e.g., adults and pregnant populations (e.g., adults and pregnant women, B/B+) and age groups women, B/B+) and age groups

Simplified, fewer, and less toxic 1Simplified, fewer, and less toxic 1stst line line regimens (TDF/XTC/EFV)regimens (TDF/XTC/EFV)

Clinically relevantClinically relevantEarlier initiation of ART Earlier initiation of ART (CD4 ≤ 500)(CD4 ≤ 500)

Immediate ART for children below 5 Immediate ART for children below 5 yearsyears

Lifelong ART in pregnant women Lifelong ART in pregnant women (option B/B+)(option B/B+)

Harmonization of ART across Harmonization of ART across populations (e.g., adults and pregnant populations (e.g., adults and pregnant women, B/B+) and age groups women, B/B+) and age groups

Simplified, fewer, and less toxic 1Simplified, fewer, and less toxic 1stst line line regimens (TDF/XTC/EFV)regimens (TDF/XTC/EFV)

WHO ARV Recommendations - WHO ARV Recommendations - 2013 guidelines2013 guidelines

Operationally relevantUse of Fixed Dose Combinations as a preferred approach

Improved patient monitoring to support better adherence and detect earlier treatment failure (increased use of VL)

Recommend task shifting, decentralization, and integration

Community based testing to complement broader HTC

Operationally relevantUse of Fixed Dose Combinations as a preferred approach

Improved patient monitoring to support better adherence and detect earlier treatment failure (increased use of VL)

Recommend task shifting, decentralization, and integration

Community based testing to complement broader HTC

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04/19/23 7

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Transition in PMTCT Regimens in the Transition in PMTCT Regimens in the 22 Global Plan Priority Countries 22 Global Plan Priority Countries

After 2010 WHO PMTCT ARV Guidelines As of June 2013

Rapid Change Towards B/B+

2013

Option AOption BOption B+ Planned/pilotingOption B+ ImplementingNot a priority country

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Where are we…….? Where are we…….?

Progress has been made in the provision of ARTProgress has been made in the provision of ART

More than 7.5 million patients received ART by the end of 2012

ART coverage increased from 49% in 2010 to 64% by the end of 2012

ART coverage was more than 80% in 10 countries

63% of pregnant women living with HIV received ARVs for PMTCT in 2012, compared with 34% in 2009 – 12 countries with a coverage of 80% or more, with 5 of them having attained 90% coverage

Improved access to ART has led to a reduction in AIDS-related deaths from 1.3 million in 2009 to 1.2 million in 2012

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Estimated % of pregnant women living Estimated % of pregnant women living with HIV who received ARVs for PMTCTwith HIV who received ARVs for PMTCT

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Programmatic challenges – Programmatic challenges –

HIV treatment cascade for sub-Saharan Africa, 2012HIV treatment cascade for sub-Saharan Africa, 2012

Source: Global AIDS Report 2013, UNAIDSPeople no longer covered

People covered

Bounds of uncertainty

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CD4 Cell Count at Start of ART

Cells/µL

Canada

Country

Tanzania

Burundi

AustraliaRwanda

Zimbabwe

Mozambique

Malawi

Kenya

Zambia

Italy

France

India

Democratic Republic of Congo

Senegal

Botswana

South Africa

Singapore

Spain

Côte d'Ivoire

Mali

Brazil

Japan

Philippines

USA

South Korea

Cameroon

Uganda

Cambodia

Benin

Burkina Faso

Malaysia

Indonesia

Thailand

China

Nigeria

246( 234 to 257)

145( 133 to 158)

230( 211 to 248)

286( 265 to 306)287( 274 to 300)

139( 133 to 145)

263( 245 to 282)

166( 161 to 172)

203( 199 to 207)

174( 172 to 176)

262( 241 to 284)

278( 273 to 283)

234( 200 to 268)

163( 153 to 172)

137 ( 98 to 176)

200( 166 to 235)

150( 148 to 152)

169( 119 to 221)

231 (223 to 238)

215( 209 to 221)

187( 173 to 201)

225( 211 to 239)

252( 206 to 298)

187( 162 to 212)

307( 301 to 314)

217( 182 to 253)

154( 146 to 163)

176( 169 to 184)

196( 148 to 244)

149( 117 to 181)

269( 257 to 281)

158( 140 to 176)

89 ( 69 to 110 )

140( 129 to 151)

118 ( 98 to 139)

185( 175 to 195)

0 50 100 150 200 250 300 350Mugglin et al. CROI 2012

Low-incomeMiddle-incomeHigh-income

Mean CD4 cell count (95% CI)

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HIV/AIDS - Programmatic HIV/AIDS - Programmatic ChallengesChallenges

HIV/AIDS - Programmatic HIV/AIDS - Programmatic ChallengesChallenges

Progress made in PMTCT; however coverage in large countries like Nigeria and DRC still remains low; funding gaps for eMTCT plans

Treatment gap in children

Virtually no country in the Region is providing services for key populations on an adequate scale and intensity

Domestic investments are increasing; however donor dependence still remains a challenge -implementing the 2013 consolidated guidelines requires additional financial investment

Progress made in PMTCT; however coverage in large countries like Nigeria and DRC still remains low; funding gaps for eMTCT plans

Treatment gap in children

Virtually no country in the Region is providing services for key populations on an adequate scale and intensity

Domestic investments are increasing; however donor dependence still remains a challenge -implementing the 2013 consolidated guidelines requires additional financial investment

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Incidence on the decline since 2003

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DOTs ExpansionDOTs Expansion

Early case detection•Screen all persons with cough of more than 2 weeks for TB•Screen all eligible patients for drug resistance

Case management•Treat all patients with 6 month short-course treatment•Ensure all drug resistant TB patients are treated with appropriate WHO regimens

Engagement of all health care providers in above interventions

DOTs ExpansionDOTs Expansion

Early case detection•Screen all persons with cough of more than 2 weeks for TB•Screen all eligible patients for drug resistance

Case management•Treat all patients with 6 month short-course treatment•Ensure all drug resistant TB patients are treated with appropriate WHO regimens

Engagement of all health care providers in above interventions

TB/HIV TB/HIV CollaborationCollaboration

Intensified Case Finding(ICF)

• Screen all PLHIV for TB• Evaluate TB patients for HIV• Use Xpert MTB/RIF as initial

diagnostic test in PLH and suspected MDR-TB

• Start ART in all TB patients living with HIV irrespective of their CD4 counts

• Provide CPT for HIV positive TB patients

Isoniazid Preventive Therapy (IPT)

• Offer IPT to all PLHIV who do not have TB even if they are on ART

Infection Control• All facilities providing HIV care

should have TB infection control measures in place

TB/HIV TB/HIV CollaborationCollaboration

Intensified Case Finding(ICF)

• Screen all PLHIV for TB• Evaluate TB patients for HIV• Use Xpert MTB/RIF as initial

diagnostic test in PLH and suspected MDR-TB

• Start ART in all TB patients living with HIV irrespective of their CD4 counts

• Provide CPT for HIV positive TB patients

Isoniazid Preventive Therapy (IPT)

• Offer IPT to all PLHIV who do not have TB even if they are on ART

Infection Control• All facilities providing HIV care

should have TB infection control measures in place

Surveillance, Surveillance, M & EM & E

Register and report all TB cases

Monitor and document all treatment outcomes

Submit data for annual Global TB reports

TB prevalence survey

Operational Research

Strengthening health systems in endemic countries

Key interventions - TBKey interventions - TB

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TB case TB case detection has detection has risen from risen from 43% in 1990 43% in 1990 to to

59% in 201259% in 2012

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10 Countries reached the target CDR of 70%

18 Countries reached the target of 85% TSRtarget of 85% TSR

5 countries reached both targets in 2012

Angola, Botswana, Ethiopia, Ghana, Kenya, Lesotho, STP, Seychelles, Tanzania and Zambia

Algeria, Benin, Burundi, DRC, Eritrea, Ethiopia, Gambia, Ghana, Kenya, Liberia, Malawi, Mauritius, Nigeria, Rwanda, Senegal, Sierra Leone, Tanzania and Zambia

Ghana, Kenya, Seychelles, Tanzania, and Zambia

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Attainment of the global target of 70% Case Detection Rate (CDR) and 85% Treatment Success

Rate (TSR)- 2012

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TB - Programmatic ChallengesTB - Programmatic ChallengesTB - Programmatic ChallengesTB - Programmatic Challenges

Emergence of MDR/XDR –TB and the high costs associated with managing drug resistant TB

Weak laboratory capacity for TB culture and drug susceptibility testing

TB/HIV co-infection and access to ART for TB/HIV co-infected individuals (In 2012, 78% of TB patients tested; 37% HIV positive but only 55% accessed ART)

TB in high risk/hard to reach areas e.g. mines, prisons and nomadic populations

Emergence of MDR/XDR –TB and the high costs associated with managing drug resistant TB

Weak laboratory capacity for TB culture and drug susceptibility testing

TB/HIV co-infection and access to ART for TB/HIV co-infected individuals (In 2012, 78% of TB patients tested; 37% HIV positive but only 55% accessed ART)

TB in high risk/hard to reach areas e.g. mines, prisons and nomadic populations

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Malaria burden - 2012Malaria burden - 2012

80% of the estimated 207 million cases of malaria worldwide were in Africa

The estimated number of malaria cases per 1000 persons at risk of malaria reduced by 31% in the African Region between 2000 and 2012

Pregnant women and children under 5 years are among the most vulnerable groups in the African Region

90% of the estimated 627,000 malaria deaths worldwide in 2012 were in Africa

86% of malaria deaths were in children under 5 years in 2012

Malaria mortality rate decreased by 49% in the general population and by 54% in children under 5 years between 2000 and 2012

80% of the estimated 207 million cases of malaria worldwide were in Africa

The estimated number of malaria cases per 1000 persons at risk of malaria reduced by 31% in the African Region between 2000 and 2012

Pregnant women and children under 5 years are among the most vulnerable groups in the African Region

90% of the estimated 627,000 malaria deaths worldwide in 2012 were in Africa

86% of malaria deaths were in children under 5 years in 2012

Malaria mortality rate decreased by 49% in the general population and by 54% in children under 5 years between 2000 and 2012

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PreventionPrevention

Insecticide-treated bednets (ITNs) / Long-lasting ITNs (LLINs)Indoor Residual Spraying

In areas of moderate to high and stable transmissionIntermittent Preventive Treatment, in pregnancy (IPTp)IPT in infancy (IPTi)

In areas of high seasonal transmissionSeasonal malaria chemoprevention

PreventionPrevention

Insecticide-treated bednets (ITNs) / Long-lasting ITNs (LLINs)Indoor Residual Spraying

In areas of moderate to high and stable transmissionIntermittent Preventive Treatment, in pregnancy (IPTp)IPT in infancy (IPTi)

In areas of high seasonal transmissionSeasonal malaria chemoprevention

Diagnosis & Diagnosis & TreatmentTreatment

Parasite based diagnosis• Microscopy• Rapid Diagnostic Tests

Artemisinin-based combination therapies (ACTs)

Case management: • Health facilities• Community Case

Management (CMM)• Private sector

Diagnosis & Diagnosis & TreatmentTreatment

Parasite based diagnosis• Microscopy• Rapid Diagnostic Tests

Artemisinin-based combination therapies (ACTs)

Case management: • Health facilities• Community Case

Management (CMM)• Private sector

Surveillance, Surveillance, M & EM & E

Routine HMISMalaria surveillance systems

Household surveys

Operational research

Strengthening health systems in endemic countries

Key interventions - MalariaKey interventions - Malaria

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Progress: Scaling up malaria Progress: Scaling up malaria treatment with ACTs - 2012treatment with ACTs - 2012

Progress: Scaling up malaria Progress: Scaling up malaria treatment with ACTs - 2012treatment with ACTs - 2012

Where ACT use is currently planned Where malaria (treatment) occurs

43 out of 44 endemic countries have adopted use of ACT as a policy Only 18 countries are reporting country-wide implementation 20 countries have a policy on parasitogical testing of suspected

malaria cases in individuals of all ages Proportion of suspected malaria cases receiving a diagnostic test in

the public sector increased from 20% in 2005 to 47% in 2011 31 have introduced the use of ACTs at community level but only 6

have scaled up its deployment

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Non AFRO

CBIs planned to include use of ACTs (39)

CBIs not implemented (7)

ACTs at community level (17)

Non AFRO

CBIs planned to include use of ACT (7)

CBIs not implemented (8)

ACTs used at community level (31)

Progress: Implementation of CBIs and use of Progress: Implementation of CBIs and use of ACTs at community level in 2009 & 2012ACTs at community level in 2009 & 2012

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Progress made in Malaria Control - Progress made in Malaria Control - 20122012

IPTp adopted in all the 33 countries where it is recommended

Increased households owning at least one LLIN from 3% in 2000 to 53% in 2012

IRS implementation expanding in the region; population at risk protected rose from les 5% in 2005 to 11% in 2010

Pre-elimination initiative in 8 countries

Reduction of more than 50% of malaria cases and deaths in 12 countries

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Decrease in incidence of malaria cases in AFRO: Decrease in incidence of malaria cases in AFRO: 2000–20122000–2012

On track for >75% decrease in incidence (9)

50%–75% decrease in incidence

< 50% decrease

Insufficient data to make trend conclusions

BotswanaCape VerdeEritreaNamibiaRwandaSTPSouth AfricaSwazilandZanzibar

Ethiopia Zambia

Madagascar

Angola, Benin, Burkina Faso, Burundi, Cameroon, CAR, Chad, Comoros, Congo, Côte d’Ivoire, DRC, Equatorial Guinea, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, Liberia, Malawi, Mali, Mauritania, Mozambique, Niger, Nigeria, Uganda, Sénégal, Sierra Leone, South Sudan, Togo, Tanzania (Mainland)* and Zimbabwe

26

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Malaria - Programmatic Malaria - Programmatic ChallengesChallenges

Malaria - Programmatic Malaria - Programmatic ChallengesChallenges

Lack of Universal Access to malaria interventions

Emerging resistance to pyrethroids and other insecticides

Threat of resistance to artemisinin-based medications and other anti-malarials

Lack of quality trend data in several countries

Moving from accelerated control towards malaria elimination

Lack of Universal Access to malaria interventions

Emerging resistance to pyrethroids and other insecticides

Threat of resistance to artemisinin-based medications and other anti-malarials

Lack of quality trend data in several countries

Moving from accelerated control towards malaria elimination

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Prospects for the Future – HIV/AIDSProspects for the Future – HIV/AIDS

MDG Target 6A: Have halted by 2015 and begun to reverse the spread of HIV/AIDS.

38.5% reduction in the regional incidence of HIV between 2001 and 2012. 34 countries with decreasing trend, with notable reductions in the incidence

MDG Target 6B: Achieve, by 2010, Universal Access to treatment for HIV/AIDS for all those who need it.

By the end of 2012, 68% of eligible PLH were receiving ART, an increase of more than 90% since 2009.

Most countries in the region have scaled up access to ART, but only 10 countries have attained the target of 80% ART coverage

16 countries with coverage below 50%.

More needs to be done to achieve the HIV/AIDS-related MDG Targets

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Prospects for the Future – TBProspects for the Future – TB

Target 6C: Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases.

Incidence of tuberculosis decreased in 25 countries while it increased or remained the same in 21 countries

On the whole, the MDG target for TB has been achieved for the African Region

The gains made need to be sustained and the challenges related to HIV and TB drug resistance addressed

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Prospects for the Future – MalariaProspects for the Future – Malaria

Target 6C: Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases.

The incidence of malaria reduced by 31% between 2000 and 2012 in the African region

It is expected to decrease by 39% in the Region by 2015, if the current annual rate of decrease is maintained.

12 countries are on course to meet the MDG target However, the 2015 projected reductions in malaria incidence and mortality are well

below the WHA and RBM 2015 targets of reducing malaria incidence rate by 75% and achieving near zero malaria deaths.

More needs to be done to achieve the Malaria-related MDG Target

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Prospects for the Future – HIV, TB & Prospects for the Future – HIV, TB & MalariaMalaria

Countries to make smart investments for enhanced impact on disease burden

More effectively target interventions to “hotspots” or areas or populations with the greatest needs

Focus on areas where progress has been limited Make use of new opportunities Increase investment in health systems Improve the monitoring of progress made and the use of data for

decision-making

Countries to plan for the post-2015 era to improve Universal Health Coverage

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Prospects for the Future – – HIV, TB & Prospects for the Future – – HIV, TB & MalariaMalaria

Partners to

Focus on areas of comparative advantage to enhance coordinated support to countries

Development partners to focus on strategic and catalytic upstream actions

Implementing partners to focus on operational level actions

Improve collaboration among ourselves

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