Mean Chhi Vun, MD, MPH NCHADS Director [email protected] Update on HIV and STI Epidemic and its Response, July 2010.

Mean Chhi Vun, MD, MPHMean Chhi Vun, MD, MPHNCHADS DirectorNCHADS [email protected]@nchads.org

Update on HIV and STI Epidemic Update on HIV and STI Epidemic and its Response, July 2010and its Response, July 2010

0.6

0.9

0.7

0.17

1.01.11.2

1.41.5

1.6

1.92.0

1.9

1.7

1.2

0.9

0.80.7

0.60.60.70.7

0.9

0.0

0.5

1.0

1.5

2.0

2.5

1995 96 97 98 99 2000 01 02 03 04 05 06 07 08 09 10 11 2012

HIV Prevalence AEM-Projected of HIV HIV Incidence Among ANC

1- HIV Prevalence Among Adult pop. 15-49 between 1995 and 2006

2- AEM-Projected Prevalence of HIV among the general population aged 15-49 year from 2006 to 2012 (With ART available)

3- HIV Incidence * among ANC by Survey year

Current HIV Status in Cambodia

33

Adjusted HIV prevalence* among DFSW, by Adjusted HIV prevalence* among DFSW, by age group and year, 1998-2006age group and year, 1998-2006

24.8

15.2

7.8

2.8

43.5 40.4

34.229.9

41.3

32.2

24.1

19.7

0

10

20

30

40

50

1998 1999 2000 2001 2002 2003 2004 2005 2006

Per

cen

t

20 years and older

<20 years

*Adjusted for results of quality assurance testing

STI prevalence among MSM by survey site

Source: NCHADS, Cambodia STI Survey 2005

STI Prevalence 1996-2005 – Brothel-based Sex Workers

0%

5%

10%

15%

20%

25%

Pre

vale

nce

1996 23.2% 22.5% 13.8% 5.4%

2001 14.2% 12.1% 2.8% 2.1%

2005 13% 14% 2.30%

Gonorrhea Chlamydia Syphilis RPR Trichomonas

Source: NCHADS 2002, Ryan et al 1998

Source: NCHADS, Cambodia STI Survey 2005Source: NCHADS, Cambodia STI Survey 2005

STI prevalence among FSW by survey year

STI cases diagnosed & treated among EWs, 2007 to 2009 STI cases diagnosed & treated among EWs, 2007 to 2009

Based on quarterly report of the Data Management Unit/NCHADS

STI cases : cervicitis, cervicitis + vaginitis, PID, GU, GW, syphilis by RPR (+),

8

HIV prevalence by drug use, July to October 2007

19.1%

25.1% 24.4%

1.3% 0.7% 1.1%

0%

20%

40%

Rehab Community Total

IDU Non IDU

Note: there were 6 HIV+ among 27 women drug users recruited from community

(5.4%-41.9%)

(0.2%-3.7%)

(17.9%-32%)

(0.7%-2.3%)

(16.4%-33.2%)

(0.4%-3.2%)

HIV Screening among Pregnant Women at ANC, Q1 2010HIV Screening among Pregnant Women at ANC, Q1 2010

0.39% 0.17% 0.18% 0.07% 0.25% 0.10% 0.10%

70.4%

86.5%

  Number of Samples Tested Each Month – 2010    Data Source: DNA PCR Register June  

     Total Samples Tested Samples Negative Samples Positive    January 32 31 1   February 78 74 4   March 52 51 1   April 58 52 6   May 98 84 14   June 50 46 4   July (so far) 60 55 5            

Prevention Package: Behaviour Change Programme: the 100% Condom Use

package (condom promotion, targeted STI care, outreach to sex workers), interventions for non-brothel-based sex workers, outreach for other high risk group, and IEC

Two complementary STI Services for high and low risk groups Continuum of Care Package

The Continuum of Care for PLHA: establishing the Continuum of Care itself, Health Facility Based Care including ART, Home-based Care, Voluntary Confidential Counselling and Testing, and Universal Precautions

Linking HIV/STI/RH/MNCH/TB services at OD level Research and Surveillance Package

HIV/AIDS and STI Surveillance and Research Management package

Planning, Resource Management and Coordination of the Programme; decentralization to Province and OD; integration within the health sector

Monitoring, Reporting and Evaluation

HIV Response in the Health sector, 1998 to 2009

Update the Result of HIV and Update the Result of HIV and STI ResponseSTI Response

(Sexual Behavioral among EW)

CD4<= 250 cc/mm3

Adult: 35,100

Children:4,500

T: 39,600

39,600

CD4<= 350cc/mm3

A: 42,000

C: 4,500

T: 46,500

Number of ART sites and Number of Active Patients on ART

from 2001 to Q2, 2010

1 24

11

32

4447 48 49 50

1

11

1922

27 2931

71 3922,230

5,974

12,355

20,131

26,664

31,19937,315

40,039

5,522

11,284

18,344

24,123

28,932

33,66736,158

452 1,071 1,787 2,541 3,0673,638

3,881

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000

0

10

20

30

40

50

60

2001 2002 2003 2004 2005 2006 2007 2008 2009 Q2-2010

# of all ART sites # of Child on ART sites # of all Active Patients on ART # of Adult on ART # of Children on ART

% of PLHIV on ART are still alive at 12 month after ART initiation (A:86.7% and C: 93.9%)% of PLHIV do not lost to follow up at 12 month is > 90%% of PLHIV are still on first line regimen at 12 month after ART initiation is > 90%

Actual number of Patients Receiving ART in Q2/2010

40,03436,153

3,881

6,166

5,847

619

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000

50,000

Total Adult ChildrenEs

tim

ate

d n

um

be

r o

f p

eo

ple

in

ne

ed

of

AR

T

on ART not yet on ART

(86.2%)

(86,3%) (86%)

2010: CD4 < 350cells/mm3

A: 42,000

C: 4,500

T: 46,500

PMTCT: Result from 2005 to 2007, PMTCT: Result from 2005 to 2007, Prior Linked ResponsePrior Linked Response(source: NCMCHC/ NCHADS/WHO)(source: NCMCHC/ NCHADS/WHO)

IndicatorsIndicators 20052005 20062006 20072007

Estimated # PWEstimated # PW 461,000461,000 461,000461,000 442,000442,000

Estimated # and % Estimated # and % of HIV PWof HIV PW

9,700 9,700

(2.1%)(2.1%)

9,7009,700

(2.1%)(2.1%)

4,5094,509

(1%)(1%)

# and % of PW # and % of PW tested for HIVtested for HIV

17,38217,382

(3.8%)(3.8%)

33,25133,251

(7.2%)(7.2%)

55,99455,994

(12.6%)(12.6%)

# and % of PW # and % of PW identified HIV +identified HIV +

279279

(1.6%)(1.6%)

383383

(1.1%)(1.1%)

435435

(0.77%)(0.77%)

# and % HIV PW # and % HIV PW who received ARV who received ARV Prophylaxis or Prophylaxis or HAARTHAART

228228

(2.4%)(2.4%)

312312

(3.2%)(3.2%)

505 505 (11.2%)(11.2%)

(405 were on OI/ART(405 were on OI/ART

before pregnancy)before pregnancy)

# Exposed Children # Exposed Children tested for HIVtested for HIV

NANA 66

(3 HIV +)(3 HIV +)

7373

( HIV +)( HIV +)

% of Exp. Children % of Exp. Children who received ARV who received ARV ProphylaxisProphylaxis

2.4%2.4% 3.3%3.3% 11.5%11.5%

PMTCT: Result from 2006 to 2009 PMTCT: Result from 2006 to 2009 (source: NCMCHC/ NCHADS/WHO)(source: NCMCHC/ NCHADS/WHO)

IndicatorsIndicators 20062006 20072007 20082008 20092009

Estimated # PWEstimated # PW 461,000461,000 442,000442,000 342,756342,756 348,536348,536

Estimated # and % Estimated # and % of HIV PWof HIV PW

9,700 9,700

(2.1%)(2.1%)

4,5094,509

(1%)(1%)

2,8792,879

(0.8%)(0.8%)

2475 2475

(0.7%)(0.7%)

# and % of PW # and % of PW tested for HIVtested for HIV

33,25133,251

(7.2%)(7.2%)

55,99455,994

(12.6%)(12.6%)

67,97767,977

(19.8%)(19.8%)

146,453146,453

(42%)(42%)

# and % of PW # and % of PW identified HIV +identified HIV +

383383

(1.1%)(1.1%)

435435

(0.77%)(0.77%)

435435

(0.77%)(0.77%)

306306

(0.48%)(0.48%)

# and % HIV PW # and % HIV PW who received ARV who received ARV Prophylaxis or Prophylaxis or HAARTHAART

312312

(3.2%)(3.2%)

505 505 (11.2%)(11.2%)

(405 were on(405 were on

OI or ART, prior OI or ART, prior pregnancy)pregnancy)

614 614 (27%)(27%)

(363 were on OI (363 were on OI or ART, before or ART, before pregnancy)pregnancy)

798 798 (32.3%)(32.3%)

(482 were on (482 were on OI or ART, OI or ART, before preg.) before preg.)

# Exposed Children # Exposed Children tested for HIVtested for HIV

66

(3 HIV +)(3 HIV +)

7373

( 17 HIV +)( 17 HIV +)

283283

(27 HIV +)(27 HIV +)

288288

(27 HIV +)(27 HIV +)

% of Exp. Children % of Exp. Children who received ARV who received ARV ProphylaxisProphylaxis

3.3%3.3% 11.5%11.5% 22%22% 29%29%

LR

Service utilization rate for target populations, April 2008 to December 2009Service utilization rate for target populations, April 2008 to December 2009

0102030405060708090

100Acceptance at ANC

Coverage of HIV testing for pregnant women

Acceptance of HIV testing of PW

Acceptance of HIV testing, partners

Enrollment into PMTCT services

ARV prophylaxis or ART among PW

ARV prophylaxis administered to infant

Linked response Standard (%)

Service utilization rate for target populations, April 2008 to December 2009Service Utilization Rate for Target Population, April 2008 to 2009

HIV Response in the Health Sector 2010 to 2015:

To avoid the 2nd Wave of HIV Epidemic

To Eliminate Pediatric HIV (<2% by 2020)

Main Route of HIV TransmissionMain Route of HIV Transmission

High risk Population

Partner Spouse

HIV, STI HIV, STIHIV, STI

HIV

MSM

HIV

SW

DU/IDUHIV

CoPCT: Combination of HIV Prevention and Care including treatment among General population and MARP (EW)

Health service delivery at OD

Public and NGO-Private

VCCT, STI, OI-ART(A and P)

ANC, BS/FP, Safe Delivery, EPI, Nutrition (children)

Safe abortion

TB, Malaria

Laboratory

EW and Partners

Community

Create Demand

EW Network:

PE and PF

NGO

HBC Team

PHC Volunt

CBO

NGO

Health Workers

RRT

Referral and Follow up Mechanism for the LRReferral and Follow up Mechanism for the LR

HC

+ +

HCSatellite

HC

Hub - RH

+

Community

VCCT

OI/ART, PAC, VCCT, ANC, BS, Safe Delivery, STI, EPI, TB, Nutrition, Lab, LSM, DM, TB + (HIV testing)

HIV information, Blood Draw for HIV testingTB + (HIV testing)

Linked HIV Testing, VCCT, Safe Delivery, TB + (HIV testing)

Referral and Follow-up

Re

ferr

al a

nd

Fo

llow

-up

Refer

ral a

nd F

ollow

-up

Referral and Follow-up

Re

ferr

al a

nd

Fo

llow

-up

VCCT

The 3 “S” StrategyThe 3 “S” Strategy

Referral & Follow

-up

OD Management Team:

Facilitate coordination between health service providers, between

facilities and community based support

Manage data to monitor and improve service delivery

Monitor progress of mother-infant pairs

Referral & Follow-up

Ref

erra

l & F

ollo

w-u

p

“S” No. 1

Strengthening linkages between facilities and communities

Home-based Care

CBS

CBS

Community-based Support (CBS)

“S” No. 2

Strengthening linkages between and within facility based services

“S” No. 3

Strengthening linkages within communities

Referral and Follow-upANC, Labor & Delivery,

Family Planning, TBVCCT, PMTCT, Pediatric AIDS Care, OI/ART, STI

Health Facilities

Community

Integrated HIV and STI into Health Service Delivery (Public and NGO including Private) (1)

VCCT: Entry point for HIV prevention and care including treatment 2010- 2011:

• Increase VCCT from 233 sites in 2009 to 245 sites in 2010 and 260 sites in 2011

• Increase the uptake of VCCT service from 600,000 in 2010 to 800,000 in 2011

• Increase the uptake of VCCT service among EW by 50% in 2011 (if enabling environment being existed)

STI Services: 2010 – 2011:

• FHC (available at Provincial Hospital and some RH at OD): 32 sites in 22 provinces

• Increase FHC from 32 sites in 2010 to 35 sites in 2011

• NGO STI clinic: 26 clinics in 11 provinces and PP

• Establish CQI for STI service: ongoing

• Increase the uptake of STI service among EW (if enabling environment being existed)

Integrated HIV and STI into Health Service Delivery (Public and NGO including Private) (2)

OI and ART service: 2010- 2011

• Increase OI/ART sites for Adult PLHIV from 50 sites in 2010 to 53 sites in 2011

• Increase the ART coverage from 90% in 2010 to 95 % in 2011

• Increase PAC from 33 sites in 2010 to 43 sites in 2011 ( being integrated in some Adult services)

• Increase PAC coverage from 90 % in 2010 to 95 % in 2011

Laboratory to support HIV Service: 2010 -2011

• Increase CD4 testing (free of charge for PLHIV): 7 sites in 2010 to 9 sites, if needed

• Increase the uptake of CD4 testing from 70,000 in 2010 to 90,000 in 2011

• Start the Viral load testing (free of charge for PLHIV) at NCHADS Lab in early 2011

• Contribute to strengthen integrated laboratory at Province and OD

Positive prevention among PLHIV: 2010 – 2011:

• Start the integration of BS/FP at OI and ART services for HIV women (condom distribution for free, oral pill, Progesterone Injection) by BS staff 2 to 3 days per week) in late 2010:

URC is committed to cover the user fee for contraceptive under health equity fund PSI and AHF are committed to donate condom for free ( 2 to 3 millions pieces per year) NCMCHC is committed to supply the contraceptive

Integrated HIV and STI into Health Service Delivery (Public and NGO including Private) (3)

Elimination of Pediatric HIV: 2010- 2011

• Scale up LR country wide in 2011• Strengthen the Referral and Follow up mechanism to support HIV positive

mothers and their babies focusing on the HIV newly identified (active search approach)

• Improve General Pediatric Care including Pediatric AIDS Care• Strengthen Positive Prevention through Integration of Birth Spacing service

at OI and ART service• Improve collaboration between HIV/STI/RH including MNCH

through joint work plan, joint training activity, joint logistic supply management, joint monitoring including reporting

• Strengthen harmonization and alignment amongst partners through common vision, common strategic plan, common monitoring

Reduce drastically TB infection among PLHIV: Expansion the implementation of 3 I (ICF,IPT and IC) from 21 OI and ART sites

to 35 sites in 2011 and country wide in 2012 CoPCT at prison:

Expansion CoPCT from 5 prisons to 10 selected prisons

Started in 2008-2009

Started in 2010

Scaling up Phase of Linked Response

Year Province OD HC

2008 2 5 67

2009 8 17 251

2010 7 44 434

Total 17/24 66/76 752

6

7

1

11

1

1

1

4

2011

Integrated Monitoring of HIV services and Linked with RH/MNCH/TB/Lab

Integrated HIV and STI Surveillance System: being started in 2014 HIV and STI Surveillance in 2010-2011: NCHADS and Partners

BSS (Round 8): ongoing (Data Analysis being finalized in Dec 2010) HSS (Round 11): ongoing (Data Analysis be finalized in early 2011) SSS (Round 4): will be started in 2011 Bros Khmer Study (FHI/NCHADS): ongoing HIV related Operational Research: BCC, clinical trial,...

QA for HIV services: Early Warning Indicators Assessment: Annually then every two years (2010:

ongoing) CQI for OI and ART service: Expansion and will include the LR services in 2011 ARV Drug Resistance Study: ongoing ART regular monitoring system: ongoing

HIV and STI Case Notification (Routine reporting): Longitudinal data base system for HIV and STI patient: on the process Linking HIV data base system with TB and RH/MNCH/Lab: be started in 2011 Be integrated in the HIS at OD level: being started in 2012

Conclusion: Is it possible to avoid the 2nd wave of Epidemic and to eliminate Pediatric HIV in Cambodia ?

Yes: Strong Political Commitment at all levels, especially Samdeach Prime Minister Strong ownership for the program implementation at all levels:

• clear and common vision, • strong leadership with clear strategic and innovative thinking (team work)• good management with transparency and accountability • Common strategic plan with Integrated or joint WP, Monitoring, LSM and capacity

building, common intervention model or approach with rapid expansion . Good partnership: all partners (government and development partners)

• Share vision, strategic intervention (model or approach), monitoring• Good coordination at all levels through the existing mechanism (not competition)

Integration or Linking services:• CoPCT• Linked Response between HIV/STI/RH including MNCH/TB/Lab/other chronic

diseases• Integrated monitoring

Decentralization to OD level: resource (human and $) and capacity Participation of the PLHIV network, CBO

Thank youThank you