Universal Access to HIV/AIDS, TB and Malaria Services in Africa; Challenges and Prospects
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Transcript of Universal Access to HIV/AIDS, TB and Malaria Services in Africa; Challenges and Prospects
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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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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
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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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