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Michael Bartos (bartosm@unaids) UZ-UCSF Annual Research Day 17 April 2015

Fast-track to ending AIDS in Zimbabwe: 90.90.90 opportunities. Michael Bartos (bartosm@unaids.org) UZ-UCSF Annual Research Day 17 April 2015. Outline.

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Michael Bartos (bartosm@unaids) UZ-UCSF Annual Research Day 17 April 2015

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  1. Fast-track to ending AIDS in Zimbabwe: 90.90.90 opportunities Michael Bartos (bartosm@unaids.org) UZ-UCSF Annual Research Day 17 April 2015

  2. Outline 1. Why the 90.90.90 TARGETS?2. TESTING – SHIFTING TO YIELDS3. TREATMENT ACHEIVEMENTS AND CHALLENGES4. SUSTAINING VIRAL SUPPRESSION5. FINANCING THE RESPONSE6. CONCLUSION

  3. New HIV infections in low- and middle-income countries, 2010–2030, with achievement of ambitious Fast-Track Targets, compared to maintaining 2013 coverage

  4. AIDS-related deaths in low- and middle-income countries, 2010–2030, with achievement of ambitious Fast-Track Targets, compared to maintaining 2013 coverage

  5. Ending the AIDS epidemic: A working definition ‘Ending the AIDS epidemic as a public health threat by 2030’ is provisionally defined as ‘reducing new HIV infections, stigma and discrimination experienced by people living with HIV and key populations, and AIDS-related deaths by 90% from 2010 levels, such that AIDS no longer represents a major threat to any population or country’

  6. Global targets for ending the AIDS epidemic

  7. Ambitious but achievable treatment target

  8. By 2020… 90% of all people living with HIV will know their HIV status 90% of all people diagnosed with HIV will receive sustained antiretroviral therapy. 90% of all people receiving antiretroviral therapy will have durable suppression.

  9. What would ending AIDS targets look like for Zimbabwe – 2030 results ? New infectionsdown 13% year on year 100,000 in 2010 currently (2013) 69,000 to 63,000 in 2015 (current projection) to 25,000 in 2020 and 10,000 in 2030 AIDS deaths down from 90,000 in 2010 currently (2013) 64,000 to 27,000 in 2015 (current projection) to 9,000 in 2030

  10. Outline 1. Why the 90.90.90 TARGETS?2. TESTING – SHIFTING TO YIELDS3. TREATMENT ACHEIVEMENTS AND CHALLENGES4. SUSTAINING VIRAL SUPPRESSION5. FINANCING THE RESPONSE6. CONCLUSION

  11. Testing: volume or yield? Current test volume 2.5m, 2018 target 3m annually

  12. Testing – results from the 2013 MICS % of sexually active young people tested in past 12 months All – ever tested Tested past 12 mths

  13. Korenromp and Stover, Democratizing Testing, UNAIDS April 2015

  14. HIVST market intervention

  15. Outline 1. Why the 90.90.90 TARGETS?2. TESTING – SHIFTING TO YIELDS3. TREATMENT ACHEIVEMENTS AND CHALLENGES4. SUSTAINING VIRAL SUPPRESSION5. FINANCING THE RESPONSE6. CONCLUSION

  16. Zimbabwe ART coverage targets 2014-2016 Ending AIDS 81% coverage target

  17. Outline 1. Why the 90.90.90 TARGETS?2. TESTING – SHIFTING TO YIELDS3. TREATMENT ACHEIVEMENTS AND CHALLENGES4. SUSTAINING VIRAL SUPPRESSION5. FINANCING THE RESPONSE6. CONCLUSION

  18. Retention of Patients Initiating ART During 2007-2009, Zimbabwe • Good retention in care observed in a retrospective cohort study in a nationally representative sample of patients initiating ART between 2007 and 2009 • 69% of patients were continuing ART treatment at 24 months, whereas 7% had died and 24% were lost to follow-up (MOHCW, 2012)

  19. 90% of those on ART virally suppressed: trade offs? • Initiation vs. retention • Routine viral load vs. ‘on demand’ • Maximally effective regimen vs. maximally forgiving regimen

  20. Community ART refill groups Model • self-selecting patient groups (7-14) • one representative picks up  ARVs for the group on quarterly basis • group contribute money for transport/ lunch/in kind support (eg work their fields) Results: 9 months pilot evaluation (n=207) • 100% retention, 99% virally suppressed • Time saving: normally 45mins waiting, 50 mins with staff (nurse, counsellor, pharmacist); ART refill groups: 30 mins to serve 8 patients – saving >10 person/hours per day in a busy 3 person clinic • Cost savings to patients from $14 per month to $48 (more remote areas) • Secondary benefits in increased resilience, reduced stigma, more participation in health governance.

  21. Outline 1. Why the 90.90.90 TARGETS?2. TESTING – SHIFTING TO YIELDS3. TREATMENT ACHEIVEMENTS AND CHALLENGES4. SUSTAINING VIRAL SUPPRESSION5. FINANCING THE RESPONSE6. CONCLUSION

  22. Building on past achievements: funds invested in AIDS programmes in low- and middle-income countries, 1986–2013 PEPFAR: The United States President’s Emergency Plan for AIDS Relief Sources: UNAIDS estimates, UNAIDS–Kaiser Family Foundation reports on financing the response to HIV in low- and middle-income countries, GARPR 2014, philanthropic resource tracking reports from Funders Concerned About AIDS, reports from the Global Fund and UNITAID.

  23. Potential room for expansion: per capita health assistance, selected countries Zimbabwe

  24. Public resource Availability for AIDS in Zimbabwe, 2009-2016, US $ million

  25. Resource needs for AIDS 2015-2025 in two different scenarios: current coverage and enhanced, more efficient coverage

  26. Additional impact: infections averted

  27. Additional impact: deaths averted

  28. Sustainability will require much more community delivery Patient-driven diagnostics and regimen switching Testing – shift from undifferentiated to targeted yield No one turned away More money will be needed (also to turn off the tap) conclusion

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