Dr R.C Choto Ministry of Health and Child Care, Zimbabwe 23 July 2017 MOHCC Guidelines and Operational Service Delivery Standards: The ‘What' and the ‘How' of Treat All in Zimbabwe Dr R.C Choto Ministry of Health and Child Care, Zimbabwe 23 July 2017

Presentation Outline Country HIV Context Progress towards achieving the 90 – 90 – 90 targets Achievements & Challenges Innovative approaches to address challenges The ‘What’ and the ‘How’ of the Zimbabwean ‘Treat All’ guidelines Conclusion

Country HIV Perspective Total Popn ~ 13 million (2012 Census) Zimbabwe remain one of the countries in the world heavily burdened by HIV/AIDS & TB 1.3M PLHIV (7% are children) (2016 HIV estimates) HIV Prevalence: 13.8% among 15-49 yr age group Female 16.7% Male 10.5% HIV Incidence: 0.48 in 2016 (down from 1.42 in 2011, 0.98 in 2013) (ZIMPHIA, 2016) Overall ART coverage of 77.4% 1st line: 96,07% 2nd line: 3.9% 3rd line: <0.02% (MOHCC quarterly report, Mar 2017) Zimbabwe has a projected population of 13m people and is among the countries in Sub-Saharan Africa worst affected by the HIV

Zimbabwe TB case notifications versus ART coverage, 2000-2013

Zimbabwe has made great progress in controlling the HIV epidemic and is well positioned to achieve the 90-90-90 Fast Track Targets The biggest gap to achieving the 90-90-90 targets is in testing. The new national HTS Strategy (2016- 2020) shifts focus from testing for coverage to targeted testing for identification of those living with undiagnosed HIV. Note: Current status as of 2016 Source: ZIMPHIA, 2016; Spectrum Zimbabwe National HIV Estimate

Gaps still remain particularly pronounced among key populations……..

Missed Opportunities in National HIV Testing Services Cascade, Jan - Dec 2016 99% 97% 3% Retest New test 7% 98% 2%

Missed Opportunities in STI Clients HIV Testing Cascade Jan-Dec 2016 Repeat cases 83% New cases 68% 17% 32% 12% 12% HIV+ rate, 49% of all cases received HIV test, 67% offered HIV tested were tested

Innovative approaches in addressing the 1st 90 Revision of HTS strategy to align with 90.90.90 global targets Adoption of 2015 HTS Guideline as well as 2015 WHO HIV Prevention and ART guidelines Strengthened Provider Initiated Testing and Counselling Community based targeted testing including index case testing Moonlighting testing services for hot spots and key population Targeted testing in hot spot areas including tertiary institutions Piloting of HIV Self testing (HIVST) using community based distribution models HIVST for key populations (FSW) and their clients) Distribution HIVST to partners of PMTCT mothers

Progress in achieving the 2nd 90% 2004 5% coverage 2016 achievement – 77.4% Adults – 72.2% Children – 92,9%) 2020 Target – 81% Source: 2016 HIV Estimates Rapid increase in ART coverage attributed to: High political will and commitment Task shifting of HIV services i.e. HIV Testing Services to Primary Counsellors (PCs) and ART initiation to nurses Resilient and dedicated Human Resources for Health (HRH) Robust and evidence informed National Strategic Plans Strong partnerships with donor community i.e. Global Fund, PEPFAR, DFID etc

Missed opportunities in ART retention among adolescents & young people, which still remain relatively low NB: Age groups exclude pregnant women at ART initiation Barriers to Retention B. Phelps, Linkage, initiation and retention of children in the antiretroviral therapy cascade: an overview, AIDS. Nov 2013; 27.. Very high overall national ART retention rates at 12 and 24 months of 87.7% and 83.0% respectively ART Outcome Study Report, 2016

Missed Opportunities in the HIV Care & Treatment Cascades, Jan - Dec 2016

Missed Opportunities in the PMTCT maternal cascade, Jan – Dec 2016

Innovative strategies being explored to achieve 2nd 90% Country adapted ‘TREAT ALL’ strategy and currently scaling it up Scale up of innovative strategies to improve quality of care linkages to care & retention in care Peer to peer support i.e. use of expert patients in defaulter tracking and navigation of patient referrals Differentiated Service Delivery (DSD) models of care Family Centred approaches Quality improvement approaches ‘One stop shop’ approaches for TB & HIV care services Capacity building for human resources for health.

Progress in achieving the 3rd 90% Despite the ZIMPHIA showing remarkable VL suppression rates among ‘those on ART’ (86%), viral load testing coverage still remains low (6.1% in 2015 and 17% in 2016) due to Low demand creation Challenged laboratory diagnostic and monitoring systems Continued leakages along the VL cascade of care Weak sample transportation systems in place

Innovative strategies explored to achieve 3rd 90% Viral Load scale up plan (2015 – 2018) developed to guide phased rolled out Integrated sample transportation system being set up leveraging on already established Early Infant Diagnosis (EID) sample transportation Viral Load TWG set up to coordinate scale up

National Consolidated Guidelines for the use of ART for the Prevention Care & Treatment of HIV New changes include Adoption of ‘Treat all’ strategy Use of TDF/3TC/EFV and ABC based regimens as preferred first line Retesting at ART initiation; Oral pre-exposure prophylaxis (PreP) HIV and co-morbidities Differentiated Service Delivery models, Treat all PLHIV regardless of CD4 count and clinical stage with measures put in place to ensure patients are adequately prepared for ART through counselling and linked to support systems TDF/3TC/EFV and ABC based regimens to be preferred first line regimen for adults/adolescents and children respectively; Retesting all patients at ART initiation; Provision of oral pre-exposure prophylaxis (PreP) for people at substantial risk of contracting HIV; Screening and management of HIV and other coinfections and co morbidities including mental health ailments and non-communicable diseases; Provision of care through differentiated care models, focusing on service intensity & frequency through different providers in different locations; Strengthening routine viral load monitoring with priority given to at risk population i.e. pregnant mothers, adolescents and those with possible treatment failure

OSDM for the Prevention, Care and Treatment of HIV in Zimbabwe Guidance on the “how to” to implement the National ARV Guidelines Defines the minimum package for care for PLHIV & scope of practice for HWs Emphasizes integration of services Identifies Differentiated care strategies across the HIV cascade Highlights special considerations for children, adolescents, pregnant and lactating women, men and key populations (KPs) Four models for ART delivery shown It outlines the “how to” on the implementation of the national guidelines, defining a minimum package of care at each level of service delivery and emphasizing integration of services The OSDM identifies differentiated care strategies across the whole continuum of care, highlighting special considerations for varios groups such as adolescents and pregnant women

Consolidated HIV and AIDS Job Aide Compliments the HIV guidelines & the Operations and Service Delivery Manual (OSDM) Desk formatted, user friendly job aide for day to day use by health care workers providing HIV prevention, care and treatment services Each section highlights Key messages and important HIV cascade algorithms to guide patient management

Dissemination of Revised HIV Guidelines since Launch Dissemination of guidelines to health workers, policy makers, PLHIV, community & civil society through meetings, print and digital media National sensitisation on the OSDM, Job Aide and guidelines – all provinces, partners, mentors Provinces further cascading to their districts with national level support Nurse tutors trained; updating pre – service training package to include TREAT All & Differentiated Service Delivery Revision of the Integrated HIV Training (HIT) curriculum for in – service training

Tools for monitoring and evaluation of Revised HIV Guidelines HIV M&E tools Updated to capture new data points including Family Centred Care, CARGs Indicator guides updated Sensitizations, trainings and mentorships of health workers on utilization of revised tools commenced and ongoing Electronic Patient Monitoring System Updated to reflect changes in source documents

Conclusion Zimbabwe is on right track in its quest to achieve the 90 – 90 – 90 targets by 2020 Concerted efforts from all stakeholders required to ensure sustainable right quality of care to the right client all the time Source: Unknown

Acknowledgements: PEPFAR, USAID and its implementing partners OPHID and FACE-HIV partners ( KAPNEK, ZAPPT) National AIDS Council (NAC) UN Family (WHO, UNICEF, UNDP, UNFPA etc.) The Global Fund Other key partners (MSF, CHAI, WEI, Pangea Zimbabwe, Solidamed, AFRICAID, ZNNP+, Newlands Clinic) MOHCC ( PMDs and DMOs and all heath care workers)