Meeting the Challenge of HIV/AIDS in South Africa: Exploring Strategy and Tactics to Expand the National Response PMTCT James McIntyre Anova Health Institute, Johannesburg, South Africa

“We have effective drugs. There is no reason why any mother should die of AIDS. There is no cause for any child to be born with HIV If we work hard enough we can virtually eliminate mother-to-child transmission.” Ban Ki Moon NY, September 2009

NSP targets

What are the implications of inadequate PMTCT rollout? Estimates from the WHO Access report 2008: South Africa: Women in need of PMTCT intervention ( – ) Estimated PMTCT coverage57% (49 – 69%) Estimated transmission in unidentified HIV +ve women25% Results in: additional infected children annually Towards Universal Access Scaling up priority HIV/AIDS interventions in the health sector Progress Report 2008: WHO

Opportunities & Obstacles

HIV prevalence among pregnant women in South Africa, 1990 to 2008

Reality Check: a question of scale Annual pregnancies in HIV positive women: United States< 7,000 Namibia 7,600 Botswana 14,000 Europe 15,000 Kenya100,000 South Africa300,000 Soweto 9,000

Reality Check CD4 counts need to be available for HIV positive pregnant women in order to decide on appropriate treatment options, and few PMTCT services have moved to include CD4 at all health service levels Provision of more complex ART requires more laboratory and toxicity monitoring, additional procurement infrastructure, and more intensive follow up Most PMTCT services (based on antenatal care) do not yet have the capacity to deliver ART

Proportion of antenatal clients tested by district T Doherty, District Health Barometer, 2007/2008., HST 2009 The average HIV testing coverage rate for the metro districts was lower than the national average. Only two metro districts, City of Cape Town and City of Johannesburg achieved higher than the national average. The coverage in Ekurhuleni, Tshwane and especially eThekwini, with a 52% testing rate, is particularly concerning… National Average: 80%

Nevirapine uptake by district T Doherty, District Health Barometer, 2007/2008., HST 2009 National Average: 76%

Opportunities and Obstacles The Implementation Challenge

. Efficacy of PMTCT programs is related to more than just the PMTCT regimen used To provide PMTCT interventions - need to identify HIV- infected women during pregnancy. Regardless of what PMTCT intervention, it must reach and be accepted by the woman. Program efficacy is likely to be more related to PMTCT cascade efficacy than PMTCT regimen efficacy Coverage and linkages

The uptake of PMTCT programmes Routine offer of testing On-site rapid tests CD4 tests

The Pearl Study: Coverage Cascade in HIV+ Women Coetzee D et al. IAS, Capetown, South Africa, July 2009, Abs. WeLBD101

HIV Positive Pregnant Women Received ARVs to Reduce MTCT in South Africa * Overall 6% increase in Women Receiving ARV for PMTCT Annual Report 2008/2009 National DOH, South Africa

T Doherty, District Health Barometer, 2007/2008., HST 2009 Increasing uptake of testing and prophylaxis

Attend ANC: 90% Counseled and tested for HIV, CD4: 70% Get ARVs (pre- and perinatal) 50% 1000 positive mothers Estimates of PMTCT cascade: “typical” sites Adapted from P. Barker, IHI, WHO PMTCT Mtg Nov 2008, L Mofenson, 2009 Overall Program Efficacy: sdNVP: 19.7% AZT/ sdNVP: 18.1% HAART : 17.6% Transmission rates: sdNVP (8% MTCT): 25 infected AZT/sdNVP (3% MTCT): 9 infected HAART (2% MTCT): 6 infected 685 No ARV (25% MTCT): 172 infected Enter into program Missed - no PMTCT

Attend ANC: 96% Counseled and tested for HIV, CD4: 99% Get ARVs (pre- and perinatal) 98% 1000 HIV +ve mothers Estimates of PMTCT cascade: “ excellent site ” Adapted from P. Barker, IHI, WHO PMTCT Mtg Nov 2008, L Mofenson, 2009 Overall Program Efficacy: sdNVP: 9.1% AZT/ sdNVP: 4.5% HAART : 3.6% Transmission rates: sdNVP (8% MTCT): 74 infected AZT/sdNVP (3% MTCT): 28 infected HAART (2% MTCT): 19 infected 69 No ARV (25% MTCT): 17 infected Enter into program Missed - no PMTCT Soweto PMTCT program 2008

Resources and Coverage Challenges Human Resources Infrastructure Disaggregated Services Health Information System Expansion 2006 – 273 facilities 2007 – 362 facilities (80%) 55 laboratories (CD4) – 6:1 11 laboratories (Viral Load) – 33:1 7 laboratories (PCR) – 52:1 Moodley, AIDS Priorities, 2009 National DOH 2009

Opportunity: Appropriate treatment and care PMTCT is a gateway to treatment Women who need ongoing antiretroviral treatment should start as soon as possible in pregnancy

“We need extraordinary measures to reverse the trends we are seeing in the health profile of our people…. we will be treating significantly larger numbers of HIV positive patients. It means that people will live longer and more fulfilling lives. ” President Jacob Zuma: 1 December 2009 "Shall I repeat garlic, shall I talk about beetroot, shall I talk about lemon... these delay the development of HIV to Aids-defining conditions, and that's the truth." Health Minister Manto Tshabalala Msimang, 7 June 2006 Opportunity: Regime change…..

Opportunity: Regimen change… – SdNVP March 2008 – “dual therapy” AZT from 28 weeks and SdNVP ART at CD4 < 200/mm 3 April AZT from 14 weeks/ sdNVP + “tail cover” ART at CD4 < 350/mm 3

Impact of dual therapy introduction in Kwazulu Natal The province rapidly implemented the revised PMTCT guidelines, bringing down transmission to as low as 4.3 percent in one district, and 7 percent on average. 38,000 women included in study: 36% HIV positive 66% received dual therapy, 14% NVP only, 13% started ART Transmission rates: 8,013 babies aged between four weeks and eight weeks tested at immunisation clinics, and found that of those whose mothers had received dual therapy, 5.6 percent were HIV-positive compared to 13.5 percent of babies whose mothers only received nevirapine. Dr Christiane Horwood, Centre for Rural Health at the University of KwaZulu-Natal.

Gauteng: Declining % positive PCR results in infants accessing early tests Gayle Shermann, NHLS

PCR tests per District (age <3 mo) Gayle Shermann, NHLS

Jan-Dec 2008 versus 2009 Gayle Shermann, NHLS

Soweto PMTCT Programme: HIV transmission rate J F M A M J J A S O N D J F M A M J J A S O N D Total number of PCR tests done: 2008 – – % HIV-exposed babies tested Coceka Mnyani, James McIntyre, PHRU/ANOVA NSP Target

Inner City Johannesburg PMTCT Programme: HIV transmission rate Oct 2008 – Aug 2009 J F M A M J J A S O N D J F M A M J J A S O N D Vivian Black, RHRU NSP Target

Infant feeding

Infant feeding is one of the most difficult and most emotive issues in HIV management in low-resource settings Even with complete coverage of an effective peripartum ART intervention, an estimated 30,000 children will acquire infection through breastfeeding each year HIV transmission during this period remains a challenge in places where infant formula cannot be safely provided Infant feeding and HIV

A new postpartum transmission ABC……….? A A bstain B B e Faithful C C ondomise A A void breastmilk B B reastmilk only C C over with ARV

ARV prophylaxis of breastmilk transmission Maternal or infant prophylaxis: For women with CD4 >350/mm 3, who do not need ongoing ART, either Infant ARV Prophylaxis (with extended nevirapine dosing) or Maternal HAART for the duration of breastfeeding may be options to prevent Postnatal HIV transmission through breast milk

ARV prophylaxis through breastfeeding The 2009 Revised WHO Recommendations … provide two alternative options for women who are not on ART and breastfeed in resource-limited settings: 1) If a woman received AZT during pregnancy, daily nevirapine is recommended for her child from birth until the end of the breastfeeding period. OR 2) If a woman received a three-drug regimen during pregnancy, a continued regimen of triple therapy is recommended through the end of the breastfeeding period.

Future Directions Improving coverage of PMTCT services Improving access to more efficacious regimens Starting HAART in symptomatic women or those with CD4 < 350 Providing prophylaxis through breastfeeding – either as extended daily nevirapine to babies or as HAART to mothers PMTCT services remain key to achieving MDGs 4 & 5

PMTCT Program linkages Prevention of new infections in women Prevention of transmission to sexual partners Prevention of transmission to infants Family planning & reproductive health services Pre-ART care Antiretroviral therapy Infant diagnosis and care Male health care Circumcision PMTCT services Nutrition Support services Improving links to reproductive health services to prevent unwanted pregnancies Strengthening links to treatment and care services to ensure ongoing care

Access Acceptance of testing ART for those in need Appropriate PMTCT regimen Attitude of staff and community Advocacy 6 A ’s Towards eradication of MTCT in low resource settings

Acknowledgements…… With thanks to: Lynne Mofenson Vivian Black Coceka Mnyani Ashraf Coovadia Daya Moodley And others for use of their data and slides