Doc ID SABCOHA STRATEGY MEETING 13 OCTOBER 2011 LESSONS LEARNT FROM THE HCT CAMPAIGN Intensifying our efforts to achieve the Millennium Development Goals

Overview To provide an overview of the HCT campaign: achievements, challenges and lessons learnt To provide key results of the HCT Campaign and progress on the ART Expansion programme To propose a Road Map from narrow NSP to expanded NSP 2012 to

NSDA: 4 outputs for health sector 2 1. Increase life expectancy at birth 2. Reduce maternal and child mortality rates 3. Combat HIV and AIDS and TB 4. Strengthen the effectiveness of the health system

Tackling HIV & AIDS is essential to meet all 4 priorities 3 Increase life expectancy at birth Reduce maternal and child mortality rates Combat HIV and AIDS and TB Strengthen the effectiveness of health systems ▪ HIV & AIDS is major component of reduced life expectancy ▪ Nearly 1/3 women aged and 1/4 men aged are living with HIV & AIDS ▪ HIV & AIDS accounts for 43% of maternal mortality and 35% of under 5 mortality ▪ 5,6 million South Africans living with HIV & AIDS ▪ One in every 100 south Africans has TB ▪ HIV/TB co-infection rate is 73% ▪ To effectively address HIV and other conditions the health system must move from treating people when sick to preventing people from getting sick; the health system needs to be strengthened to deal with HIV & AIDS as a chronic disease

HCT campaign: Doing something different in fight against HIV & AIDS, TB and other chronic diseases 4 With a target of 15 million tests we aimed to ▪ Make a big health intervention: test a third of the county’s population, reduce stigma related to HIV and AIDS and use HCT as the entry into wellness and treatment programmes ▪ Involve all stakeholders: target too big for public sector alone ▪ Strengthen the health system: enhance skills and expand infrastructure to provide integrated basket of services ▪ Change the delivery paradigm: force the system to focus on implementation and refine actions vs. perfect planning

Other aims of the campaign 5 ▪ Scale up the integrated prevention strategy which includes NINE prevention strategies ▪ Ensure that people know their status early and reach them with messages demonstrating the benefits of prevention and early access to treatment ▪ Simultaneously increase the number of people on Anti- Retroviral Therapy (ART) ▪ Screen for TB and other chronic diseases

Large mountain to climb – situation before the campaign 6 ▪ 3 million South Africans tested for HIV per year ▪ HCT and ART available in 490 of health facilities ▪ ART initiated at hospitals and largely by doctors ▪ Less than 300 nurses initiating ART ▪ Lay counsellors only did counselling and were not allowed to use HIV rapid tests

Large mountain to climb - starting point before the campaign 7 ▪ Most facilities were providing Voluntary Counseling and Testing not the provider Initiated HIV counseling and testing ▪ PHC services was provided in SILOS - TB, MCH, & PMTCT was not fully integrated ▪ TB funding was not included in the Conditional Grants, ▪ Provinces had different structures and functions for providing HIV and AIDS and TB, many instances we had no dedicated staff

Large mountain to climb - starting point before the campaign 8 ▪ Department of Health planned largely in isolation, from other partners, the execution of plans was not driven by data, targets and strict timelines ▪ Developmental partners were poorly aligned with the national priorities, they focused on small scale interventions, therefore lack high coverage and impact ▪ Poor coordination between government departments, SANAC sectors and development partners

Campaign accomplishments 9 HCT tests People on ART ART facilities Nurses trained on NIMART Patients started on IPT 3 million 1 million , million 1.4 million 2,100 1, ,000 Pre- campaign year Campaign year >400% +40% +430% +600% +1000% % change

2 types of success factors standout 10 TechnicalManagerial ▪ Policy and protocol changes that allowed us to reach more people ▪ Scaled up ART access, through task shifting and community mobilization ▪ Changes to how we manage ‘business unusual’ allowed us to achieve substantial results in a short period of time ▪ Results focused, project management approach using data against agreed targets

Technical success factors 11 ▪ NIMART (nurse initiated and managed ART) ▪ PICT (provider initiated counseling and testing) ▪ Most facilities offering ART ▪ Lay counsellors trained to both counsel and test Technical success factors: our policies and protocols

Managerial success factors 12 ▪ Bias for action – ‘just do it’ and learn as you go ▪ High level political leadership and commitment ▪ Clear targets at facility, district and provincial levels ▪ Use of data to drive transparency and accountability ▪ Multi-sectoral approach - all stakeholders in the same room ▪ Work within the existing system – no parallel structures Managerial success factors: how we got it done

What else we learned 13 ▪ South Africans are ready for us to step up our response (e.g., people waiting hours in line for HCT shows understanding and commitment) ▪ Stigma is slowly fading (e.g., political leadership and CEOs testing made it clear that HIV concerns everyone, not only ‘high risk’ groups of people) ▪ People are looking to take care of themselves (e.g., those found HIV+ seeking next steps and appropriate care)

What else we learned 14 ▪ Strong political commitment from the President and Deputy President provided clear direction: World AIDS 2009 Announcement, Launch of HCT, Deputy President, Medupi, HCT Campaign, MOH Disease Burden Seminars ▪ SANAC sectors strong commitment to Action (Sector driven campaigns: women, children, men and NGO and PHLWA) ▪ Greater involvement of public in the HCT Campaign(Radio and Press coverage, South African public coming forward to test

What else we learned 15 ▪ Strengthening of Health sector response : (Institutionalize provider initiated HCT in all facilities, NIMART a permanent feature of ART provision, Community Health worker expanded, PHC integration of HIV, TB, MCH and PMTCT) ▪ Build a strong basis to attain the Health MDGS ( HCT as entry point provide a service platform for address the NSDA outputs; combat HIV and AIDS and TB, reducing maternal and child mortality, increasing life expectancy and strengthening health system)

What else we learned 16 ▪ Enhanced South Africa international standing in addressing the quadruple disease burden ( In Vienna the Deputy President was commended for political leadership, HLM meeting in New York, South Africa HCT campaign was seen as an examples of intensifying efforts to eliminate HIV ▪ The HCT campaign, ART expansion, MMC, PMTCT, and will contribute to the new NSP development: ( setting of clear, achievable goals, targets and indicators as demonstrated in the HCT campaign provide a new approach for the attainment of new NSP )

Roadmap from current NSP to Expanded NSP Intensify efforts to eliminate HIV by 2030

Visioning Hyper epidemic phase NSP 2011 to 2012Endemic phase: Expanded NSP 2012 to 2018Elimination phase: Enhance effort to elimination

Hyper epidemic phase Low uptake of HCT Deferred treatment at cd4 less 200 Low coverage on treatment Poor treatment outcomes High co morbidity, include TB/HIV co infections High infections, high morbidity, high death and reduce life expectancy Weak health systems, barriers to access, structural and social issues related to stigma, discrimination High costs, reduced productivity, security concerns

Epidemic phase 2012 to 2016: Rapid expansion phase High HCT offering to reach 90% of population testing at least once a year High uptake of HCT as entry point to ART, TB, MCH to reach universal access 80% coverage Linkage to integrated care programme HIV/TB. MCH and chronic disease

Epidemic phase 2012 to 2016: rapid expansion Universal access to ART, MCH, TB and chronic care to achieve 90% access Decentralized social mobilization, peer to peer interventions at community and households Health systems strengthening to rapidly scaling up of resources, capacity, provision, reach, coverage and impact Intensify efforts to address social determinants of health to reduce vulnerability and address barriers to access, reduce stigma, discrimination, address norms and behaviors that increase individual risks

Epidemic phase 2012 to 2016: rapid expansion Intensify efforts to achieve over 90% of HCT uptake at least once annual Early treatment at 350, reaching 3 million by 2015 Scale up combination prevention structural, behavioral and biomedical: MMC to reach 4,3 million by 2015 Social mobilization and peer to peer interventions at community level to address stigma Strengthening of health systems, multi sectoral response and investment

Elimination phase: sustain and expand efforts Move from endemic to elimination by intensifying efforts to reduce new infections below 1 person per 100,000 persons at risks All persons being offered HCT, uptake on testing, link to care, seek test and treat ART, universal adherence to achieve 90% targets Rapidly scale up implementation of combination prevention modalities on behavioral, structural and biomedical to reach 90% of at risk Reduce the period from infection to treatment to less that five years in general population, Achieve community level reduction of viral load, reduce pool of infective people and achieve positive prevention

Three Scenarios: Three Choices Hyper epidemic: 2007 to 2011 Endemic: 2011 to 2015 Elimination: 2016 to 2020 R16 Billion R32 Billion Impact Intensify efforts Effects Targets

Outcomes and Impact Hyper epidemic phase: of continued we will double the expenditure from R16 million to R32 billion by 2030, with increase infections, morbidity, death and costs: Non sustainable Endemic phase: require amplification of services to achieve universal access to prevention, treatment, care and support: Rapidly increase capacity to offer, uptake, link to care, ART, adherence and combination prevention

Outcome and Impact Elimination phase: require universal HCT exceed 90% annual. 90% uptake, linkage to care off positive to achieve 90%, seek, test and treat to achieve 90% within five years after infection, achieve universal adherence first regime, reduce loss to follow and simplified treatment Achieve universal access to combination prevention: to MMC, Condoms, PMTCT and Microbicide and BCC Reduce substantial vulnerability and high risk exposure by address social determinants of health, stigma, discrimination and legal barrier to access of risk groups