2. Presentation Outline The Global Cities Context Why the need to Fast Track and Intensify HIV and TB response Cities? eThekwini - Epidemiology of HIV and TB (Common trend in cities) What does Fast track 90-90-90 mean for eThekwini Massive scale up of prevention, treatment, care and support services Conclusion

3. The Global Cities Context The majority of the world’s population is lives in urban areas. By 2030, 60% of the global population will live in cities—a 72% increase in only three decades (8). More than half the global HIV burden is found in urban areas. An estimated 60% of the 35 million people living with HIV live in urban areas. HIV prevalence in urban areas is estimated to be, on average, 1.5 to 2 times higher than in rural areas In all regions of the world, cities bear a disproportionate burden of the AIDS epidemic. Cities are therefore a key location for the Global AIDS response. Cities have become central economic players. For example, six cities in South Africa contribute more than 50% of that country’s national GDP (State of the world’s cities 2010/2011. Cities for all: bridging the urban divide. Nairobi: United Nations Human Settlements Programme; 2010.)

4. Why the need to Fast Track and Intensify HIV and TB response Cities? In 2012 Sub Saharan Africa accounted for 70% of all new HIV infections. In 2013 there were 2,1 million new HIV infections South Africa, Nigeria and Uganda accounted for 48% of the total new HIV infections in Africa in 2013 In Sub Saharan Africa 45% of People Living With HIV (PLHIV) reside urban areas Complex HIV and TB epidemic in cities: High numbers of key populations and High Transmission Areas Prevalence of HIV as high as 50 - 70% amongst sex workers AIDS and TB epidemics in cities continues to outrun the current responses, increasing the need for treatment (both HIV and TB), with long term need for HIV treatment and continued costs for treatment

5. eThekwini - Epidemiology of HIV and TB (Common trend in cities) 1.HIV Prevalence (15 – 49 years) Spectrum (draft 2014): 29.7% ANC Sentinel Survey (2013): 41.1% HSRC (2012): 14.5% [11.2 – 18.6] 2.Number of PLHIV (Spectrum preliminary estimates 2014): 650,000 –Adults: 617,900 –Children: 32,600 3.New HIV infections (Spectrum preliminary estimates 2014): 28,450 Adults 15+: 25,427 Children: 3,023 4.AIDS deaths (Spectrum preliminary estimates 2014): 12,672 5.TB prevalence (DHP): 1 032/ 100 000 (TB leading cause of death, followed by HIV) 6.TB/HIV co-prevalence (DHP): 70% 7.Delivery rate <18 years (DHP): 5.6%

7. Massive scale up of prevention, treatment, care and support services Mechanism: Operation Sukuma Sakhe: Community based response centred on households. Together with committed leadership, creating sustainable livelihoods through the provision of integrated services to communities, promoting fast tracked responses at grass root level.

8. Ward AIDS Committee (WAC): In touch with local community context of HIV and TB epidemic. Multi- sectoral team. Action plan of locally relevant response. Eg: Organise and train local peer supporters, condom distribution. Mobilise and conduct community based activities. Zonal AIDS Committee: Co-ordination of the reporting by the WAC. District AIDS Council: Monitor, evaluate, provide feedback and track appropriateness and progress of HIV and TB district response. Also mobilise relevant resources. War Room: Household and individual needs presented at war room. War Room is a collection of decision makers at ward level. Refer to relevant departments Community Cadres: Allocated households which they profile, including those requiring HIV care. Provide report to War Room and Monitor that departments have delivered service through follow up visits District Task Team: Provides report of HIV and TB activities through OSS. Report to Provincial Task Team Sub District Local Task Team (LTT): Mobilise resource, action plan for service providers, report to DTT Government Departments and Partners: Bringing services closer to the people. Deliver service to those referred by cadres and war room, and report back to war room.

9. Progress to date: Prevention: Prevention of mother to child transmission: Focus on integrated Basic Antenatal Care – PCR positivity at and around six weeks reduced from +/- 23% in the early 2000s to current < 2% Shift towards focus on general wellness rather than pure verticalisation of HAST Increasing numbers of HIV tests conducted HIV incidence reduced from 3,8% in 2005 to +/- 1% in 2014 Challenges: poor uptake of MMC, men lagging behind in HIV testing uptake, behaviour change slow, girls and young women still at highest risk including key populations Treatment ART provision at all public health facilities, with focus on developing competence for NIMART (Nurse initiated and managed ART) Using electronic patient information system - Tier.Net (Assists in Tracking patient to ensure retention in care and VL monitoring Reduction in reported HIV and AIDS related deaths reduced from over 40 000 in 2008 to 12 672 in 2014 Increase in TB Cure rate from 48% in 2008 to 75% in 2013 HTA, Key populations - Taking services to key populations (internalised stigma) - Sundowners by both partners and the municipality Challenges : Substantial number of persons still coming with low CD4 counts, Fear of public perceptions and stigma challenges to accessing of care

10. Conclusion The world today is defined by its cities, which home to the largest and most dynamic economies; and characterized by young, mobile, diverse populations. As cities grow at unprecedented speeds, city leaders routinely face the challenge of allocating limited resources to grapple with a range of development issues Cities offer the density and economies of scale, institutional response frameworks, public and private sector infrastructure and health systems that can help to address the AIDS epidemic in a more effective manner and contribute to national and international responses towards ending the AIDS epidemic A concerted push to reach the specific populations most at risk in cities will maximize the gains in preventing new HIV infections and stopping AIDS-related deaths.” If the response is to truly strive towards ending the epidemic, efforts must increasingly understand and address evolving social, political, economic and spatial determinants of HIV infection, particularly urbanization. In 2016, South Africa is planning a high level meeting of mayors from about 19 Fast Track cities, to discuss ways of strengthening effective city partnership arrangements to fast-frack “Ending AIDS and TB in South African Cities by 2030 We cannot end AIDS without mobilising the cities that account for one third of the global burden. In the global collective thrust towards ending the AIDS epidemic in the post-2015 era, cities will be critical venues for decision-making, political commitment, norm-setting and service delivery. Therefore cities are the central driving platform for delivering the Fast Track Strategy and the 2020 vision of 90- 90-90.

11. Thank You