1. Overview of HIV/AIDS in Ethiopia HIV Care and ART: A Course for Healthcare Providers

2. 2 Learning Objectives  Describe the global and national HIV/AIDS epidemiological profile  Describe the Ethiopian national AIDS strategies, guideline for implementation of ART, and roadmap to accelerate care and treatment for PLWHA  List the major achievements, challenges and opportunities during the implementation of the ART program in Ethiopia

3. 3 Learning Objectives (2)  Explain the Ethiopian National Policy on ARV drugs, supply and use  Convey the current status of the ART program in Ethiopia  List prevention strategies to reduce the spread of HIV infection in the country

4. Global and Ethiopian Summary of HIV/AIDS Epidemic

5. 5 Global Summary of the AIDS Epidemic, December 2005  PLWHA 40.3 million (36.7 – 45.3) Adults 38.0 Million (34.5-42.6) Women 17.5 Million (16.2-19.3) Children <15 yrs 2.3 Million (2.1-2.8)  New infections 4.9 million (4.3–6.6) Adults 4.2 Million (3.6-5.8) Children <15 yrs 700,000 (630,000 – 820,000)  AIDS Deaths 3.1 million (2.8 – 3.6) Adults 2.6 Million (2.3 – 2.9 million) Children <15 yrs (570,000-670,000)

6. 0 5 10 15 20 25 30 35 40 45 Million Number of people living with HIV 19851990199520002005 Year Oceania North Africa & Middle East Eastern Europe & Central Asia Latin America and Caribbean North America and Western Europe Asia Sub-Saharan Africa Source: WHO/UNAIDS, 2006 Estimated number of adults and children living with HIV by region, 1986–2005

7. 7 Est. Number Newly Infected With HIV During 2005: 4.9 Million North America44,000 Caribbean53,000 Latin America240,000 Western Europe21,000 North Africa & Middle East92,000 Sub- Saharan Africa 3.1 million Eastern Europe & Central Asia210,000 East Asia & Pacific290,000 South & South- East Asia890,000 Australia & New Zealand5,000 Source: UNAIDS/WHO

8. Global HIV prevalence in adults, 2005 Source: WHO/UNAIDS, 2006

9. 9 Est. Adult and Child Deaths From HIV/AIDS During 2005: 3.1 Million North America16,000 Caribbean36,000 Latin America95,000 Western Europe65,000 North Africa & Middle East28,000 Sub-Saharan Africa 2.3 million Eastern Europe & Central Asia60,000 East Asia & Pacific51,000 South & South- East Asia490,000 Australia & New Zealand700 Source: UNAIDS/WHO

10. 10 Source: UNAIDS/WHO 2004

11. Percent of adults (15+) living with HIV who are female 1990–2005 0 10 20 30 40 50 60 70 1990199520002005 Year Percent female (%) Sub-Saharan Africa Caribbean GLOBAL Latin America Asia Eastern Europe and Central Asia Source: WHO/UNAIDS. [2006 Report on the global AIDS epidemic, UNAIDS]

12. Number of people on antiretroviral therapy in low- and middle-income countries, 2002–2006 Source: WHO/UNAIDS (2005). [Progress on global access to HIV antiretroviral therapy: An update on “3 by 5.” ] [Updated with 2006 data, WHO/UNAIDS] North Africa and the Middle East Europe and Central Asia East, South and South-East Asia Latin America and the Caribbean Sub-Saharan Africa End 2002 Mid- 2003 End 2003 Mid- 2004 End 2004 Mid- 2005 End 2005 People receiving therapy (thousands) Mid- 2006 0 200 400 600 800 1000 1200 1400 1600 1800

13. 13 Ethiopian Prevalence  National single point estimate (SPE)......... 2.1%  National Prevalence for 2005........... 4.7% Women….5.0% Men….3.8%  Urban prevalence in 2005...................12.5%  Urban prevalence SPE in 2006 …… 7.7%  Rural prevalence in 2005....................3.0%  Rural SPE prevalence 2006 ………….0.9%

14. 14 HIV/AIDS Indicators in Ethiopia (2006) Bases on single point estimate  Number of PLWHA929,699  Estimated new annual infection 122,971  PLWHA requiring ARVs244,835  Annual AIDS deaths 88,997  Adults and Children on ART Ever started 122,243 Current on ART 90,212 Pediatrics 4484 (January 10, 2008)

15. 15 HIV/AIDS Indicators in Ethiopia (2006) (2) Single point estimation  Total orphans5,401,636  AIDS orphans 656,058  Children living with HIV/AIDS 61,864 New HIV infections……… 13,836  Annual AIDS deaths in children10,887  Children newly needing ART 14,396  Children on ART >4000

16. 16 Age & Sex Distribution of Reported AIDS Cases (1986 - June 2003, Ethiopia) Source: AIDS in Ethiopia, 5th ed., MOH, July, 2004

17. 17 Impact on Rural Households  Loss of income (50% or more) Loss of labor Loss of skilled manpower and knowledge Loss of land Loss of remittances  Reduction in savings and investment Expenses for treatment, funeral, teskar Need to sell livestock to meet expenses

18. 18 Impact on Industry  Loss of workers Expenses for recruiting and training replacements Reduced productivity in cases of skilled workers or managers  Lost work days due to sickness and funeral leave  Increased health care costs 50% illness due to AIDS Loss of skilled professionals

19. National response to HIV/AIDS in Ethiopia

20. 20 Historical Overview of HIV/AIDS in Ethiopia  1984: The first evidence of HIV infection in Ethiopia  1986: The first two AIDS cases reported to the Ministry of Health  1989: HIV/AIDS surveillance started  2003: Fee base ART started  March, 2005: Free ART program started

21. 21 Background on  Health Services 138 hospitals 650 Health centers 6175 health posts  Access to HIV/AIDS Services ART 260 (117 HP & 143 HC) HCT 889 PMTCT 390 health facilities are providing HIV services

22. 22 National Comprehensive and Expanded Response against HIV.AIDS Epidemic  HAPCO was established in 2000  Policies and Strategy documents that are issued  HIV/AIDS policy in 1998 (currently on revision)  ARV drug supply and use developed in 2002  5 Years strategic planning was developed (SPM) with a principle of the three ones (one plan one budget one report)  Road map developed (2007-2010) : As part of the national ART scale up and implemented

23. 23 National Comprehensive and Expanded Response against HIV.AIDS Epidemic  National M&E Frame developed and implemented  HIV/AIDS Multi Sectoral Response Framework (2001-2005)  Social Mobilization strategy focusing on community response.  Various Program Implementation guidelines and manuals (PMTCT, STI, HCT, pediatrics, Social mobilization etc)

24. 24 VCT Site Distribution by Region, 2005

25. 25 VCT Before and After ART VCT not much benefited from free ART program

26. 26 Missed opportunity - VCT Absence of ART at most Health centers, private sectors, NGO clinics

27. 27 ART Site Expansion Versus Target 2006 >100%

28. 28 Why Missed opportunity  Absence of ART at most Health Centers (Gov.) Private Health facilities  Lack of knowledge about ART  Poor referral and linkage system  Stigma and discrimination  Poor involvement of community and PLWHA

29. 29 Regional Distribution of ART

30. 30 PMTCT – Achievement 105675105675 5301653016 47584758 37003700 1700

31. 31 National Response  HIV/AIDS Policy formulated by MOH and adopted by the Council of Ministers in 1998 Enabled HIV/AIDS prevention and control Supplemented existing health, women’s, and education and training policy Called for a multisectoral response Guaranteed rights of PLWHA  ARV Drugs Supply & Use Policy formulated July 2002

32. 32 National Response (2)  HIV/AIDS Prevention & Control Office (HAPCO) established June 2002 Restructured from NACS (April 2000) Sits under Prime Minister’s Office Established at all levels of government  Runs the daily activities of NAC Resource mobilization Advocacy Coordination of the sectoral responses

33. 33 National Response (3)  HIV/AIDS Strategic plan for five years 2004 - 2008  Social mobilization & community involvement Community ownership  Scaled up ART program AIDS fund was initiated Free ART program was scaled up

34. 34 HIV/AIDS Intervention Strategies  Prevention Social mobilization IEC/BCC HIV counseling and testing Voluntary (VCT) Provider initiated (PIHCT) STI prevention and control Condom promotion Infection prevention Prevention of mother to child transmission (PMTCT) Post exposure prophylaxis

35. 35 HIV/AIDS Intervention Strategies (2)  Care and Treatment Palliative care Community home based care Opportunistic infection treatment Tuberculosis treatment Treatment of AIDS patients  Support for Orphans and vulnerable children (OVC) People living with HIV/AIDS (PLWHA)

36. 36 Major Achievements  National HIV/AIDS Policy  National AIDS Council Secretariat  Five editions of “AIDS in Ethiopia”  National ARV Policy (revised and published in January 2005)  Roadmap to accelerate access to HIV/AIDS care and treatment  M&E framework

37. 37 Major Achievements (2)  Five-year strategic plan revised & updated Used as main input for the National Strategic Framework adopted by NAC Contains strategic outline of interventions at federal and regional levels  Key guidelines developed: HIV Surveillance Guideline HIV Surveillance Training Manual Voluntary Counseling & Testing Guideline

38. 38 Major Achievements (3)  Key guidelines (continued): AIDS Case Management Guideline STI Management Guideline Home-Based Care Guideline Private HIV Labs Licensing Guideline PMTCT Guideline Home Care Training Manual Counseling Training Manual ARV Guideline Universal Precautions & Post Exposure Prophylaxis

39. 39 Major Achievements (4)  >900 VCT sites established  163 sentinel surveillance sites established  MOH has been the primary advocate for a multi- sectoral response to HIV/AIDS: Formulated and disseminated HIV/AIDS and ARV Drugs Supply & Use Policies Acts as a catalyst for several multi-sectoral HIV/AIDS committees that pre-dated the NAC

40. 40 Major Achievements (5)  Integrating HIV/AIDS into health programs: Reproductive health Mother and child health Hospital hygiene Health education Integrated disease surveillance TB/HIV Initiative

41. Policy of ARV Supply and Use in Ethiopia

42. 42 Introduction  Care and support of PLWHA plays an important role in preventing the spread of HIV/AIDS  ART is an important component of care for PLWHA  ARVs also have an important place in PMTCT and PEP  ARVs have enormous benefits, but affordability, toxicity, adherence and resistance are challenging

43. 43 National ARV Policy  Policy approved in July 2002  Objectives of the policy: Reduce MTCT Prolong and improve the quality of lives of PLWHA Reduce accidental HIV infection within health institutions

44. 44 General Policy  Determines type of ARVs that will be used in health care services  The Government of Ethiopia: Coordinates & facilitates the supply of ARVs Builds capacity for making available safe, effective and quality antiretroviral drugs, and for ensuring proper use of these drugs Ensures sustainable supply of ARVs by encouraging involvement of all stakeholders

45. 45 General Policy (2)  The Government of Ethiopia (cont): Nurtures international partnerships to strengthen sustainable supply and use of ARVs Encourages research on modern and traditional HIV/AIDS treatment Establishes strong systems to monitor ARV supply and use

46. 46 General Strategies 1.Selection of ARVs Determine the type of ARVs to be used in Ethiopia Incorporate selected ARVs into the national drug list Permit the import of ARVs that are not included in the national drug list

47. 47 General Strategies (2) 2.Supply of ARVs ARVs for ART: Exempted from taxation Supplied at reduced prices through government negotiation with manufacturers, importers and distributors Purchased by a system of bulk and generic substitution Local production of ARVs encouraged Benefaction of ARVs facilitated by the Ethiopian Government Ethiopian Government supplies ARVs for PMTCT

48. 48 General Strategies (3) 3.Drug Use Prepare and implement standardized prescription paper Prepare and implement national guidelines for safe and effective use of ARVs Sustainable public education on ARV drugs

49. 49 General Strategies (4) 4.Research and Development Government of Ethiopia encourages research on modern and traditional HIV/AIDS treatment Government of Ethiopia shall make efforts to strengthen the capacity of research institutions Rights and benefits of citizens that enroll in research studies shall be respected National and international ethical norms and values in human experimentations shall be observed

50. 50 Scaling up ART Uptake  Need capacity development to: Initiate treatment Help patients adhere to their treatment regimens Monitor the efficacy and toxicity of the regimens Diagnose treatment failure Monitor overall resistance in society  ART program must be implemented at Health Center level  Nursing initiative to prescribe ARVs is being piloted

51. 51 Key Points  AIDS is a global, regional, and national crisis  The national HIV seroprevalence rate in Ethiopia is 2.1% (SPE) Urban rate is 7.7% Rate in rural area is 0.9 %  Approximately >104,000 people in Ethiopia are currently receiving ART

52. 52 Key Points (2)  ARV guidelines have been written, policies have been adopted, and training is being conducted in Ethiopia  ARVs have enormous benefits and challenges. The challenges include: Developing capacity to initiate treatment Supporting adherence Monitoring efficacy and toxicity Diagnosing treatment failure Monitoring resistance