1. MaxART: Maximizing ART for Better Health and Zero New HIV Infections Strengthening community- and facility-based interventions towards Early Access to ART for All in Swaziland Dr. Velephi Okello, Senior Medical Officer/National ART Coordinator Ministry of Health, Swaziland July 23, 2014

2. Outline  Introduction to the MaxART Program  Achievements from Phase 1  Phase 2: MaxART Early Access to ART for All Implementation Study 2

3. 3 The Dream….began in 2010….. To reach all people in Swaziland who are in need of treatment with an ultimate goal for preparing the country for the possibility of ending the HIV epidemic in the country. The question is: What will it take to do that in a relatively small population with the highest HIV prevalence in the world?

4. Situation of HIV in Swaziland then...... 4

5. Overall Objectives of MaxART Program Mobilize community, achieve universal access to information, testing, treatment, care, and support following the current HIV treatment guidelines Understand realities and needs of people living with HIV, conduct epidemiological modeling and social science research to ensure evidence- and rights-based approach 5 Conduct “Early Access to ART for All” implementation study PHASE 1 2011-2014 PHASE 2 2014-2017

6. Mobilize Communities HIV Testing Enrollment in Care ART Initiation Retention 6  Community mobilization through CBVs  Involve traditional leaders  Male-focused health days  Adolescent support initiative  Strengthen provider- initiated testing and counseling  Fast Track – community-solutions to mobilizing men and adolescents for testing  POC CD4 testing  Treatment support  Improved linkages, including referral system & TB screening  Nurse-led ART initiation  Strong adherence counseling  Improved laboratory services (sample transportation)  Strong supply chain system  SMS appointment reminder system  Treatment support  Linkages with CHWs  Reduced stigma through PLHIV-led initiatives  Counseling  Condoms  Referral male circumcision  Retest – 8 weeks  Sexual Reproductive Health Services Prevention Services MaxART Phase 1 Initiatives Along Continuum of Care

7. Outline  Introduction to the MaxART Program  Achievements from Phase 1  Phase 2: MaxART Early Access to ART for All Implementation Study 7

8. Mobilizing Communities in Swaziland Key Accomplishments 8 “I am glad that MaxART recognizes traditional leaders as the custodians of communities. Being engaged from the start enables us to fully support the program.” Chief-Prince Susa Dlamini Nsingizini Chiefdom, Swaziland 260 Community Dialogues Reached 27,656 People 80,442 People Reached Through Door-to-Door Visits 570 Community Events (especially targeting men) 35 Fast Tracks Conducted – increased HTC for men

9. HIV Testing in Swaziland Displayed in thousands/year ART in Swaziland Displayed in thousands/year HTC Target: Increase annual testing to at least 250,000 per year by end of 2014 Achieved: >300,000 tests done during 2013 (target for 2014 revised to 364,000 tests) ART Target: Increase those on treatment to 90% of those in need (CD4 350) by end of 2014 Achieved: 83% of eligible on ART at end of 2013

10.  Involvement of GNP+ and SWANNEPHA throughout MaxART Program  Focus to date has been and will continue to be on understanding the realities of people living with HIV in Swaziland through: - Positive Health, Dignity and Prevention (PHDP) research – Stigma Index - Human Rights Monitoring - Establishing a Community Advisory Board for the Implementation Study  Social Science Research by the University of Amsterdam to understand the barriers to access services and retain in care, with a focus on men and adolescents 10 Involvement of People Living with HIV

11. Outline  Introduction to the MaxART Program  Achievements from Phase 1  Phase 2: MaxART Early Access to ART for All Implementation Study and Pre-Implementation Study 11

12. Summary of Results - Pre- Implementation Study – Social Science IssueTotal (%)Women %Men % Willing to start ART on same day as receiving HIV+ results 69.776.258.3 Willing to start ARVs while feeling healthy 57.661.950.0 Willing to start early to reduce chances of infecting others 67.776.050.0 Initiating ART regardless of CD4 count would be a good decision for SZ 65.563.466.7 On clients being told of the prevention benefits of ART 68.162.279.2 12

13. MaxART Pre-Implementation Study: Findings – Experiences of PLHIV with HIV services  Two clients reported that they had not received any counselling; for example, a female client who had known her HIV status for three years told us: “When I arrived it was like the doctor needed to run some tests, so when I got to the nurse who conducted the tests [she] told me point blank that my blood was HIV positive… I didn’t receive any counselling, it was a bombshell!” Recommendation: Develop a Communication Strategy for Early Access to ART for All – targeting the HCWs and the Community 13

14. Early Access to ART for All Implementation Study - Study Aim To evaluate the feasibility, acceptability (also focusing on clinical outcomes, affordability and scalability) of offering early ART for all PLHIV in Swaziland’s Government-managed health system. 14

15. Study Design  3-year randomized stepped wedge design (2014 – 2017)  14 facilities in Hhohho region grouped into 7 steps (2 facilities per step)  Sites are grouped to transition two at a time from the control (standard of care) to intervention (ART for all HIV-positive clients) stage  Open enrollment for all HIV+ adults ≥ 18 years of age, excluding pregnant and breastfeeding women  Strategic mix of research methodologies will be applied, including implementation science research, social science research, economic evaluations and cost-effectiveness analyses, and incidence modeling.

16.  MaxART strengthens the community-based and facility-based interventions and linking the two with the objective of piloting the initiation of ART for all PLHIV  MaxART relies on clients (PLHIV) perceptions obtained through social science research and human rights monitoring to implement Early ART interventions that are based on human rights and reduce stigma and discrimination 16 Conclusion

17. The MaxART Programme is made possible with the financial support of the Dutch Postcode Lottery and the leadership of the Ministry of Health, Government of the Kingdom of Swaziland. The second phase of the programme is made possible with additional support of the Dutch Ministry of Foreign Affairs, Mylan, MSF Swaziland and British Colombia Centre of Excellence for HIV/AIDS