1. 1 5 th Inter-Agency Meeting on Coordination and Harmonization of HIV/AIDS, TB and Malaria Strategies Universal Access to HIV/AIDS, TB and Malaria Services in Africa; Challenges and Prospects

2. 2 Overview of Presentation   For each of the 3 diseases   Situation and Trends   Trends in the Response   Programmatic Challenges   Prospects for the Future   For each of the 3 diseases   Situation and Trends   Trends in the Response   Programmatic Challenges   Prospects for the Future

3. 3 HIV/AIDS Situation -2012   People living with HIV – 25 million (71% of global burden)   Children <15 years living with HIV – 2.9 million (89% of global burden)   Regional Prevalence – 4.7%   People newly infected with HIV in 2012 – 1.6 million   AIDS related deaths in 2012 – 1.2 million   People living with HIV – 25 million (71% of global burden)   Children <15 years living with HIV – 2.9 million (89% of global burden)   Regional Prevalence – 4.7%   People newly infected with HIV in 2012 – 1.6 million   AIDS related deaths in 2012 – 1.2 million

4. 4 HIV Burden in sub-Saharan Africa, 1990-2012 Source: UNAIDS and WHO

5. 5 The Health Sector's Contribution to Achieving Universal Access to HIV/AIDS Interventions Expanding testing and counselling Accelerating treatment scale up Maximising prevention Strengthening health systems STRATEGIC INFORMATIONSTRATEGIC INFORMATION

6. 6 Clinically relevant  Earlier initiation of ART (CD4 ≤ 500)  Immediate ART for children below 5 years  Lifelong ART in pregnant women (option B/B+)  Harmonization of ART across populations (e.g., adults and pregnant women, B/B+) and age groups  Simplified, fewer, and less toxic 1 st line regimens (TDF/XTC/EFV) Clinically relevant  Earlier initiation of ART (CD4 ≤ 500)  Immediate ART for children below 5 years  Lifelong ART in pregnant women (option B/B+)  Harmonization of ART across populations (e.g., adults and pregnant women, B/B+) and age groups  Simplified, fewer, and less toxic 1 st line regimens (TDF/XTC/EFV) WHO ARV Recommendations - 2013 guidelines Operationally relevant  Use of Fixed Dose Combinations as a preferred approach  Improved patient monitoring to support better adherence and detect earlier treatment failure (increased use of VL)  Recommend task shifting, decentralization, and integration  Community based testing to complement broader HTC Operationally relevant  Use of Fixed Dose Combinations as a preferred approach  Improved patient monitoring to support better adherence and detect earlier treatment failure (increased use of VL)  Recommend task shifting, decentralization, and integration  Community based testing to complement broader HTC

7. 7 8/30/20157

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10. 10 Transition in PMTCT Regimens in the 22 Global Plan Priority Countries After 2010 WHO PMTCT ARV Guidelines As of June 2013 Rapid Change Towards B/B+

11. 11 Where are we…….?  Progress has been made in the provision of ART  More than 7.5 million patients received ART by the end of 2012  ART coverage increased from 49% in 2010 to 64% by the end of 2012  ART coverage was more than 80% in 10 countries  63% of pregnant women living with HIV received ARVs for PMTCT in 2012, compared with 34% in 2009 – 12 countries with a coverage of 80% or more, with 5 of them having attained 90% coverage  Improved access to ART has led to a reduction in AIDS-related deaths from 1.3 million in 2009 to 1.2 million in 2012

12. 12 Estimated % of pregnant women living with HIV who received ARVs for PMTCT

13. 13 Programmatic challenges – HIV treatment cascade for sub-Saharan Africa, 2012 Source: Global AIDS Report 2013, UNAIDS People no longer covered People covered Bounds of uncertainty

14. 14 CD4 Cell Count at Start of ART Cells/µL Canada Country Tanzania Burundi Australia Rwanda Zimbabwe Mozambique Malawi Kenya Zambia Italy France India Democratic Republic of Congo Senegal Botswana South Africa Singapore Spain Côte d'Ivoire Mali Brazil Japan Philippines USA South Korea Cameroon Uganda Cambodia Benin Burkina Faso Malaysia Indonesia Thailand China Nigeria 246 (234 to 257) 145 (133 to 158) 230 (211 to 248) 286 (265 to 306) 287 (274 to 300) 139 (133 to 145) 263 (245 to 282) 166 (161 to 172) 203 (199 to 207) 174 (172 to 176) 262 (241 to 284) 278 (273 to 283) 234 (200 to 268) 163 (153 to 172) 137 ( 98 to 176) 200 (166 to 235) 150 (148 to 152) 169 (119 to 221) 231 (223 to 238) 215 (209 to 221) 187 (173 to 201) 225 (211 to 239) 252 (206 to 298) 187 (162 to 212) 307 (301 to 314) 217 (182 to 253) 154 (146 to 163) 176 (169 to 184) 196 (148 to 244) 149 (117 to 181) 269 (257 to 281) 158 (140 to 176) 89 ( 69 to 110) 140 (129 to 151) 118 ( 98 to 139) 185 (175 to 195) 050100150200250300350 Mugglin et al. CROI 2012 Low-income Middle-income High-income Mean CD4 cell count (95% CI)

15. 15 HIV/AIDS - Programmatic Challenges   Progress made in PMTCT; however coverage in large countries like Nigeria and DRC still remains low; funding gaps for eMTCT plans   Treatment gap in children   Virtually no country in the Region is providing services for key populations on an adequate scale and intensity   Domestic investments are increasing; however donor dependence still remains a challenge -implementing the 2013 consolidated guidelines requires additional financial investment   Progress made in PMTCT; however coverage in large countries like Nigeria and DRC still remains low; funding gaps for eMTCT plans   Treatment gap in children   Virtually no country in the Region is providing services for key populations on an adequate scale and intensity   Domestic investments are increasing; however donor dependence still remains a challenge -implementing the 2013 consolidated guidelines requires additional financial investment

16. 16 Incidence on the decline since 2003

17. 17 DOTs Expansion  Early case detection Screen all persons with cough of more than 2 weeks for TB Screen all eligible patients for drug resistance  Case management Treat all patients with 6 month short-course treatment Ensure all drug resistant TB patients are treated with appropriate WHO regimens  Engagement of all health care providers in above interventions DOTs Expansion  Early case detection Screen all persons with cough of more than 2 weeks for TB Screen all eligible patients for drug resistance  Case management Treat all patients with 6 month short-course treatment Ensure all drug resistant TB patients are treated with appropriate WHO regimens  Engagement of all health care providers in above interventions TB/HIV Collaboration  Intensified Case Finding(ICF) Screen all PLHIV for TB Evaluate TB patients for HIV Use Xpert MTB/RIF as initial diagnostic test in PLH and suspected MDR-TB Start ART in all TB patients living with HIV irrespective of their CD4 counts Provide CPT for HIV positive TB patients  Isoniazid Preventive Therapy (IPT) Offer IPT to all PLHIV who do not have TB even if they are on ART  Infection Control All facilities providing HIV care should have TB infection control measures in place TB/HIV Collaboration  Intensified Case Finding(ICF) Screen all PLHIV for TB Evaluate TB patients for HIV Use Xpert MTB/RIF as initial diagnostic test in PLH and suspected MDR-TB Start ART in all TB patients living with HIV irrespective of their CD4 counts Provide CPT for HIV positive TB patients  Isoniazid Preventive Therapy (IPT) Offer IPT to all PLHIV who do not have TB even if they are on ART  Infection Control All facilities providing HIV care should have TB infection control measures in place Surveillance, M & E  Register and report all TB cases  Monitor and document all treatment outcomes  Submit data for annual Global TB reports  TB prevalence survey  Operational Research Surveillance, M & E  Register and report all TB cases  Monitor and document all treatment outcomes  Submit data for annual Global TB reports  TB prevalence survey  Operational Research Strengthening health systems in endemic countries Key interventions - TB

18. 18 TB case detection has risen from 43% in 1990 to 59% in 2012

19. 19 10 Countries reached the target CDR of 70% target of 85% TSR 18 Countries reached the target of 85% TSR 5 countries reached both targets in 2012 Angola, Botswana, Ethiopia, Ghana, Kenya, Lesotho, STP, Seychelles, Tanzania and Zambia Algeria, Benin, Burundi, DRC, Eritrea, Ethiopia, Gambia, Ghana, Kenya, Liberia, Malawi, Mauritius, Nigeria, Rwanda, Senegal, Sierra Leone, Tanzania and Zambia Ghana, Kenya, Seychelles, Tanzania, and Zambia 19 Attainment of the global target of 70% Case Detection Rate (CDR) and 85% Treatment Success Rate (TSR)- 2012

20. 20 TB - Programmatic Challenges   Emergence of MDR/XDR –TB and the high costs associated with managing drug resistant TB   Weak laboratory capacity for TB culture and drug susceptibility testing   TB/HIV co-infection and access to ART for TB/HIV co-infected individuals (In 2012, 78% of TB patients tested; 37% HIV positive but only 55% accessed ART)   TB in high risk/hard to reach areas e.g. mines, prisons and nomadic populations   Emergence of MDR/XDR –TB and the high costs associated with managing drug resistant TB   Weak laboratory capacity for TB culture and drug susceptibility testing   TB/HIV co-infection and access to ART for TB/HIV co-infected individuals (In 2012, 78% of TB patients tested; 37% HIV positive but only 55% accessed ART)   TB in high risk/hard to reach areas e.g. mines, prisons and nomadic populations

21. 21 Malaria burden - 2012  80% of the estimated 207 million cases of malaria worldwide were in Africa  The estimated number of malaria cases per 1000 persons at risk of malaria reduced by 31% in the African Region between 2000 and 2012  Pregnant women and children under 5 years are among the most vulnerable groups in the African Region  90% of the estimated 627,000 malaria deaths worldwide in 2012 were in Africa  86% of malaria deaths were in children under 5 years in 2012  Malaria mortality rate decreased by 49% in the general population and by 54% in children under 5 years between 2000 and 2012  80% of the estimated 207 million cases of malaria worldwide were in Africa  The estimated number of malaria cases per 1000 persons at risk of malaria reduced by 31% in the African Region between 2000 and 2012  Pregnant women and children under 5 years are among the most vulnerable groups in the African Region  90% of the estimated 627,000 malaria deaths worldwide in 2012 were in Africa  86% of malaria deaths were in children under 5 years in 2012  Malaria mortality rate decreased by 49% in the general population and by 54% in children under 5 years between 2000 and 2012

22. 22 Prevention  Insecticide-treated bednets (ITNs) / Long- lasting ITNs (LLINs)  Indoor Residual Spraying In areas of moderate to high and stable transmission  Intermittent Preventive Treatment, in pregnancy (IPTp)  IPT in infancy (IPTi) In areas of high seasonal transmission  Seasonal malaria chemopreventionPrevention  Insecticide-treated bednets (ITNs) / Long- lasting ITNs (LLINs)  Indoor Residual Spraying In areas of moderate to high and stable transmission  Intermittent Preventive Treatment, in pregnancy (IPTp)  IPT in infancy (IPTi) In areas of high seasonal transmission  Seasonal malaria chemoprevention Diagnosis & Treatment  Parasite based diagnosis Microscopy Rapid Diagnostic Tests  Artemisinin-based combination therapies (ACTs)  Case management: Health facilities Community Case Management (CMM) Private sector Diagnosis & Treatment  Parasite based diagnosis Microscopy Rapid Diagnostic Tests  Artemisinin-based combination therapies (ACTs)  Case management: Health facilities Community Case Management (CMM) Private sector Surveillance, M & E  Routine HMIS  Malaria surveillance systems  Household surveys  Operational research Surveillance, M & E  Routine HMIS  Malaria surveillance systems  Household surveys  Operational research Strengthening health systems in endemic countries Key interventions - Malaria

23. 23 Progress: Scaling up malaria treatment with ACTs - 2012 Where ACT use is currently plannedWhere malaria (treatment) occurs   43 out of 44 endemic countries have adopted use of ACT as a policy   Only 18 countries are reporting country-wide implementation   20 countries have a policy on parasitogical testing of suspected malaria cases in individuals of all ages   Proportion of suspected malaria cases receiving a diagnostic test in the public sector increased from 20% in 2005 to 47% in 2011   31 have introduced the use of ACTs at community level but only 6 have scaled up its deployment

24. 24 Non AFRO CBIs planned to include use of ACTs (39) CBIs not implemented (7) ACTs at community level (17) Non AFRO CBIs planned to include use of ACT (7) CBIs not implemented (8) ACTs used at community level (31) Progress: Implementation of CBIs and use of ACTs at community level in 2009 & 2012

25. 25 25 Progress made in Malaria Control - 2012 IPTp adopted in all the 33 countries where it is recommended Increased households owning at least one LLIN from 3% in 2000 to 53% in 2012 IRS implementation expanding in the region; population at risk protected rose from les 5% in 2005 to 11% in 2010 Pre-elimination initiative in 8 countries Reduction of more than 50% of malaria cases and deaths in 12 countries

26. 26 Decrease in incidence of malaria cases in AFRO: 2000– 2012 On track for >75% decrease in incidence (9) 50%–75% decrease in incidence < 50% decrease Insufficient data to make trend conclusions Botswana Cape Verde Eritrea Namibia Rwanda STP South Africa Swaziland Zanzibar Ethiopia Zambia MadagascarAngola, Benin, Burkina Faso, Burundi, Cameroon, CAR, Chad, Comoros, Congo, Côte d’Ivoire, DRC, Equatorial Guinea, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, Liberia, Malawi, Mali, Mauritania, Mozambique, Niger, Nigeria, Uganda, Sénégal, Sierra Leone, South Sudan, Togo, Tanzania (Mainland)* and Zimbabwe 26

27. 27 Malaria - Programmatic Challenges   Lack of Universal Access to malaria interventions   Emerging resistance to pyrethroids and other insecticides   Threat of resistance to artemisinin-based medications and other anti-malarials   Lack of quality trend data in several countries   Moving from accelerated control towards malaria elimination   Lack of Universal Access to malaria interventions   Emerging resistance to pyrethroids and other insecticides   Threat of resistance to artemisinin-based medications and other anti-malarials   Lack of quality trend data in several countries   Moving from accelerated control towards malaria elimination

28. 28 Prospects for the Future – HIV/AIDS   MDG Target 6A: Have halted by 2015 and begun to reverse the spread of HIV/AIDS.   38.5% reduction in the regional incidence of HIV between 2001 and 2012.   34 countries with decreasing trend, with notable reductions in the incidence   MDG Target 6B: Achieve, by 2010, Universal Access to treatment for HIV/AIDS for all those who need it.   By the end of 2012, 68% of eligible PLH were receiving ART, an increase of more than 90% since 2009.   Most countries in the region have scaled up access to ART, but only 10 countries have attained the target of 80% ART coverage   16 countries with coverage below 50%.   More needs to be done to achieve the HIV/AIDS-related MDG Targets

29. 29 Prospects for the Future – TB   Target 6C: Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases.   Incidence of tuberculosis decreased in 25 countries while it increased or remained the same in 21 countries   On the whole, the MDG target for TB has been achieved for the African Region   The gains made need to be sustained and the challenges related to HIV and TB drug resistance addressed

30. 30 Prospects for the Future – Malaria   Target 6C: Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases.   The incidence of malaria reduced by 31% between 2000 and 2012 in the African region   It is expected to decrease by 39% in the Region by 2015, if the current annual rate of decrease is maintained.   12 countries are on course to meet the MDG target   However, the 2015 projected reductions in malaria incidence and mortality are well below the WHA and RBM 2015 targets of reducing malaria incidence rate by 75% and achieving near zero malaria deaths.   More needs to be done to achieve the Malaria-related MDG Target

31. 31 Prospects for the Future – HIV, TB & Malaria   Countries to make smart investments for enhanced impact on disease burden   More effectively target interventions to “hotspots” or areas or populations with the greatest needs   Focus on areas where progress has been limited   Make use of new opportunities   Increase investment in health systems   Improve the monitoring of progress made and the use of data for decision-making   Countries to plan for the post-2015 era to improve Universal Health Coverage

32. 32 Prospects for the Future – – HIV, TB & Malaria   Partners to   Focus on areas of comparative advantage to enhance coordinated support to countries   Development partners to focus on strategic and catalytic upstream actions   Implementing partners to focus on operational level actions   Improve collaboration among ourselves

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