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 CoordinatorMinistry of Health, Swaziland

July 23, 2014

Outline

Introduction to the MaxART Program

Achievements from Phase 1

Phase 2: MaxART Early Access to ART for All Implementation Study

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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?

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

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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

Conduct “Early Access to ART for All” implementation study

PHASE 1 2011-2014

PHASE 2 2014-2017

Mobilize Communities

HIV Testing

Enrollment in Care

ART Initiation

Retention

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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 InitiativesAlong Continuum of Care

Outline

Introduction to the MaxART Program

Achievements from Phase 1

Phase 2: MaxART Early Access to ART for All Implementation Study

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Mobilizing Communities in SwazilandKey Accomplishments

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“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 DlaminiNsingizini 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

2011 2012 2013* 2014 Target

180000

238000

300000 317000

145000184000

237000 250000

TestsEstimated number of people tested

HIV Testing in SwazilandDisplayed in thousands/year

2011 2012 2013** 2014 Target

7200087000

101000 110000

On Treatment

ART in Swaziland Displayed in thousands/year

HTC Target: Increase annual testing to at least 250,000 per year by end of 2014Achieved: >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

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

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

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Summary of Results - Pre-Implementation Study – Social Science

Issue Total (%) Women % Men %

Willing to start ART on same day as receiving HIV+ results

69.7 76.2 58.3

Willing to start ARVs while feeling healthy

57.6 61.9 50.0

Willing to start early to reduce chances of infecting others

67.7 76.0 50.0

Initiating ART regardless of CD4 count would be a good decision for SZ

65.5 63.4 66.7

On clients being told of the prevention benefits of ART

68.1 62.2 79.2

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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

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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.

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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.

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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36

Facilities Step 7 C C C C C C C C C C C C C C C C C C C C C C C C C C C C T T T T I I I I

Step 6 C C C C C C C C C C C C C C C C C C C C C C C C T T T T I I I I I I I I

Step 5 C C C C C C C C C C C C C C C C C C C C T T T T I I I I I I I I I I I I

Step 4 C C C C C C C C C C C C C C C C T T T T I I I I I I I I I I I I I I I I

Step 3 C C C C C C C C C C C C T T T T I I I I I I I I I I I I I I I I I I I I

Step 2 C C C C C C C C T T T T I I I I I I I I I I I I I I I I I I I I I I I I

Step 1 C C C C T T T T I I I I I I I I I I I I I I I I I I I I I I I I I I I I

Standard of Care (Control )

Trans iti on Period from SOC to Treatment for Al l (Intervention)

Treatment for Al l (Intervention)

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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

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Conclusion

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