Epidemiology and Policy Summary South Africa COP 2018 Regional Planning Meeting March 1, 2018 Internal Use Only What Does it Take to “Eliminate HIV”? • Utilize Underlying Population Data • Triangulate Program Data • Ensure a Supportive Policy Environment • Shift the Program for Impact • Intensify Partner Management 2 South Africa: Decreasing Incidence, Increasing Treatment 8,000,000 7,000,000 6,000,000 5,000,000 4,000,000 3,000,000 2,000,000 1,000,000 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Total HIV infections Cumulative AIDS deaths Total number of ART patients Total new HIV infections Total new on Treatment 3 South Africa: Same Trend Where It Matters Most KwaZulu Natal Gauteng 2,000,000 2,000,000 1,800,000 1,800,000 1,600,000 1,600,000 1,400,000 1,400,000 1,200,000 1,200,000 1,000,000 1,000,000 800,000 800,000 600,000 600,000 400,000 400,000 200,000 200,000 0 0 Total HIV infections Total AIDS deaths Total HIV infections Total AIDS deaths Total new HIV infections Total number of ART patients Total new HIV infections Total number of ART patients Total new on Treatment Total new on Treatment 4 Clinical Cascade 1st 90* 2nd 90* 3rd 90** *Thembisa model v 3.2 [Johnson LF, Dorrington RE, Moolla H. (2017) Progress towards the 2020 targets for HIV diagnosis and antiretroviral treatment in South Africa. Southern African Journal of HIV Medicine.18(1): a694] **NHLS program data Oct 2017 5 South Africa: Burden of HIV by Sex 6 Provincial HIV Burden: Highest-Burden Provinces PLHIV Gauteng 2017 Male Female Male PLHIV KwaZulu-Natal 2017 Female Age Group Age Group *Thembisa model v 3.2 [Johnson LF, Dorrington RE, Moolla H. (2017) Progress towards the 2020 targets for HIV diagnosis and antiretroviral treatment in South Africa. Southern African Journal of HIV Medicine.18(1): a694] 7 Clinical Cascade by Sex Adult Women Adult Men 1st 90* 2nd 90* PLHIV PLHIV = = 4 471 347* 2 542 120* 3rd 90** *Thembisa model v 3.2 [Johnson LF, Dorrington RE, Moolla H. (2017) Progress towards the 2020 targets for HIV diagnosis and antiretroviral treatment in South Africa. Southern African Journal of HIV Medicine.18(1): a694] **NHLS program data Oct 2017 8 Highest-Burden Districts F 15- F 15-24 F 15-24 24 F 15-24 15% 14% M 25+ 19% 18% M 25+ M 25+ Distribution of 41% M 25+ 43% 40% coverage gap 46% 90% F 25+ F 25+ F 25+ F 25+ 33% 34% 27% 39% 80% 70% 60% 50% % PLHIV on ART on % PLHIV 40% 30% 20% 10% 0% <15 15-24 25+ <15 15-24 25+ <15 15-24 25+ <15 15-24 25+ <15 15-24 25+ <15 15-24 25+ <15 15-24 25+ <15 15-24 25+ M F M F M F M F gp City of Johannesburg gp City of Tshwane Metropolitan gp Ekurhuleni Metropolitan kz eThekwini Metropolitan 9 Metropolitan Municipality Municipality Municipality Municipality Political Requirements for a Supportive Policy Environment POLICY STATUS Self Screening Working with Government of South Africa Approval to fast-track approval (April) PrEP Final policy in place (AGYW to start in April) Same-Day Initiation Policy in place, reminder circular out Differentiated Care Policy in place; discussing improvements to National Adherence Guidelines UID/IUD Policy in place, implementation varied TRAP Weekly facility review in practice POLICY STATUS HRH Policy Task force for monitoring and policy needed CHW Policy Initiated but not complete, to include SOW, Remuneration, Sustainability Community ART Initiation No policy 10 FY2018 Quarter One Performance South Africa COP 2018 Regional Planning Meeting March 1, 2018 Internal Use Only Our Performance is Not on Track FY2017 Q1 FY2017 Q2 FY2017 Q3 FY2017 Q4 FY2017 APR FY2017 TARGET % Achievement HTS_TST FY2017 2,456,092 Q1 FY2017 2,567,085 Q2 FY2017 2,870,112 Q3 FY2017 2,778,479 Q4 FY2017 10,671,768FY2018 APR FY2017 Q1 5,767,766 TARGETFY18 TARGET% Achievement185%% HTS_TSTHTS_TST_POS 2,456,092 221,892 2,567,085 234,127 2,870,112 241,300 2,778,479 223,025 10,671,768 920,344 2,282,560 5,767,766 839,648 10,026,497 185%110%23% HTS_TST_POSHTS Yield 221,8929.0% 234,1279.1% 241,3008.4% 223,0258.0% 920,344 8.6% 181,486 839,648 14.6% 977,545 110%19% HTSTX-NEW Yield 183,9579.0% 191,3059.1% 155,6468.4% 163,8168.0% 694,724 8.6% 8% 965,13114.6% 10% 82%72% TX-NEWLinkage 183,95783% 191,30582% 155,64665% 163,81673% 694,724 75% 143,187 965,131 115% 1,032,601 14%72% LinkageTX_CURR 2,950,89483% 3,040,02182% 3,157,13765% 3,157,96573% 3,157,96575% 79% 3,935,927115% 106% 75%80% TX_CURRTX_NET_NEW 2,950,894 235,131 3,040,021 89,127 3,157,137 117,116 3,157,965 828 3,157,965 442,202 3,221,849 3,935,9271,220,164 4,362,429 74%80%36% TX_NET_NEWTX_RET 235,131 89,127 117,116 82870% 442,202 70% 63,884 1,220,16490% #VALUE!36%78% TX_RETTX_PVLS 70%85% 70%85% 90%91% 78%93% TX_PVLSVMMC_CIRC 44,626 47,280 158,791 189,95085% 440,647 85% 61,503 393,465 91% 570,879 112%11%93% VMMC_CIRCPrEP_NEW 44,626 304 47,280 381 158,791 698 189,950 768 440,647 2,151 724 393,465 1,279 18,171 112%168%4% PrEP_NEWKP_PREV 304 116,930 381 698 71,115 768 188,045 2,151 61,503 109,385 1,279 570,879 168%172%11% KP_PREVPP_PREV 116,930343,849 752,441 71,115 1,096,290 188,045 109,385579,323 172%189% PP_PREVOVC_SERV 343,849442,200 752,441762,304 1,096,290 799,820 724 579,323664,521 18,171 189%120%4% OVC_SERV 442,200 762,304 799,820 664,521 120% • PEPFAR SA is not on track for Case finding, Treatment initiation, and Treatment retention • VMMC is currently in the low season and is on track to meet FY18 targets; FY18 Q1 results out-perform FY17Q1. • PrEP is expected to accelerate with the launch of AGYW programming in April 2018. 12 We are Monitoring Case Finding on a Weekly Basis We are monitoring yield optimization in real time HTS_POS case identification 1800 1600 eThekwini MM 1400 Ekurhuleni 1200 gp City of Johannesburg 1000 gp City of Tshwane 800 600 400 200 0 13 Proxy Linkage Doesn’t Match New on Treatment FY18 Q1 Partner TX_NEW Proxy Linkage, facility Outlay Anova Health Institute (17020) 33% 93% 24% Right To Care, South Africa (17021) 19% 79% 27% Broadreach (17023) 14% 101% 19% Foundation for Professional Development (17036) 8% 84% 19% Wits Reproductive Health& HIV Institute (17037) 27% 109% 27% MatCH (17038) 17% 101% 28% Kheth'Impilo (17046) 9% 105% 20% Health Systems Trust (18481) 13% 84% 13% TB/HIV Care (18482) 8% 97% 17% Aurum (18484) 13% 89% 21% 14 Enhanced Monitoring for Partner Management: Direct Linkage to ART PEPFAR SA HTS providers are required to link to ART (and we are tracking it) • Beginning FY18, partners reporting HTS data also report Direct linkage indicator: HTS_TST_ART 14-day ART initiation outcomes among clients who HTS_TST Numerator: # clients who initiate ART ≤14 days of HIV diagnosis test positive (HTS_TST_ART) HTS_TST_POS Denominator: HTS_TST_POS • As a testing program metric, this indicator places HTS_TST_ART Disaggregations: Age; Sex; accountability for linking Modality (Community/Facility) clients to ART directly with HTS providers 15 New Direct Linkage Indicator Partner Management Action ART initiation <14 days following positive HIV test result Example: Facility HTS_TST_ART results, FY18 Q1, by age/sex Facility Proxy linkage TX_NEW/ HTS_TST_POS Facility Direct linkage HTS_TST_ART/ HTS_TST_POS Directly measured 14-day ART initiation outcome, as reported by HTS partner 16 Unique Patient Identifiers: On Track to 80% Coverage in FY18 UID completeness as % of TROA 90% Need to drive UID in priority districts 84% 80% 74% 74% 68% 70% 66% 61% 59% 58% 60% 55% 50% 50% 45% 46% 42% 40% 37% 40% 35% 35% 33% 30% 29% 30% 20% 10% 0% Based on partner reports, January 2018. 17 TX_NEW FY16-FY18 Q1, 27 Focus Districts and 4 Highest-Burden Districts 27 Focus Districts combined 4 Highest-Burden Districts 250,000 35,000 UTT re-set the baseline, but we need to do more 30,000 200,000 25,000 150,000 20,000 15,000 100,000 10,000 50,000 5,000 - 0 FY16-Q1 FY16-Q2 FY16-Q3 FY16-Q4 FY17-Q1 FY17-Q2 FY17-Q3 FY17-Q4 FY18-Q1 FY16-Q1 FY16-Q2 FY16-Q3 FY16-Q4 FY17-Q1 FY17-Q2 FY17-Q3 FY17-Q4 FY18-Q1 Jul-Sep '15 Oct-Dec '15 Jan-Mar '16 Apr-Jun '16 Oct-Dec '16 Jan-Mar '17 Apr-Jun '17 Jul-Sep '17 Oct-Dec '17 Jul-Sep '15 Oct-Dec '15 Jan-Mar '16 Apr-Jun '16 Oct-Dec '16 Jan-Mar '17 Apr-Jun '17 Jul-Sep '17 Oct-Dec '17 gp City of Johannesburg Metro gp Ekurhuleni Metro kz eThekwini Metro 18 VMMC Weekly Trend Analysis – Through February 16, 2018 12000 10,787 Ramping up for high season 10000 8000 Weekly Target 7,420 6,889 6,260 6,279 6000 5,392 5,433 4,244 4,137 4,145 4,369 4000 2,863 1,820 1,961 2000 1,510 0 1/1/2018 1/3/2018 1/5/2018 1/7/2018 1/9/2018 2/2/2018 2/4/2018 2/6/2018 2/8/2018 11/6/2017 11/8/2017 12/2/2017 12/4/2017 12/6/2017 12/8/2017 1/11/2018 1/13/2018 1/15/2018 1/17/2018 1/19/2018 1/21/2018 1/23/2018 1/25/2018 1/27/2018 1/29/2018 1/31/2018 2/10/2018 2/12/2018 11/10/2017 11/12/2017 11/14/2017 11/16/2017 11/18/2017 11/20/2017 11/22/2017 11/24/2017 11/26/2017 11/28/2017 11/30/2017 12/10/2017 12/12/2017 12/14/2017 12/16/2017 12/18/2017 12/20/2017 12/22/2017 12/24/2017 12/26/2017 12/28/2017 12/30/2017 November December January February 19 PrEP Trend by Sub-Population (SW and MSM) We will continue acceleration in SW and MSM; AGYW to begin in April 2018 to get us 600 on track for annual PrEP targets 500 400 PrEP_NEW MSM 300 PrEP_NEW TG PrEP_NEW FSW 200 100 0 2 3 1 0 0 Oct to Dec 2016 Jan to Mar 2017 Apr to Jun 2017 Jul to Sep 2017 Oct to Dec 2017 20 Maximize TB Entry Points, including TB Suspects, for Case Identification TB-HIV CLINICAL CASCADE FY2017 180,000 160,000 96% know their status 140,000 66% are positive 120,000 93% are on ART 100,000 80,000 60,000 40,000 20,000 0 TB_STAT TB_STAT TB_STAT Pos TB_ART D N N N 21 COP 2018