Overview of lessons learned from previous biomedical HIV prevention interventions in South Africa Presented by: Elizabeth T. Montgomery, Ph. D February 7, 2012 www. rti. org RTI International is a trade name of Research Triangle Ins
Background • The history of other biomedical HIV prevention methods introduced in South Africa may offer insights relevant to the introduction of oral Pr. EP and vaginal microbicides – Case studies to consider: • PMTCT • Male circumcision www. rti. org
Case Study 1: PMTCT, timeline • • HIVNET 012 results published in 1999 First SAG policy drafted in 2001 – Original Department of Health plan was to implement single dose Nevirapine (NVP) at 18 pilot sites (1 urban, 1 rural, per province) July 2002: “lobby groups” won a case against the NDOH in the Constitutional Court. National expansion of PMTCT mandated – • August 2005: ~2525 sites offering PMTCT www. rti. org
PMTCT Timeline continued • SAG published new PMTCT guidelines in 2008 to include provision of dual therapy – • 2008 PEPFAR estimates of ARV coverage for HIV+ pregnant women in South Africa just under 60% 2010 Updated Guidelines published 4 www. rti. org 3/18/2018
PMTCT Programme Intervention 5 www. rti. org 3/18/2018
h 6 www. rti. org 3/18/2018
PMTCT Analysis – one perspective www. rti. org
PMTCT Programme in South Africa Strengths • Policy drafted in 2001 • New guidelines published in 2008 • Wide consultation on policies and plans • PLWHA and disability sector involved in the social mobilization plan for PMTCT www. rti. org Weaknesses • Protocol does not fully match international best practice standards • Men not sufficiently involved • Adolescent mothers not included in PMTCT planning • Inadequate human resources • Poor quality counseling • Infant formula supply problems • Inaccurate M & E
PMTCT Programme – another perspective PMTCT: A Winnable Battle in South Africa • National cross-sectional facility-based survey of infant-caregiver pairs attending the 1 st infant immunization visit • Dried blood spot (DBS) specimens from 4 -8 week old infants were tested for HIV antibodies – Exposed infants further tested using DNA PCR 9 www. rti. org 3/18/2018
PMTCT Programme results • 9610 enrolled infant-caregiver pairs, 2888 (30%) HIVexposed infants were identified. • National MTCT rate at 4 -8 week postpartum was estimated to be 4. 0% (95%CI 3. 3%-4. 8%). – Unplanned pregnancy (AOR=1. 7; 95%CI 0. 9 -2. 9) associated with MTCT. – Exclusive breast-feeding (AOR=0. 6; 95%CI 0. 4 -0. 9); and maternal triple antiretroviral treatment (AOR=0. 4; 95%CI 0. 20. 8) were protective factors. 10 www. rti. org 3/18/2018
PMTCT – important lessons • Civil society keeps up with research and will hold SAG accountable to all citizens, not just those in “pilot” areas – Early preparation needed • More than just a pill – Prevention interventions complex and rely on a series of interventions and a holistic approach of how the pills fit in • Importance of ongoing and evidence-based evaluation www. rti. org
Case Study 2: Male circumcision OVERVIEW • 2005 -2006 Clinical trial results: ~60% reduction in HIV acquisition • 2007 WHO/ UNAIDS recommendations issued • South Africa identified as a priority country • March 2011 South African National Implementation Guidelines for Medical Male Circumcision www. rti. org
National and multinational goals • South African Guidelines goal: to make accessible, safe MMC services available to all South African men. The priority age group is young men aged between 15 and 49. • WHO/ UNAIDS Strategic Framework seeks to achieve the following goal: By 2016 countries with generalized HIV epidemics and low prevalence of MC have: – a) VMMC prevalence of at least 80% among 15– 49 year old males, and – b) Established a sustainable national programme that provides VMMC services to all infants up to 2 months old and at least 80% of male adolescents. 13 www. rti. org 3/18/2018
VMMC Considerations • Goal(s) • Guiding principles, e. g. supportive leadership, safe and effective practice, human rights, gender sensitivity, socio-cultural sensitivity, comprehensive HIV prevention • Implementation Activities – – – www. rti. org Management at different levels Service Delivery Clinical Guidelines Communication Leadership and partnerships HR, Financing, Costing, Supplies, etc etc 3/18/2018 14
South Africa Estimates of VMMC • 130, 000 VMMC in South Africa by end of 2010 (UNAIDS) • To date: Catey and Carlos? • Successes and Weaknesses of VMMC programme 15 www. rti. org 3/18/2018
Summary and Conclusions • Issues of potential relevance to Oral Pr. EP/ Vaginal Microbicides – – – – – www. rti. org Political Leadership Role of civil society Costs of intervention/ opportunity costs Degree of integration with other RH activities and HIV prevention efforts • related impact on capacity of service delivery Training and human resources Supply/ commodity demands Marketing and communications Counseling needs, issue of partial efficacy Need for ongoing monitoring and evaluation 3/18/2018 16
And finally • What have we learned from implementation of other (non HIVrelated) interventions that could be useful? 17 www. rti. org 3/18/2018
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