Test and treat: Key to ending HIV PSI acting district focal person Mr Lionel Mufema
PSI acting district focal person Mr Lionel Mufema

PSI acting district focal person Mr Lionel Mufema

Paidamoyo Chipunza recently in Manicaland

“Testing and giving people antiretroviral therapy (ART) as soon as they test HIV-positive is the only way to get everyone on treatment by 2020. That said, necessary steps must be taken to ensure that we do not experience drug stockouts before ending Aids,” were the words of Manicaland activist Mr Lloyd Dembure.

 Responding to questions on World Health Organisation’s (WHO) new guidelines on management of HIV by giving everyone ARVs as soon as they test positive regardless of their CD4 count testing, Mr Dembure who is also Manicaland provincial coordinator for the Zimbabwe Network for People Living with HIV, urged all people from Manicaland to get tested and commence treatment early to prolong their lives.

“Although issues of drug stockouts are now a thing of the past, Government and its partners must ensure that test and treat is applicable and sustainable in the Zimbabwean set-up but everyone must also get tested for them to receive treatment early,” said Mr Dembure.

Manicaland and Matabeleland South are the only provinces that are now initiating all people testing HIV positive into ARVs regardless of their CD4 count.All other provinces are still giving ARVs to HIV-positive people with a CD4 Count of 500 and below.

Explaining the test and treat programme during a National Aids Council organised media tour in Makoni recently, Rusape General Hospital acting district medical officer (DMO) Dr Tendayi Nyafesa said the programme was implementable in the Zimbabwe set-up.

Dr Nyafesa said since they started the programme in July this year, the number of people on ART had gone up to 17 000 from 14 000 at the beginning of the year.Dr Nyafesa said they were targeting to put at least 23 000 people on ARVs by the end of this year.

“In partnership with the Organisation for Public Health Interventions and Development (OPHID), we have intensified our provider initiated HIV testing and counselling services by identifying key departments where we are likely to diagnose many patients such as the casualty, outpatients and admissions.

“We make sure that everyone who passes through these departments is offered an HIV test unless they opt out,” said Dr Nyafesa.He said the hospital also identified voluntary referral facilitators who assist those tested HIV-positive to link with relevant departments of care such as ART initiation and any other necessary follow-up.

Manicaland provincial coordinator for the Zimbabwe National Network for People Living with HIV Mr Lloyd Dembure

Manicaland provincial coordinator for the Zimbabwe National Network for People Living with HIV Mr Lloyd Dembure

Dr Nyafesa said those who do not come to health institutions because they are still well are captured through community visits spearheaded by the Family Health International (FHI) 360 and Population Services International (PSI).Through its programme known as index testing, FHI 360 offers HIV testing to spouses and family members of people who would have tested positive in a health facility while PSI is targeting groups of people that are mostly affected by HIV, also known as key populations. Zimbabwe’s key populations are youths between the age groups of 15 and 24 years, prisoners, commercial sex workers and long distant truck drivers.

“We hope Government will be able to pick the remaining estimated 480 000 people living with HIV and put them on ART if this strategy is implemented on a national scale,” said Dr Nyafesa.Policy advocacy and communications manager with OPHID Mrs Loveness Mlambo-Chimombe said the test and treat programme was currently running in seven districts namely, Mutare, Mutasa, Makoni and Chipinge, Gwanda, Bulilima and Mangwe.

Mrs Mlambo-Chimombe said with support from the US President’s Emergency Plan for AIDS Relief (PEPFAR) through the United States Agency for International Development (USAID), OPHID was leading implementation of the initial phase meant to draw lessons and strengthen the programme before a national roll out.

“Previously, there were eligibility issues where HIV-positive people were initiated on ART only if their CD4 count was 500 and below but with the new guidelines, all limitations were removed.

“There is no longer any waiting period for somebody to be on ARVs, so what we are saying is that HIV treatment is now available for everyone who tests HIV-positive,” said Mrs Mlambo-Chimombe.FHI 360 Makoni district coordinator Mrs Loveness Mangena said through their index testing, they were working with all testing sites in Makoni to identify people who would have tested positive.

Mrs Mangena said with the consent of the tested individual, they follow up on their sexual partners and their children offering them HIV tests from their homes.“Research has shown that if one person tests HIV-positive, chances are high that another family member could also be HIV-positive either a sexual partner or a child so we follow-up on them,” said Mrs Mangena.

She said during the follow-up, they also offer other health services such as screening and treatment for sexually transmitted diseases and tuberculosis.To ensure that no one is left behind, PSI acting district focal person Mr Lionel Mufema said his organisation was targeting key populations.

“Our aim is to reduce HIV infection among young people and to do that we are targeting young women and men above 25 years.“We are specifically targeting men above 25 years because statistics have shown us that older men infect younger women so our approach is to reduce HIV infection among young people,” said Mufema.

He said they were also offering pre exposure prophylaxis (PreP) to those at high risk of contracting HIV in the district.Several studies have also shown ARVs reduce the risk of acquiring HIV by 96 percent. Latest statistics from the Ministry of Health and Child Care show that an estimated 1,4 million Zimbabweans are living with HIV and about 920 000 people are on treatment.

In line with the global HIV targets, Zimbabwe must ensure that at least 1,3 million people know their status by the year 2020 and from those who know their status at least 1,2 million of them must be on antiretroviral therapy (ART) by the same year.

In addition, Zimbabwe’s target is to ensure that from those on ART, at least 1,1 million of them should have their viral load suppressed to undetectable levels by the same year in line with global efforts to end Aids by 2030.

Ministry of Health and Child Care’s head of Aids and tuberculosis unit Dr Owen Mugurungi said while an estimated 920 000 were on treatment, the remaining 480 000 were difficult to identify since they were generally well people. Dr Mugurungi said to close this gap and meet the country’s 2020 target, there was need for concerted efforts from all corners to ensure that no one is left behind to end Aids.

According to the World Health Organisation, ending Aids means a national prevalence rate of less than five percent by the year 2030.The country’s national prevalence rate currently stands at 15 percent.

“We have a window of opportunity of five years to kick start the ending of Aids, massive scale up in HIV prevention care and treatment to all populations (including key populations) and localities, make sure that no one is left behind, until 90 percent of all persons know their HIV status, 90 percent of those who know their status are on treatment and 90 percent of those on treatment are adherent and have sustained viral suppression,” said Dr Mugurungi.

He said test and treat was therefore ideal for Zimbabwe to maximise the number of people on treatment.

“We know treatment saves lives (reduces illness and deaths), improves quality of life and reduces risk of infection,” said Dr Mugurungi.Asked about sustainability of the programme on a national scale considering Zimbabwe’s constrained fiscal space, Dr Mugurungi said Government will continue engaging with its development partners to ensure that treating everyone becomes a success.

Although the burden of HIV is on a decline in Zimbabwe, it still remains a public health problem with about 29 000 Aids related deaths recorded in 2015 alone and 64 000 new infections in the same year.

8 ways funding for the global HIV response could go further

1. Protect and promote human rights

Public resources are wasted on enforcing laws that criminalise HIV transmission and dehumanise at-risk populations. By contrast, laws that protect at-risk populations are powerful, low-cost tools that help ensure that financial and scientific investments for HIV are not wasted. Enacting laws based on sound public health and human rights will ensure new prevention and treatment tools – such as PrEP [pre-exposure prophylaxis], male circumcision and microbicides – reach those who need them. Changes in the legal and policy environment, along with other interventions, could lower new adult HIV infections to an estimated 1,2 million by 2031 (compared to 2,1 million if current efforts continue unchanged). Mandeep Dhaliwal, UNDP

2. Make drugs cheaper

One way to make limited funds go further is to challenge drug companies on the high price of life-saving drugs. The use of unmerited patents by pharmaceutical companies to secure monopolies on their products must stop.

Make Medicines Affordable is working with civil society to challenge unmerited patents and use Trips agreement flexibilities. Julia Powell, International Treatment Preparedness Coalition

In lower middle-income countries, the average antiretroviral (ARV) treatment cost for a new adult patient is around $350. Of that, just 40 percent is the cost of the ARV – 35 percent is non-ARV recurrent costs (clinical salaries, laboratory etc) and then 25 percent is programme management. We really need to dissect non-drug costs and find ways to reduce costs with regard to generic licensing and optimising manufacturing costs. AnandReddi, Gilead Sciences

3. Support adherence to ARVs

Drug resistance is a huge issue and one to which we are only just waking up. The World Health Organisation has produced a 2017-21 action plan which, I think, underlines that we have neglected to focus on adherence and support people not just to access ARVs, but to stay on them. Mike Podmore

4. Integrate HIV into health sectors

Finance ministers tend to think in terms of sectors (eg health) or a clusters of sectors (eg the social sectors – education, health, social welfare), rather than in terms of individual issues like HIV.

We need to integrate Aids financing into domestic health financing and make the argument to finance ministers that they need to increase investment in the social sectors, and health in particular.

We need to underscore why this is an important investment in human capital and, therefore, in economic development. David Wilson, World Bank

5. Collect and spend taxes on health

Some countries with major HIV epidemics have actually progressively reduced the share of the government budget they allocate to health, and many African countries with major HIV challenges collect a smaller share of GDP as revenue – and spend more collecting that small share – than comparable economies elsewhere.

We must ensure that a significant share of the greater revenue collected is allocated to health, and spent as efficiently as possible. David Wilson

6. Integrate HIV and water and sanitation programmes

Safe water can make an enormous difference to the health and well being of people living with HIV. It can increase drug effectiveness by reducing diarrhoea and collaboration between HIV specialists at Safaids and in the water and sanitation sector have identified ways to integrate water and HIV programming more effectively in southern Africa to streamline investments.

In addition, a recent systematic review showed that water and sanitation interventions to reduce morbidity among people living with HIV were cost-effective, particularly when incorporated into complementary programmes. Louisa Gosling, WaterAid

7. Coordinate responses

In the HIV/Aids space, we can work with others focusing on health to share costs. In Malawi, for example, our mobile clinic teams test and treat for malaria and TB even though our core focus is HIV. Also, in our door-to-door testing pilot – where a team of eight canvases a village over a week to perform HIV tests – that same team will check for bed nets. If they do not have one, our HIV testing team will leave one and teach the family how to use it.

One team, but two major health issues covered. Joel Goldman, The Elizabeth Taylor AIDS Foundation

8. Push for more funding

We must reject the assumption that we will/can have less money and, instead, make it clear that less money, or even maintaining the same levels of funding, will lead to an increase in infections and deaths globally.

Many organisations working on the global HIV and TB responses are shouting loudly about the funding alarm. It became even more urgent when the Kaiser Family Foundation found that global donor financing had reduced by 13 percent from 2014 to 2015.

Our only way forward is to increase general public awareness and demand for donors and INGOs to increase HIV and TB funding up to 2020, and make it possible to end the epidemics by 2030. If not, we risk a terrifying rebound of the epidemics that we will struggle to get a grip on again. – theguardian.com

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