Size of the country; size of the epidemic; size of art programme Rich country!

• Size of the country; size of the epidemic; size of ART programme

• Rich country!

• De Cock: If South Africa fails, we all fail

“"There is a need for honesty and peer review in situations that impact public health policy. When AIDS denialism enters public health practice, the consequences are tragic. The implications start in honest science but extend to the need for accountability and, perhaps, public health reform." Chigwedere P, Essex M. AIDS Denialism and Public Health Practice. AIDS and Behavior, 2010; DOI: 10.1007/s10461-009-9654-7 http://www.sciencedaily.com/releases/2010/01/100118132134.htm

• “"There is a need for honesty and peer review in situations that impact public health policy. When AIDS denialism enters public health practice, the consequences are tragic. The implications start in honest science but extend to the need for accountability and, perhaps, public health reform." Chigwedere P, Essex M. AIDS Denialism and Public Health Practice. AIDS and Behavior, 2010; DOI: 10.1007/s10461-009-9654-7 http://www.sciencedaily.com/releases/2010/01/100118132134.htm

5 year survival on ART in Botswana

• 5 year survival on ART in Botswana

Our models: 1 hospitalisation, 2-3 clinic visits per person put on ART

• Our models: 1 hospitalisation, 2-3 clinic visits per person put on ART

• “Test and treat” modellers – 2-9 days hospitalisation averted per person on ART

• Hugely cost saving in SA WHATEVER CD4 you use (in Kenya, not so)

Urban and rural: Initiation CD4 80-100 since 2004

• Urban and rural: Initiation CD4 80-100 since 2004

• Johannesburg inner city – average CD4 106, despite 70% coverage, and massive escalation of HIV testing

• ¼ of all South Africans had an HIV test in 2008 (Shisana, HSRC Mandela survey, 2009)

50% loss to follow up at EVERY step

• 50% loss to follow up at EVERY step

Not even done at a provincial level

• Not even done at a provincial level

• Starts with HIV testing – but EVERY step needs to be counted

Decent maternal ART=unemployed HIV paediatricians

• Decent maternal ART=unemployed HIV paediatricians

• BUT hard to identify, hard to treat

• Suffer the most in poor health systems

• Prevention is better than treatment

Cost of SA health care workers is very high

• Cost of SA health care workers is very high

• Excuse for not scaling up, despite relatively high staffing levels

• Paradoxically, meant that task shifting has not happened

ART best way to prevent TB

• ART best way to prevent TB

• IPT very hard to implement

History – confrontational

• History – confrontational

• Patch up the gaping holes in the programme

• Now: sustainability and technical ability – ESPECIALLY critical reviews of data and resource usage

We’re still treating HIV as an acute illness

• We’re still treating HIV as an acute illness

• Mortality is driven by late diagnosis, poor referral, and delayed ART – we aren’t acting urgently post diagnosis

• People who get ART, generally stay on it DESPITE the system (commonest reason for LTFU – changing jobs)

• Adherence is good, but failures are costly

Quick and (relatively) easy: TDF, FDC’s, use tender process to get better deals on drug packaging, PMTCT

• Quick and (relatively) easy: TDF, FDC’s, use tender process to get better deals on drug packaging, PMTCT

• ANC and TB clinics to test and start ART

• Programmatically hard: Targets for every step – starting with the provinces, down to a clinical level

• Creative and expensive: Chronic disease grants, medicine pick ups

• Expand HIV testing in health facilities

• Critically review certain programmes for LTFU – ‘know your status’ not good enough

• Review SANAC

Health systems and retention in care

• Health systems and retention in care

• The average South African does not want to attend a state health facility (for good reason!)

• Retention in care affects – OI prophylaxis, IPT, ‘prevention for positives’, discordant couple interventions, etc etc

• ? A chronic care system is the silo we need

• Finally: Public health leadership – tough choices, tough priority setting – focus on using existing resources more intelligently