HIV/AIDS + TB

ISSUE

APPROACH

CHAI was founded in 2002 with a transformational goal: help save the lives of millions of people living with HIV/AIDS in the developing world by dramatically scaling up antiretroviral treatment. Today, CHAI remains committed to combating HIV/AIDS and TB around the world with new and innovative solutions.

The Issue

HIV and tuberculosis (TB) remain significant threats globally, representing the leading causes of infectious disease mortality, and place a growing burden on health systems and societies. In 2013, there were 35 million people living with HIV globally, with 2.1 million new infections and 1.5 million AIDS-related deaths in that year alone. TB for the first time now surpasses HIV/AIDS in infectious disease mortality worldwide and HIV/ TB co-infection causes one-third of all AIDS-related deaths. In 2014, the World Health Organization (WHO) estimated that 9.6 million people developed TB and 1.5 million died from the infection. While TB incidence rates are decreasing overall, the rate of decline remains slow.

The Approach

Given CHAI’s strong relationships with ministries of health and tradition of bringing new thinking and energy to areas that have been overlooked and under-resourced, CHAI is well-positioned to continue to build upon its early work and drive transformational impact and reduce HIV and TB-associated mortality globally. Given high rates of HIV/TB co-infection, and the fact that even in some low- HIV prevalence countries such as India, TB continues to be a leading cause of mortality especially in women of child-bearing age, CHAI’s response to strengthening HIV programs is increasingly inclusive of a focus on TB.

Issue

In 2002, the year CHAI was founded, over 3 million people died in the developing world from HIV/AIDS and only 70,000 people outside of South America received treatment, despite the fact that treatment had been available and effective in the developed world since the mid-1990s. In 2002 and 2003, CHAI initiated the first programs in Africa and the Caribbean that aimed to scale up HIV/AIDS care and treatment throughout entire countries. Since that time, CHAI’s HIV work has expanded to include both global and national level efforts to increase access to lifesaving drugs and diagnostics, train health workers in appropriate care and treatment practices, establish strong supply chains, and prevent new infections, among other areas.

However, despite year-on-year declines in deaths and new infections, 1.5 million AIDS-related deaths are far too many, and with 2.1 million infections every year, the overall number of people living with HIV continues to grow. Like many others, though, CHAI is increasingly optimistic about the possibility of ending the AIDS epidemic. Scale-up of treatment for HIV, for example, reached 17 million patients by the end of 2015. This scale-up is partly behind the decline in new infections, including significant reductions in new pediatric infections as pregnant and breastfeeding women are given treatment to prevent transmission to their children. Substantial work remains to be done, however, in order to reach new and ambitious treatment targets for 2020 and 2030, and in order to eliminate new pediatric infections and sharply reduce new adult infections through interventions such as voluntary medical male circumcision and pre-exposure prophylaxis (PrEP).

Approach

Since our inception in 2002, CHAI has focused on an efficient and effective HIV response, led fully by the national governments of affected countries, that provides quality prevention and treatment services to all who need them. CHAI works in 24 countries in Africa, Asia, Eastern Europe, and the Caribbean with a focus on scaling up access to effective treatment for all adults and children, driving uptake of proven prevention interventions, and creating the fiscal space to achieve these goals.
These objectives include work to reach universal access to treatment for infected adults and children, drive dramatic reductions in HIV-related mortality by accelerating the scale-up of effective interventions including high-quality HIV care, voluntary medical male circumcision, and the elimination of mother-to-child transmission of HIV (eMTCT) programming, and working with governments to ensure national HIV/AIDS programs are sustainably funded well into the future. The expansion of treatment eligibility recommendations set by the WHO in 2013 and accepted by most countries calls for even more ambitious treatment coverage, and CHAI is confident that with continued support, countries will be able to test and treat many more patients. This will sharply reduce AIDS-related deaths and will drive down new infections, since people living with HIV are 96 percent less likely to infect partners once they are on effective treatment themselves.

Change

Beginning in 2009, CHAI assisted the government of South Africa, the nation with the highest HIV burden in the world, with the largest scale up of HIV care and treatment ever attempted, from 800,000 people in 2009 to a projected 3 million people in 2015. CHAI helped negotiate agreements to lower HIV and TB drug prices that have saved the South African government almost US$1 billion, which is being used to treat more people within existing budgets. With assistance from CHAI and partners, South Africa scaled up its AIDS care and treatment facilities from less than 500 to over 4,000 to enable treatment expansion. In addition, CHAI provided critical technical and policy support to the South African government to roll out the largest HIV counseling and testing program ever undertaken with 15 million tests conducted in a 17-month period, quadrupling the number of tests conducted prior to this program.

Tuberculosis (TB)

Issue

TB, for the first time, now surpasses HIV/AIDS in infectious disease mortality worldwide and is now the leading killer of HIV-positive people, causing one in three HIV deaths in 2015. After decades spent working to address TB, the world is still far from fully controlling the epidemic: although global incidence rates have fallen steadily over the years (an average of 1.5 percent per year since 2000) and is now 18 percent lower than it was in 2000, it is not nearly enough to address the estimated 9.6 million people who developed TB and 1.5 million who died from the infection in 2014. Many millions of people who develop TB do not receive timely diagnosis and treatment, resulting in far too many deaths and new infections. Poor quality of treatment management and inappropriate use of anti-TB drugs lead to many failed treatment outcomes, and often the development of Multi-Drug Resistant TB (MDR-TB). Simple prevention interventions that can protect vulnerable and exposed populations—such as children living in a household with a TB-infected person or people living with HIV—are not being scaled up. Fresh thinking and bold actions are urgently needed to drive down TB transmission and mortality around the world.
Pediatric TB is particularly neglected, due to the lack of systematic efforts to screen vulnerable children for TB, as well as difficulties with diagnosing TB in children using existing technologies. It is estimated that in 2014, only 35 percent of pediatric TB cases were detected and registered with the national TB programs in several high-burden countries. Many of these “missing cases” are likely to have been misdiagnosed as other common childhood illness such as pneumonia, leading to an unknown toll on overall child health. In addition, drug-resistant TB, which is far more deadly and costly to treat, is spreading.

The increasing burden of MDR-TB in the world, with approximately 480,000 cases in 2014, is a major cause for concern and threatens the progress and continued efforts made to combat TB. The lack of capacity in most countries to meet the more complex and costly diagnosis and treatment required have resulted in many deaths and further MDR-TB infection through transmission.

Approach

CHAI’s early TB work focused on strengthening the management of TB in vulnerable populations, including miners and children. CHAI continues to work closely with ministries of health in high-burden countries to better understand critical areas of weakness in national TB programs and find promising solutions to increase uptake of new drugs and diagnostics. This work includes better identification of cases among high-risk populations such as HIV-positive people and exposed children, as well as the evaluation and development of new disease and patient management techniques to improve case-finding, treatment, and prophylaxis to drastically (rather than incrementally) reduce deaths and new infections. It also includes better quality diagnosis and treatment through increased utilization of GeneXpert testing devices and introduction and scale-up of new drugs such as bedaquiline and linezolid, the recently WHO-recommended, short course regimen to address the growing MDR-TB burden.

To address pediatric TB, CHAI is working closely with ministries of health in four focus countries (Malawi, Uganda, Zambia, and Zimbabwe) to improve understanding of the pediatric TB landscape, strengthen national responses, and include a TB emphasis in our Pediatric HIV program. Activities include developing and rolling out national guidelines on the management of TB in children, supporting training of healthcare workers, and strengthening the availability and accuracy of pediatric TB data at the national level. CHAI’s objective is to improve the detection and treatment of pediatric TB while supporting efforts to prevent new cases in vulnerable children through the provision of Isoniazid Preventive Therapy (IPT).

CHAI works closely with the ministries of health in seven focus countries (Vietnam, Myanmar, India, Nigeria, South Africa, Ethiopia, and Uganda) to help improve national responses to address challenges in MDR-TB. Activities include support in quantifying and forecasting MDR-TB drugs, advising on changes in national guidelines and diagnostic and treatment guidelines, developing national implementation plans for the adoption and scale-up of new drugs, and pharmacovigilance systems to monitor the administration of these drugs.

Change

CHAI-supported accomplishments have included:

  • CHAI has supported active case-finding for TB in Swaziland, which has the highest TB incidence rate in the world. The incidence rate is particularly high in the Shiselweni region, which has a significant concentration of miners, and where TB case detection has been a major challenge. It is estimated that only 38 percent of TB patients in Swaziland are identified and placed on treatment, which fuels further transmission and increases mortality. In 2014, in partnership with the Ministry of Health and Médecins Sans Frontières, CHAI conducted a “Fast Track” pilot project in the Shiselweni region, with the goal of increasing TB and HIV testing through door-to-door campaigns and community-level outreach activities. These efforts accounted for 49 percent of TB screenings and 62 percent of HIV tests that took place at government facilities in the community during the 2-month “Fast Track” period. Following the success of this pilot project, Swaziland’s National Tuberculosis Control Program decided to scale up the “Fast Track” program in its national strategy, with the goal of rolling out 55 Fast Tracks across the country over the next three years.
  • CHAI has worked closely with Zimbabwe’s Ministry of Health to develop a national response to TB in the country’s mining sector. Zimbabwe has one of the largest gold mining sectors in the region, and the majority of the workforce is unregistered. This lack of regulation inhibits an accurate understanding of the scale of the health challenges faced by this population, and thus limits the ability to design appropriate responses. CHAI has worked with the National TB Program (NTP) and partners in the public and private sectors to develop the first national road map and coordinating structure for a multi-sectoral response to TB in the mining sector. CHAI also conducted an initial mapping of the mining landscape in the country, which has provided the basis for large-scale initiatives to strengthen national and regional responses to TB.
  • CHAI has supported Vietnam’s Ministry of Health to develop guidelines for and roll out a pediatric isoniazid preventive therapy (IPT) program to reach HIV-positive children and prevent them from developing TB. The rollout was based on an assessment to explore the extent to which IPT reduced the rate of active TB among HIV-positive children, and to determine the safety of IPT in HIV-positive children. IPT and ART led to a 97 percent reduction in TB incidence (compared to 78 percent for ART alone). As a result, the Ministry has procured and delivered pediatric isoniazid to all 63 provinces so that all children living with HIV can access a simple, safe, and low-cost (US$3 per 6-month treatment course) method to prevent TB.
  • In Vietnam, CHAI developed Access to Care Information System (ACIS), an internet-based, SMS delivered referral and treatment support tool that has increased patient referral success by 50 percent. In Ho Chi Minh City alone, 1,652 HIV patients had been referred from an HIV clinic to a TB clinic through ACIS with an 85 percent successful referral rate, and 562 TB patients have been referred to HIV clinics through ACIS with an 81 percent successful referral rate. ACIS is operational at over 350 TB and HIV facilities across 20 provinces in Vietnam with expansion to an additional 26 provinces planned for 2016.
  • In India, CHAI, with support from the Bill & Melinda Gates Foundation and DFID, coordinates the Initiative for Promoting Affordable and Quality TB Tests (IPAQT) program, which aims to bring quality diagnostics to the private sector. Undertaken in close partnership with the National TB Program, the Initiative is a key element of the Revised National TB Control Program’s strategy to engage with the private sector. IPAQT partner labs tested over 146,000 TB samples on WHO-endorsed quality platforms in 2015, up from 75,000 samples in 2014, and over 22,000 positive TB cases diagnosed at IPAQT labs were notified to the National TB Program in 2015, up from 1,444 cases in 2014.
  • CHAI provides specific support to governments to improve their responses to drug-resistant TB. This work includes increasing access to molecular diagnostics which will enable more TB patients to be diagnosed and access life-saving treatment for drug resistant TB. In South Africa, CHAI successfully supported the introduction of two new multidrug-resistant TB drugs—bedaquiline and linezolid—by assisting with forecasting, procurement, and tendering for treatment of patients with multidrug-resistant TB who cannot be treated with the standard regimen, as well as those with pre-extensively drug-resistant TB.

Elimination of Mother-to-Child Transmission of HIV (eMTCT)

Issue

While there has been tremendous progress at reducing the transmission of HIV from mothers to children, 150,000 children are still infected with HIV each year according to UNAIDS estimates. The good news is that we now have the technology, policies, and funding to both prevent future infections and make sure infected children receive the best possible care and treatment. Antiretrovirals turn HIV from a death sentence to a manageable chronic disease, and when taken consistently during pregnancy and breastfeeding, virtually eliminate pediatric infection.

Approach

CHAI is helping address these issues through a comprehensive effort that focuses on the entire elimination of mother-to-child transmission and pediatric HIV continuum. We aim for ambitious but achievable impact on new pediatric HIV infections, pediatric treatment coverage, and mortality. CHAI’s work focuses on addressing the dual challenge of eliminating new infections and providing treatment to infected children who are in need of treatment. CHAI helps governments introduce sustainable and systematic changes to prevent new infections and make sure that children who do become infected at any point are identified, referred, and retained in care and treatment. The ultimate goal of this work is to help governments move toward achieving an AIDS-free generation.

Change

CHAI-supported accomplishments have included:

  • CHAI has worked to scale up the deployment of early infant diagnostics (EID), specific tests required to confirm infection in children under 2 years old, from 50,000 to over 1 million tests per year.
  • From 2008-2011, CHAI helped reduce mother-to-child transmission of HIV by 40 percent in high-burden areas of six countries through a focus on increasing the demand for services at the community level and improving service delivery. CHAI worked with communities to increase uptake and retention in services and to reduce stockouts of essential supplies, improve mechanisms for the diagnosis of HIV, increase initiation of preventative medicines, and increase the number of children tested for HIV.
  • In 2015, CHAI worked in 10 high-burden districts in the Center Region of Cameroon to strengthen the quality of prevention of mother-to-child transmission programs, as well as to further build and support adult and pediatric HIV care and treatment programs. Through the work in the region, nearly 90,000 pregnant women—95 percent—were tested and 7,311 HIV-positive pregnant women—85 percent—received antiretroviral therapy.
  • Within CHAI’s project in Ukraine, all newborns born to HIV-positive clients who reached the age of 18 months in 2015 were HIV-negative. Over the duration of the program, with CHAI support in partnership with AIDS LIFE Association (Life Ball) and the Olena Pinchuk ANTI-AIDS Foundation, the mother-to-child HIV transmission rate was reduced to 0.9 percent among injection drug-using project clients compared to the national 7 percent mother-to-child transmission level among injection drug users across the country.
  • In Papua New Guinea, funded by the Australian Government, in 2015 CHAI’s prevention of mother-to-child transmission program supported HIV testing for pregnant women and health facility deliveries for HIV-positive women. From January to September of 2015, 93 percent of pregnant women were tested for HIV in all CHAI-supported provinces, up from 88 percent in 2013, and CHAI is supporting the treatment of those who tested positive.
  • CHAI, with support from UNITAID, has worked since 2014 to ensure ongoing supply stability for optimized pediatric antiretroviral therapy and Early Infant Diagnosis (EID) commodities in 26 focal countries. Also with support from UNITAID, CHAI has engaged with ministries of health across seven focal countries to introduce new point-of-care EID technologies, which have the potential to dramatically improve linkage to treatment and save lives.
  • In Uganda, CHAI supported the Ministry of Health to address key challenges along the eMTCT-pediatric HIV cascade by reducing turnaround times for EID test results and improving tracking and follow-up for mothers and infants in care. An earlier pilot using phone follow-up and home visits showed an increase in retention amongst HIV-positive mothers from 73 percent to 80 percent, and a 70 percent increase in return rate for missed appointments that were followed up. In January 2016 Uganda adopted this follow-up model to be the national standard of care for follow-up of mother-infant pairs in all prevention of mother-to-child transmission sites nationwide.
  • CHAI, with support from UNITAID, has facilitated the creation of a competitive market place for Point-of-Care (POC) EID technologies with three commercially available products and a health pipeline of potential market entrants. POC EID testing has been shown with reduce turnaround times from sample collection to clinical action by more than 90 percent and increase timely initiation of patients on treatment to over 80 percent.

Pediatric HIV

Issue

When CHAI began working on pediatric HIV/AIDS in 2005, kids were being left behind: only one in 40 children in need was on treatment. The cost of pediatric medications was prohibitively high, dosing was difficult, and infant testing for HIV was almost non-existent. There has been significant progress since 2005, but according to UNAIDS estimates, 110,000 children still continue to die each year from AIDS-related causes and only 882,000 (49 percent) children are on treatment out of the 1.8 million children living with HIV.

Approach

The overall objective of CHAI’s pediatric HIV treatment scale-up work is to significantly increase the number of HIV-positive infants and children accessing testing, care, and treatment, while aiming to achieve the “90-90-90” targets in the medium term and to eliminate pediatric HIV in the long term. CHAI works closely with ministries of health in 24 countries in Africa, Asia, Eastern Europe, and the Caribbean with a focus on scaling up access to effective treatment for all children, driving uptake of proven prevention interventions, and creating the fiscal space to achieve these goals. Specifically, in five countries, CHAI is working with ministries of health and partners to aggressively pursue opportunities to accelerate pediatric case identification and initiation on antiretroviral therapy.

As a part of this work, CHAI supports ministries of health to develop and introduce child-friendly HIV policies and guidelines, train and mentor health workers in pediatric care and treatment, strengthen related drug quantification and distribution systems, improve retention along the eMTCT/pediatric HIV continuum, and coordinate partner activities and funding.

Change

CHAI-supported accomplishments have included:

  • Starting in 2004 and 2005, CHAI led a global effort to scale up treatment for children with AIDS in 34 countries, from 15,000 on treatment to over 800,000 who are on treatment today. Working with UNITAID, which was formed under the leadership of the French government and with CHAI’s assistance, prices of first-line pediatric AIDS drugs were reduced from over US$600 per child per year to around US$60 per child per year.
  • In Vietnam, CHAI’s work, in partnership with PEPFAR, GFATM, and the World Health Organization (WHO), helped ensure 86 percent of HIV-positive children were on antiretroviral therapy as of mid-2015, one of the highest coverage rates in the world. This represents an over 900 percent increase from the 9 percent of children on treatment in mid-2006 when CHAI was first established in Vietnam with funding from the Australian Government.
  • In Mozambique, CHAI in partnership with UNICEF supported the Ministry of Health to roll out a screening program to identify lost-to-follow-up children who may be HIV-exposed or HIV-positive. In one province, 2,600 children were found and initiated on antiretroviral therapy during a seven-month period.
  • In Zimbabwe, CHAI led the costing and coordination of an Accelerated Action Plan which helped the Ministry of Health quantify partner engagement and resources for pediatric HIV activities in-country, as well as identify gaps in financing needed to reach the government’s targets of 67 percent treatment coverage for HIV-positive children by 2018, and universal coverage by 2020.