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 is second only to HIV/AIDS in infectious disease mortality worldwide and HIV/ TB co-infection causes one-fourth of all AIDS-related deaths. In 2013, the World Health Organization (WHO) estimated that 9 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, is on pace to reach the ambitious target of 15 million patients by the end of 2015, with 13.6 million patients under treatment as of June 2014. 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.

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 is second only to HIV/AIDS in infectious disease mortality worldwide, and HIV/TB co-infection causes one quarter of all AIDS-related deaths. After decades spent working to address TB, the world is still far from fully controlling the epidemic: in 2013, the WHO estimated that 9 million people developed TB and 1.5 million died from the infection. Many millions of people infected with the disease do not receive timely diagnosis and treatment, resulting in far too many deaths and new infections. 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 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.

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. This work includes better identification of exposed children, as well as the consideration of fresh disease management techniques and the potential for far more aggressive approaches to case-finding, treatment, and prophylaxis to drastically rather than incrementally drive down deaths and new infections.

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).

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 (MOH) 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 MOH 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.

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

Issue

Eliminating mother-to-child transmission of HIV (eMTCT) is one of the most exciting goals in public health, and CHAI firmly believes that an AIDS-free generation is attainable. Progress has been impressive: by 2013, 68 percent of pregnant women living with HIV in 21 priority countries in sub-Saharan Africa received prevention of mother-to-child transmission (PMTCT) services, up from 34 percent in 2009. New pediatric HIV infections reduced to 240,000 in 2013, representing a 40 percent decline since 2009. While this progress is commendable and has helped drive down six-week transmission rates, the job is far from done because 20,000 children are still infected every month. Half of all new episodes of HIV transmission to children occur during the breastfeeding period and until eMTCT coverage is extended to the end of breastfeeding, the elimination agenda cannot be achieved. Efforts are falling short during the last mile of eMTCT, and fail to make the critical link between infected infants and treatment initiation. The good news is that we now have the technology, policies, and funding to both prevent future infections and make sure that infected children receive the best possible care and treatment. Antiretrovirals turn HIV from a death sentence to a manageable chronic disease, and when taken during pregnancy and breastfeeding, virtually eliminate pediatric infection.

Approach

CHAI’s approach to eMTCT is closely linked to our pediatric HIV work. CHAI has launched a comprehensive effort in select high-burden countries that focuses on the entire continuum of pediatric HIV prevention and treatment, with the ultimate goal of eliminating new infections, scaling up pediatric treatment, and reducing HIV-related child mortality. Our emphasis is on bringing about a paradigm shift to focus efforts on infant outcomes at the end of the breastfeeding period, when eMTCT services for mothers and infants should technically end; and ensuring that children who do become infected at any point are identified, referred, and retained in care and treatment.

Change

CHAI-supported accomplishments have included:

  • From 2008 to 2011, CHAI helped reduce mother-to-child transmission of HIV (MTCT) 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 Uganda, CHAI supported the Ministry of Health to develop and nationally scale systems to reduce EID turnaround times; improve tracking of infant ART initiation through the nationwide rollout of the HIV-positive infant follow-up forms; and pilot a comprehensive PMTCT follow-up program to improve retention of HIV-positive mothers and their infants in care. The follow-up program was piloted in four regions across 20 facilities from April to October 2014. The program saw a 7.5 percent increase in five-month retention rates for HIV-positive mothers, and a 20 percent increase in retention rates for HIV-exposed infants. These results, although observed for a short period of time, provide some evidence that patient tracking tools and community follow-up systems have the potential to address retention challenges along the eMTCT/pediatric cascade. CHAI is working with the government to develop policy recommendations based on findings from the pilot.
  • In Cameroon, CHAI has rapidly expanded quality comprehensive PMTCT Option B+ services in the country’s Center region from approximately 33 sites to just over 600 sites since it began work in this area in 2014. Going forward, the focus will remain on improving access and quality of care.

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, compared to one in eight adults. The cost of pediatric medications was prohibitively high, dosing was difficult, and infant testing for HIV was almost non-existent. Despite significant progress since 2005, HIV treatment coverage for children still lags behind coverage rates for adults around the world. It is estimated that 190,000 children continue to die each year from AIDS-related causes and 3.2 million children are living with HIV.

Approach

To help address these issues, CHAI’s pediatric HIV treatment scale-up work aims to close the gap between adult and pediatric HIV coverage rates and achieve universal pediatric treatment coverage, with the goal of eliminating pediatric HIV in the long term. CHAI works closely with ministries of health in high-burden countries to strengthen the identification of pediatric HIV and TB, improve retention along the eMTCT/pediatric HIV continuum, and expand access to high-quality pediatric HIV and TB services.

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 600,000 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.
  • 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.