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Phyllis J. Kanki, 15+ Years of PEPFAR: Getting to Zero

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Phyllis J. Kanki, 15+ Years of PEPFAR: Getting to Zero

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October 7, 2019

On October 7, 2019, the Harvard Global Health Institute will host a one-day symposium to explore what enabled this visionary program, and to showcase how it has transformed not just the worldwide HIV/AIDS response but global health delivery more broadly.
There are many lessons learned in PEPFAR’s story - from what it took to build a supply chain where there was none, to establishing the use of generic antiretroviral therapies (ARTs) and leveraging human capacity. This event convened the early architects of PEPFAR as well as experts and implementers currently leading the charge. We took a historically informed look at what it will take to stop global transmission, and shared tools useful for others hoping to move the needle on vexing problems in global health.

For more information, visit our website at https://petrieflom.law.harvard.edu/events/details/15-years-of-pepfar

October 7, 2019

On October 7, 2019, the Harvard Global Health Institute will host a one-day symposium to explore what enabled this visionary program, and to showcase how it has transformed not just the worldwide HIV/AIDS response but global health delivery more broadly.
There are many lessons learned in PEPFAR’s story - from what it took to build a supply chain where there was none, to establishing the use of generic antiretroviral therapies (ARTs) and leveraging human capacity. This event convened the early architects of PEPFAR as well as experts and implementers currently leading the charge. We took a historically informed look at what it will take to stop global transmission, and shared tools useful for others hoping to move the needle on vexing problems in global health.

For more information, visit our website at https://petrieflom.law.harvard.edu/events/details/15-years-of-pepfar

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Phyllis J. Kanki, 15+ Years of PEPFAR: Getting to Zero

  1. 1. 15+ Years of PEPFAR: Getting to Zero Phyllis J Kanki Harvard T.H. Chan School of Public Health October 7, 2019
  2. 2. The Track 1.0 program request for funding was released in late 2003. Required experience in care of HIV-infected individuals in > 3 of the target countries: Botswana, Cote d’Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Nigeria, Rwanda, South Africa, Tanzania, Uganda, and Zambia. President’s Emergency Plan For AIDS Relief Four grants were awarded, 2004-2012. Goals: Treatment to > 2 million people Care to >10 million people Prevention of Mother-to-Child Treatment ~ 16 million.
  3. 3. The Track 1.0 program provided ART to 1.3 million patients at 1,300 health facilities across 13 countries. (2004-2012)
  4. 4. Provided ART to 79,584 AIDS patients Provided HIV care to 95,389 and ART to 61,891 Master Trainer Corps: Trainers treated 13,578 AIDS patients
  5. 5. 90-90-90 An ambitious treatment target to help end the AIDS epidemic through global solidarity, evidence-based action and multisectoral partnerships. Although many strategies will be needed to close the book on the AIDS epidemic, one thing is certain. It will be impossible to end the epidemic without bringing HIV treatment to all who need it. As the world contemplates the way forward following the 2015 deadline for the targets and commitments in the 2011 Political Declaration on HIV and AIDS, a final target is needed to drive progress towards the concluding chapter of the AIDS epidemic, promote accountability and unite diverse stakeholders in a common effort. Whereas previous AIDS targets sought to achieve incremental progress in the response, the aim in the post-2015 era is nothing less than the end of the AIDS epidemic by 2030. consultations focused on civil society, laboratory medicine, paediatric HIV treatment, adolescents and other key issues. Powerful momentum is now building towards a new narrative on HIV treatment and a new, final, ambitious, but achievable target: By 2020, 90% of all people living with HIV will know their HIV status. By 2020, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy. By 2020, 90% of all people receiving antiretroviral therapy will have viral suppression. THE TREATMENT TARGET virally suppresseddiagnosed on treatment 90% 90% 90%
  6. 6. I. Data Systems Paper Records Daily, on- site data entry Regular transfer to data managers Physician views patient data in clinic APIN Harvard provides TA to APIN SI team Feedback to sites
  7. 7. I. High quality data systems enabled robust outcome analyses RESEARCH ARTICLE Long-Term Outcomes on Antiretroviral Therapy in a Large Scale-Up Program in Nigeria Seema T. Meloni1 , Charlotte A. Chang1 , Geoffrey Eisen2 , Toyin Jolayemi3 , Bolanle Banigbe3 , Prosper I. Okonkwo3 , Phyllis J. Kanki1 * 1 Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America, 2 Center for Global Health, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America, 3 AIDS Prevention Initiative in Nigeria, Limited by Guarantee, Abuja, Federal Capital Territory, Nigeria * pkanki@hsph.harvard.edu Abstract Background While there has been a rapid global scale-up of antiretroviral therapy programs over the past decade, there are limited data on long-term outcomes from large cohorts in resource- constrained settings. Our objective in this evaluation was to measure multiple outcomes during first-line antiretroviral therapy in a large treatment program in Nigeria. Methods We conducted a retrospective multi-site program evaluation of adult patients (age 15 years) initiating antiretroviral therapy between June 2004 and February 2012 in Nigeria. The baseline characteristics of patients were described and longitudinal analyses using pri- mary endpoints of immunologic recovery, virologic rebound, treatment failure and long- term adherence patterns were conducted. Results Of 70,002 patients, 65.2% were female and median age was 35 (IQR: 29–41) years; 54.7% were started on a zidovudine-containing and 40% on a tenofovir-containing first-line regi- men. Median CD4+ cell counts for the cohort started at 149 cells/mm3 (IQR: 78–220) and , Jolayemi Long-Term a Large E 11(10): 164030 an open ms of the which nd the original hese data dical cy would be M A J O R A R T I C L E Tuberculosis Incidence and Risk Factors Among Human Immunodeficiency Virus (HIV)-Infected Adults Receiving Antiretroviral Therapy in a Large HIV Program in Nigeria Charlotte A. Chang,1 Seema Thakore Meloni,1 Geoffrey Eisen,3 Beth Chaplin,1 Patrick Akande,4 Prosper Okonkwo,4 Holly E. Rawizza,1,5 Eric Tchetgen Tchetgen,2 and Phyllis J. Kanki1 Departments of 1 Immunology and Infectious Diseases and 2 Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; 3 Center for Global Health, Northwestern University Feinberg School of Medicine, Chicago, Illinois; 4 AIDS Prevention Initiative Nigeria, Ltd./Gte., Abuja; and 5 Brigham and Women’s Hospital, Boston, Massachusetts Background. Despite the benefits of antiretroviral therapy (ART), tuberculosis (TB) is the leading cause of mortality among human immunodeficiency virus (HIV)-infected persons in Africa. Nigeria bears the highest TB burden in Africa and second highest HIV burden globally. This long-term multicenter study aimed to determine the incidence rate and predictors of TB in adults in the Harvard/AIDS Prevention Initiative in Nigeria (APIN) and President’s Emergency Plan for AIDS Relief (PEPFAR) Nigeria ART program. Methods. This retrospective evaluation used data collected from 2004 to 2012 through the Harvard/APIN PEP- FAR program. Risk factors for incident TB were determined using multivariate Cox proportional hazards regression with time-dependent covariates. Results. Of 50 320 adults enrolled from 2005 to 2010, 11 092 (22%) had laboratory-confirmed active TB disease at ART initiation, and 2021 (4%) developed active TB after commencing ART. During 78 228 total person-years (PY) of follow-up, the TB incidence rate was 25.8 cases per 1000 PY (95% confidence interval [CI], 24.7–27.0) overall, and it decreased significantly both with duration on ART and calendar year. Risk factors at ART initiation for incident TB included the following: earlier ART enrollment year, tenofovir-containing initial ART regimen, and World Health Organization clinical stage above 1. Time-updated risk factors included the following: low body mass index, low Tuberculosis incidence rate and risk factors among HIV-infected adults with access to antiretroviral therapy Enju Liua , Abel Makubie , Paul Drainf , Donna Spiegelmana,b,c,d , David Sandog , Nan Lia , Guerino Chalamillag , Christopher R. Sudfelda , Ellen Hertzmarkb and Wafaie W. Fawzia,b,d Objective: The objective of this study is to determine the incidence rate and risk factors of tuberculosis (TB) among HIV-infected adults accessing antiretroviral therapy (ART) in Tanzania. n=70,002 patients person-years= 136,852 n=50,320 patients person years= 78,228 n=67,686 patients Open Forum Infectious Diseases, 2015 Plos One, 2016 AIDS, 2015
  8. 8. II. Laboratory Infrastructure Laser-based CD4+ cell counts 24 laboratories Automated Hematology Chemistries for toxicity 24 laboratories HIV serologic diagnosis 64 laboratories Sequencing Drug resistance mutations 3 laboratories PCR-based viral load monitoring PCR-based early infant diagnosis 10 laboratories
  9. 9. 48% (205/430) HIV drug resistance muta;ons, primarily to NNRTIs HIV prevalence CRF02_AG G.WA-I G.WA-II G.CA A CRF06 Rec/Other CRF02_A G G.WA-I G.WA-II G.CA A CRF06 Rec/Othe r CRF02_AG G.WA-I A-II G.CA A CRF06 Rec/Other NORTH SOUTH NORTH- CENTRAL
  10. 10. III. The importance of training Botswana’s Clinical Master Trainer program Mother Sites Middlepit Bokspit Goodhope Palapye Masunga Werda Kalkfontein Newxade Clinics supported by Mother site
  11. 11. University of Ibadan – D. Olaleye, I. Adewole Ahmadu Bello University – H. Muktar University of Jos – O.Agbaji, S. Sagay University of Lagos – S. Ogunsola, S. Akanmu University of Maiduguri – W. Gashau University of Nigeria – C. Chukwuka, E. Nwobi AIDS Prevention Initiative in Nigeria – P. Okonkwo Harvard T H Chan School of Public Health – P. Kanki Northwestern University – R. Murphy Medical Education Partnership In Nigeria (2010-2015)
  12. 12. Minister of Health Isaac Adewole launches Turning the Tide: AIDS in Nigeria Abuja April 11, 2019
  13. 13. Kanki Lab Charlotte Chang Beth Chaplin A.Dieng Sarr Lana Dinic G. Eisen Steve Fake Rocio Garza Morgaine Gilchrist- Scott Don Hamel Jalal Hosseini Lydia Lo M-F Mclane Seema Meloni Chris Mullins Nsovu Nulenga Harry Reyes Matt O Rourke Tara Rao Holly Rawizza J-L Sankalé Connie Smith Craig Wen
  14. 14. Our partners in Botswana, Tanzania and Nigeria
  15. 15. Acknowledgements This work was funded, in part, by the U.S. Department of Health and Human Services, Health Resources and Services Administration. P. Kanki (PI) S. Meloni B. Chaplin C. Chang H. Rawizza J-L. Sankalé G. Eisen D. Hamel N. Ulenga L. Dinic J. Hosseini C. Smith R. Murphy K. Scarsi K. Hurt B. Taiwo C.Achenbach P. Okonkwo T. Jolayemi J. Samuels B. Banigbe R. Olaitan P. Akande B. Akinyemi O. Eberendu I. Adewole D. Olaleye J. Idoko S. Sagay O. Agbaji O. Idigbe D. Onwujekwe C. Okany R. Nkado W. Gashau H. Muktar J. Abah C. Chukwuka S. Akanmu F. Ogunsola All our colleagues at the APIN PEPFAR sites in Nigeria Most of all, our patients
  16. 16. PMTCTCounseling & Testing ART treatment Adults & Pediatric 100,000 patients 1,000,000 HIV/TB HIV Adults Care Pediatric Care Orphans 150,000 Lab Infrastructure Monitoring & Evaluation
  17. 17. Microbial Sequencing Workshop December 6-12, 2016, Boston, MA NIH/Fogarty Medical Education Partnership Initiative Universities of Ibadan, Jos and Lagos
  18. 18. Harvard School of Public Health PEPFAR Nigeria 2000 Tanzania 1992 Botswana 1995
  19. 19. Harvard PEPFAR Nigeria •Through Bill & Melinda Gates funding, Harvard has been working with multiple hospitals and prevention programs in Nigeria since 2000 •Started PEPFAR ART activities at 6 tertiary hospitals in 2004 and expanded to a total of 26 ART sites and 64 PMTCT sites.
  20. 20. Implementation Research • Diagnostics for the Real World: Evaluation of point of care SAMBA HIV Q and SQ nucleic acid (Harvard, JUTH, NIMR) • CDC-U01-GH000770: HIV Drug Resistance: Implications for optimizing antiretroviral therapy (NIMR, JUTH, UCH, Harvard) • CDC-U01-GH002109: Reaching 90% target of HIV viral suppression: The role of point of care VL monitoring in resource constrained settings (JUTH, Harvard, DRW)
  21. 21. University of Ibadan MEPI Junior Faculty Research Training Program (UI-MEPI-J) STAMINA Support for Training and Mentoring in Nigeria for Academics UNIVERSITY OF JOS & AHMADU BELLO UNIVERSITY Medical Education Partnership Initiative Research Capacity Building Junior Faculty (2015-2020) University of Lagos
  22. 22. CD4 Each green triangle indicates one pickup of antiretroviral medications. Orange triangles indicate a change in regimen. Log of Viral Load Laboratory Values Pharmacy Pickups
  23. 23. Honourable Minister of Health Professor Lambo launches the AIDS in Nigeria book for APIN Abuja April 12, 2006 Book Launch and Reception: AIDS in Nigeria:AIDS in Nigeria: a Nation on thea Nation on the ThresholdThreshold April 12, 2006, 4PM Ladi Kwali Hall Sheraton Abuja Funded by The Bill and Melinda Gates Foundation

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