Transcript 6 - Fareed Abdullah

LESSONS AND CHALLENGES IN HIV/AIDS
ODI
7 June 2006
SCALING UP ART IN THE WESTERN CAPE
PROVINCE OF SOUTH AFRICA
Unless treatment reaches significant numbers of
people living with AIDS its public health impact will
be severely limited
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PROJECTED AIDS CASES (SA)
No ART
1,400,000
1,200,000
1,000,000
800,000
600,000
400,000
200,000
0
2020
2018
2016
2014
2012
2010
2008
2006
2004
2002
2000
No ART
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PROJECTED HIV POSITIVE PERSONS
(SA)
No ART
7,000,000
6,500,000
6,000,000
5,500,000
No ART
5,000,000
4,500,000
2020
2018
2016
2014
2012
2010
2008
2006
2004
2002
2000
4,000,000
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PROJECTED NUMBER HIV INFECTED BY
STAGE OF DISEASE (SA)
7,000,000
6,000,000
5,000,000
Stage 4
4,000,000
Stage 3
3,000,000
Stage 2
2,000,000
Stage 1
1,000,000
2019
2016
2013
2010
2007
2004
2001
1998
1995
0
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AIDS RELATED DEATHS (SA) UNDER
VARIOUS TREATMENT SCENARIOS
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Describing the intervention
SL – 1.78 years
FL – 2.68 years
HIV infection 7.5 – 9.1 years
Failing 1.6 years
Failing 1.6 years
Stage 4 – 1.47 – 1.8 years
Median survival from initiating treatment of 4.5 years
if two regimens offered, mean 6.06 years, mean
benefit of 4.46 years
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SCALING UP ART IN THE WESTERN CAPE
PROVINCE
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HIV EPIDEMIOLOGY

Antenatal prevalence – 15.4%

District level surveys show range
of 1% - 33%

200 000 – 250 000 HIV positive

5-10% need HAART
ANTENATAL PREVALENCE
15.4%
300,000
250,000
200,000

S tage 4
S tage 3
25% of all hospital admissions by
150,000
2010
100,000
S tage 2
S tage 1
50,000
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2009
2007
2005
2003
2001
1999
1997
1995
1993
1991
1989
0
1987
23% of all PHC visits by 2010
1985

BACKGROUND TO THE WESTERN CAPE HEALTH
SERVICE

252 fixed and 131 mobile clinics

64 community health centres

36 district and regional hospitals

3 tertiary referral hospitals (1 for
children)

Population 5 million spread over
129 370 km2
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PRIMARY HEALTH CARE SERVICES

Chronic understaffing

Poor management and
organisation

Lack of computerisation

8 million visits per year to clinics

4 million visits per year to
community health centres
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LEVELS OF CARE

Clinic level – nurse driven, VCT,
minor ailments, ongoing
counseling, workup including CD4
count

Community health centre or
district hospital OPD initiation and
maintenance of HAART

Secondary referral for sputum
negative TB, immune
reconstitution, major side effects

Special arrangements for children,
pregnancy, psychiatry
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HAART is a simple and feasible intervention,
appropriately implemented at PHC level,
requiring the engagement of a doctor for treatment
initiation,
entirely affordable within the SA context
The entire discussion on HAART must always aim
at finding the balance between treating as many
people as possible and protecting against drug
resistance
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SPEED

Using the budget as a policy and
planning tool

Pharmacy management (parallel
systems

Mobiising GFATM resources

Staff and infrastructure

NGO Partners and Partnership
management (can’t scale up alone)
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PLANNING AND BUDGETING

Estimate numbers of patients by
site

Allocate budgets for drugs and
labs, counselors, nutrition,
community psycho social support

Allocate staff on a subjective basis

All other costs to be met by
general facility budget
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WITHIN THE METROPOLITAN AREA (start in the
districts with the highest burden and where
infrastructure exists)

93 clinics

48 community health centres

Majority of hospital beds and all 3
tertiary hospitals

Two thirds population

72% depend on the public sector
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PHARMACY

ARV programme is pharmacy
intensive

Separate supply chain with
customised new central store

Forecasting drug utilisation

Multiple suppliers

New tender

NVP based first line R80 per month
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Forecast vs Consumption: Stavudine 30mg
(Adult: Protocol 1)
3000
Change
No. of Containers
2500
Change
2000
1500
1000
500
0
Jul
Aug
F1
Sep
F2
Oct
F3
Nov
Consumpn
Dec
Jan
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Number of ARV Sites by Year
Number
50
40
30
ARV
sites
20
10
0
2001 2002 2003 2004 2005 2006
Years
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NGO Partners

Khayelitsha (MSF)

Gugulethu (DTHC, CRUSAID)

Langa (CCT, MTCT PLUS)

Groote Schuur Hospital (1 to 1
FOUNDATION, KIDZPOSITIVE)

Red Cross Hospital (UCT)

Tygerberg Hospital (clinical trials)

GF Jooste Hospital (NMF, SAMA)
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SCALE ACHIEVED OVER TWO YEARS

PMTCT universally available using
dual and triple therapy regimens
(fast track for pregnant women
with CD4 < 200)

Vertical transmission < 5%

HAART rolled out to all major
towns (45 sites)

17 300 patients on HAART (65%
coverage)

75% of children on treatment
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LIMITING DRUG RESISTANCE

Regimen selection (public health,
protocol driven approach)

Site and patient selection

Adherence support, drug literacy

Secondary referral (raises quality
of medical care)
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SITE SELECTION

Llimit liberal prescribing practice

Treatment initiation by medical
officer

District hospital or community
health centre ideal setting for ARV
treatment

GPs, NGOs, hospices ??
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PATIENT SELECTION

Clinical and biological criteria

Psycho social criteria – residency,
history of adherence, alcohol/drug
dependency

Factors promoting adherence

Global decision by team

Excessive pressure to favour
treatment

Ethical but also public health issue
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PSYCHO SOCIAL SUPPORT FOR ADHERENCE

Site based counselling

Sign up to support groups

Community based adherence support

Drug literacy

Proximity to health facility

Outsourced to NGOs
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ADHERENCE SUPPRT MODELS

Clinic based counselors

Community models

Dedicated ARV counselors, paid, 1
for every 20 – 30 patients

Home based care

DOTS

Treatment coach or advocate
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DEATH RATE FOR ADULTS ON ART
Duration (months)
2001
2002 2003 2004 2005 Grand Total
3
8.9
10.1
7.8
4.0
6
12.7
11.7
9.7
5.8
6.7
12
16.5
13.8
12.9
8.5
10.4
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16.5
16.6
16.7
36
20.3
18.1
48
25.8
3.5
4.5
16.6
19.0
25.8
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PERCENTAGE OF PATIENTS WITH CD4 COUNT LESS THAN 50 CELLS/ul
AT THE TIME OF ENROLLING ON ARV
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
2
05
Q
4
04
Q
2
04
Q
4
03
Q
2
Q
4
03
02
Q
2
02
Q
4
Q
01
01
Q
2
CD<50prop
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PERCENTAGE OF PATIENTS ON SECOND LINE TREATMENT
STRATIFIED BY DURATION OF TREATMENT
10.0%
8.0%
6.0%
4.0%
2.0%
0.0%
8.2%
8.9%
4.5%
0.6%
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1.1% 1.9%
12
18
24
30
36
Months on Treatment
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VIRAL SUPPRESSION
TIME ON TREATMENT
ADULTS
After 36 months
90.10%
After 24 months
94.20%
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IN CONCLUSION
PMTCT/ART interventions provide the most powerful impact
on all mortality indicators.
Only large numbers at scale deliver the outcomes that we all
desire.
Early analysis of mortality statistics shows a significant
decreases in infant, child and maternal mortality and
significant decrease in overall adult mortality for the
Province.
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