Transcript Universal Access - International AIDS Society

Achieving Universal Access to
Antiretroviral Therapy in a Rural District
in Malawi:
How was it done ?
Thyolo District, Malawi
Authors: M. Massaquoi, R. Naligunkwi, U. Von Pilar, B. Mwagomba, M.
Bemelmans, R. Zachariah, A.D. Harries
Médécins Sans Frontières
District Health Services- Thyolo, Malawi
Ministry of health and population- Malawi
HIV AND AIDS PROFILE, MALAWI
• Population
= ±12 million
• HIV Infected
= ± 1 million
• HIV /AIDS related deaths
= 90,000/year
• Needing ART
= 170,000
• Becoming eligible/year
= 90,000
Source: HIV and Syphilis Sero –Survey and National HIV Prevalence and AIDS Estimates Report, MOH, 2007
The National Goal
(Universal Access)
Year
2005
New patients on ART
each year
25,000
Cumulative patients ever
started on ART
37,840
2006
35,000
70,000
2007
40,000
110,000
2008
45,000
155,000
2009
45,000
200,000
2010
45,000
245,000
(141,449)
From 2008 on, 45,000 new patients (50% of need) each year
Thyolo district
Mulanje
Range
Achieving Universal ART Access in a rural district
like Thyolo, Malawi
Universal access = 80% of all
people in urgent need of
treatment.
GOAL FOR Universal Access
Thyolo district population:
Global HIV infection rate:
People living with HIV/AIDS:
Needing “ART”
Universal access
± 600,000
10 %
60,000
9- 12,000 (15-20%)
7,200 – 9,600
MSF targets:
•Start 10,000 by Dec. 2007
•And then 5000-7000 new patients each year.
METHODS (1)
Universal Access !
How did we do it ?
Key: Keep it “standardized and simple”
METHODS (2)
• A “public health approach” (TB-DOTS model)
• Standard system of “case-finding”
• “Free” standard treatment
• Standardized “patient monitoring & outcomes”
• National ART training / supervision / accreditation
METHODS (3)
• ART Eligibility:
–
–
–
–
Positive HIV test
An understanding of the implications of ART
WHO Clinical Stage III / IV
CD4 counts < 250 cells/mm³ when available
• ART Regimen:
– One first-line regimen, D4T/3TC/NVP ( FDC)
– Available/Easy to administer/Cheap
– Alternatives D4T & EFV
METHODS (4)
• Patient flow in HIV Clinic: a “track system” (slow/medium/fast)
for maximum efficiency.
• Decentralization to health centres
• Task shifting at different levels
• HTC from Nurse  lay counselors (HSAs / PLWAs)
• ART initiation: Clinical Officer  Medical Assistant  Nurse
• Community involvement +++
• Opt-Out HIV-testing :TB, paediatrics, NRU, wards
• Quarterly Monitoring : Paper based system
RESULTS (1) HIV- testing
1997 – 2007
Evolution of HIV counseling & Testing in Thyolo District
80000
No. Tested
70000
60000
Started increasing testing sites
50000
40000
30000
20000
10000
0
1997
1998
1999
2000
2001
No. Tested
2002
2003
2004
No. tested positive
2005
2006
No. of Sites
30
25
East
West
North
20
15
10
5
0
2007
No. of Sites
90000
90
80
70
“Task shifting” : Nurses to HSA /
PLWA’s
60
± 50
40
30
20
10
0
1st 2nd 3rd 4th
Qtr Qtr Qtr Qtr
RESULTS (2)
RESULTS (3)
Universal Access
Ever started ART:
– Retained in care
• Alive and on ART
• Transfer out
– Attrition from care
• Deaths
• Defaulters
• Stopped
13,702 (June 2008)
10, 541 (77%)
: 9,856 (72%)
: 685 (5%)
3151 (23%)
: 1480 (11%)
: 1644 (12%)
:
27 (0.2%)
Universal access target reached: August 2007 (10,273)
Thyolo district
Comparative analysis: Hospital vs health centres
(ART Initiations: June 2006-June 2007)
Hospital
Health Centre
Ever started on ART
2,904
1,170
Retained
2,463 (84.9%)
82.1%
2.7%
999 (85.4%)
85%
0.4%
<0.001
<0.001
<0.001
439 (15.1%)
7%
7.8%
<0.4%
171 (14.6%)
12.8%
1.5%
<0.3
0.5
<0.001
< 0.001
0.6
Alive & Active
Transferred out
Attrition
Died
Defaulted
Stopped
P-value
RESULTS (5)
Probability of attrition: Hospital & health centres
1.00
0.80
0.60
0.40
Log rank test 0.54, P=0.5
0.20
Hospital
Health centres
0.00
0
2
4
6
8
10
Time in months since starting ART
12
14
RESULTS (6)
Universal access: Costing
Cost for:
100 ART patients (2007)
–
–
–
–
:18,569 Euro*
Consultations
Essential drugs
Laboratory
ARV
10, 000 patients (universal access) :1, 856, 900 Euro
3 Euros/inhabitant/year for Thyolo (600,000 inhabitants) !!
* Excluding coordination costs
CURRENT CHALLENGES
• Maintaining universal access
• Human Resources shortages
• Sustaining motivation & avoiding burn-out in the midst of cumulative
cohorts and workload
• Drug supplies / Infrastructure
• Durability of the first-line regimen
• drug resistance and long term side effects
• Access to second-line therapy
• Future funding: as about 60% of spending is donor
driven
CONCLUSIONS (1)
In a rural district of Malawi:
• It has been feasible to scale-up ART to achieve
“universal access” targets
• Retention rates are high and attrition rates are
acceptable.
CONCLUSIONS (2)
• The key has been:
– A simple, structured, & standardised approach to
ART delivery
– Use of task-shifting
– Active involvement of communities
“Good for many instead of best for few”
THYOLO TEN YEARS 10,000 PATIENTS
ACKNOWLEDGEMENTS
District Health Services, Thyolo District
Ministry of Health HIV Unit, Malawi
Financial support:
Donors:
CIFF & Elton John Foundation,
ELMA, DGCD, EuropAid, Danish
Telethon,
Partners: MoH/Global FUND
Others….