Transcript Poster presentation

Abstract:
Problem Statement: Complex health problems -- including HIV and multidrug-resistant tuberculosis (MDR-TB)
-- are more likely to afflict resource-poor communities of the world. Ironically, the communities with the highest
prevalence of these diseases are often those with the fewest resources available to manage them.Yet in order
to prevent continued spread of these infections, to curb the development of additional drug resistance
rendering treatment more difficult, and to alleviate human suffering, interventions aimed at addressing these
chronic infections must be put into place in resource-poor settings.
Objectives: To describe the programmatic features of two successful MDR-TB and HIV treatment programs in
two resource-poor settings.
Design: Seven-year (August 1996-August 2003), observational, qualitative study of programmatic factors
associated with favorable treatment outcomes.
Settings: Rural Haiti and urban Lima, Peru.
Populations: Impoverished patients living with MDR-TB and HIVand the programs and persons that have
provided treatment to them.
Results: Outcome measure of interest included clinical improvements, rise in CD4 counts and the absence of
opportunitsic infections among the patients with HIV and cure or likely cure from MDR-TB among the patients
with this disease. Both programs were widely successful in managing these complex health problems even in
the resource-poor settings in which they were grounded. The HIV treatment program in Haiti has been in
operation for over 4 years and has provided care—including antiretroviral therapy—to more than 500
individuals with more than 90% demonstrating some positive clinical benefit. The MDR-TB treatment program
in Peru has treated more than 1,400 individuals over the last seven years with complex drug regimens; over
80% of these patients have been cured of their disease or are likely cures. Although both programs are
different, they share a set of overarching principles that seem to contribute to their success, including: 1) the
use of trained community health workers to provide daily supervision of care; 2) the provision of close
monitoring and management of adverse effects; 3) the development of context specific protocols and
algorithms for rapid triage and management of problems that arise during treatment; and 4) the provision of
services that address the socioeconomic conditions in which most of these patients struggle to survive,
including nutritional support, assistance with housing, and support finding jobs.
Conclusions: Programs aimed at addressing complex health problems such as HIV and MDR-TB can be
successful in even the most resource-poor settings providing they are strongly connected to the communities in
which they operate and are mindful of and attempt to address socioeconomic barriers that may affect medical
care.
Improving the Use of Medications
to Treat Complex Health
Problems in Resource-Poor
Settings: Community-Based
Examples from Haiti and Peru
Jennifer Furin, Paul Farmer, and Edward Nardell
Partners In Health
Division of Social Medicine and Health Inequalities,
Brigham and Women’s Hospital, Boston, MA, USA
Background
• HIV and TB (including strains of drug resistant
disease) are two of the most pressing health
concerns facing the world’s poor1
• These diseases are more prevalent in areas of
poverty and limited resources and both are
complex to manage, requiring the use of mutliple
medications over prolonged periods of time2
• Interventions are needed to address these
problems and curb further spread of disease3
• Successful interventions have been put into
place to address multidrug-resistant TB (MDRTB) and HIV in poor settings in Haiti4 and Peru5
Objective and Methods
• Objective: To document factors associated with
treatment program success for HIV and MDR-TB
in resource-poor settings of Haiti and Peru
• Methods: Qualitative study from August 1996 to
August 2003 in which a variety of ethnographic
methods (including participant observation, key
informant interviewing, and focus groups) were
used to obatin data from programs and patients
in rural Haiti and urban Lima, Peru
HIV Treatment Program in Haiti
• HIV Equity Initiative launched in 1999
• Provides HIV care, including highly active antiretroviral
therapy (HAART), to over 500 individuals
• Relies on the use of community health workers known as
accompagnateurs
• 90% of patients have had a beneficial clinical response
defined as weight gain, absence of opportunistic
infections, or a rise in CD4 count
• None of the patients receiving HAART has died
• Program is expanding to 5 different sites in rural Haiti
Comparison of Outcomes
Outcome
Group A (HAART)
Groups B and C
100
200 [100 + 100]
Mortality at end of study period
0
43 [14 + 29]
Tuberculosis incidence
2
21/100*
0.24
3.3
10.3 kg increase
6.0 kg decrease
0
23.4
Initial: 2
Final: 3.8
Initial: 2.7
Final: 2.3
n
Number of opportunistic infections from
start of interventions
Average weight change
Number of days in hospital from start of
intervention to end of study period or death
ADL score for people surviving one year
after the intervention
*Data available only for Group B
“I was a walking skeleton before I began therapy. I was afraid to
go out of my house and no one would buy things from my shop.
But now I am fine again… My wife has returned to me and now my
children are not ashamed to be seen with me. I can work again”.
MDR-TB Treatment Program in
Peru
• Began in 1996
• Has treated more than 1400 patients with
MDR-TB
• Relies on the use of community health
workers known as promoters
• Over 80% of the patients are cured or
likely to be cured of the disease
• Has expanded to sites throughout the
country
abandoned
therapy
7%
failed therapy
1%
died
7%
culture
positive
0%
Cured, or in treatment and culture
negative
85%
Cure rates for first cohort of
MDRTB patients
Overarching Program Principles
• Community health workers provide daily
supervision of treatment
• Close monitoring of patient progress and
management of adverse effects
• Context-specific management protocols are in
practice
• Measures in place to address socioeconomic
conditions associated with poor health
outcomes, including nutritional support, housing
assistance, and job placement
Conclusions
• Complex health problems such as HIV and
MDR-TB can be successfully treated, even
in the most resource-poor settings
• Programs more likely to be successful if
they have strong base in the community
and if they address socioeconomic forces
that place patients at risk for poor health
outcomes
References
• 1. Guelar A, Gatell JM, Verdejo J, et al. A prospective study of the
risk of tuberculosis among HIV-infected patients. AIDS
1993;7(10):1345-9.
• 2. Badri M, Ehrlich R, Wood R, et al. Association between
tuberculosis and HIV disease progression in a high tuberculosis
prevalence area. Int J Tuberc Lung Dis 2001;5(3):225-232.
• 3. Iseman M, Madsen L. Drug-resistant tuberculosis. Clinics in
Chest Medicine 1989; 10(3): 341-353.
• 4. Farmer P, Leandre F, Mukherjee J, et al. Community-based
approaches to HIV treatment in resource-poor settings. Lancet
2001;358:404-409.
• 5. Mitnick CD, Bayona J, Palacios E, et al. Community-based
therapy for multidrug-resistant tuberculosis in Lima, Peru. N Engl J
Med 2003;348(2):119-28.