Transcript Mukherjee JS.

Prevention, Treatment, Retention, Care
Joia S. Mukherjee, MD, MPH
Medical Director, Partners in Health
Harvard Medical School
Global Epidemiology of HIV
• 40 million people world wide have HIV.
• 90% of the epidemic is concentrated in the
developing world.
• 90% of AIDS infected children and 70% of newly
diagnosed HIV infections are in sub-Saharan
Africa.
• 28 of the 40 million people with HIV are from
sub-Saharan Africa.
• Four decades of gains in life expectancy and infant
mortality have been lost due to HIV.
Gender Inequality
• Financial or material dependence on men
• Often women cannot control when, with whom
and in what circumstances they have sex
• Many women have to exchange sex for material
favors, for daily survival
• Domestic servitude
Smith Fawzi MC, Lambert W, Singler JM, et al. Factors associated
with forced sex among women in rural Haiti: implications for the
prevention of HIV and other STDs. Soc Sci & Med 2005;60(4):679689.
War, Displacement
Rwanda
• Of 250000 women who survived the
genocide, 70% are HIV positive
• 1 million orphans and vulnerable children,
many become servants or are forced into
prostitution
Childhood
Uganda
• 15% in 1991 to 4.1% in 2003 Nationally vs.
11.3% among HCW in 2001 in the district
of Gulu unchanged since 1998
• AIDS accounts for 69% of all deaths in the
Gulu area, a region of Northern Uganda
Westerhaus MA, Finnegan AC, Zabulon Y, Mukherjee JS. Northern Uganda
and paradigms of HIV prevention: The need for social analysis. Global Public
Health, 2008, 3(1)
Work
Rural to Urban Movement
• Migration for work wave in rural
Africa
– Enclaves of migrant men with few female
partners and high levels of social isolation
– Work as domestic servants
• Recurrent of seasonal migrants bring
infection to village
2001 Durex Global Sex Survey
• 18 500 adults worldwide.
• 28 countries: (South Africa and Nigeria)
• Onset of sexual activity: Range: Americans 16Chinese 22.
• Average number of lifetime sexual partners:
–
–
–
–
–
–
Global 7.7
Nigeria 4.2
South Africa 8.2
USA 14.2
Wales 13
France 17 men, 4 women
Tackling HIV in Resource Poor
Countries
Mukherjee, JS et al. BMJ 327 (8), 2003
Deaths per 100,000 Population
Trends in Age-Adjusted Death Rate
due to HIV Infection,1982-1998
18
16
14
12
10
8
6
4
2
0
82
84
86
88
90
92
94
96
Year
*Using the age distribution of the projected
year 2000 US population as the standard.
**Preliminary 1998 data
98**
The Outcome Gap
Age adjusted death rate: AIDS
Deaths/100,000
800
700
600
United
States
subSahara
500
400
300
200
100
99
19
97
19
95
19
93
19
91
19
89
19
87
19
19
85
0
Year
Individual Members of the Harvard Faculty. Consensus Statement on
Antiretroviral Treatment for AIDS in Poor Countries.
Topics in HIV Medicine 2001 Jun; 9(2).
It’s too hard…………2000
It's 17 to 25 pills a day...
Every two hours....
And you have to change
the cocktail …every
three or four months , or
you can die from the
toxicity of the drugs.
'Many people in Africa have never seen a clock or a
watch their entire lives. And if you say, one o'clock in
the afternoon, they do not know what you are talking
about.'
Original Guidelines for Inclusion:
HIV Equity Initiative
•
•
•
•
•
•
Absence of tuberculosis
Recurrent opportunistic infections
Chronic enteropathy with wasting
Significant weight loss
Neurologic complications attributable to HIV
Severe anemia, leukopenia or thrombocytopenia
Real Inclusion Criteria:
CIOS (Carried In On Stretcher)
DOT-HAART: Supervised Therapy
for Advanced HIV Disease, 2001
• Over 1500 HIV-positive people followed
• 60 patients treated with DOT-HAART
• Each DOT-HAART patient has an
accompagnateur.
• Accompagnateurs observe ingestion of the
therapy at least once a day.
• They all gained weight
Farmer, P et al. Lancet 2001; 358
The drugs are too
expensive…………
Vasan A, Hoos D, Mukherjee JS, et al. The pricing and procurement of antiretroviral
drugs: an observational study of data from the Global Fund. Bull World Health Org
2006 May, 84(5):393-398.
Full price,
proprietary
$10,000
USD/pt/yr
Concessional
pricing,
proprietary
$1600
USD/pt/yr
Generic &
Prioprietary
with WHO
preapproval
$800
USD/pt/yr
IDA
quality
controlled
$300
USD/pt/yr
Number of patients treated
1200
1000
800
600
400
200
0
1999
2000
2001
2002
2003
Clinton
Foundation
$150
USD/pt/yr
Original Covenants from UDHR
Civil and Political Rights
• Vote
• Judiciary
• Free speech
• Privacy
Social and Economic
Rights
• Food
• Shelter
• Jobs
• Health Care
Basing treatment on rights rather than
ability to pay: 3 by 5
Mukherjee, JS The Lancet 363, 2004
• The Global Fund to Fight AIDS, TB, and
Malaria was created to increase resources
available to treat these diseases
• US$ 4.7 billion in financing 2001 to 2008.
• Committed US $ 1.5 billion in funding to
support 154 programs in 93 countries
worldwide.
AIDS treatment siphons resources
from primary care………
Integrated HIV Prevention and Care
Strengthens Primary Health Care
Walton, D et al. J.Pub Health Pol 25( 2), 2004
Affect on General Medical Care
Number of Ambulatory Visits per Day
Site
Before July 02
End of 2003
Lascahobas
20
400
Belledere
0
150
Thomonde
10
250
Boucan Carre
10
250
Adherence in Developing Countries
• Compares favorably to that reported in the
developed world (Senegal, South Africa)
• Provision of free therapy improves
adherence (Senegal, Botswana)
• Additional out of pocket costs to patients
serve as a deterrent to ART adherence
(Malawi, Rwanda)
Source: AIDS 2003, 17 (suppl 3):S103–S108 and AIDS 2003, 17:1369–1375;
J Acquir Immune Defic Syndr 2003;34:281–288); Int J Tuberc Lung Dis. 2005 Mar;9(3):263-9.
• Behavior
• Incentives
– Information
– Motivation
– Behavior skills
– Money
– Food
– Prison?
PLWA
• Relationship
– Peer educators
– Home visits
• Enablers
– Directly Observed Therapy
– Transportation vouchers
– Pill boxes/reminders
Health Professionals
Health
Prof
• Waiting lists for enrollment
• Errors in initiation and follow up
– Availability of trained personnel to
assess patients needing therapy
– Training focuses on “ART protocols”
but little practical
Health Systems
• User fees for service and
testing remain a barrier
• No functioning primary care
system to bring patients in
• Lack of basic tools and
supplies
Health
System
Community and Home Environment
• When basic necessities lacking
(food, shelter) ART becomes a
lower priority
• Long distances from clinic
• Lack of transportation fees
• Patients new to the medical
model of care
Home
Inputs that effect whether pills are taken
Health
Prof
Home
Health
System
PLWA
Mukherjee JS, Ivers L, Leandre F, Farmer PE, Behforouz H. Antiretroviral therapy in
resource-poor settings. Decreasing barriers to access and promoting adherence. J
Acquir Immune Defic Syndr. 2006 Dec 1;43 1:S123-6.
Accompagnateurs
• Selected by the patient needing treatment
• Visit patients at home once or twice daily; each
accompagnateur follows an average of 4 patients
• Monthy salary is 300 Haitian dollars ($38
American)
• Supervised by the head nurse, who regularly meets
with each patient and accompagnateur to discuss
medication adherence
Mukherjee JS, Eustache E. Community health workers as a cornerstone for
integrating HIV and primary healthcare. AIDS Care. 2007;19 Suppl 1:7382
Cost of Adherence Intervention
per Patient (USD)
if Second Line Regimen
6000
5000
4000
ARV cost
CHW
Food
3000
2000
1000
0
1 year
2 year
3 year
There isn’t enough
absorptive
capacity………
The Team!
• Adding HIV/AIDS care and treatment
cannot be done without a investment in
health care workers.
• Public health clinics stand empty because
salaries are too low and working conditions
are unacceptable.
– Salary increases
– AIDS prevention equipment
Central Department: pop 500,000
Clinic
MD 15
RN, Pharm,
Lab 40
Auxilliaire 100
Ajan
Sante/Ajan
200
Expected
HIVFanm
20,000
Expected active TB 1500
Accompagnateurs 500
Community
Expansion Successes
• Over 8000 HIV-positive people followed
• 1500 patients now being treated with
directly observed HAART (“DOTHAART”).
• 6 public health clinics are operational in
the central plateau now with 341000
ambulatory visits per year
Efficacy of ART in Resource-Poor
Settings
• ART treatment programs in resource-poor
settings have efficacy rates similar to those
reported in developed countries.
• The provision of medications free of charge
to the patient is associated with a
significantly increased probability of
virologic suppression at months 6 and 12 of
ART.
Ivers, L et al. CID 2005:41 (15 July)
Goals of Therapy….
• Suppression of viral
replication
• Recovery of CD4
cells
•Defense against
opportunistic
infections
•Decreased mortality
•Improved quality of
life
•Decreased
transmission
“Everyone with AIDS should be able
to get treatment, since we’re all
God’s children. Science is for
everyone.”
St. Ke, Kanj, Haiti 2001
(7 years on first line ART, doing really,
really well!)