Challenges in adapting chronic HIV/TB services to high mobile populations in Southern Africa

Eric Goemaere, MD Médecins Sans Frontières

IAS Washington , July 25th 2011

OWN, SCALE-UP & SUSTAINThe 16th International Conference on AIDS & STIs in Africa

4 to 8 December 2011, Addis Ababawww.icasa2011addis.org

High mobility , high HIV and TB prevalence

• High regional mobility• Different patterns of migration • Mobility = survival• Chronic care designed for

residents• Migrants

– Hardly attending health facility– Fear of deportation, health

system barriers, xenophobia – Access to treatment often

denied due to fears about adherence and continuity of care

Failure to identify migrants at ART initiation triggers a high rate of loss to follow-up

• Multivariate analysis -> AHR for LTFU in migrants at one year 6.69 ( 3.18-14.09)

Trends in loss to follow-up among migrant workers on ART in a community cohort in Lesotho Helen Bygrave1*, and all , Plos One , October 2010 | Volume 5 | Issue 10 | e13198

14 % of migrants amongst ART initiations

Cd4 results collection among migrants testing HIV(+) Central Methodist Church, Johannesburg , 2009-2010

• Central Methodist Church is a shelter for up to 3000 homeless mostly Zimbabwean migrants in central Johannesburg

• MSF opened a clinic in CMC in 2008

• Cd4 testing was initially implemented in a traditional passive way

• After implementing a testing campaign and active case tracing, outcomes where significantly increased

Defining the problem

• HIV/TB care designed for resident population

• Mobility = survival for migrants • Different treatment protocols in

different countries• Medications & documents

frequently stolen or lossed during irregular crossings

• No cross-border information‘s on where and how to access services

• Fear of arrest /deportation• Staff attitude towards migrants• Illegal fees

Establishing mobile HIV/Tb units, Musina border, Limpopo, South Africa

21,000 living on commercial farms along border

Circular seasonal migration

Decentralized MSF/DOH nurse based mobile clinics on farms, offering PHC services but referral for integrated HIV/TB initiation .

SOUTH AFRICA

MUSINA

Initial outcomes : continuum of HIV care in farms

ART eligible380

Pre-treatment

steps

CD4 results given 951 (44%)

CD4 count sample

provided2171

Initiated ART193 51%

95% CI 46%-56%

HIV+ diagnosed population

Testing to etsablish eligibility

ART eligibility to ART initiation

Adapting services to integrated HIV/Tb care

ART and TB treatment initiation offered on the spot in farm

Point of care CD4 Peer education network on

farms (HIV awareness, linkage to care, adherence to ART/TB, defaulter tracing..)

Adapted strategyfor providing HIV/TB care to "migrant" patients

• Each visit, patient asked about travel plan and documented

• Health passports + alternative treatment points

When time to go , issued with a ‘travel pack’

• Temporary Transfer Out (TTFO): = plans to return (circular migration)

• 3 months ARV supply + tail protection

• If not intention to return, self addressed stamped envelope signed by receiving sites

Impact of adapted strategy on continuum of HIV care

ART eligible

380

226Pre-

treatment steps

CD4 results given

951 (44%)

594 (81%)

CD4 count sample

provided2171735

Initiated ART193 ( 51% )

95% CI 46%-56%18883%

95% CI 78%-88%

HIV+ diagnosed population

Testing to etsablish eligibility

ART eligibility to ART initiation

37%

32%

Preliminary ART outcomes ,Musina

TTFO n = 63

Conclusions

• HIV/TB care can be successfully adapted to migrant population pending :• clear regulations in terms of

access to health care for non-nationals , including ART and TB

• Access to be free of charge • Adapting health service to

provide acceptable access • Harmonize ART practices, regimen &

documentation -> Regional ART/TB health passport• Achievements of R9 global fund grant

( 12 M $) with SADC secretariat in Gaborone?

Acknowledgements

• Tambu Matambo , Helen Bygrave, Gilles Van Cutsem

• Mobile MSF/DOH teams in Musina

• Department of Health, Limpopo , South Africa

• People living with HIV in Musina