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LESSONS AND CHALLENGES IN HIV/AIDS SCALING UP ART IN THE WESTERN CAPE PROVINCE OF SOUTH AFRICA ODI 7...
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Transcript of LESSONS AND CHALLENGES IN HIV/AIDS SCALING UP ART IN THE WESTERN CAPE PROVINCE OF SOUTH AFRICA ODI 7...
LESSONS AND CHALLENGES IN HIV/AIDS
SCALING UP ART IN THE WESTERN CAPE PROVINCE OF SOUTH AFRICA
ODI
7 June 2006
2
Unless treatment reaches significant numbers of
people living with AIDS its public health impact will
be severely limited
3
PROJECTED AIDS CASES (SA)
No ART
0200,000400,000600,000
800,0001,000,0001,200,0001,400,000
20
00
20
02
20
04
20
06
20
08
20
10
20
12
20
14
20
16
20
18
20
20
No ART
4
PROJECTED HIV POSITIVE PERSONS(SA)
No ART
4,000,000
4,500,000
5,000,000
5,500,000
6,000,000
6,500,000
7,000,000
20
00
20
02
20
04
20
06
20
08
20
10
20
12
20
14
20
16
20
18
20
20
No ART
5
0
1,000,000
2,000,000
3,000,000
4,000,000
5,000,000
6,000,000
7,000,000
1995
1998
2001
2004
2007
2010
2013
2016
2019
Stage 4
Stage 3
Stage 2
Stage 1
PROJECTED NUMBER HIV INFECTED BY STAGE OF DISEASE (SA)
6
AIDS RELATED DEATHS (SA) UNDER VARIOUS TREATMENT SCENARIOS
7
Describing the intervention
HIV infection 7.5 – 9.1 years Stage 4 – 1.47 – 1.8 years
FL – 2.68 years
SL – 1.78 years
Failing 1.6 years
Failing 1.6 years
Median survival from initiating treatment of 4.5 years if two regimens offered, mean 6.06 years, mean
benefit of 4.46 years
8
SCALING UP ART IN THE WESTERN CAPE
PROVINCE
9
HIV EPIDEMIOLOGY
Antenatal prevalence – 15.4%
District level surveys show range
of 1% - 33%
200 000 – 250 000 HIV positive
5-10% need HAART
25% of all hospital admissions by
2010
23% of all PHC visits by 2010
ANTENATAL PREVALENCE 15.4%
0
50,000
100,000
150,000
200,000
250,000
300,000
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
2007
2009
Stage 4
Stage 3
Stage 2
Stage 1
10
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
11
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
12
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
13
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
14
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)
15
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
16
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
17
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
18
Forecast vs Consumption: Stavudine 30mg
(Adult: Protocol 1)
0
500
1000
1500
2000
2500
3000
No.
of
Con
tain
ers
Jul Aug Sep Oct Nov Dec Jan
F1 F2 F3 Consumpn
Change
Change
19
Number of ARV Sites by Year
0
10
20
30
40
50
2001 2002 2003 2004 2005 2006
Years
Nu
mb
er
ARVsites
20
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)
21
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
22
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)
23
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 ??
24
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
25
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
26
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
27
Duration (months) 2001 2002 2003 2004 2005 Grand Total
3 8.9 10.1 7.8 4.0 3.5 4.5
6 12.7 11.7 9.7 5.8 6.7
12 16.5 13.8 12.9 8.5 10.4
24 16.5 16.6 16.7 16.6
36 20.3 18.1 19.0
48 25.8 25.8
DEATH RATE FOR ADULTS ON ART
28
0.00%10.00%20.00%30.00%40.00%50.00%60.00%70.00%
CD<50prop
PERCENTAGE OF PATIENTS WITH CD4 COUNT LESS THAN 50 CELLS/ul AT THE TIME OF ENROLLING ON ARV
29
0.6%1.1% 1.9%
4.5%
8.2% 8.9%
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
6 12 18 24 30 36
Months on Treatment
PERCENTAGE OF PATIENTS ON SECOND LINE TREATMENT STRATIFIED BY DURATION OF TREATMENT
30
VIRAL SUPPRESSION
TIME ON TREATMENT ADULTS
After 36 months90.10%
After 24 months94.20%
31
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.
IN CONCLUSION