LESSONS AND CHALLENGES IN HIV/AIDS SCALING UP ART IN THE WESTERN CAPE PROVINCE OF SOUTH AFRICA ODI 7 June 2006.

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