Wesat2001

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Scaling-Up HIV Treatment Experience from Cameroon in Operational

Research: Main outcomes Sinata Koulla-Shiro MD

Chief, Division Of Operations Research, Cameroon,Vice Chair, National AIDS Control Committee and Infectious

Disease Service,Yaoundé Central Hospital

XVII International AIDS Conference3-8 August 2008, Mexico City

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OUTLINE

1. Background

2. The Public Health Approach to Scaling –Up

3. Cameroon Model of scaling-up ARV drug access

4. Operations Research and scaling-up programme • Characterisics• Main Outcomes• Key challenges

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Background (1/2)

2001: 1st UN General Assembly Special Session on HIV/AIDS(UNGASS):Targets and member states committment

2004- 2005: Political Committment accompanied by flow of financial ressources(Domestic, multilateral, Bilateral and Private)

2006: UNGASS: Countries agreed toward Universal Access to Comprehensive Prevention, Care and Support by 2010

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Background (2/2)

2007: Better tools led to Readjustment of figures by UNAIDS and WHO

33 million people live with HIV at global level 2.7 million people newly infected in 2007

9.7 million need treatment in low and middle income countries end 2007 (WHO,UNAIDS,UNICEFprogress report)

Unprecedented Momentum of Antiretroviral Treatment in Africa

3 million received ART and >2 million in sub-saharan Africa

Access equal or higher among women

Adherence equal or greater than un Europe and North America

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Number of people receiving antiretroviral therapy in low- and middle-income countries, 2002–2007

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Antiretroviral therapy coverage in sub-Saharan Africa, 2003–2007

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Women as a percentage of all people receiving antiretroviral therapy versus women as a percentage of all people needing treatment, selected low- and middle-income countries, 2007a

10% 40% 50% 60%

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The public health approach to scaling up antiretroviral therapy

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Cameroon Approach to Scaling –Up HIV Drug Access 2001-2002 ART Programme mainly at Central and Regional

levels

2003:Standardized guidelines for ART in place 2004:Decentralization to District Hospitals catalysed by WHO

« 3by5 » Initiative Strenghthening Health sysytem (procurement, laboratory, task

shifting, M/E tools) Subsidies allocated to initial and follow up lab tests

2005:Mentorship Strategy: Tertiary/2ndry hospitals mentor Primary District Hospitals Training and supervision Referral for laboratory tests Referal for complex cases Process accompanied by Operational Research(ANRS)

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Reduction in ARV prices in Cameroon between 2001 and 2007

600 000

300 000

70 00022 000 5 000 0

Before CENAME Nov 2000 to21/03/ 2001

1st drop22/03/2001

2nd drop1/08/2002

3rd drop1/10/2004

4th drop1/05/2007

Source: NACC Progress Report

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National Coverage of Antiretroviral Treatment Sites in Cameroon, 2005

Source: NACC

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5

12

4

4

7

546

5

5

Accredited Treatment centres (ATC) Mentors per province

Management Units(MU)

Number of MU mentored

National Coverage of ART Management Units and Mentors, 2006

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Figure 6 : Evolution du nombre des malades sous ARV au Cameroun: juillet 2005 à décembre 2007

10 000

15 000

20 000

25 000

30 000

35 000

40 000

45 000

50 000

juil o5 sept o5 déc o5 mars o6 juin o6 sept o6 déc o6 mars 07 juin 07 sept- 07 déc - 07

Source: NACC, 2008

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File active des Enfants ( < 15 ans) sous ARV

1 700

1 536

310

643

674

8761 001

1 014 1 183

1 360

300

500

700

900

1 100

1 300

1 500

1 700

1 900

juil o5 déc o5 mai o6 août o6 sept o6 déc o6 mars o7 juin-07 sept-07 déc-07

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First line ARV drug regimens used for adults in Cameroon, 2007-2008

61,9

10,914,2

11,56

0,15 1,29

0

10

20

30

40

50

60

70

D4t+3TC+NVP AZT+3TC+NVP D4t+3TC+EFV AZT+3TC+EFV TDF Bases

Regimens

Other

ARV Regimens

%Adult First Line ARV Regimens used in Cameroon, 2008

Source: NACC Progress Report, April 2008

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First line ARV drug regimens used for children in Cameroon, 2007-2008

35,831,9

11,6 11,2 9,5

0

5

10

15

20

25

30

35

40

D4t+3TC+NVP AZT+3TC+NVP D4t+3TC+EFV AZT+3TC+EFV Other

ARV Regimens

%

Source: NACC Progress Report, April 2008

First Line ARV Regimens used for Children in Cameroon, 2008

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Components of Scaling-Up Operations Research 4 Complementary Projects

ANRS 12110 trial Stratall,Charles Kouanfack

ANRS 12120: Problematic of Access to Treatment: Advances, Limits and perspectives of decentralization, F. Eboko

ANRS 12108: Scaling –Up and Procurement of Drugs and Biological Tools, B. Coriat/M.J Essi (Presented yesteday)

ANRS 12116: Impact of Access to HIV Management and living conditions of Patients, J. P Moatti/SC Abega

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The Eval ANRS 12116 Study

Primary Objective: Evaluate the quality of care of patients on ART

About 3000 patients; 26 Health care Facilities;Urban and rural Variables studied Medical Effeciency: Sociobehavioral Factors

Adherence to treatment Health Related Quality of life Sociodemograhic and economic factors

Cost effectiveness Equity Impact on risky behaviour: Impact on Health System KAP

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Outcome of decentralization

Early outcomes better at district level : Early access to treatment HIV service performance HRQL especially mental Adherence to therapy Task shifting Positive role of associations of PLWH

Patients perception in favour of decentralization

Financial accessibility of HIV services remains a major barrier

Other Challenges of ART scale-Up ARV drug stocks out unsafe sex common among PLWH on ART and erronous beliefs that ART

efficacy prevents HIV transmission is a major determinant Unfelt impact of Community relay workers: need revisiting Health workers dissatisfied with working conditions Sustained efforts on HIV Prevention

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Impact of 3 scenarios on HIV infection in sub-saharan Africa, 2003-2020