Aids treatment as a public health interventionExperiences from Khayelitsha , South Africa

Aids treatment as a public health intervention Experiences from Khayelitsha , South Africa Briefing session for 56th World Health Assembly Geneva , May 2003

Khayelitsha project: key figures 1.

2.

3.

4.

5.

Urban township with an estimated 500.000 inhabitants PMTCT pilot project started by local gvt in Jan 99 -> ~ 5000 HIV women diagnosed and treated to date HIV dedicated public clinics open in February 2000 HAART introduced in May 2001 PWA’s widely involved in awareness and education activities

HIV prevalence rate Khayelitsha Antenatal HIV Prevalence 1999 - 2003 30% 28% 26%

% Prevalence

24% 22% 20% 18% 16% 14% 12% 10% Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun Jul-Sep Oct-Dec 1999

2000

2001

Mean Prevalence (95 % CI)

2002

HAART project objectives Feasibility

To demonstrate

Acceptability

Affordability

To Study

Impact on the health services

Standardized regimen, monitoring, staff training‌ Adherence, treatment litteracy, awareness‌impac t on prevention ..

Costs involved, savings , costeffectiveness..

Staff use, PHC integration TBHIV links,

Attendance in HIV clinics, Total # of booked patients in 3 years: ~4500

Khayelitsha HIV Clinics October 2000 - July 2002 1800 1594 1561 1513 1386 1354

1600 1400 1200 933

1000

1098 935

988

596

600 384 363

549

NC

935 826

787

800

400

1014

12011191

FU

590 572

302

150 143 153 130 178 140 115 116 126 116 128 107 124 189 139 176 200 121 117 94

236

151 138

0 Oct

Dec

Feb

Apr

Jun

Aug

Oct

Dec

Feb

Apr

Jun

Candidates Selection process Patients meeting clinical and biological criteria:

stage III and IV and < 200 CD4 count ( B or C and <20 % CD4/TLC ) Asses regularity

: to have attended

HIV clinics for a least 3 months and been on time for the last 4 visits.Compliant to Cotrimoxazole Home visit to assess social criteria : residence, disclosure,

family support

Final selection by community selection committee

Scaling up and selection : a difficult balance Evolution of recruitment for HAART treatments. May 01 to Dec 03 700 600 500 400

HAART treatments

300 200 100

Dec 03

May 03

Feb 03

nov-02

Aug 02

May02

Feb 02

nov-02

Aug 01

May 01

0

Standardized HAART Regimens:

First-line

Second-line

ddI/3TC AZT/3TC/Nvp or EFV Lop-Rtv DDI/3TC/EFV AZT/3TC/Kal

• Basically 2 lines available • Semi-standardized regimen • Use of FDC as far as possible

Results in adults

他Median gain weight at 6 months: 8.8 kg 他General survival(intention to treat) at 12 months: 82 % 他 89 % undetectable VL at 3 months, 87 % at 6 months and 82 % at 12 months

Survival in adults by initial CD4 count after 18 months on HAART (May 2001 – Dec 2002)

1.00 0.95

100 - 149 cells / µl

Proportion surviving

0.90 50 – 199 cells / µl

0.85 0.80 0.75

<50 cells / µl

0.70 0.65 0.60 0.55 0.50

0

3

6

9 Months on treatment

12

15

18

CD4 Cell Counts at Baseline Adults N = 149 47

50 Nmb people

40

33

33

30

21

20 9

10 0 <10

10-49

50-99

100-149

150-199 >=200

6

Opportunistic infections per patient-year

Incidence rates for OIs 6 5.5 5 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0

0.8 0.7 0.6 69% ⇓

0.5 0.4 0.3

85% ⇓

0.2 0.1 All (pre-ARV) All (on ARV) Incidence risk ratio: 3.19 (95% CI: 2.62-3.91)

0 TB (pre-ARV) TB (on ARV) Incidence risk ratio: 6.81 (95% CI: 3.02-19.00)

Mean CD4 Cell Count Change Mean increase in CD4 count by starting CD4 count category 400

Mean CD4 count

350 300

16

10 12

250 200

3

150 100

39

50 0

16

30

<10

10-49

6-12 month increase - mean 0-6 month increase - mean

50-199

Starting CD4 count category

>=200

Nurse based care • Treatment initiation and modification are doctor based but follow-up by nurses • Typical team is made out of 2/3 nurses and 2 counsellors for 1 doctor ( 400-500 patients/months ARV and non ARV)

• Standardized approach,on-off diagnosis tools and specific nurse ARV training

Nurses friendly management of AEâ&#x20AC;&#x2122;s AZT600+ 3TC300+ NVP200

ASAT/ALAT after 2 weeks Grades 1

AZT600+ 3TC300+ NVP400 Monitor every 2 weeks for 1 month

Grades 3/4

Grade 2

AZT600+ 3TC300+

EFV600 ASAT/ALAT after 2 weeks

Grades 1

Grade 2

Grades 3/4

AZT600+ 3TC300+ NVP400

AZT600+ 3TC300+ NVP400

AZT600+ 3TC300+

Monitor every 2 weeks for 1 month

EFV600

Services integration

HIV seroprev

25

1400 1300 1200 1100 1000 900 800

20 15 10 1998

1999

2000

2001 (Q1&2)

Cape Town study: patients on antiretroviral therapy had 82% less TB

TB inc/100,000

Evolving HIV and TB epidemics in Khayelitsha, 1998-2001

HIV

TB

Cost reduction strategies - Triple therapy : $ 1.08 /day for AZT/3TC- Nvp since use of Brazilian generics.

- Can be reduced to $ 0.80 if use of DDI/D4T/Nvp in fixed dose combination - Monitoring : $ 200 /year( based on CD4 and viral loads 2 x /year ) -> Objective to reduce to $ 70 /year with use of alternative CD4 and VL methods