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