a brief overview of art services at qech, malawi kudzala aub. mmedsc. student sr. lead art...
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A brief overview of ART services at QECH, Malawi
Kudzala Aub. MMEDsc. Student
Sr. Lead ART Clinician/ HIV Medicine Registrar
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OOutlineutline
•Current Challenges
•Genetic Barriers of Regimens
•Rationale for the clinical decision
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Challenges
•Drug shortage problems
•Especially 3TC, NVP
•Laboratory back up
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Challenges
Quantity versus Quality
Demand versus Supply
Shortage of health care personnel
Toxicity of the 1st line regime
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Lancet 2000
- expensive- complicated- logistics- adherence
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2000 1 clinician 25 patients Fee-paying
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Malawi ART clinics 2002
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TM&IH 2005
- Many lost to follow up- ATN - Poor adherence
Personal financeDrug shortage
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2004 ART SCALE UP PROGRAMME
HIV Unit Ministry of HealthHIV Unit Ministry of Health
Global fund to fight AIDS-TB-Malaria
National ART Guidelines
Training of > 2000 clinicians and nurses
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2004 ART SCALE UP PROGRAMME
HIV Unit Ministry of HealthHIV Unit Ministry of Health
Establishments of ART clinics within the existing HCS
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PUBLIC HEALTH APPROACH TO ART
Large number of ART in RLS
Standardized than individualized
Simplified monitoring of treatment
Predominant use of Clinical Officers and Nurses
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PUBLIC HEALTH PUBLIC HEALTH APPROACH TO ART APPROACH TO ART
ART to be free of charge
Follow experiences of the national TB programme
Standardised monitoring and reporting
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PUBLIC HEALTH APPROACH TO ART
Quarterly supervision
Strong drug logistics
Harries et al - BMJ 2004
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Cost of ARV drugs
Netherlands:
• Truvada®
• Stocrin®
USD 10,000 / year
Malawi: Triomune 30®
USD 100 / year
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Malawi ART clinics 20082002
2010
5 377
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270,000 patients started ART
9% children 9% children 60% females 60% females
• 93% on the same first line regimen
• 5% on alternative first line regimen
• <1% on second line regimen
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Major Changes to the National ART Programme in 2011
PMTCT, Paediatric, Adult ART integration
Strategic phasing out of Stavudine
CD4 threshold increase
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CHALLENGESCHALLENGES
Quantity versus Quality
Demand versus Supply
Shortage of health care personnel
Toxicity of the first line regime
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CHALLENGESCHALLENGES
Early ART mortality
ART failure
ART delivery Infrastructure
Limited Laboratory Back up
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DRUG SUPPLY DRUG SUPPLY CONTINUESCONTINUES
Possible reasons for the Drug Possible reasons for the Drug Shortage?Shortage?
•Increased # of clients on non standard regime.
•Inadequate financing or under-budgeting.
•Inefficiencies in supply and distribution chain.
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SELECTED POINT SELECTED POINT EXAMPLES OF DRUG EXAMPLES OF DRUG
SUPPLYSUPPLY•Drug shortage is the main problem
•June 2010 3TC = 0, NVP = 117
•August 2010 3TC = 0, NVP = 0
•Sept. 2010 3TC = 55, NVP = 100
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Conclusion Conclusion
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Malawi ART Scale up Malawi ART Scale up Programme Programme
•Successful under difficult circumstances using public health approachLarge number of patients on ARTFavourable outcomes
• Many challenges
•Current Challenges
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AcknowledgementsAcknowledgements
Joep van Oosterhout, M.D., PhD, Joep van Oosterhout, M.D., PhD, Associate Professor of Internal Associate Professor of Internal Medicine, University of Malawi, Medicine, University of Malawi, College of MedicineCollege of Medicine
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AcknowledgementsAcknowledgements
James Blessings Mwambene, James Blessings Mwambene, Dip.Clin.Med, PGD(Mgt studies), Dip.Clin.Med, PGD(Mgt studies), The ART Outreach Coordinator, The ART Outreach Coordinator, Queen Elizabeth Central Hospital, Queen Elizabeth Central Hospital, MalawiMalawi
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AcknowledgementsAcknowledgements
Cooper Nyirenda, M.D.,MMED, Cooper Nyirenda, M.D.,MMED, FRCP, Chief Govt. Physician, FRCP, Chief Govt. Physician, Queen Elizabeth Central HospitalQueen Elizabeth Central Hospital