Aids treatment as a public health intervention

Experiences from Khayelitsha , South Africa

Briefing session for 56th World Health AssemblyGeneva , May 2003

Khayelitsha project: key figures

1. Urban township with an estimated 500.000 inhabitants

2. PMTCT pilot project started by local gvt in Jan 99 -> ~ 5000 HIV women diagnosed and treated to date

3. HIV dedicated public clinics open in February 2000

4. HAART introduced in May 2001

5. PWA’s widely involved in awareness and education activities

Khayelitsha Antenatal HIV Prevalence 1999 - 2003

10%

12%

14%

16%

18%

20%

22%

24%

26%

28%

30%

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 2002

% P

reva

len

ce

Mean Prevalence (95 % CI)

HIV prevalence rate

HAART project objectives

Feasibility Standardized regimen, monitoring, staff training…

To demonstrate

Adherence, treatment litteracy, awareness…impact on prevention ..

Acceptability

Affordability Costs involved, savings , cost-effectiveness..

To Study Impact on the health services

Staff use, PHC integration TB-HIV links,

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

Khayelitsha HIV ClinicsOctober 2000 - July 2002

121 117 94 150 143 153 130 178 140 115 116 126 116 128 107 124189 139 176 236

151 138

384 363 302

596 549 590 572

787933

1014935 988 935

1098

826

12011191

1354

15941513

1386

1561

0

200

400

600

800

1000

1200

1400

1600

1800

NCFU

Oct Dec Feb Apr Jun Aug Oct Dec Feb Apr Jun

Candidates Selection processPatients 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

0100200300400500600700

May 0

1Au

g 01

nov-0

2Fe

b 02

May0

2Au

g 02

nov-0

2Fe

b 03

May 0

3De

c 03

HAARTtreatments

Standardized HAART Regimens:

ddI/3TCLop-Rtv

AZT/3TC/Kal

AZT/3TC/Nvpor EFV

DDI/3TC/EFV

Second-lineFirst-line

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

Results in adults

Median gain weight at 6 months: 8.8 kgGeneral survival(intention to treat) at

12 months: 82 % 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)

Pro

porti

on s

urvi

ving

Months on treatment0 3 6 9 12 15 18

0.50

0.55

0.60

0.65

0.70

0.75

0.80

0.85

0.90

0.95

1.00

50 – 199 cells / µl

<50 cells / µl

100 - 149 cells / µl

Pro

porti

on s

urvi

ving

Months on treatment0 3 6 9 12 15 18

0.50

0.55

0.60

0.65

0.70

0.75

0.80

0.85

0.90

0.95

1.00

0.50

0.55

0.60

0.65

0.70

0.75

0.80

0.85

0.90

0.95

1.00

50 – 199 cells / µl

<50 cells / µl

100 - 149 cells / µl

CD4 Cell Counts at BaselineAdults N = 149

33

47

33

21

96

0

10

20

30

40

50

<10 10-49 50-99 100-149 150-199 >=200

Nm

b p

eo

ple

Incidence rates for OIs

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

TB (pre-ARV) TB (on ARV)

85% ⇓

00.5

11.5

22.5

33.5

44.5

55.5

6

All (pre-ARV) All (on ARV)

69% ⇓

Opp

ortu

nist

ic in

fect

ions

per

pat

ient

-yea

r

Incidence risk ratio: 3.19 (95% CI: 2.62-3.91)

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

12

1610

16

39

3

300

50

100

150

200

250

300

350

400

<10 10-49 50-199 >=200

Starting CD4 count category

Mea

n CD

4 co

unt

6-12 month increase - mean0-6 month increase - mean

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 AE’s

ASAT/ALAT after 2 weeks

AZT600+3TC300+NVP200

Grades 1

Grade 2

Grades 3/4

AZT600+3TC300+NVP400

AZT600+3TC300+EFV600

Monitor every 2 weeks for 1 month

Grades 3/4

AZT600+3TC300+EFV600

ASAT/ALATafter 2 weeks

Grades 1

AZT600+3TC300+NVP400

AZT600+3TC300+NVP400

Monitor every 2 weeks for 1 month

Grade 2

Services integrationEvolving HIV and TB epidemics in Khayelitsha, 1998-2001

10

15

20

25

1998 1999 2000 2001(Q1&2)

HIV

sero

prev

80090010001100120013001400

TB in

c/10

0,00

0

HIV

TB

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