Médecins Sans Frontières

in collaboration with

Treatment Action CampaignProvincial Government of the Western Cape

City of Cape TownUniversity of Cape Town, Infectious Disease Epidemiology Unit

Population = 500.000 Adult HIV prevalence: 32% in 2007 Highest TB case finding in the world:

1600/100.000 in 2006 Mostly informal housing;

unemployment rate ± 60%; highly mobile population; pop. density > 6000/km2; electricity 76% of households; high rates of crime and sexual violence.

0%

5%

10%

15%

20%

25%

30%

35%

40%

1999 2000 2001 2002 2003 2004 2005 2006 2007

Mean Prevalence (95 % CI)

1998: Creation of TAC1999: start of PMTCT programme2000: HIV care pilot project (3

clinics)2001: First patient started on ART2004: National HIV plan leads to

increased enrolment on ART2009: 12,000 people started on ART

at 9 sites

Existing ARV clincis

Extension 2006/07

ER1 :To develop a new model of care and to decentralise existing

HIV/AIDS dedicated services -including ART- to five peripheral clinics

Existing public health facilities

• 3 community health centers (day hospitals)

• 2 maternities (MTCT ante and peri-natal)

• 8 local clinics (STI, FP, TB, <5 health, post-natal MTCT)

• No hospital (under construction)

• 3 hospices – 1 only for DR TB

• “Home based care” NGOs

CHC based ARV clincis

New HIV clinics

2000: demonstrate feasibility of ART at primary health care level in resource-limited, peri-urban setting

2004: scaling up ART, TB/HIV integration, and integration into Provincial ART programme

2008: feasibility of achieving NSP targets, including “universal coverage” by 2011

80 % of needs ART coverage -> 800.000 to 1 million on Rx

80 % initiated and followed by nurses

50 % of children treated at PHC

Reduction of HIV transmission by 50%

1998: 450 people tested for HIV in Khayelitsha

Well functioning PMTCT programme since 1999

Vertical transmission = 3.5% in 2007

100% acceptance rate, formula feeding, AZT+NVP

Integration of ART provision within MOU since 2004

43 43 42

3734

31 30

2001 2002 2003 2004 2005 2006 2007

Khayelitsha: IMR, 2001-2007(Deaths of babies under 1 yr of age, out of 1,000 live births)

0

10000

20000

30000

40000

50000

60000

70000

80000

2001 2002 2003 2004 2005 2006 2007

To

tal

nm

b o

f vi

sits

0%

50%

100%

150%

200%

250%

300%

350%

400%

450%

Rat

io A

RT

/no

nA

RT

Tot ART Tot non ART Ratio

New patients 2006 2007 2008 2009 2010

  2007 2008 2009 2010 2011

Enrolled 2,122 2,322

Target (new stage IV)* 3217 3485 3708 3847 3929

% needs covered 66% 67%

Remaining in care (%) 12 M 24 M 36 M 48 M

2001 83.4 81.2 78.0 73.82002 84.9 79.5 78.3 75.42003 86.4 81.7 77.3 73.5

2004 88.6 82.6 77.0 74.22005 87.8 82.6 77.62006 88.3 81.52007 86.6

Remaining in care (RIC) = (total initiated) – (deaths + loss to follow-up)

Adults

0

500

1000

1500

2000

2500

Adu

lts s

tart

ed o

n A

RT

Treatment naïve 82 206 389 1,063 1,647 2,122 2,322

Prior treatment or transferred in 9 7 18 66 229 304 168

2001 2002 2003 2004 2005 2006 2007

Children < 14 years

0

50

100

150

200

250

Adu

lts s

tart

ed o

n A

RT

Treatment naïve 33 37 63 98 127 101

Prior treatment or transferred in 6 24 39 64 56 35

2002 2003 2004 2005 2006 2007

Median baseline CD4 and IQR by year (Adults)

48 41.5

7385

105 112

0

50

100

150

200

2001 2002 2003 2004 2005 2006

Time eligible for ARV's to treatment start

05

01

00

150

200

2000 2001 2002 2003 2004 2005 2006 2007excludes outside values

Me

dia

n tim

e fro

m d

ate

elig

ible

to

sta

rtin

g tre

atm

en

t

Year eligible for treatmentSource: Louise Knight 2008, internal report

Expand providers: nurse based follow-up

Simplify follow-up routines: Fast track systems (clubs, “chronic

dispensing”) Limit number of follow-ups

Improve functioning of administrative section Blood results, data entry

Khayelitsha Monthly Total in Care

May2009 

Total Adults Total Children TOTAL

% of total

Kuyasa 686 96 782 6,5M. Goniwe 1000 45 1045 8,7Michael M 3005 166 3171 26,5Nolungile 2527 238 2765 23,1Ubuntu 3702 278 3980 33,2Site C Youth 87 87 0,7Site B Youth 52 52 0,4Town II 89 89 0,7

Khayelitsha 11148 8231197

1

May2009

New Adults

New Childre

n

TFI Total (New)

Target % of total

Kuyasa 33 4 3 37 25 10,8M.Goniwe 38 1 4 39 35 11,3Michael M 85 1 1 86 75 25,0Nolungile 74 6 3 80 75 23,3Ubuntu 75 2 6 77 100 22,4Site C Youth 2 222 2 2 10 0,6Site B Youth 8 0 8 15 2,3Town II 15 0 0 15 ? 4,4

Khayelitsha

total

330 14 19 344 335

Facility based “clubs”▪ Green clinic: patient stable, > 12 months on ARV’s,

undetectable Community based “clubs”

▪ Functions : monthly support group meeting, clinical screening, drug distribution , data record.

▪ Management : community adherence counsellors ▪ Accountability : to the “mother clinic”▪ Supply : drugs “patient’ labelled, nutritional

support

Diagnosed DR-TB cases

All cases referred to Referral OPD

Severe clinical condition and XDR-TB admitted for intensive phase (or until culture conversion) 4-6 months

Others referred for clinic based treatment (intensive and continuation phase)

Continuation phase treatment, clinic based

Patients Started Tx = 52Patients started Tx in Hospital = 9Patients started Tx in Clinic = 43

Patients not Started Tx = 8

Initiation of Treatment Quarter 1 2009 (prepared May 27th, 2009)

Increase in HIV has been followed by increase in TB

70% of TB patients are HIV-infected in Khay.

Increase in smear-TB and EPTB

Increase in M/XDR-TB

Need for TB/HIV integration

Khayelitsha TB incidence 2002-2006

0

200

400

600

800

1000

1200

1400

1600

1800

2002 2003 2004 2005 2006

Incide

nce p

er 10

0 000

All TB New smear (+)TB New smear (-)TB EPTB

Khayelitsha: VCT in TB services  

Proportion TB patients counselled

Proportion accepted testing

Proportion testing HIV +

2002 49% 89% 26%

2003 62% 84% 45%

2004 62% 87% 73%

2005 72% 91% 76%

2006 99% 95 % 67%

2007 99% 95 % 67%

TB/HIV juxtaposition: 1 folder, different admin & clinicians

Managerial integration: 1 folder & same admin, different clinicians and clinical pathway (Ubuntu).

True TB/HIV integration: ARV delivery integrated within TB programme: one-stop service with same staff (admin & clinical) and patient flow (Town 2).

1. ART in a poor public sector setting is feasible.2. Increased enrolment on ART has resulted in

decreased mortality.3. Saturation of large sites led to increased losses

to follow-up. There is a need for decentralisation of ART to the most peripheral clinics.

4. Success of nurse-based, doctor-supported strategy. Regulatory framework on the way.

5. TB/HIV integrated services led to quicker diagnosis and treatment of both diseases in co-infected patients.

6. Decentralized management of DR TB has led to increased diagnosis and number started on treatment.

7. Collaboration between MSF, CoCT, and PGWC was an essential condition for success.

Enrolment of children on ARTAdherence in youth and pregnant

womenEnhanced adherence strategiesFurther decentralizationRegulatory framework for

decentralised nurse-based careDR- TB: new diagnostic and

treatment options