AMANI MASSOUD, EIPROTHMAN MELLOUK, ITPC

Barriers to Access to HIV Treatment in Six Countries of North Africa

Missing the Target North Africa :

ITPC: Worldwide coalition of PLWHIV and their supporters and advocates. Uses a community based approach to achieve universal access to treatment, prevention and all health care services for PLWHIV and those at-risk.

The treatment monitoring and advocacy project (TMAP): produces « Missing the Target » reports series that identify barriers to delivery of AIDS services and holds national governments and global institutions accountable for improved efforts.

About ITPC

North Africa Context

MENA region has the lowest coverage rate of access to HIV treatment in the world : 11%

No data on North Africa as sub-region (North Africa different from Middle East)

Country data available but only quantitative (number of PLWHIV on ART)

Officially: HIV Treatment is available and free for all BUT problem of testing

Objectives of the research

Identify barriers to access to HIV treament from Civil Society and PLWHIV perspective

Develop capacities of community activists in: research, data collection & analysis and their use in advocacy

Set priorities for advocacy in the sub-region with the goal to reach Universal Access to HIV treatment

Methodology

Incountry research teams: all community activists including 2 PLWHIV Mauritania, Morocco, Algeria, Tunisia, Libya and

EgyptStandardized research template for data

collectionRevue and analysis of available litterature

articles, publications, national reports etc.Interviews with key stackeholders:

NAP, bi and multilateral cooperation, health professionals, social workers, AIDS activists

Interviews and focus-groups with PLWHIV

Research Template

Epidemiological situation in the countryOrganization of testingOrganization of care for PLWHIVNational treatment guidelinesTreatment coverageAvailability of ARVsLab testsPrevention and treament of opportunistic infectionsCo-infections Treatment litteracy and education Impact of stigma and discrimination Impact of intellectual property protectionRole of Civil society

Key Findings

Voluntary Counseling and Testing

Limited offer of voluntary testing facilities: Low in numbers and Geographical inquetities

Countrty VCT Centers NGO VCT Centers

Estimated Tests / Year

1 Test/Nbre Habitants

Mauritania 22 3 7.738 426

Morocco 44+8 mobiles 44+8 55.451 561

Algeria 54 1 12.589 2.859

Tunsisia 19 - 8.000 1.325

Libya 0 0 - -

Egypt 14+9mobiles 4 5-6.000 13.300

Voluntary Counseling & Testing

Centralized confirmation of positive results: 1 site in most countries, delays in confirmation, problem for

linkage to care« Anarchic testing » in private labs

no link with national system of reference no counseling no confirmation of positive results

Compulsory testing still widely existing: Inmates at admission, Algeria « Populations with a special risk of danger »?, foreigners,

prenuptial tests, some professions (Canal de Suez Org, General prosecuter), Egypt

Hospitalization, Libya Army, majority of countries

HIV testing not targetted toward MARPs Ex: in Tunisia PUD represent 2,6% of VCT clients, while PUD

represent 25% of HIV+ cases.Weak involvement of civil society (with exceptions)No voluntary testing in Libya

Organization of care

Limited offer of care facilities for PLWHIV Several centers not equipped or non-functionnal (Morocco, Algeria) Geographical distribution:

In pocket travel fees Delays , treatment interruptions linked to travel (Algeria, Egypt+++)

Good example: 2 guest houses for PLWHIV in Morocco: Agadir, Casablanca

Weak involvement of civil society: No links between NGOs and treatment centers (Except Morocco++, Algeria and Tunisa+)

Country Number of care centers for PLWHIV

Mauritanie 4

Maroc 10

Algérie 8

Tunisie 4

Libye 2

Egypte 5

Access to ARV Treatment

Country Number of PLWHIV on ARV Coverage rate

Mauritanie 1.621 25%

Maroc 3.356 28%

Algérie 1.526 13%

Tunisie 402 10%

Lybie 2.600 ?

Egypte 538 10%

• Countries have updated treatment guidelines (WHO 2010) except Libya • ARV treatment available and free in all 6 countries• No official waiting list BUT because of CD4 interruptions PLWHIV can wait several months before accessing treatment (Mauritania++)

ARV Treatment

1st line treatment and at least one 2nd line option available in all countries

Problem of patients in treatment failure: Egypt++

In 2010-2011: ARV stock-outs reported in ALL countries (Algeria++) Stock outs during revolutions (2months in Tunis, NOW

in Libya++)High number of people lost from care system

(40% in some centers in Algeria) and Libya

ARV Availability

Morocco offers the highest choice of ARVs, followed by Tunisia and Maritania.

Very limited choice of ARVs in EgyptSpecific case Egypt: regular change of

regimens based on availability causing drug resitance

Treatment not optimized: choice of ARV motivated by financial constraints and not benefits to PLWHIV

Problem of availability of pediatric formulations: Morocco++

Biological Tests

Only Morocco and Tunisia offer satisfying biological follow up (CD4, VL, resistance test)

Algeria, Lybia, Egypt: follow up based on CD4 only, viral load non available

Lab tests available in 1 site only: travel fees, delays to obtain results

CD4 counters often « out-of-service »PLWHIV need to go to private labs:

Expensive!

Prevention and treatment of OI

In general: lack of medicinesTreatment free for inpatients, otherwise at

charge of PLWHIV (treatment & prevention): Egypt, Libya, Tunisia +++

NGO support for OI medicines in Morocco (ALCS) and aids with « disability status » in Tunisia

Co-infections: TB treatment available, None of the countries offer treatment for Hepatitis

Treatment Education and Litteracy

Only Morocco and Tunisia have treatment education program (problem of human ressources in Tunisia)

Sporadic activities in Algeria and MauritaniaSome informations by health workers and

pharmacists in Libya and EgyptOnly Tunisia has an updated manual on

treatment for PLWHIV (but in french)Non outdated manuals in Mauritania and

MoroccoStrong opposition to allow CSO and PLWHIV

(non medical) to run treatment education activities (Egypt, Tunisia)

Impact of stigma and discrimination

Negative on testingRefusal of care by health workers Breach of confidentialityHigh level of stigma for excluded populations:

sex workers, MSM, PUD, migrants…Higher in Egypte and Libya

Impact of Intellectual Property Rights

Most countries use generic versions of ARVs (1st line non patented drugs)

Lack of 2nd and 3rd line linked to their high price (patented in producing countries: India)

Same for some OI drugs (antifungicals) and HepC treatment

Morocco: supply of Tenofovir delayed several months because of patent status (even if not patented)

Recent disturbing developments: 5 of 6 countries (except Mauritania) excluded from the

Gilead/Medicines Patent Pool (MPP) licence (june 2011) Also the recent Johnson&Johnson voluntary licence (dec

2011)

Summary

Access to HIV status (Testing) remains a major obstacleBUT several gaps in the existing treatment programs

Geographical distance Lack of treatment optimization Availability of 2nd and 3rd line regimens Failing biological monitoring: maintenance problems, stock-outs of

reagents Stock outs of ARVs: failing procurement & supply channels,

complicated procurement procedures, monitoring Lack of medicines for OI Inaccessibility of information on treatment Stigma and discrimination Intellectual property rights

Aknowledgements

Research team:Nadia Rafif, Souheila Bensaid, Fatimata Ball,

Abdullah Turki, Skander Soufi, Ragia El Guerzawy

The FORD Foundation