Adherence & Retention

This is very sad.

Do our African governments have mechanisms put in place to detect and give early warnings on important issues like this one?

Cross-posting

I thought you might be interested in this conversation, which was started in the new HIV Prevention community earlier this week:

http://www.ghdonline.org/hivprevention/discussion/ny-times-says-keeppreventio...

Dear Raphael and Claire:
Thanks for your reaction. Yes, indeed quite depressing but unfortunately not surprising – we have been discussing what will happen as PEPFAR and few major others winds down. I worry very much that many folks on ART or in need to start will be left without drugs simply because no one steps forward to assume responsibility for them. Guess we just have to hang in there and continue to fight the fight in whatever capacity –
Best,
Jean
Cape Town, South Africa

I can't help but wonder if the situation is inevitable so long as prevention
and treatment are not linked and equally pushed. The cost of ARTs for life
for a growing patient population does not seem something that is sustainable
given the world's economic situations, and the increasing interdependence of
national economies on each other. With such volatility likely to resurface
in the future, shouldn't funders be seeking ways to reduce the population in
need of ARTs by preventing new infections at the same time as they fund
ARTs?

Jean and Raphael, have you seen any signs of change in funders' thinking?
Any moves toward a more integrated approach?
__________________
Claire B. Cole, MPH
Case writer
Global Health Delivery Project
FXB Center for Health and Human Rights
Harvard School of Public Health
office: (001) 617.432.7267
cell: (001) 917.523.6523
email:
globalhealthdelivery.org | ghdonline.org | twitter.com/ghdonline

Hi Claire:

Last year, about 3 million people became newly infected with HIV, half of whom were young adults (<24 year old) with the majority residing in developing countries. The sad reality today is that for one HIV+ patient started on ART, 2.5 to 3 other individuals are becoming HIV-infected. You do the math. So the epidemic continues unabated, especially in Africa, and I agree with you, it will require more aggressive and integrated multiple prevention and treatment programs if we are to succeed in slowing the spread of this deadly epidemic in the absence of a magic HIV prevention bullet (vaccine).

In the first decade of HIV infection, the major focus of prevention was on ABC strategy (with mixed results) and needle exchange programs in IVDUs. More recently, we learned the failures of STI control and non-ART Microbicides interventions for prevention of HIV acquisition. However, two of the most successful biomedical interventions have been use of ART for pMTCT, and male circumcision. Exception of pMTCT in the US, rolling out these interventions worldwide still a challenge and barriers need to addressed.

An exciting and optimistic area is that effective ART in the highly adherent patient greatly reduce the ...

Hi Claire:

Last year, about 3 million people became newly infected with HIV, half of whom were young adults (<24 year old) with the majority residing in developing countries. The sad reality today is that for one HIV+ patient started on ART, 2.5 to 3 other individuals are becoming HIV-infected. You do the math. So the epidemic continues unabated, especially in Africa, and I agree with you, it will require more aggressive and integrated multiple prevention and treatment programs if we are to succeed in slowing the spread of this deadly epidemic in the absence of a magic HIV prevention bullet (vaccine).

In the first decade of HIV infection, the major focus of prevention was on ABC strategy (with mixed results) and needle exchange programs in IVDUs. More recently, we learned the failures of STI control and non-ART Microbicides interventions for prevention of HIV acquisition. However, two of the most successful biomedical interventions have been use of ART for pMTCT, and male circumcision. Exception of pMTCT in the US, rolling out these interventions worldwide still a challenge and barriers need to addressed.

An exciting and optimistic area is that effective ART in the highly adherent patient greatly reduce the likelihood of sexual transmission from infected individuals to their sexual partners. As a result, most treatment guidelines in the developed world recommend that infected partners of HIV-discordant couples should be started on ART regardless of their CD4 count, but further encourage the consistent use of other prevention methods (condoms,…). More than ever, as HIV providers interested in ART adherence, we need to add to our list of patient education/counseling sessions the topic of "ART adherence as Prevention of Sexual Transmission".

The ongoing debate about "test-and-treat" model in which universal HIV testing with immediate HIV ART for infected persons would be incorporated with other prevention strategies is likely to continue to be controversial for some time. However, if this model is feasible and affordable, it could potentially reduce HIV incidence and mortality to less than one case per 1,000 people per year by 2016. But achieving full access to these interventions for all at-risk populations may prove to be more difficult than any mathematical model could predict, especially now that patients in need of ART (CD4<350) are being rejected due to ART shortage.

Additional studies are exploring pre-exposure or post-exposure prophylaxis with ART (tenofovir/ftc) to further reduce transmission but results are not yet out there. So one can see that effective control of HIV/AIDS will likely require a combination of multiples prevention strategies (to include effective ART for the benefit of the individual but also for the community). Pre- and post-exposure ART prophylaxis interventions are likely to be a home run but again rolling them out is likely to prove difficult without additional financial resources and political leadership.

Is there any sign of funders thinking? I would say yes. But too little and may be too late. Time will tell! In meantime, continuing/increasing efforts in investing in HIV research (both basic, clinical, operational) and advocacy for prevention, treatment and care should remains high on the agenda.

Best,

Jean

Hi Claire,

Eric Goosby has stated on several occasions that prevention, as well as
treatment, is a critical goal for PEPFAR and he is calling for an integrated
approach. Here is an excerpt from a recent interview he gave at UCSF:

³My top priorities as PEPFAR moves into its next phase are intensifying the
focus on HIV prevention; pursuing strong country partnerships, country
ownership and coordinated, multilateral engagement; supporting the
strengthening of health systems through programs and country-driven
planning; and taking effective interventions to scale to achieve
population-level health outcomes.²

I think the NY Times article rightly highlighted the new challenges we face
given the slowed growth in US and other funding for treatment; however, I
think a lot can be gained through efficiency and multilateral engagement.

Jessica

Dear Claire,
First is to acknowledge and appreciate the great insight given by Jean and Jessica on this topic.

According to my observation at the community level here in Kenya,am seeing more AIDS organization concentrating more on Testing.There numerous HIV Testing campaigns being undertaken at every available forum.Groups are 'competing' to conduct door-to-door testing.Mobile testing tents are pitched in most public spaces and in most public events.

Everyone is saying that the donor is now interested in HIV Testing;they are more concerned about people knowing their HIV Status.

On the Western side of Kenya the emphasize is on male circumcision as a preventive measure. Government and civil society are working on Rapid Response Initiative(RRI),they are more interested in numbers for both cases.They argue that majority of Kenyans are aware about HIV/AIDS and service being offered.

Raphael.

Dear Raphael and Jean,

Thank you both for your keen insight and quick response. I share your hope
increased global attention to integrated prevention & treatment responses.

With best wishes,
Claire

Thanks all for sharing your thoughts. At last, South Africa (under Zuma's new HIV leadership) seems now moving in the right direction...by expanding and integrating HIV prevention & treatment services similar to what is reported by Raphael in Kenya.
Weblink below FYI-
Best,
Jean

http://www.nytimes.com/2010/05/15/world/africa/15zuma.html?scp=2&sq=Zuma&st=cse

Claire:

We have already been forced to make the adjustments that are necessary when
external funding is lost. Our program was funded for four years under
MTCT-Plus, but that program ended. We have successfully switched to a
self-funded model, continuing to receive free drugs through the national HIV
treatment program and charging a small monthly consultation fee. I think
that inevitably the external funding will decrease so adjustments need to be
made in advance to reduce the shock. Focusing on continued availability of
drugs is the most critical component of the treatment program. I heard
recently from some visitors from South Africa that very low cost generic HIV
meds were being manufactured there. Is that true.

We have initiated a contact tracing program within our HIV treatment
program. It is showing a lot of promise in finding recently infected
patients and we hope decreasing the amount of transmission.

Dennis


Dennis Palmer, DO., FACP, FWACP (Int Med)
Program Director, Christian Internal Medicine Specialization Residency
Mbingo Baptist Hospital
Cameroon

Hi Dennis and others,
Thanks so much for such an interesting discussion. Your post in particular got me thinking about how one moves from the rhetoric of linking prevention and treatment and actually operationalizes it on the ground. There has been a lot of talk recently about treatment as prevention, which is an interesting reframing. I wondered if another way to link them would be to use HIV prevention resources for adherence support--if a community health worker or other visits a household daily, she/he could both observe therapy and offer prevention messaging/counseling. Are there examples of this, or other models for linking prevention for positives with treatment adherence support? Any data on whether this is an effective strategy?

Dennis, I would love to learn more about the switch from external funding to self-funding with government support. Perhaps you could post here (as a new line of topic) or in the prevention community? Many of the programs we're studying are facing this challenge now and it'd be great to have your insights on how to avoid/minimize disruptions in the services that the community receives.

Cynthia Pearson and colleagues provide a good example of or support for combining observed therapy with adherence counseling from peers (see attached). Their mDOT was delivered at clinic, but I would imagine that the success of such an approach would generalize to in-home visits as well. Prevention with positives is a growing area of research...focusing on risk prevention strategies specifically within HIV-positive populations and often this work involved people who are on ART. I do think, however, that this is a somewhat different question from treatment-as-prevention where the goal is the control of VL as a prevention strategy, so the target would be improved or sustained high adherence to effective regimens. I would imagine that the idea of both (reduction in VL and adoption of safer sex or IDU behaviors) would be presumably an even more effective approach but I am not aware of research or mathematical modeling that speaks to the actual impact of both together. I too would be interested in learning more about this.
Rivet Amico
Center for Health Intervention and Prevention- USA

I would like to share some articles such as disease control programs should be organized around health systems and what are the prospects for public health between public and private services

Hi Dennis,

I am interested to know more about how your organization has made the switch
from a donor-funded to self-funded portfolio/ structure. How exactly did you
make that switch? How long did it take your organization to make the
transition, and what procedures or structures did you need to set up to
facilitate it? Any and all insight would be most welcome.

Regarding South Africa's ARVs, my understanding is that South Africa has
been manufacturing ARVs in-country but that it has yet to see a sustainable
cost or sufficient savings to justify/ enable them to manufacture in this
way for the long term. This link suggests that they are looking into
alternative options: http://www.southafrica.info/about/health/arv-150410.htm

Does anyone in the community know whether there's been any progress to that
end?

Thanks in advance, Dennis. My colleagues and I are eager to know more about
your transition to a self funded model, and whether you think this is an
approach more organizations can take to guard against future donor
volatility.

With best wishes,
Claire
__________________
Claire B. Cole, MPH
Case writer
Global Health Delivery Project
FXB Center for Health and Human Rights
Harvard ...

Self-funded treatment programs

Sorry but I am not smart enough to begin a new topic.

Here in Cameroon, we are a large church based health care system delivering
largely rural health care for more than 60 years. So we have a large
infrastructure built up for general medical care. We have been involved in
HIV care for 10 years, beginning with pMTCT services and expanding to HIV
treatment five years ago. We were initially able to get funding through the
MTCT-plus program. Their support, along with some short term funding from
USAID and drugs from the national Global Fund funded program, enabled us to
rapidly scale up care and treatment to five treatment centers and more than
8000 patients on ART. The MTCT-Plus program ended more than a year ago and
Cameroon is not part of the PEPFAR program, so we were not able to identify
any external donors willing to pick up the cost of our program.

When we realized that we would not have external funding, we made the
following changes in the program:

We instituted a small monthly consultation fee for patients. Patients were
instructed that we had given them free care when we had resources but ...

Self-funded treatment programs

Sorry but I am not smart enough to begin a new topic.

Here in Cameroon, we are a large church based health care system delivering
largely rural health care for more than 60 years. So we have a large
infrastructure built up for general medical care. We have been involved in
HIV care for 10 years, beginning with pMTCT services and expanding to HIV
treatment five years ago. We were initially able to get funding through the
MTCT-plus program. Their support, along with some short term funding from
USAID and drugs from the national Global Fund funded program, enabled us to
rapidly scale up care and treatment to five treatment centers and more than
8000 patients on ART. The MTCT-Plus program ended more than a year ago and
Cameroon is not part of the PEPFAR program, so we were not able to identify
any external donors willing to pick up the cost of our program.

When we realized that we would not have external funding, we made the
following changes in the program:

We instituted a small monthly consultation fee for patients. Patients were
instructed that we had given them free care when we had resources but now
they would need to assist us if we were going to continue with our treatment
program. They accepted the explanation and continued to receive care in our
program. We also emphasized that patients should continue to come to the
clinic even if they did not have the money for the consultation fees.

We have developed a very cost efficient laboratory system which has enabled
us to generate some income to support the clinics. We use a low reagent
cost system for CD4 counts (Guava) which helped us keep down costs.

Drugs continue to be provided free through the national HIV Treatment
program although the supplies are irregular at times.

Within 5-6 months of making these changes, we were generating enough income
from the clinics to cover the basic operational costs. There was concern
that our lost-to-follow-up rates would increase with these changes but we
have not seen any problem with this.

So, we now feel more secure in our ability to continue to provide chronic
HIV care to our patients. Our program continues to grow but the income
matches this. We do not have extra funds from our patient fees to allow us
to purchase new equipment or buildings and staff complain that salaries are
not as high as they would like. Overall, I am happy with the transition. I
think the stability of the program is better and our focus is more on caring
for our patients. I don't know if this program is generalizable. Many
programs do not have the support of a large general medical system and this
has been important to us. We have also benefited from having a highly
motivated clinic staff who work hard in caring for these patients.

I doubt that external funds will continue to increase and begin to fall back
so beginning to focus on sustainability is appropriate. We can survive with
the locally generated funds, but are completely dependent on free drugs to
treat our patients. Perhaps a reasonable compromise in use of external
funds would be to use them to ensure adequate drug supplies and to direct
more support toward prevention programs.

Dennis

it is sad, for a whole African countries to ignore health programmes and go in for political issues or wars in short. The drug shortage is not only in Cameroon, the same story in Uganda. It became worse when the government was looking for money to burn expired drugs, yet more HIV patients had not been started on drugs yet they wanted. For sum of us who meet these patients on a daily basis we are disapointed by our African governments who look at donations which are not managed well. AFRICANS LET US WAKE UP AND SHARE THE CHALLENGE TO FIGHT HIV!!!!!!