A Multicultural Caribbean United Against HIV/AIDS Dominican Republic 5 – 7 March 2004

1. Comprehensive HIV/AIDS Prevention and Treatment Centers to curb the AIDS Epidemic: The Haiti-GHESKIO Model A Multicultural Caribbean United Against HIV/AIDS Dominican Republic 5 – 7 March 2004 P.Joseph, R.Verdier, MMDeschamps,M Ascencio, F.Noel, G Bois, R Grand ’Pierre,D.Fitzgerald,P.Sévère,PD Leger, J Bonhomme, S Nerette, H Theodore, A Marcelin, J Duperval,P.Wright.WDJohnson WD et. JW Pape*+,

2. What is the best intervention likely to slow down the AIDS epidemic in developing countries? • HIV prevention ? • Care ?

3. VCT….A model to curb the AIDS epidemic • Prevention • counseling • Screening and specific counseling • Care

4. The Haitian Group for Kaposi Sarcoma and Opportunisitic Infections(GHESKIO) – May 2, 1982 MISSION • Care • Training • Operational research • On the following diseases • Chronic diarrhea • HIV/AIDS • Sexual Transmission Infection (STI) • Tuberculosis • On reproductive health

5. History of GHESKIO Services1982 - 2003 • Services were added sequentially in response to: • The needs of service population • The results of research studies conducted at GHESKIO and abroad • The Haitian MOH’s need for feasibility and model program for the nation • First Voluntary counseling and Testing Center inaugurated in 1985

7. Interventions to Decrease HIV Transmission • Increased condoms use • Treatment of STIs • Reduction in the number of sexual partners • Mother to child transmission program • Prophylaxis against other HIV intercurrent diseases • ARTs

8. AIDS: Clinical Manifestations in Haiti… • Skin: prurigo, zona, herpes • Pulmonary: Tuberculosis • Gastro-intestinal • Oesophagal candidiasis • Coccidies associated with chronic diarrhea

9. Causes of chronic diarrhea in HIV-infected individuals Pape J.W., Verdier, R-I., and Johnson, W.D.: Therapy and prophylaxis of Isosporabelli infection in patients with the acquired immunodeficiency syndrome. N. Eng. J. Med., 320:1044-47, 1989

10. Isosporiasis Pape et al. NEJM 320:1044, 1989DeHovitz et al. NEJM 315:87, 1986

11. Cyclosporiasis Pape et al. Ann Int Med 121:654, 1994

12. Establishment of STIs as co-factors for HIV transmission • Identify risk factors in HIV transmission • STI • Clinical status Deschamps MM et al Ann. Int. Med 1996 ; 125 • Develop STI algorithm for treatment (1994) • Essential for STI control STI control manual (1994)

13. One Brand (Pantè)Male Condom Sale 1992 -2002

14. HIV and Tuberculosis in Haiti • The most affected country in the Americas • 50 % of adult patients in sanatoria were HIV+ (1988) • About 10%/year of HIV+ PPD+ are developing active TB • Estimated that at least 30% of new TB cases are due to HIV

15. Research as a Tool for Better Services and Training in Tuberculosis • Can we effectively screen patients coming at VCT for active tuberculosis? Burgess A et al AIDS 2001 15: 1875-1879 2. Does Primary prophylaxis with isoniazid (INH) work for HIV+ individuals? Pape JW et al; The Lancet 1993; 342 • Do HIV+ patients with TB respond as well as HIV- TB patients to anti-TB regimens? Should secondary prophylaxis with INH be done? Fitzgerald D et al; The Lancet 2001;375

16. Tuberculosis Screening New patients coming for HIV testing No Cough Cough Smear negative (Same day screening) Smear positive Culture and Chest X-Ray Weight loss and HIV+ No weight loss and HIV- If Fever > 38 O BACTEC Hemoculture Low risk for TB Culture and Chest X-Ray in special situation

17. Effect of Preventive INH on the Incidenceof Active and Irogression of HIV Infection Pape JW et al: The Lancet 342: 1993

18. PPD Positive Individual PPD Negative Individual Pape JW et al: The Lancet 342: 1993

19. Tuberculosis Preventionin HIV and PPD Positive Persons Rate of active tuberculosis cases per 100 person-years Placebo Intervention Author/Place/Date Pape et al/Haiti/1993 INH, X 1 year 10 1.7 Markowitz et al/USA/1997 INH, X 6 mo 4.7 1.6 Whalen et al/Uganda/1997 INH, X 6 mo 3.41 1.08 INH+RIF, X 3 mo 3.41 1.32 INH+RIF+PZA, X 3 mo 3.41 1.73 Halsey et al/Haiti INH, 2X/week, X 6 mo - 1.0 RIF +PZA , X 8 weeks - 3.7 INH = Isoniasid ;RIF = Rifampin; PZA = Pyrazinamide

20. Duration of Isoniazid prohylaxis and time of recurrence of Tuberculosis Fitzgerald D, Morse MM, Pape JW, Johnson WD Jr CID 2000; 311495-1497

21. 233 patients treated for TB Randomised HIV+ (142) HIV- (91) Placebo (74) Isoniazid (68) Placebo (40) Isoniazid (51) • Recurrent TB 12 2 0 1 • Recurrence rate per 100 persons-years (95% CI) 7.8 (4.1-13.3) 1.4 (0.0-3.4) 0.0 (0.0-4.0) 0.7 (0.0-3.9) Fitzgerald D, Desvarieux M, Sévère P, Joseph P, Johnson WD Jr, Pape J.W. The Lancet 2000 356 : 1470-74 Effect of Post-treatment Isoniazid on Prevention of TB in HIV-infected Individuals

22. Effect of Post Treatment Isoniazid Prophylaxis on TB Recurrence Among Hiv+ Patients Proportion free of recurrent tuberculosis Population free of recurrent tuberculosis Time from completion of TB therapy (months) Fitzgerald D, Desvarieux M, Sévère P, Joseph P, Johnson WD Jr, Pape J.W. The Lancet 2000 356 : 1470-74

23. New individuals tested for HIV at GHESKIO (VCT Center)

25. HIV testing and counseling HIV Care Adults Infants and children Tuberculosis Diagnostic screening Treatment STI Syndromic Management Reproductive Health Services Family Planning Prenatal care Women Survivors of sexual violence N = 21278 patients 3531 327 2750 501 7490 7463 1000 57 Patients Care Services at GHESKIO

26. Evolution of GHESKIO Voluntary and Testing Center 1985-2002

27. Training at GHESKIO • Fogarty support through US universities provided training to the GHESKIO’s staff • French institutions provided additional training opportunities • In the last 10 years, GHESKIO provided training to over 7,000 persons nationwide in comprehensive and integrated care for HIV,STI,TB and associated diseases and the provision of family planning

28. Integrated Package Services at VCT • Pre-post test counseling • HIV screening: 22% HIV+ • STI screening • For syphilis ( rapid test for pregnant woman) : care for 10% RPR+ ,evaluation of partners; • Screening and treatment of other STI: 22% + • TB screening: • >30% of individuals presenting with cough received care for active TB (n=500) • TB prophylaxy: HIV+ PPD+ without active TB received INH (n=1,000) • Screening and treatment for OIs: 2,500/an; • Prophylaxy for OIs (trimethoprim-sulfamethoxasole): 2,000/year • Family planning mostly for HIV+ woman : • Reduction of pregnancy rate in HIV+ from 24% to 4% • MTCT : • Reduction of mother to child HIV transmission from30% to 9% • ART for woman in MTCT project and others with CD4<200 • Short course ARTfor raped woman and AES • Nutritional support: 4000 family • Home care: >1,000 family

29. Expansion of this VCT Model throughout Haiti • 25 institutions nationwide: 2/department (1 private, 1 public) • Training at GHESKIO(physician, lab technicians, nurses) • Supervision with a mobile team from GHESKIO • Rapide test for HIV and syphillis • Quality control of test at GHESKIO

30. Services at the expanded VCT for the 1st year • Pre and post test counseling • Screening for HIV and syphillis: treatment for syphillis • Screening and treatment of other STI • Screening and treatment of OIs • Family Planning • MTCT

31. National HIV Seroprevalence in Haiti (1993-2003) Pregnant women at 1st antenatal visit MSPP/IHE/CDC/GHESKIO

32. Conclusion • Developping countries must develop strategies for reducing HIV transmission adapted to their reality. • Voluntary counseling and testing (VCT) is one of the few potentially effective and affordable methods for reducing the transmission of HIV in developing countries. • Haiti-GHESKIO’s VCT model can be replicate in other developping settings.