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Scaling up of ARV at GHESKIO and Zanmi Lasante

Scaling up of ARV at GHESKIO and Zanmi Lasante. A Multicultural Caribbean United Against HIV/AIDS Dominican Republic 5 – 7 March 2004 P. Severe, F. Leandre, JW Pape, Paul Farmer. Background. Haiti is the poorest country in the Western Hemisphere Per capita income: $US 300

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Scaling up of ARV at GHESKIO and Zanmi Lasante

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  1. Scaling up of ARV at GHESKIOand Zanmi Lasante A Multicultural Caribbean United Against HIV/AIDS Dominican Republic 5 – 7 March 2004 P. Severe, F. Leandre, JW Pape, Paul Farmer

  2. Background • Haiti is the poorest country in the Western Hemisphere • Per capita income: $US 300 • Country most affected by HIV/AIDS outside sub-Saharan Africa • HIV prevalence: 4.5% (2000) • PLWA: 300,000

  3. Background (contn’d) • Drastic increase of TB because of the HIV epidemic • Haiti ranks among the highest countries in the world for TB per capita

  4. Objective • Demonstrate that the scaling up of ART is feasible in both rural and urban settings in spite of the constraints inherent in the complexity of ART and the poverty in a country such as Haiti

  5. Haitian Study Group on Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO) • Oldest Institution dedicated to AIDS (1982) • Mission: Services,Training, Research in: HIV/AIDS; Sexually Transmitted Infections (STI); Tuberculosis; Diarrheal Diseases • Partners: • International partners: • US: Cornell, Vanderbilt, Hastings Center • France: Institut Pasteur, Biomerieux, Institut Alfred Fournier • Local partners: • Ministry of Health • Haitian Medical Association and • > 116 public and private institutions • Community through active community advisory board

  6. The GHESKIO VCT model with integrated services Post-HIV exposure Counseling and HAART STI Management Pre-test Counseling HIV, Syphilis, Tuberculosis Post-Test Counseling Reproductive Health Services (family planning and prenatal care) HIV+ women Prevention HIV MTCT with HAART Same day TB screening / Rx / Px • Care to HIV infected individual / affected family • OI Rx/Px • HAART for AIDS or CD4 count  200 • Nutritional support • Psychosocial support Rx = Treatment Px = Prophylaxis

  7. Major VCT Interventions • Pre/post test Counseling for HIV, STI, TB • Screening for HIV, STI, TB • Prevention and treatment of OI, bacterial pneumonia, STI, TB • ARV • HAART for AIDS • Short Course • MTCT: FP and ARV • Raped victims and persons exposed to HIV+ blood: short course ART Peck R, Fitzgerald D, Liautaud B et al: JAIDS:33;470-475, 2003

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

  9. VCT Centers (20) 2003 VCT Centers (20)(GFATM) Legend National Expansion of VCT Integrated Services Press a key to continue …

  10. VCT Centers Centers of Excellence (10) 2004 Total VCT Centers (45) Legend GHESKIO’s Peripheral Centers (10) CANGE’s Peripheral Centers (8) Other Peripheral Centers (17) National Expansion of VCT Integrated Services Nippes Press a key to continue …

  11. VCT Centers Centers of Excellence (10) 2009 Total VCT Centers (100) Legend GHESKIO’s Peripheral Centers (10) CANGE’s Peripheral Centers (8) Other Peripheral Centers (72) National Expansion of VCT Integrated Services Nippes Press a key to continue …

  12. GHESKIO Trainees 2003 (Counseling,HIV,STI, TB, FP)

  13. Guidelines Development • ARV international workshop: Nov. 2002 • Moving from model to implementation: April 2003 • National guidelines: (MSPP and partners, 2003) • ART guidelines: educational brochures, guidelines for home care • Development of standard operating procedures for recruitment, enrollment, follow-up, pharmacy, laboratory and specific counseling focus on compliance

  14. ART Provision at GHESKIO • Implementation of a pilot ART short course intervention (PEP), 2000 • First 96 patients on ARV 1999-2001 • Long-term ART provision: 100 patients/month (Feb 2002)

  15. Research Questions (1) • When to start treatment? • Does TLC <1200 correlate with CD4 <200 in the Caribbean? • Are there other valid clinical or laboratory markers (e.g., ESR, anemia) that can be used to correlate with CD4 <200? • What treatment regimen to start? • Will the use of NVP in first-line regimens impact its use in prevention of MTCT (and vice versa)? • Are generic drugs of adequate quality? • When to start therapy with active Tbc. • How to monitor therapy?

  16. Research Questions (2) • How to assess treatment failure? • Will clinical endpoints correlate with CD4 decreases? • Can we define other specific markers of disease progression? • What treatment to change to? • What about drug resistance? • What’s the prevalence of baseline resistance in the community? • How does treatment failure correlate with resistance?

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