Scaling up of ART at Zanmi Lasante: the rural experience

1. Scaling up of ART at Zanmi Lasante:the rural experience Fernet Léandre, MD Partners In Health Zanmi Lasante A Multicultural Caribbean United Against HIV/AIDS Dominican Republic, March 2004

2. Five facts about Zanmi Lasante • ZL is now rural Haiti’s largest health-focused NGO. • ZL is the leader of the region’s “Unité Communale de Santé #3,” which comprises the health district stretching from the Dominican border to beyond Thomonde. • Some 1000 employees from the Central Plateau report to ZL. • Over 500,000 people live in the Département du Centre. • ZL plays an important role in public health, with over 700 community health workers. Aside from our main clinic in Cange, four health centers and a hospital also report to ZL.

3. Introduction of HIV prevention and care, central Haiti • 1986: First case of HIV in Central Plateau • 1988: Free serologic testing to diagnose HIV • 1990: Intensified prevention efforts • Hampered by political violence and resultant migration • Hampered by gender inequality and deep poverty • 1995: AZT given to HIV-positive pregnant women in order to block mother-to-child transmission • >90% of women offered HIV testing accepted testing after AZT was made available free of charge

4. Use of HAART at Clinique Bon Sauveur • 1997: Post-exposure prophylaxis with a three-drug regimen to victims of rape or professional injury • 1998: HAART offered to a small number of patients with longstanding HIV disease who no longer responded to treatment of opportunistic infections

5. Implementation of HAART in central Haiti • All medicines provided for free • Limited number of treatments available • No CD4 or viral load available in 2002 • Clinical criteria used to identify sickest patients • Patients with other treatable OIs (including TB) treated for their OIs first

6. Central Plateau – use of Global Fund monies Years 1 and 2 of a five-year plan Cange Thomonde Boucan Carré Lascahobas Belladère Mirebalais 80 accompag. 2 doctors 1 nurse 1 social worker 1 lab tech Building renovation Improved lab capacity 30 accompag. 1 doctor 1 nurse 1 social worker 1 accountant 1 nurse midwife Building renovation in process >100 accompag. 5 doctors 2 nurses 1 social worker 1 secretary 1 administrator 1 accountant 3 volunteers 2 lab techs 15-bed facility built >20 accompag. 2 doctors 2 nurses Introduction of HIV care package Improved lab capacity TB/HIV Collaboration with other NGO HAART supervised by ZL

7. Four Pillars of HIV Prevention and Care • VCT/PEP/PMTCT - Prenatal care and women’s health • Screening and treatment for TB • Screening and treatment for all STIs/OIs • HIV prevention and care / DOT-HAART

8. DOT-HAART: supervised therapy for advanced HIV disease • Over 5000 HIV-positive people followed • Over 750 patients now being treated with directly observed HAART (“DOT-HAART”) • Each DOT-HAART patient has an accompagnateur • Accompagnateurs observe ingestion of the therapy at least once a day • All patients have responded with weight gain, improvement of health

9. Lascahobas, February 2004 • Fully functioning clinic: 350 outpatient visits daily • 15-bed hospital; 6 TB isolation rooms/UV lights • All services provided for nominal, all-inclusive fee • Medical staff: 5 doctors, 2 nurses, 1 nurse midwife, 9 nurse auxiliaries, 2 laboratory technicians, 1 pharmacist, administration team • Services provided: general medicine, infectious disease, pediatrics, obstetrics and gynecology

10. Lascahobas, February 2004 (cont.) • Well-stocked pharmacy, including ARVs • High quality laboratory testing, including CD4 capacity • Back-up generator for 24-hour electricity • Extensive community network, with 96 accompagnateurs working in the surrounding villages. TB case detection rate nearly 100% • Satellite for internet communication and EMR • More than 300 TB patients and 187 DOT-HAART patients

11. Biggest challenges for scale-up? • Creation of coalitions to expand and “harmonize” prevention and care services • Communications between far-flung partners • Training and monitoring rational use • Avoiding of drug stockouts • Assessing generic drug quality • Use of fixed-dose combinations • Drug-resistant HIV; second-line regimens

12. Overcoming the challenges • If an HIV treatment project is integrated into a well-functioning TB-control program, many of the necessary medical delivery systems will already be in place • Good supervision of therapy (e.g., DOT) will likely slow the incidence of inevitable mutations • Accompagnateurs can provide the missing “infrastructure” and provide social support to patients, families, and communities and also contribute to reduced stigma

13. Conclusion • GHESKIO and Zanmi Lasante have effective models for expanding delivery of ART in resource-poor settings and adapted respectively to urban and rural areas. • Duplication of the VCT-integrated health structure model throughout the country will help extend HIV prevention and control programs nationwide. • Multisectorial collaboration among public, private, non-governmental and international organizations is necessary for sustainability and efficacy in treating and preventing HIV-AIDS nationwide • Operational research will strengthen the scaling-up ART • Both centers are playing a major role to scale-up HIV prevention and care and are the pillars of the Global Fund program and President Bush initiative

14. Thank you. www.pih.org