Scaling up ART: Joint Clinical Research Centre (JCRC) Experiences

1. Scaling up ART: Joint Clinical Research Centre (JCRC) Experiences Cissy Kityo Mutuluuza MBChB, MSc Deputy Director, Joint Clinical Research Centre Uganda January 4th, 2008

2. JCRC is Africa's Pioneer • use of ART in Africa • HIV vaccine trials

3. JCRC ART SITES- December 2003 SUDAN DEMOCRATIC REPUBLIC CONGO Soroti Mbale Buhinga Jinja Kampala KENYA Mbarara Kalangala Nyakibale Kabale TANZANIA KEY RWANDA JCRC ACTIVE JCRC Centre of Excellence

4. Timetable forthe Regional Expansion of Antiretroviral Therapy (TREAT) TREAT Program started in Dec 2003, Funded by USAID under PEPFARObjectives: Increasing access to ART Capacity building Infrastructure development Training Human Resource Logistics management Adherence to ART Communication M&E

5. The strategy for JCRC ART Rapid scale up model MOH Leadership • Partnerships. • Public and Private sector, NGO’s, Religious organizations • Commitment to quality and accountability • Plan and address constraints as you progress: • Infrastructure / Human resources / Logistics

6. Increasing Access to ART • From 6 ART sites in 2003 to • 50 ART sites and 25 outreaches in 2007 • Number of persons accessing ART increased • from 10,764 in 2004 to 54,501 by Sept 2007. • Where 6,819 are children and 47,682 adults • Serving 39 districts in Uganda.

7. Cumulative patients on ART from JCRC supported centers, 2004-2007

8. Coverage of TREAT HIV care/ART services as of 31st October 2007

9. Treatment as a preventive tool : • Promotion of VCT • Cost Recovery Program • Free ARVs

10. Voluntary Counseling and Testing: Entry Point for HIV Care

11. Trends of VCT utilization by AIC region/branch over the years

12. Disclosure • Stigma & social discrimination • Family disruption • HIV infected children • New relationships/companioship • Need to have children

13. AppropriateOperational Research Joint Clinical Research Centre, Kampala, Uganda & Academic Alliance, Mulago Hospital, Uganda MRC/Uganda Virus Research Institute Programme on AIDS,Entebbe/Kampala, Uganda & TASO, Uganda MRC CTU Imperial College University of Zimbabwe, Harare, Zimbabwe GSK Gilead Boehringer-Ingelheim Rockefeller Foundation MRC, UK DfID, UK Rock House Foundation

14. Centre Entebbe Kampala Harare ALL Women in DART 685 893 578 2156 < 45 at enrolment 589 775 502 1866 Ever pregnant 85 65 48 198 Two pregnancies 12 4 3 19 Three pregnancies 1 0 1 2 Total pregnancies 99 69 53 221 Median follow up is 2.8 yrs

15. All pregnancies: incidence by age group and time since enrolment

16. Positive Prevention • Link treatment to prevention • ABC strategy • Negative effects of ART on HIV risk behavior • Cross sectional study of 723 respondents at JCRC compared sexual behavior in prior 6 months between ART experienced and ART naïve patients • No significant differences (one or more casual sexual partners in addition to a main partner) • The ARV-experienced respondents were more likely to report consistent condom use with their spouses than were ARV-naïve respondents (OR 2.82 95% CI 1.74–4.6). • Similar to experiences from South Africa where a Medicines san Frontiers project provided free ARVs

17. Adherence • Studies done so far show high levels of adherence • Social barriers to Adherence • Poverty • Transport • Food availability • Carers of children/orphans • Stigma • Religion • Traditional practioners

18. Adolescents in HIV/AIDS care • Orphans • School drop out • Early pregnancies • Prostitution • Disclosure and stigmatization • Concerns • Relationships • Marriage/Family

19. JCRC Adolescent clients performing group

20. ART complimentary services

21. The killer side of AIDS is often ignored Opportunistic Infections (OIs) • More expensive than ART • More cumbersome to treat • Fatal without ART.

22. Nutritional Support • School fees • Specialised counseling for children • JCRC has strengthened linkages with organizations that can provide the services

23. Universal Access • The most serious equity issue is lack of universal access to ART! • Unequal distribution of health services and lack of access to ART • Most of the ART clinics have been established in main hospitals within the towns in the regions. • Limited access in rural areas served by the lower health centers or units.

24. 10 N J E Z A 8 T I R I B O G O M A L I M A 14 M U S A A L E - M A G A L A M U D U M A 11 L U G Y O M B A Z Z I 7 B U L E R E J J E 9 5 K O L O L O 6 L U V U M B U L A 15 K I R I N G E N T E S E K I W U N G A K I S I T U F O R E S T R E S E R V E B U M O O Z I K A K O O L A 12 K A V U L E W A R D D K A F U M U K I K O N D O L W A G W A W A R D B M A Z I B A L W A N G A 1 4 MUTUBAGUMU M U Y I R A 13 K Y A N J A K A N Y I K E G A N G U F O R E S T R E S E R V E M P I G I T C K O N K O M A K Y A L I 2 K A M M E N G O 3 B U T O O L O K A M E N G O L U W A L A S M U A Mawokota North Constituency Health Sub District in Mpigi District Key for Health Centres 1- Kampilingisa HC 2- Ggoli HC 3- Butooro HC 4- Kibanga HC 5- Katende HC 6- Sekiwunga HC 7- Epi Centre 8- Muduuma HC 9- Bujuuko HC 10-Jeza HC 11-Kibumbilo HC 12-Kafumu HC 13-Kyaali HC 14-Nswanjele HC 15-Konge HC

25. Best practices for ART roll out • Community Mobilization • Make your presence felt in the area - Open with a bang! • Use the launching occasion for IEC and to “break” Stigma.

26. President Museveni opening Rushere ART Clinic

27. First Lady during Itojo Launch

28. Minister of State for health opening Mpigi Health Centre