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HEALTH CARE MANAGEMENT OF HIV/AIDS PATIENTS IN MARTINIQUE

HEALTH CARE MANAGEMENT OF HIV/AIDS PATIENTS IN MARTINIQUE. André CABIÉ, Sylvie ABEL, Samuel M’PAY, Véronique BEAUJOLAIS, Bernard LIAUTAUD, Guy SOBESKY Service de Maladies Infectieuses et Tropicales CHU de Fort-de-France. FORT de FRANCE. HIV INFECTION IN MARTINIQUE.

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HEALTH CARE MANAGEMENT OF HIV/AIDS PATIENTS IN MARTINIQUE

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  1. HEALTH CARE MANAGEMENT OF HIV/AIDS PATIENTS IN MARTINIQUE André CABIÉ, Sylvie ABEL, Samuel M’PAY, Véronique BEAUJOLAIS, Bernard LIAUTAUD, Guy SOBESKY Service de Maladies Infectieuses et Tropicales CHU de Fort-de-France

  2. FORT de FRANCE HIV INFECTION IN MARTINIQUE First case of AIDS in 1983 As of september 30 2002 558 AIDS cases 1462.9 / 106 inhab Estimated prevalence of HIV infection = 0.5 à 1% Prevalence in pregnant women = 0.3% French Department in America 381 427 inhabitants MartiniqueMetrop. Pop density 338 108 GDP/hab (K€) 11 992 20 388 Mean income (€) 9 087 13 200 Min welfare allow. 8.0% 1.6% (RMI) Unemployment 23.8% 8.9%

  3. The « Centres d’Information et de Soins de l’Immunodéficience Humaine (CISIH) » • Medical and administrative structure • Spread all over France and all its departments • Rationalization of care provided to PLWH/AIDS • Reference Center of excellence • Also deliver Information, teaching, screening, prevention Ministry of Health CISIHs Design national strategy against AIDS Provide appropriate tools Write with experts National Guidelines (rapport “Delfraissy”) Multicentric drug trials (ANRS) Epidemiological and economical data Set up of on site care Apply National guidelines Clinical Research

  4. PRESCRIPTION AND DELIVERY OF ANTIRETROVIRAL DRUGS (ARV) • 100% free of charge • EU « AMM » and « ATU » = Drug Marketing Authorization and Temorary Drug use Autorisation • Availability: Hospital or private drugstores • Every year first prescription must be delivered by specialist from the CHU • ARV comittee • Specialist MD • Pharmacist ARV comittee • Access to all available antiretroviral drugs

  5. FOLLOW-UP SITES FOR PLWH/AIDS CHU de Fort de France n= 508 Dispensaire Vernes n = 70 Le Lamentin CHG du Lamentin n = 50 FORT de FRANCE Prison UCSA n= 20

  6. Outpatient clinic « Action SIDA Martinique » Association Day Hospital Regular Counselling + treatment adherence Antenna of Hospital drugstore The Patient Social Worker Psychologist City-Hospital network MANAGEMENT OF CARE IN MARTINIQUE Medical Hotline 24h/24 Home Help Personnel Regular in-patient hospitalisation

  7. HEALTH CARE MANAGEMENT OF HIV/AIDS IN MARTINIQUE TOOLS • Virology Lab • Serology, rapide tests • Viral load • Genotyping • Immunology Lab • CD4 - CD8 • Therapeutic drug (ARV) monitoring (G. Peytavin, GH Bichat Claude-Bernard) • Technical equipment of the CHU • TDM, MRI, Standard X-rays • Endoscopy • Microbiology, Hematology, Pathology Labs...

  8. HEALTH CARE MANAGEMENT IN MARTINIQUE • Weekly multidisciplinairy Staff • Doctors • Virologists • Pharmacists • Social worker • Psychologist • Treatment Counsellor • Introducing treatment • Review of failures and side effects • Modifying treatment regimen • Drug trirals enrolment (ANRS)

  9. INTRODUCING ART

  10. HIV COHORT FOLLOWED AT CHU OFFORT-DE-FRANCE IN 2002 508 patients HIV infected followed at CHU of Fort-de-France • 321 men and 187 women, from all socio-economical categories • Mean age 43.5 years, higher than in Metropolitan France Ages’ Pyramid (excluding children)

  11. HIV TRANSMISSION Martinique 2002

  12. Evolution of HIV cohort Followed at CHU Fort-de-France • From 1988 to 2002 • 1418 HIV/AIDS patients • 980 men • 472 women In 2002 508 HIV/AIDS patients HCV co-infection : 39 (7.6%)

  13. ANTIRETROVIRAL USE IN MARTINIQUE4th trimester 2002

  14. EVOLUTION IN TREATMENT STRATEGIES 1998 - 2002

  15. EFFICACY OF ARV IN 2002 • Number of patients treated • 350/508 = 69% • Viral Load < 400 cop/ml and < 50 cop/ml

  16. IMMUNE STATUS IN AIDS PATIENTS1997 - 2002

  17. CUMULATIVE PROGRESSION TO DEATH AFTER AIDS DIAGNOSISMartinique, 1988-2002 • Before 1997 (n = 377) • 24 months Survival = 0.43 • Since 1997 (n = 188) • 24 months Survival = 0.71 • LOGRANK • p < 0.0001 Probability of survival, % Since 1997 Before 1997 Months from start to therapy

  18. VIROLOGICAL AND IMMUNOLOGICAL RESPONSE TO ANTIRETROVIRAL THERAPYTHERAPY-NAIVE PATIENTS 1997 - 2003 Viral Load, log copies/mL CD4 cell count, x 106/L

  19. AIDS INCIDENCE AND PREVALENCE EVOLUTIONCHU de Fort-de-France

  20. MORTALITY EVOLUTION In 2002

  21. HIV TESTING AND PREVENTION • Free anonymous counseling and volontary testing • Pregnant women • HIV testing • Prevention of Mother-to-Child transmission • Management of exposures to HIV, HBV and HCV • Postexposure prophylaxis • Occupational • Non-occupational

  22. OBSTACLES TO HEALTH CARE MANAGEMENT • NON ADHERENCE OF PATIENTS • Material Precariousness • Fear of sex partner, familialy, professionnal, and social exclusion • Psychological and/or psychiatric Precariousness • Addictive Behaviors • Vulnerability • elderly, • illiteracy, • Family/friends abuse • NON COMPLIANCE OF PATIENTS • Selection of resistant strains • ARV class resistance • Transmission of Resistant viruses (primary resistance) • SIDE EFFECTS OF ARV

  23. Some thoughts about Antiretroviral therapy in Martinique... Compliance is not • Lesser in • Caribbeans • Lesser educate persons • Older persons • Predictible a priori • A fixed and definitive variable Compliance is • Better if • Well explained to patients • Take into account side effects of drugs • Social assistance • Simplified acces to drugs

  24. Some thoughts about Antiretroviral therapy in Martinique... • Complexe issue and constantly evolving • Numerous drugs available • Treatment strategies rapidly moving • When to start ? • Permanency of drug resistance threat • Numerous side effects • Severe • Negative impact on quality of life • Pharmacology

  25. Control Pharmacology intervention N=214 Stop or change of treatment = 34 cases LFUp/Dc = 10 cases INTEREST OF PROTEASE INHIBITORS PLASMA LEVELS • 204 patients / 258 events / 445 drug monitor. N=258

  26. Some thoughts about Antiretroviral therapy in Martinique... • Gold standard today = obsolete strategy few months later • « Errors » from past history • Mono-, bi- then triple therapy • Simply adding protease inhibitors in 1996 • NNRTI use in pre-treated patients • Patient not sufficiently taken in account • Unsufficient preparation of patient • Prescription of drugs too early without analyzing cofactors influencing compliance • Unsufficient analyzis of failures

  27. CONCLUSION-1 Antiretroviral prescription is possible and effective in our region, but... …we learn from our experience that this prescription is a necessary and efficient step but not sufficient in the process of health care management to reach a long term efficiency

  28. CONCLUSION-2 HIV infection = chronic disease • Multidisciplinary management • Patient centered management • Associate a social engagement to treatment and care

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