Department of Public Service and Administration (DPSA) Wellness Indaba – Durban 2007

Dr Stanley Moloabi & Dr Leon Regensburg & Mr. Rodney Cowlin

Disease Management Strategy as

Part of Health Promotion

in the Workplace –

a Southern African Perspective

Agenda

Brief overview of Global HIV Infection Estimates

Introduction to aid for aids (AfA)

Benefits of early enrolment on the AfA programme

The positive impact early enrolment on HIV disease

management programme has on HIV/AIDS related health

costs

Impact of lack of disease management on productivity in

the workplace

Work done by AfA beyond South African borders

Estimated adults & children living with HIV, end 2006

Total: 43.6 (36.7 – 45.3) million

Western & Central Europe

744 000744 000[590 000 –915 000][590 000 –915 000]

North Africa & Middle East578 000578 000

[271 000 – 1.4million][271 000 – 1.4million]

Sub-Saharan Africa28.6 million28.6 million[26 – 31.2 million][26 – 31.2 million]

Eastern Europe & Central Asia1.9 million 1.9 million

[990 000 – 2.3 million][990 000 – 2.3 million]

South & South-East Asia8.2 million8.2 million[5 – 13.3 million][5 – 13.3 million]

Oceania81 00081 000

[45 000 – 120 000][45 000 – 120 000]

North America1.2 million1.2 million

[650 000 – 1.8million][650 000 – 1.8million]

Caribbean327 000327 000

[220 000 – 551 000][220 000 – 551 000]

Latin America1.9 million1.9 million

[1.4 – 2.4 million][1.4 – 2.4 million]

East Asia970 000970 000

[496 000 – 1.7 million][496 000 – 1.7 million]

HIV infection estimates

Over 11 000 new HIV infections a day in 2006

More than 95% occur in low and middle income countries

About 1500 occur in children under 15 years of age

About 10 000 occur in adults aged 15 years and older

2006 Global HIV and AIDS estimates - Children (<15 years)

Children living with HIV: 2.3 million [1.7 – 3.5 million]

New HIV infections in 2006: 530 000 [410 000 – 660 000]

Deaths due to AIDS in 2006: 380 000 [290 000 – 500 000]

Aid for AIDS

More than 9 years experience in providing HIV

disease management solutions

More than 36 000 patients currently registered

ART approved for over 24 000 patients

Introduction to Aid for AIDS

Aid for AIDS

Implemented HIV workplace programmes for a number of

multinational companies in Southern Africa

Implementation of a donor funded treatment programme in

rural South Africa

Experience in providing treatment programmes in a number

of countries outside South Africa

Services offered

Epidemiological & Demographic surveys

Voluntary counselling and testing (VCT)

Financial Impact analysis

KAP (Knowledge, Attitudes and Practices) surveys

Education and awareness programmes.

Legal & Ethical Services Workplace Policies

Clinical Disease Management Programme

Provision of comprehensive HIV/AIDS Treatment programmes

Clients

Partnerships with International Donor Funders for public sector

treatment programmes

21 medical schemes contracted to AfA and administered by

Medscheme

Bonitas, Medshield, Fedhealth, Protector, Liberty…

12 medical schemes contracted to AfA and administered by

“other” administrators

GEMS, Nimas, Swazimed, Nampak, Randwater…

21 companies contracted to AfA for the provision of a workplace

treatment programme:

De Beers, Nestle, Daimler Chrysler, BP Africa, Barloworld, Sun

International …

Cost benefits of early enrolment

-6 -3 0 3 6 9

R 0

R 1,000

R 2,000

R 3,000

R 4,000

R 5,000

R 6,000

Per

pati

en

t p

er

mo

nth

co

st

Months relative to enrolment

CD4 > 350

CD4 < 50

Source: Aid for AIDS Database.

Benefits of early enrolment on the AfA programme

Benefits of early enrolment on the AfA Programme

Patients should be on treatment before they

develop opportunistic infections.

Patients who initiate ART at the optimal time have

better survival prospects.

Comparative 24 month survival by CD4 count for patients on HAART – all patients

0%

20%

40%

60%

80%

100%

200 - 349 50 - 199 0 - 49

CD4 count (cells/µL) at HAART commencement

24 m

on

th s

urv

ival

(%

)

British Columbia Drug Treatment Programme

Aid for AIDS programme

Centers for Disease Control USA

Chan K et al 2002 AIDS 16(12)

Hogg R et al 2001 JAMA 286(20)

CD4 count results relative to ART commencement – all patients

0

50

100

150

200

250

300

350

400

450

500

0 1 3 6 12 18 24 30 36 42 48 54 60 66 72 78

Months relative to ART commencement

CD

4 C

ou

nt

cel

ls/µ

L

CD4 count results relative to ART commencement – PEPFAR (President’s Emergency Plan for AIDS Relief Partners) Treatment programme

0

50

100

150

200

250

300

350

 CD4_00   CD4_06   CD4_12 

Ave

rag

e C

D4

cou

nt

Outcomes of MTCTP programme – all patients

N Hlatshwayo, M S Hislop, M Cotton, G Maartens, L D Regensberg. Mother to child HIV transmission prevention (MTCTP) in a managed care setting in South Africa - no role for short-term antiretroviral therapy (ART)? . 15th World AIDS Conference, Bangkok 2004.

25.0%

5.1%

1.2%

0%

5%

10%

15%

20%

25%

30%

NO ART MONO ART HAART

% m

oth

er t

o c

hil

d H

IV

tran

smis

sio

n

Source: Aid for AIDS Database.

Direct & indirect costs, individual & organisational

• Insurance premiums• Accidents due to ill and

inexperienced workers• Litigation over benefits,

dismissals, etc.

Direct Costs Indirect Costs

• Reduced on-the-job

productivity• Increased absenteeism• Supervisor’s time• Vacancy• Lower productivity during

replacement’s startup period

• Senior management time• Production disruptions• Loss of workforce morale• Loss of experience and

institutional memory• Reduced returns to training

investments• Deteriorating labor relations

Total Cost to Firm of HIV/AIDS in the Workforce

• Benefits payments• Medical care• Recruitment and

training of replacement worker

Individual

(From one employee with HIV/AIDS )

Organisational

(From many employees with HIV/AIDS)

Boston University - Center for International Health and Development 2003

Impact of lack of disease management

Timing of Cases and Costs

Progression of HIV/AIDSin the Workforce

Cost to Company

Morbidity begins (some early mortality, some long-term non-progressors).

Employee becomes infected.

Employee leaves workforce through death or disability retirement (some long-term survivors).

Company hires replacement employee.

No cost to company at this stage.

Morbidity-related costs are incurred(absenteeism, productivity loss, supervisor’s time, medical care)

End of service costs are incurred (death and disability benefits, management time, loss of morale, institutional memory, and experience)Turnover costs are incurred (vacancy, recruiting, training)

Timeline

Year 0

Year 2-8

Year 6-12

Year 6-12

Employee remains asymptomatic and fully productive.

No cost to company at this stage.Year 0-8

Boston University - Center for International Health and Development 2003

Impact of not having adequate Disease Management Programmes on the Workforce

Skills within the organisation are lost due to illness

Takes ~ 60% longer to replace skilled worker than unskilled worker

Takes ~ 6 times longer to replace a professional than a skilled worker

On-the-job training costs add to cost of replacing an employee

Botswana Public Officers Medical Aid Fund

PULA Medical Scheme

Botswana Government Public / Private Sector HIV

programme (joint venture with Associated Fund

Administrators)

Debswana ( De Beers and Botswana) Treatment

Programme

Aid for Aids Beyond South African Borders

AfA in AfRICA

TUNISIA

MOROCCO

IVORY COAST

NIGERIA

EGYPT

ZIMBABWE

KENYA

BOTSWANA

ZAMBIA

MALAWI

NAMIBIA

SOUTH AFRICA

SWAZILAND

TANZANIAANGOLA

ALGERIA

Conclusions

AfA facilitates effective access to

comprehensive HIV management and enables

extensive outcome data to be collected.

A key success component of HIV treatment is

the ability to provide on-going patient support

to ensure adherence to therapy.

Managed access to ART improves morbidity,

but timing is critical - people are still presenting

far too late.

Conclusions

Early managed access to ART improves clinical outcomes and

reduces the cost of treating HIV/AIDS.

Managed access to ART should improve productivity in the

workplace

Aid for AIDS has a proven track record and the expertise to

provide comprehensive HIV treatment programmes which are

flexible enough to be implemented in any setting.

Aid for AIDS is seeking to accelerate the work it does in

conjunction with employer organisations – we have significant

capacity and experience which could be shared.

Acknowledgements

• N Hlatshwayo, M S Hislop, M Cotton, G Maartens, L D Regensberg. Mother to child HIV transmission prevention (MTCTP) in a managed care setting in South Africa - no role for short-term antiretroviral therapy (ART)? . 15th World AIDS Conference, Bangkok 2004.

• Chan K et al 2002 AIDS 16(12)• Hogg R et al 2001 JAMA 286(20)

• Boston University - Center for International Health and Development 2003

• UNAIDS - Global summary of the HIV and AIDS epidemic, December 2006

• World Health Organisation - Global summary of the HIV and AIDS epidemic, December 2006

“ Future generations will judge us by the adequacy of our response. ”

Nelson Mandela