Durban Msf Satellite - 2011 - Gilles - Final

7/31/2019 Durban Msf Satellite - 2011 - Gilles - Final

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ART in Khayelitsha

2001-2011

Achievements, lessons learned,way forward

Dr Gilles Van CutsemMedical Coordinator

Mdecins Sans Frontires

10 years of ART in the public sector in Africa: Key successes and window into the future.Durban HIV Conference 2011


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Model of care1. District-based planning and coordination between MSF, TAC,

PGWC, City

2. Early implementation of PMTCT

3. Large scale HCT & treatment literacy

4. Community condom distribution

5. Decentralization of ART to all primary care clinics

6. Nurse-led care including ART initiation

7. TB/HIV integration as a one-stop service

8. Male clinic & Youth clinics

9. Three tier system for monitoring and evaluation10. Good secondary referral & support system

11. Ongoing district-based training and mentoring

12. Decentralised management of DR TB


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1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Prevalence 0.153 0.192 0.255 0.247 0.254 0.271 0.288 0.312 0.302 0.314 0.305 0.263

Tested 5325 4879 6816 7593 7172 8177 8601 8957 9258 10111 10303 9459

0%

5%

10%

15%

20%

25%

30%

35%

HIVPrevalenceinpregn

antwomenatfirstbooking Khayelitsha antenatal HIV prevalence 1999-2010


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PMTCT

12.5%

2.5%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

2002 2003 2004 2005 2006 2007 2008 2009 2010

Estimated mother to child HIV transmission rates


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0

20

40

60

80

100

120

140

160

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Children started on ART

CHCs City Clinics


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0

5

10

15

20

25

30

35

0

10000

20000

30000

40000

50000

60000

2005 2006 2007 2008 2009 2010

%infected

Numbertest

ed

Nmb tested % HIV infected

HCT

PITC Facility and out-of-facility HCT Awareness Campaigns


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Mass Community Condom distribution


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Male Clinic


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Medecins Sans Frontieres

CHC ARV clinics

ART in 2008

ART in 2009

ART in 2010

ART decentralization to all PHC clinics


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Nurse-based care


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Enrolment on ART

0

50100

150

200

250300

350

400

450

500

May-01

Feb-0

2

Nov-02

Ma

-03

Feb-0

4

Nov-04

May-05

Feb-0

6

Nov-06

May-07

Feb-0

8

Nov-08

May-09

Feb-1

0

Nov-10

m

onthlyARTEnrollments

CHC

City Clinic

Total

Monthly targetmid 2010


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Earlier initiation

4347

7485

103

112

131148

152

162

0

20

40

60

80

100

120

140

160

180

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

MedianbaselineCD4

Median baseline CD4 adults3 Khayelitsha CHC's

0

10

20

30

40

50

60

2002 2003 2004 2005 2006 2007 2008 2009 2010

PERCENTAGE

WHO stage at the moment of ART initiation

WHO1+2WHO 3

WHO 4


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TB/HIV integration


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0

500

1,000

1,500

2,000

2,500

3,000

2003 2004 2005 2006 2007 2008 2009 2010*

TB Case-finding 2003-2010

Smear+ Smear- Smear not done EPTB


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Decentralised DR TB care

14

58

118

157

211

231

200

0

50

100

150

200

250

2003/04 2005 2006 2007 2008 2009 2010

Numberofcases

72 71 71

50

40

33

0

10

20

30

40

50

60

70

80

2005 2006 2007 2008 2009 2010

MedianDays

15 19

58

74 71

6 15

85 81

42

19 14

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2006 2007 2008 2009 2010Percentageo

fpatientsstartingDR-TBtreatment

Clinic Khayeli tsha step-down facil ity Hospital

Case detection

Time to treatment

Location of treatment


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Challenges & Future


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(Pre-)ART LTF

0%

10%

20%

30%

40%

50%60%

70%

80%

Q1-10 Q2-10 Q3-10 Q4-10

LTFU of treatment eligible pre-ART patients in 2 Youth Clinics

Site C Youth

Site B Youth


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Community drug dispensingCommunity ARV groups in

Mozambique

Decroo T et al, JAIDS 2010

U b d l h Adh


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Urban model: the AdherenceClubs in Khayelitsha

Groups of 30 stablepatients

Meet every 2 months

Clinic & out-of-clinic

Run by 1 or 2 lay healthworkers

Clinical check + educationsession + drugs

Clinician visit every 6months

Khayelitsha 10 Year Report, 2011.

755 patients in 22 clubs

Median 1029 days on ART atentry

RIC at 1y. 99.2%, 2 y. 97.5%

RIP 0.6%, LTF 1%, TFO 2.5% Transfer from club to clinic6.2%

Roll out in pilot sites in WC


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Stabilisation of loss to care

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

2003 2004 2005 2006 2007 2008 2009

RIP and LTFU after 12 months of ART

combined RIP and LTFU RIP

Adherence

Clubs


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Adherence and drug options

17

9

4

0

2

4

6

810

12

14

16

18

currently detectable VL re-suppressor 3rd line ART

Patients on second line ART with detectable VLs

30% re-suppressed after enhanced adherence support Cost of 3rd line: 1000-3000 R per month


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Future Start ART at CD4 500 and/or viral load threshold to further reduce

infectiousness at community level (TASP)

Out-of-facility community base testing (in schools , taxi ranks... )

PREP targeting young females (? & older males)

Development of new long acting ARV formulations (like TMC 278)

combined with other bio-medical preventive interventions

New drug formulations and technologies including:

Fixed dose combinations (FDC)

Point of care (POC) viral load to monitor adherence and identify early treatment

failures

POC CD4 devices to reduce lost to follow-up pre-ART, mostly among adolescents

More robust and forgiving regimens, including drugs like darunavir,


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Durban Msf Satellite - 2011 - Gilles - Final

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