Mtt north africa
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AMANI MASSOUD, EIPROTHMAN MELLOUK, ITPC
Barriers to Access to HIV Treatment in Six Countries of North Africa
Missing the Target North Africa :
ITPC: Worldwide coalition of PLWHIV and their supporters and advocates. Uses a community based approach to achieve universal access to treatment, prevention and all health care services for PLWHIV and those at-risk.
The treatment monitoring and advocacy project (TMAP): produces « Missing the Target » reports series that identify barriers to delivery of AIDS services and holds national governments and global institutions accountable for improved efforts.
About ITPC
North Africa Context
MENA region has the lowest coverage rate of access to HIV treatment in the world : 11%
No data on North Africa as sub-region (North Africa different from Middle East)
Country data available but only quantitative (number of PLWHIV on ART)
Officially: HIV Treatment is available and free for all BUT problem of testing
Objectives of the research
Identify barriers to access to HIV treament from Civil Society and PLWHIV perspective
Develop capacities of community activists in: research, data collection & analysis and their use in advocacy
Set priorities for advocacy in the sub-region with the goal to reach Universal Access to HIV treatment
Methodology
Incountry research teams: all community activists including 2 PLWHIV Mauritania, Morocco, Algeria, Tunisia, Libya and
EgyptStandardized research template for data
collectionRevue and analysis of available litterature
articles, publications, national reports etc.Interviews with key stackeholders:
NAP, bi and multilateral cooperation, health professionals, social workers, AIDS activists
Interviews and focus-groups with PLWHIV
Research Template
Epidemiological situation in the countryOrganization of testingOrganization of care for PLWHIVNational treatment guidelinesTreatment coverageAvailability of ARVsLab testsPrevention and treament of opportunistic infectionsCo-infections Treatment litteracy and education Impact of stigma and discrimination Impact of intellectual property protectionRole of Civil society
Key Findings
Voluntary Counseling and Testing
Limited offer of voluntary testing facilities: Low in numbers and Geographical inquetities
Countrty VCT Centers NGO VCT Centers
Estimated Tests / Year
1 Test/Nbre Habitants
Mauritania 22 3 7.738 426
Morocco 44+8 mobiles 44+8 55.451 561
Algeria 54 1 12.589 2.859
Tunsisia 19 - 8.000 1.325
Libya 0 0 - -
Egypt 14+9mobiles 4 5-6.000 13.300
Voluntary Counseling & Testing
Centralized confirmation of positive results: 1 site in most countries, delays in confirmation, problem for
linkage to care« Anarchic testing » in private labs
no link with national system of reference no counseling no confirmation of positive results
Compulsory testing still widely existing: Inmates at admission, Algeria « Populations with a special risk of danger »?, foreigners,
prenuptial tests, some professions (Canal de Suez Org, General prosecuter), Egypt
Hospitalization, Libya Army, majority of countries
HIV testing not targetted toward MARPs Ex: in Tunisia PUD represent 2,6% of VCT clients, while PUD
represent 25% of HIV+ cases.Weak involvement of civil society (with exceptions)No voluntary testing in Libya
Organization of care
Limited offer of care facilities for PLWHIV Several centers not equipped or non-functionnal (Morocco, Algeria) Geographical distribution:
In pocket travel fees Delays , treatment interruptions linked to travel (Algeria, Egypt+++)
Good example: 2 guest houses for PLWHIV in Morocco: Agadir, Casablanca
Weak involvement of civil society: No links between NGOs and treatment centers (Except Morocco++, Algeria and Tunisa+)
Country Number of care centers for PLWHIV
Mauritanie 4
Maroc 10
Algérie 8
Tunisie 4
Libye 2
Egypte 5
Access to ARV Treatment
Country Number of PLWHIV on ARV Coverage rate
Mauritanie 1.621 25%
Maroc 3.356 28%
Algérie 1.526 13%
Tunisie 402 10%
Lybie 2.600 ?
Egypte 538 10%
• Countries have updated treatment guidelines (WHO 2010) except Libya • ARV treatment available and free in all 6 countries• No official waiting list BUT because of CD4 interruptions PLWHIV can wait several months before accessing treatment (Mauritania++)
ARV Treatment
1st line treatment and at least one 2nd line option available in all countries
Problem of patients in treatment failure: Egypt++
In 2010-2011: ARV stock-outs reported in ALL countries (Algeria++) Stock outs during revolutions (2months in Tunis, NOW
in Libya++)High number of people lost from care system
(40% in some centers in Algeria) and Libya
ARV Availability
Morocco offers the highest choice of ARVs, followed by Tunisia and Maritania.
Very limited choice of ARVs in EgyptSpecific case Egypt: regular change of
regimens based on availability causing drug resitance
Treatment not optimized: choice of ARV motivated by financial constraints and not benefits to PLWHIV
Problem of availability of pediatric formulations: Morocco++
Biological Tests
Only Morocco and Tunisia offer satisfying biological follow up (CD4, VL, resistance test)
Algeria, Lybia, Egypt: follow up based on CD4 only, viral load non available
Lab tests available in 1 site only: travel fees, delays to obtain results
CD4 counters often « out-of-service »PLWHIV need to go to private labs:
Expensive!
Prevention and treatment of OI
In general: lack of medicinesTreatment free for inpatients, otherwise at
charge of PLWHIV (treatment & prevention): Egypt, Libya, Tunisia +++
NGO support for OI medicines in Morocco (ALCS) and aids with « disability status » in Tunisia
Co-infections: TB treatment available, None of the countries offer treatment for Hepatitis
Treatment Education and Litteracy
Only Morocco and Tunisia have treatment education program (problem of human ressources in Tunisia)
Sporadic activities in Algeria and MauritaniaSome informations by health workers and
pharmacists in Libya and EgyptOnly Tunisia has an updated manual on
treatment for PLWHIV (but in french)Non outdated manuals in Mauritania and
MoroccoStrong opposition to allow CSO and PLWHIV
(non medical) to run treatment education activities (Egypt, Tunisia)
Impact of stigma and discrimination
Negative on testingRefusal of care by health workers Breach of confidentialityHigh level of stigma for excluded populations:
sex workers, MSM, PUD, migrants…Higher in Egypte and Libya
Impact of Intellectual Property Rights
Most countries use generic versions of ARVs (1st line non patented drugs)
Lack of 2nd and 3rd line linked to their high price (patented in producing countries: India)
Same for some OI drugs (antifungicals) and HepC treatment
Morocco: supply of Tenofovir delayed several months because of patent status (even if not patented)
Recent disturbing developments: 5 of 6 countries (except Mauritania) excluded from the
Gilead/Medicines Patent Pool (MPP) licence (june 2011) Also the recent Johnson&Johnson voluntary licence (dec
2011)
Summary
Access to HIV status (Testing) remains a major obstacleBUT several gaps in the existing treatment programs
Geographical distance Lack of treatment optimization Availability of 2nd and 3rd line regimens Failing biological monitoring: maintenance problems, stock-outs of
reagents Stock outs of ARVs: failing procurement & supply channels,
complicated procurement procedures, monitoring Lack of medicines for OI Inaccessibility of information on treatment Stigma and discrimination Intellectual property rights
Aknowledgements
Research team:Nadia Rafif, Souheila Bensaid, Fatimata Ball,
Abdullah Turki, Skander Soufi, Ragia El Guerzawy
The FORD Foundation