OPPORTUNITIES FOR EXPANDING HIV-RELATED HEALTHCARE

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OPPORTUNITIES FOR EXPANDING HIV-RELATED HEALTHCARE

• Douglas Wilson
• Infectious Diseases Research Unit
• University of Cape Town

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We are confronting the greatest single healthcare
challenge in modern history
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• National government has a central and essential
  role to play in co-ordinating HIV care.
• The public, private and NGO sectors need to work
  together.
• Information on HIV care centres needs to be
  readily available.
• The epidemic can be used as an opportunity to
  create a sustainable and multifunctional
  health-care system.

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Specific needs

• Simple, comprehensive healthcare messages.
• A national website for HIV resources.
• Available and integrated HIV services.
• Effective tuberculosis control.
• HIV medications obtainable through the private
  sector at State tender prices.
• Opportunities for accessing antiretroviral drugs
  through well managed programmes.

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LINDIWES STORY

• Studied in Gcuwa in the E. Cape - passed Standard
  10 in 1998.
• Brief relationship with an older man from
  Gauteng.
• Moved to Cape Town in 2000, to look for work,
  staying with her Grandmother in Khayelitsha.
• Met her boyfriend in early 2001, working at the
  oil refinery.
• Developed a painful skin rash late 2001.

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Lindiwes story continued.

• Taken by boyfriend to a private doctor.
• Diagnosed with shingles.
• Cost of generic aciclovir R400.00
• Queued at local community health clinic
• Confirmed diagnosis but aciclovir not on code -
  referred to Jooste Hospital

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Lindiwes story continued...

• Seen late that night by casualty doctor who took
  blood tests .
• The next morning told to take the discharge
  letter to the hospital pharmacy for aciclovir
  (cost to the state R52.90).
• Read through letter before handing it in ..

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Diagnosis HIV positive
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loveLife
SHAME - SHE DIDNT REALISE HER SUGAR- DADDY ALSO
GAVE HER HIV
I DONT JUST WANT SEX SHOW ME THE MONEY!
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Lindiwes story continued ..

• Lindiwe did not disclose her diagnosis to anyone.
• She separated from her boyfriend.
• She became withdrawn and depressed.
• She stopped looking for work.
• I was just waiting to die.

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OPPORTUNITY

• Lindiwe could have been referred for voluntary
  counselling and testing (VCT).
• Lindiwe could have paid for her treatment from
  the private pharmacy if the state price were made
  available to the private sector on a marginal
  profit basis.

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Voluntary counselling and testing

• Allows South Africans to choose if, where and
  when they will be tested for HIV infection.
• Allows for adequate pre-test counselling, and
  time for consideration and family discussion
  before the test.
• Allows for psychological preparation.
• A constructive response to a positive result is
  much more likely.

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Voluntary testing and counselling continued.

• VCT is time and labour intensive.
• Adequate infrastructure is essential
• Counsellor debriefing is vital in order to
  prevent burnout.

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Why didnt the doctors provide Lindiwe with VCT?

• Too busy.
• Too difficult.
• I'm feeling so helpless and guilty
• Where are the VCT facilities?
• There is nothing out there!

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OPPORTUNITY

• A national HIV service resource directory needs
  to available on the Web - and to be regularly
  updated!
• Healthcare workers need to be empowered to care
  for their patients properly.
• Healthcare workers need to be taught about the
  importance of VCT.

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Why was the treatment so expensive at the private
pharmacy?

• South Africa has two parallel systems for drug
  distribution
• The State obtains drugs at massively discounted
  prices due to bulk purchase.
• The private sector cannot (legally!) access these
  drugs.

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OPPORTUNITY

• The private sector has the potential to play a
  huge role in delivering HIV care if the
  medications were available at the State tender
  price.
• Profiteering could be prevented by widely
  publishing the tender price
• (Possibly a role for TAC in policing private
  prices.)

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OPPORTUNITY

• HIV infection needs to be destigmatised.
• Positive role models need to be promoted
  nationally.
• HIV positive people need to be taught how to look
  after themselves.

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OPPORTUNITY

• A support group would have helped Lindiwe to come
  to terms with her diagnosis, provided accurate
  information on HIV, and helped her to resume
  living her life.
• Support groups need funding, infrastructure and
  supervision which can be provided by National
  Government and NGOs

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Lindiwes story continued ..

• Lindiwe began to loose a great deal of weight, to
  cough and sweat at night.
• Itchy bumps came out all over her skin.
• People began to whisper that she was HIV
  positive.
• Her depression and social withdrawal deepened

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Lindiwes story continued ..

• Her Granny became increasingly worried and took
  her to the TB clinic.
• She was given containers to cough into.
• Three days later she was told she did not have TB
• She became increasingly weak, had diarrhoea all
  the time, and spent most of the day in bed.

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Lindiwes story continued ..

• Her Granny became desperate and arranged for a
  car to take her to Jooste Hospital.
• Lindiwe was afraid, but too weak to refuse.
• She was admitted, had a chest X-ray and an
  ultrasound scan
• Disseminated tuberculosis was diagnosed.
• AIDS-defining, CD4 count 82 cells/µl

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TUBERCULOSIS
.. where youth grows pale, and spectre thin,
and dies ..
(Keats)
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OPPORTUNITY

• Are the standard national protocols for the
  diagnosis of HIV-related TB accurate?
• TB is the one of the commonest causes of death in
  HIV infected people in Africa.
• TB can be prevented and cured.

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OPPORTUNITY

• People need to be taught about TB symptoms, and
  to know that if they are HIV positive special
  tests may need to be done to diagnose the TB.
• National TB programmes need to be refined by so
  that HIV-associated TB is diagnosed rapidly and
  accurately.
• Research is needed .

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OPPORTUNITY

• TB can be prevented the best way is by rapidly
  diagnosing and curing all people with contagious
  disease (DOTS programme).
• Prophylaxis with isoniazid reduces the risk of
  tuberculosis by 60-70 for with positive
  tuberculin skin tests.
• Highly active antiretroviral therapy prevents
  TB..

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Effect of HAART on TB risk at Somerset Hospital
NON-HAART
HAART
TB incidence per 100 person years
Overall
WHO 1/2
CD4 gt350
CD4 200 - 350
CD4 lt200
WHO 3/4
Badri, Wilson, Wood Lancet 2002 359 2059-64
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Lindiwes story continued ..

• Lindiwe received DOTS from the community
  Nompilo.
• After 2 months of TB treatment she had gained 8
  kg, and she felt much stronger.
• What about my future ?.. What is this about
  antiretrovirals? ..

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Lindiwes options
EITHER

• 1-2 years of reasonable quality life followed by
  terminal illness, and home-based care.
• Antiretroviral therapy

OR
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OPPORTUNITY

• Home based care would offer Lindiwe some
  assistance with managing her increasing
  disability and symptoms.
• Service is delivered by paid community care
  givers.
• She would still need numerous clinic visits and
  several hospital admissions.

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THABILES STORY

• 32 year old postman, married, 2 children, wife
  working for Telkom.
• Decided to test for HIV in 2000 after loosing
  gt10kg of weight, with ongoing diarrhoea ..
• Diagnosed with tuberculosis and Cryptosporidium
  at Somerset Hospital.
• CD4 count 54 cells/µl.

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Thabiles story continued ..

• Disclosed status to his wife - supportive
  response.
• Disclosed to his employer - too unwell to ride
  his bicycle so put onto shift work ..
• Could not cope so accepted boarding.

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Thabiles story continued ..

• Together with his wife decided that he must start
  antiretrovirals.
• Sold the car to pay for the first few months
  treatment.
• Endured three months of nausea and diarrhoea due
  to side effects from the combination of TB
  treatment and HAART.

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Thabiles story continued..

• Employer motivated for the medical aid to meet
  some of the cost of HAART.
• His wife encouraged him to continue to take his
  treatment regularly every day.
• Thabiles condition began to slowly improve ...

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Thabiles story continued..

• 18 months later he has regained all his weight,
  feels completely well and wants to go back to
  work.
• Thabile will still need regular check-up visits
  to the HIV clinic.

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Thabiles options ..

• Remaining on HAART for the foreseeable future,
  and remaining well.
• Possibly developing long-term drug side-effects.
• Possibly developing HIV resistance.

OR
OR
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OPPORTUNITY

• National Government has the power and South
  Africa has the capacity to support large
  antiretroviral pilot programmes using locally
  manufactured generic drugs.
• Side effect and resistance screening should be an
  integral part of these programmes.
• Experience gained from DOTS programmes and the
  MSF initiative could be tapped ..

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VOLUNTARY COUNSELLING AND TESTING
CO-ORDINATION BY NATIONAL GOVERNMENT
POSITIVE MEDIA DESTIGMATIZATION SUPPORT GROUPS
HOME BASED CARE
TB DIAGNOSIS / DOTS
HAART / ADHERENCE SUPPORT / PMTCT
COLLABORATION BETWEEN PUBLIC AND PRIVATE
HEALTH CARE SYSTEMS
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Other health conditions benefiting from similar
infrastructure

• Hypertension
• Diabetes
• Asthma
• Epilepsy
• Alcoholism
• Smoking
• Domestic violence

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WITH LEADERSHIP AND CAPACITY BUILDING THE WAR
AGAINST HIV CAN BE WON. THE FUTURE IS POSITIVE.
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Acknowledgements

• Prof Gary Maartens
• Dr Karen Cohen
• Prof Robin Wood
• Dr Linda Gail Bekker
• Dr Ashraf Grimwood
• HIV Clinicians Society

• Sr Mary Sihlangu
• Mrs Cordelia Faleni