A Comprehensive Approach to HIV Treatment, Care and Support

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A Comprehensive Approach to HIV Treatment, Care
and Support
International Roundtable on Increasing Access to
HIV Treatment in Resource-Poor Settings Canberra,
September 20, 2002
Dr. Masami Fujita HIV/AIDS and STI Unit WHO
Western Pacific Regional Office
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• HIV treatment as part of comprehensive HIV/AIDS
  care
• Country situation on continuum of care
• Key elements of regional strategy for
  comprehensive HIV/AIDS care (draft)

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(No Transcript)
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Estimates of yearly AIDS DeathWPRO- 2000 and 2005
Number of AIDS cases
Malaysia
Vietnam
Cambodia
China
Camb
China
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Diverse needs of PHA

• Prolonged life
• Prevention and treatment of OI including TB
• Mental/spiritual distress, suicide
• Social stigma, discrimination human rights
  violation
• Becoming poorer Food, Shelter, Cloths, Debt,
  etc.
• Orphans
• Burden of care givers
• Prevention of further HIV transmission
• Living positively

Even if ARV becomes available, comprehensive
care needed
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Comprehensive HIV/AIDS Care

• Prevention, prophylaxis, screening treatment of
  OI including TB

• Symptomatic care and palliative care

• Psychological care including counseling

• Socio-economic support and reducing discrimination

• Health promotion including nutrition, family
  planning, and prevention of further HIV
  transmission

• Support for orphans and care givers

• Antiretroviral treatment ARV

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Conditions for Effective Coverage
Effective

• (3) Continuity/Adherence
• People who continue to use
  service
• (2) Access/Use
• People who can physically access
  and start to use service
• (1) Availability
• People for whom service is
  available

Continue/Adhere
Access/Use
Available
Target Pop.
Source Tanahashi 1978, Modified
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At present, Availability is the bottleneck for
ARV
Effective
Continue/Adhere
Access/Use
Available
Target Pop.

• Number of People

Source Tanahashi 1978, Modified
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Adherence vs Plasma Viral Load
patients with viral suppression lt400 copies/ml
70
90-95
lt95
70-80
80-90
Percent adherence to therapy
From Peterson et al, 6th Conf ROI 1999 abstr 92
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Correlation between optimal therapeutic response
and adherence to HIV therapy
As measured by the Medication Event Monitoring
System (MEMS)
Paterson et al. Ann Intern Med 2000
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In the near future, Adherence may become a
major bottlenecks, causing ARV Resistance

Effective
Continue/Adhere
Access/Use
Available
Target Pop.
Source Tanahashi 1978, Modified
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Factors affecting the conditions for effectiveness

• Availability
• Selection, Procurement, Distribution,
  Laboratory,
• Trained health workers for rational use
• Physical access and Use
• - Decentralizing services, Transportation,
  Outreach,
• - Demand, Socioeconomic barrier, Perception
  of services,
• Referral from VCT and community
• Continuity/Adherence
• Education, Counseling, Managing
  side-effect,
• Client satisfaction, Socio-economic
  barriers,
• Peer and family support, Follow-up,
  Workload of HCW

Even for making ARV effective, comprehensive
care needed
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• HIV treatment as part of comprehensive HIV/AIDS
  care
• Country situation on continuum of care
• Key elements of regional strategy for
  comprehensive HIV/AIDS care (draft)

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Continuum of care

• 1. Health facility based care (HFBC)
• Hospitals (Prefecture, County)
• Health centers / Health posts
• Other health service outlets

• 2. Home-based care (HBC)
• Homes of PHA

• 3. Community-based care (CBC)
• Geographical community
• Social network, Workplace, Clubs

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Country Situation in the Region Health Facility
Based Care (HFBC)

• Low coverage of VCT, OI management, ARV and care
  counseling, palliative care
• High user charge even for the poor in general
  health services
• Limited psychosocial support
• Limited link with HBC and CBC
• Governments play major roles, with increased
  funding
• Wide coverage for PHC, TB and other programs

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Situation of Countries in the Region Home Based
Care (HBC)

• Home visit services One of few HIV/AIDS care
  activities
• Diverse situation,
• - Home visit NOT existent in any health
  programs
• - Existent, HCW overwhelmed / Com.Org or PHA
  well mobilized
• - Existent, cost effective in urban areas /
  expensive in rural areas unless integrated
• - Well linked / poorly linked to HFBC and CBC
• Opportunity to develop PHA group

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Situation of Countries in the Region Community
Based Care (CBC)

• Significant stigma and discrimination
• Health volunteers are not functional well
• Decentralization of public administration
• Experiences of multisectoral cooperation for HIV
  prevention
• Extensive network of community-based
  organizations in some countries

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Country Situation in the RegionHIV/AIDS Care in
general

• Partial/fragmented

Multisectoral experienced, but weak
planning/management for HIV/AIDS care at
intermediate levels
Availability Limited (VCT, OI, ARV, Care
counseling Sympt./Palliative, Psychosocial,
Reducing stigma etc.)
Access/use Limited (IDU, SW, home-less, the poor
etc)
Continuity/adherence Ready??

• Receiving large funding (GFATM, Bilateral donors)

• Developing practical strategies and care models
  to be integrated into existing health system

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An approach to reinforce continuum of carein
resource poor settings

• Day Care Center (DCC) for PHA
• DCC is the place where PHA freely meet together
  and conduct wide range of activities, facilitated
  and supported by HCW.
• In Northern Thailand, many DCC established
  attached to provincial and district hospitals.
• DCC are established in some health centers, too.

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The DCC can be launched with a room and a staff,
without capital investment
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Supporting each other (peer support)
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Peer support
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Spiritual support
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Health education for self-care, home care and
prevention
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Producing and providing herb
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Socio-economic support
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Occupational promotion, Income generation
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Prophylaxis and early detection of OI

• The DCC serves as a mechanism to ensure adherence
  to IPT, with peer support and user friendly
  environment (short waiting time, intimate staff)
• The DCC also promotes early detection of OI
  including TB.

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Results of TB Preventive Therapy (IPT) in
hospital B

Remark Defaulter is defined as missing
appointment for more than 45 days.
CDC 10 MOPH Thailand
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Efficiency of IPT Service in District Hospital E
Results of TB Preventive Therapy (IPT) in
hospital C

Remark Defaulter is defined as missing
appointment for more than 2 months.
CDC 10 MOPH Thailand
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Results of TB Preventive Therapy (IPT) in
hospital A

Remark Defaulter is defined as missing
appointment for more than 1 month
CDC 10 MOPH Thailand
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IPT provided as part of DCC activities
Clinical Phase
Asymptomatic HIV
Symptomatic/AIDS

• TB Preventive Therapy
• Asymptomatic HIV only
• Repeated counseling provided for assessing
  readiness completing IPT
• Follow-up for 3 yrs, with CXR 1/yr

Diag Treat OIs
V C T
TB Treat / DOTS
Service Provided
PMCT
PCP Second. Prophy.
PCP Prim.Prophy. after IPT others
Day Care Center

Managing Unit
HP Section
AIDS Unit
Sanitation Section
CDC 10 MOPH Thailand
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IPT provided for mothers after PMCT, not linked
to DCC
Clinical Phase
Symp. HIV/ AIDS
Asymptomatic HIV
TB Preventive Therapy
Asymptomatic HIV only Target changed from DCC
members to HIV mothers from PMCT (1998)
No follow-up after IPT completion
Dx Rx OIs
V C T
TB Rx / DOTS (1998)
Service Provided
(targeting)
PCP Second. Prophylaxis
PMCT
Day Care Center

ltHP Sectiongt
AIDS Committee
Managing Unit
Sanitation Section
CDC 10 MOPH Thailand
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DCC does not exist in the hospital
Clinical Phase
Asymptomatic HIV
Symptomatic/AIDS

• TB Preventive Therapy
• Asymptomatic HIV only
• Follow-up not practiced

Diag Treat OIs
V C T
TB Treat / DOTS
Service Provided
PCP Second Prophy
PCP Prim Prophy
PMCT
Managing Unit
ltHP Sectiongt
Sanitation Section
CDC 10 MOPH Thailand
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• DCC has been reinforced and expanded after ARV
  was extensively introduced in Northern Thailand,
  as critical mechanism to ensure adherence.

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Base for home visit by PHA
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Base for work with community
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Mobilize community for HFBC
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Situation of Countries in the Region Peer
support / PHA group

• Many initiatives are going on or starting
• Peer support in top referral hospital providing
  ARV
• Peer support group of marginalized women
• Peer support building on HBC
• Establishment of PHA Network
• Friend-to-Friend Club
• Coffee shop for HIV/AIDS
• Peer support/education for home-less people
• Home of Red Ribbon, Warm Home

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Comprehensive peer support mechanism

• Increases
• Availability
• (Psychosocial, Sympt. care, PCP prophylaxis,
  ARV)
• Access/use
• (IDU, SW, TB case finding)
• Adherence/continuity
• (IPT, PCP prophylaxis, ARV)

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• HIV treatment as part of comprehensive HIV/AIDS
  care
• Country situation on continuum of care
• Key elements of regional strategy for
  comprehensive HIV/AIDS care (draft)

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Key elements of regional strategies for
comprehensive HIV/AIDS care (draft)

• Multi-sectoral political commitment
• Making essential care package available
  mobilizing PHA and community organizations
• Establishing Interface for PHA to access health
  services
• Ensuring adherence/continuity with peer support
• Promoting mutual learning and creativity for
  responding to diverse and changing situation
• Monitoring and evaluation for accountability

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Approaches for translating the strategies into
operation

• Province/district level as a hub, with HIV/AIDS
  care coordinator
• Comprehensive peer support mechanism
• Social marketing and IEC