Scaling up of ARV at GHESKIO and Zanmi Lasante

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Scaling up of ARV at GHESKIOand Zanmi Lasante

• A Multicultural Caribbean United Against HIV/AIDS
• Dominican Republic
• 5 7 March 2004
• P. Severe, F. Leandre, JW Pape, Paul Farmer

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Background

• Haiti is the poorest country in the Western
  Hemisphere
• Per capita income US 300
• Country most affected by HIV/AIDS outside
  sub-Saharan Africa
• HIV prevalence 4.5 (2000)
• PLWA 300,000

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Background (contnd)

• Drastic increase of TB because of the HIV
  epidemic
• Haiti ranks among the highest countries in the
  world for TB per capita

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Objective

• Demonstrate that the scaling up of ART is
  feasible in both rural and urban settings in
  spite of the constraints inherent in the
  complexity of ART and the poverty in a country
  such as Haiti

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Haitian Study Group on Kaposis Sarcoma and
Opportunistic Infections (GHESKIO)

• Oldest Institution dedicated to AIDS (1982)
• Mission Services,Training, Research in
  HIV/AIDS Sexually Transmitted Infections (STI)
  Tuberculosis Diarrheal Diseases
• Partners
• International partners
• US Cornell, Vanderbilt, Hastings Center
• France Institut Pasteur, Biomerieux, Institut
  Alfred Fournier
• Local partners
• Ministry of Health
• Haitian Medical Association and
• gt 116 public and private institutions
• Community through active community advisory board

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The GHESKIO VCT model with integrated services
Post-HIV exposure Counseling and HAART
STI Management
Pre-test Counseling HIV, Syphilis, Tuberculosis
Post-Test Counseling
Reproductive Health Services (family planning and
prenatal care) HIV women Prevention HIV MTCT
with HAART
Same day TB screening / Rx / Px

• Care to HIV infected individual / affected
  family
• OI Rx/Px
• HAART for AIDS or CD4 count ? 200
• Nutritional support
• Psychosocial support

Rx Treatment Px Prophylaxis
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Major VCT Interventions

• Pre/post test Counseling for HIV, STI, TB
• Screening for HIV, STI, TB
• Prevention and treatment of OI, bacterial
  pneumonia, STI, TB
• ARV
• HAART for AIDS
• Short Course
• MTCT FP and ARV
• Raped victims and persons exposed to HIV blood
  short course ART

Peck R, Fitzgerald D, Liautaud B et al
JAIDS33470-475, 2003
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New individuals tested for HIV at GHESKIO (VCT
Center)
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• National Expansion of VCT Integrated Services

2003 VCT Centers (20) (GFATM)
Legend
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• National Expansion of VCT Integrated Services

2004 Total VCT Centers (45)
Legend
GHESKIOs Peripheral Centers (10)
CANGEs Peripheral Centers (8)
Other Peripheral Centers (17)
Nippes
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• National Expansion of VCT Integrated Services

2009 Total VCT Centers (100)
Legend
GHESKIOs Peripheral Centers (10)
CANGEs Peripheral Centers (8)
Other Peripheral Centers (72)
Nippes
Press a key to continue
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GHESKIO Trainees 2003 (Counseling,HIV,STI, TB, FP)
92-95 96-99 2000 2001 2002 2003 Total
Lab technicians 137 220 30 72 131 128 718
Social workers 385 301 12 3 26 84 811
Nurses 409 501 93 356 322 300 1981
Physicians 629 906 47 108 138 116 1944
Others 140 173 - 47 202 219 781
Religious/community leaders 26 571 - - 23 620
Total 1726 2672 182 586 842 847 6855
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Guidelines Development

• ARV international workshop Nov. 2002
• Moving from model to implementation April 2003
• National guidelines (MSPP and partners, 2003)
• ART guidelines educational brochures, guidelines
  for home care
• Development of standard operating procedures for
  recruitment, enrollment, follow-up, pharmacy,
  laboratory and specific counseling focus on
  compliance

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ART Provision at GHESKIO

• Implementation of a pilot ART short course
  intervention (PEP), 2000
• First 96 patients on ARV 1999-2001
• Long-term ART provision 100 patients/month (Feb
  2002)

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Research Questions (1)

• When to start treatment?
• Does TLC lt1200 correlate with CD4 lt200 in the
  Caribbean?
• Are there other valid clinical or laboratory
  markers (e.g., ESR, anemia) that can be used to
  correlate with CD4 lt200?
• What treatment regimen to start?
• Will the use of NVP in first-line regimens impact
  its use in prevention of MTCT (and vice versa)?
• Are generic drugs of adequate quality?
• When to start therapy with active Tbc.
• How to monitor therapy?

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Research Questions (2)

• How to assess treatment failure?
• Will clinical endpoints correlate with CD4
  decreases?
• Can we define other specific markers of disease
  progression?
• What treatment to change to?
• What about drug resistance?
• Whats the prevalence of baseline resistance in
  the community?
• How does treatment failure correlate with
  resistance?