Presentation on theme: "Médecins Sans Frontières in collaboration with Treatment Action Campaign Provincial Government of the Western Cape City of Cape Town University of Cape."— Presentation transcript:
Médecins Sans Frontières in collaboration with Treatment Action Campaign Provincial Government of the Western Cape City of Cape Town University of Cape Town, Infectious Disease Epidemiology Unit
Population = 500.000 Adult HIV prevalence: 32% in 2007 Highest TB case finding in the world: 1600/100.000 in 2006 Mostly informal housing; unemployment rate ± 60%; highly mobile population; pop. density > 6000/km 2 ; electricity 76% of households; high rates of crime and sexual violence.
1998: Creation of TAC 1999: start of PMTCT programme 2000: HIV care pilot project (3 clinics) 2001: First patient started on ART 2004: National HIV plan leads to increased enrolment on ART 2009: 12,000 people started on ART at 9 sites
Existing ARV clincis Extension 2006/07 ER1 :To develop a new model of care and to decentralise existing HIV/AIDS dedicated services -including ART- to five peripheral clinics
Existing public health facilities 3 community health centers (day hospitals) 2 maternities (MTCT ante and peri-natal) 8 local clinics (STI, FP, TB, <5 health, post-natal MTCT) No hospital (under construction) 3 hospices – 1 only for DR TB Home based care NGOs
CHC based ARV clincis New HIV clinics
2000: demonstrate feasibility of ART at primary health care level in resource-limited, peri-urban setting 2004: scaling up ART, TB/HIV integration, and integration into Provincial ART programme 2008: feasibility of achieving NSP targets, including universal coverage by 2011
80 % of needs ART coverage -> 800.000 to 1 million on Rx 80 % initiated and followed by nurses 50 % of children treated at PHC Reduction of HIV transmission by 50%
Year20032004200520062007 Tested16,02420,57626,68132,38332,069 Positive4,9286,4748,8049,6918,749 %HIV +ve 31% 33%29.9%27.3% 1998: 450 people tested for HIV in Khayelitsha
Well functioning PMTCT programme since 1999 Vertical transmission = 3.5% in 2007 100% acceptance rate, formula feeding, AZT+NVP Integration of ART provision within MOU since 2004
New patients20062007200820092010 20072008200920102011 Enrolled2,1222,322 Target (new stage IV)*32173485370838473929 % needs covered66%67% Remaining in care (%)12 M24 M36 M 48 M 200183.481.278.073.8 200284.979.578.375.4 200386.481.777.373.5 200488.682.677.0 74.2 200587.882.6 77.6 200688.3 81.5 2007 86.6 Remaining in care (RIC) = (total initiated) – (deaths + loss to follow-up)
Source: Louise Knight 2008, internal report
Expand providers: nurse based follow-up Simplify follow-up routines: Fast track systems (clubs, chronic dispensing) Limit number of follow-ups Improve functioning of administrative section Blood results, data entry
Khayelitsha Monthly Total in Care May 2009 Total AdultsTotal ChildrenTOTAL % of total Kuyasa 68696782 6,5 M. Goniwe 1000451045 8,7 Michael M 30051663171 26,5 Nolungile 25272382765 23,1 Ubuntu 37022783980 33,2 Site C Youth 87 0,7 Site B Youth52 0,4 Town II89 0,7 Khayelitsha 1114882311971
May 2009 New Adults New Children TFITotal (New) Target% of total Kuyasa33433725 10,8 M.Goniwe38143935 11,3 Michael M85118675 25,0 Nolungile74638075 23,3 Ubuntu752677100 22,4 Site C Youth22222210 0,6 Site B Youth80815 2,3 Town II1500 ? 4,4 Khayelitsha total 3301419344335
Facility based clubs Green clinic: patient stable, > 12 months on ARVs, undetectable Community based clubs Functions : monthly support group meeting, clinical screening, drug distribution, data record. Management : community adherence counsellors Accountability : to the mother clinic Supply : drugs patient labelled, nutritional support
Diagnosed DR-TB cases All cases referred to Referral OPD Severe clinical condition and XDR-TB admitted for intensive phase (or until culture conversion) 4-6 months Others referred for clinic based treatment (intensive and continuation phase) Continuation phase treatment, clinic based
Patients Started Tx = 52 Patients started Tx in Hospital = 9 Patients started Tx in Clinic = 43 Patients not Started Tx = 8 Initiation of Treatment Quarter 1 2009 (prepared May 27 th, 2009)
Increase in HIV has been followed by increase in TB 70% of TB patients are HIV-infected in Khay. Increase in smear-TB and EPTB Increase in M/XDR-TB Need for TB/HIV integration
TB/HIV juxtaposition: 1 folder, different admin & clinicians Managerial integration: 1 folder & same admin, different clinicians and clinical pathway (Ubuntu). True TB/HIV integration: ARV delivery integrated within TB programme: one-stop service with same staff (admin & clinical) and patient flow (Town 2).
1. ART in a poor public sector setting is feasible. 2. Increased enrolment on ART has resulted in decreased mortality. 3. Saturation of large sites led to increased losses to follow-up. There is a need for decentralisation of ART to the most peripheral clinics. 4. Success of nurse-based, doctor-supported strategy. Regulatory framework on the way. 5. TB/HIV integrated services led to quicker diagnosis and treatment of both diseases in co-infected patients. 6. Decentralized management of DR TB has led to increased diagnosis and number started on treatment. 7. Collaboration between MSF, CoCT, and PGWC was an essential condition for success.
Enrolment of children on ART Adherence in youth and pregnant women Enhanced adherence strategies Further decentralization Regulatory framework for decentralised nurse-based care DR- TB: new diagnostic and treatment options