1. HIV in Suriname Ministry of Health Suriname M.Sigrid Mac Donald – Ottevanger, MD Focal point HIV Treatment and Care, NAP

2. HIV in Suriname Inhabitants 531.000¹, Multi-ethnic population Estimated HIV prevalence 1.1² Universal access to HAART/medicines for OI CD 4 and VL testing free of charge Prevalence for HIV & pregnant women: 1% 42 repeat pregnancies in 2012! baby-formula Access to HAART 66% of advanced HIV² Only 62% still on HAART after one year²

3. Number of people on Treatment

4. >50% decrease in incidence of HIV (UNAIDS)

5. Healthcare System & Suriname Health care expenditure of US$ 324.26 per capita per year Primary health care is provided by –RGD (Regional Health Services), –MZ (Medical Mission) 300 clinics –Private sector. The RGD provides health care in the coastal area & capital Medical Mission provides health care in the interior (over 50 clinics!) Secondary health care is provided in 5 hospitals, of which 4 are in the capital Paramaribo ARVs available at all Hospital pharmacies (RGD/MZ)**

6. HIV & Suriname Policies The Government of Suriname adopted the UNGASS Declaration of Commitment in June 2001, National Commitment to the response against HIV and AIDS. In 2002 Surinamese Government initiated a process for the systematic and strategic control of HIV. In 2007, the second National Strategic Plan for HIV (NSP) 2009-2013 was developed. A multi sectoral approach of HIV/AIDS prevention, treatment and care ARV purchasing fully funded by government!

7. HIV & Suriname Ministry of Health Focal point system –Focal point HIV treatment & care –Focal point PMTCT (case manager) –Focal point Prevention Technical unit Monitoring & Evaluation manager Center of Excellence NGO’s One Stop Shop for chronic disease management

9. Center of Excellence Primary Health Care Secundary Health Care Providers Protocol development support, Advisory function Treatment and care of PLWHA in WHO stages I & II Social support & Reducing stigma NGOs, Religious groups

10. Fundaments of HIV Treatment in Suriname Public Health approach Multiple VCT sites Primary care physicians treat HIV Complicated HIV is referred to secondary care Patient support Family Peer counselors and buddy’s NGO’s / Religious groups Social workers National treatment guidelines since 2000 Current guidelines are third revision (2010)

11. “TO HALT THE SPREAD OF HIV AND TO INCREASE THE QUANTITY AND QUALITY OF LIFE OF PEOPLE LIVING WITH HIV”. Main objective:

12. Treatment guidelines (I) Newly diagnosed HIV not seriously ill preferably work-up by primary care physician Patient history Medical history Psychological status Social status : work, family, relationships, children Intoxications: alcohol/ drugs Emphasis on Acceptance of HIV Building patient support Physical exam Clinical condition/ symptoms of opportunistic infections Laboratory tests CD4 counts, CBC, liver and kidney function tests, screen for TB, cervical cancer

13. Treatment guidelines (II) CD4 count above 200 CD4 count > 350 no HAART (exception PMTCT, HIV dementia, hepatitis B, HIVAN ) CD4 count 200-350: HAART depending on patient motivation, adherence and age CD4 count ≤ 200 or WHO stage III/ IV prepare to start HAART

14. Treatment guidelines (III) Inform patient (and buddy) Need for treatment Importance of adherence Foreseeable visits to clinic, laboratory exams Potential adverse effects First-line regimen Duovir-N ( AZT/ 3TC/ NVP) Second – line regimen: PI Register patient with HIV program Referral to second line care when needed

15. Concerns Denial and stigma Patients enter late into care Estimated > 50 % in secondary care High percentage LTFU In pharmacy data after start HAART Patients get LTFU after diagnosis (VCT’s) Patients get LTFU after PMTCT

16. Concerns & Challenges Challenge has now evolved from acute to chronic care (One stop shop) PMTCT – repeat pregnancies – importance of Eliminiation Initiative prongs 1-4 HIV-infected infants and children now survive to adolescence and adulthood –Obstacle: scaling up paediatric care An increasing number of HIV-infected children highlights the primary importance of PMTCT HIV/TB Comorbidity Hard to reach populations –(Interior, covert SW)