SCALING UP ART IN KENYA: Programmatic issues Mary Wangai MD Deputy Director National AIDS and STD Programme

Introduction 2.2 m Kenyans estimated to be HIV+ and 200, 000 needing antiretroviral therapy (ART) Negative impact on all sectors of society Reversed previous health gains: life expectancy 62 to 46 years 50% to 70% of hospital bed occupancy at medical wards in many government hospitals are HIV related Increased death rate: Est. 500 deaths daily

National estimate summary Significant drop in national HIV prevalence in the last 3 years: 13 to 10% The country experienced high infection rates in the mid 90’s culminating in peak prevalence in 1998, 1999, Initially the prevalence among the young was higher than the older age group but now it is lower or equal in almost all the sites and in the national statistics.

HIV Prevalence in Pregnant Women in Sentinel Surveillance Sites in Kenya

HIV Prevalence by Age Group

Trends in mortality among children under five years old,

Working Programme Goal “Progressively deliver effective ART, reaching 20% by 2005 and 50 – 60% by 2008, so as to increase quality of life and survival by 10 years; reduce HIV-related hospital admissions by 60% and enhance significantly national prevention efforts”

GOK Policy HIV/AIDS Control is top priority for current government Funds committed in 2002/3 budget Lab capacity for monitoring patients Assuring drug quality Seed money to purchase ARVs for regional sites Parallel importation of brand and generic drugs Commitment to private-public sector partnership Ensure quality, standard care and access Recognition that ARVs are essential drugs Cost sharing/recovery in the public sector

Program gains Guidelines on ARV use, OI prophylaxis, home based care and VCT are available Standard regimen determined National 1 st and 2 nd line ART ARV training of health workers is ongoing Branded and generics ARVs are available Costs are falling, due to increasing access – generic 1 st line cost US$ 35 to $40 /month

National ART regimens Adults: 1 st line: Stavudine + Lamivudine + Nevirapine/Efavirenz 2 nd Line: Zidovudine + Didanosine + Nelfinavir/Kaletra(Lopinavir/Ritonavir) Children: Zidovudine + Lamivudine + Nevirapine

NASCOP Situational Assessment Assessment covered: National Central Management Unit and ART in Kenya generally ( Nov to Dec 2002) 13 sites using JSI modified instrument (May 2003): 7 Provincial Hospitals 4 High volume Districts 2 Teaching Hospitals

Current anti-retroviral therapy ART Activities Est. 7 to 9,000 patients are on ART in Kenya. ART available at ~ 20 private companies, numerous private physicians and hospitals 34 / 57 mission hospitals, increased from 600 to 2400 patients in 1 year 5 public health facilities in collaboration with partners; 1500 patients 2 NGO health facilities; 50 patients

Public Sector and partners Currently providing ART Homabay MSF-F Eldoret MOI Nairobi CDC Amref MSF -B Nakuru MOH Mombasa FHI GOK Partners

Faith based Hospitals Currently providing ART Kiambu-3 Thika Nyeri-2 Nyandarua Machakos Meru-2 Meru-N Meru-S Nairobi-4 Kisumu-2 Nyando Rachuonyo Trans Mara Bomet Kakamega Butere Bungoma

Issues for Scaling up Public and private sector partnership Private sector target those who can pay Public sector target this with limited ability Systems concerns Trained personnel Procurement & Logistics Data management Infrastructure Quality assurance and Quality Control M& E : HMIS and patient tracking system

Scale up ART Homabay MSF Eldoret MOI Nairobi CDC/ Amref MSH-F Nakuru MOH Mombasa FHI GOK Partners Mombasa General Kenyatta N.Hosp New Nyanza Hosp Thika Garissa Embu Nyeri Machakos Kakamega Mbagathi Busia Kitale Kisii Kilifi

GOK to support 5-6 Faith based Hosp CHAK Nazareth Maua Tenwek MEWA Tabaka Kendu-bay Catholic CHAK Muslim CHAK

Challenges Inadequate funds and system related weaknesses Physical infrastructure at health facilities Policy gaps e.g. equity, waiver system Human resources- numbers, training and cadre Quality control and assurance mechanisms Home Based Care Facilities-inadequate

Way Forward Policy Formulation Human resources assessment, planning and training. Strategic plan formulation Operational planning exercise – upscale to 13 sites by January To include communication strategy, LMIS, M&E Framework, Adherence Strategy