1. Improving the Use of Medications to Treat Complex Health Problems in Resource-Poor Settings: Community-Based Examples from Haiti and Peru
Jennifer Furin, Paul Farmer, and Edward Nardell
Partners In Health
Division of Social Medicine and Health Inequalities, Brigham and Women’s Hospital, Boston, MA, USA

2. Objective and Methods
Objective: To document factors associated with treatment program success for HIV and MDR-TB in resource-poor settings of Haiti and Peru
Methods: Qualitative study from August 1996 to August 2003 in which a variety of ethnographic methods (including participant observation, key informant interviewing, and focus groups) were used to obtain data from programs and patients in rural Haiti and urban Lima, Peru

3. HIV Treatment Program in Haiti
HIV Equity Initiative launched in 1999
Provides HIV care, including highly active antiretroviral therapy (HAART), to over 500 individuals
Relies on the use of community health workers known as accompagnateurs
90% of patients have had a beneficial clinical response defined as weight gain, absence of opportunistic infections, or a rise in CD4 count
None of the patients receiving HAART has died
Program is expanding to 5 different sites in rural Haiti

4. Comparison of Outcomes
Group A (HAART)
Groups B and C n
100
200 [ ]
Mortality at end of study period
43 [ ]
Tuberculosis incidence 2
21/100*
Number of opportunistic infections from start of interventions
0.24
3.3
Average weight change
10.3 kg increase
6.0 kg decrease
Number of days in hospital from start of intervention to end of study period or death
23.4
ADL score for people surviving one year after the intervention
Initial: 2
Final: 3.8
Initial: 2.7
Final: 2.3
*Data available only for Group B

5. “I was a walking skeleton before I began therapy
“I was a walking skeleton before I began therapy. I was afraid to go out of my house and no one would buy things from my shop. But now I am fine again… My wife has returned to me and now my children are not ashamed to be seen with me. I can work again”.

6. MDR-TB Treatment Program in Peru
Began in 1996
Has treated more than 1400 patients with MDR-TB
Relies on the use of community health workers known as promoters
Over 80% of the patients are cured or likely to be cured of the disease
Has expanded to sites throughout the country

7. Cure rates for first cohort of MDRTB patients
Cured, or in treatment and culture negative
85%
In 1998, the first cohort of patients completed treatment. Cure rates exceeded 85%, better than the results seen at US hospitals and treatment centers.
In July of that year, PIH invited international health experts and pharmaceutical manufacturers to Boston and presented our results. The long term outcome of this and subsequent meetings was a change in the WHO’s treatment recommendations and a dramatic reduction in the cost of MDRTB drugs.
Cure rates for first cohort of MDRTB patients

8. Overarching Program Principles
Community health workers provide daily supervision of treatment
Close monitoring of patient progress and management of adverse effects
Context-specific management protocols are in practice
Measures in place to address socioeconomic conditions associated with poor health outcomes, including nutritional support, housing assistance, and job placement

9. Policy Agenda
Complex health problems such as HIV and MDR-TB can be successfully treated, even in the most resource-poor settings
Programs more likely to be successful if they have strong base in the community and if they address socioeconomic forces that place patients at risk for poor health outcomes

10. Future Directions Additional roles of community health workers
Adapting protocols in different geographic and cultural settings
Training of health workers
Other program pillars of success