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HIV/AIDS treatment - challenges in a remote rural area of Tanzania.

Johan N. Bruun

Department of Infectious Diseases Ullevål University Hospital

Oslo, NORWAY

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Haydom Lutheran Hospital

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HIV/AIDS programmeHaydom Lutheran Hospital

• Voluntary counselling and testing (VCT)– Local hospital initiative

– NORAD supported project from 2002 planned in collaboration with Centre for International Health, Bergen

• HIV treatmentProject planned and supported by:

– Ullevål University Hospital, Oslo

– Sørlandet Hospital, Kristiansand

– NORAD support for drugs

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Necessary conditions for starting HAART

• HIV-testing and counselling (VCT)– Established through NORAD project early 2003

• Diagnostic procedures– Evaluation of immunodeficiency – CD4 cell counts– Diagnosis of opportunistic infections / WHO stage III-IV

or CDC stage B (ARC) – C (AIDS)– Laboratory tests necessary for treatment follow up –

detection of serious side effects

• Drug supply– Antiretroviral drugs– Drugs for treatment of opportunistic infections

• Free treatment• Clinical skills for evaluation of patients

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Problems with antiviral therapy

• A combination of drugs have to be taken every day – To be continued even if patient feels well

• Development of resistance – Insufficient drug combinations

– Lack of adherence

• Side effects

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Adherence problems• Insufficient understanding of the

disease, the effect of treatment and the risk of resistance

• Stigma – lack of openness towards family and surrounding society – lack of acceptance

• Side effects

• Difficulties with drug supply

• Follow up

• Problems with care and nutrition

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Problems with follow up

• Long distance from hospital

• Cost of travel

• No one to care for family at home

• No one to provide food in hospital

• Stop of treatment and follow up when improved

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Indications for starting HAART

• Pregnancy in order to prevent HIV transmission to the child

• Development of laboratory signs of immunodeficiency– CD4-cell count < 200x109/L

• Symptomatic disease - Clinical signs of immunodeficiency– AIDS – CDC clinical stage C disease or WHO stage

4 disease

– ARC (AIDS Related Complex) - CDC clinical stage B disease or WHO stage 3 disease

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DOT – Directly Observed Therapy in HAART treatment

Modified DOT regimen

• Initial phase – 14 days– Outpatients attend the HIV outpatient clinic once daily. The first

daily dose to be taken at clinic – the second dose delivered to the patient to be taken in the evening

– Blood sample at day 14

• Initial phase - week 3 and 4– Patients are given drugs for one week at the time – return of the

bottle for pill count and new drugs once a week

– Blood sample at day 28

• Continuation phase– Patients are given drug for 4-5 weeks – return with the bottles

for pill count and new drugs every 4 weeks

– Blood sample at week 12 and then every 3 months

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Preliminary results

01.01.2005 01.05.2005

• Evaluated patients 152 300

• Started on CART 128 139

• Deaths 35 50

• Lost to follow up 9

CART: Combination antiretroviral therapy

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Differences between the Haydom project and relief projects by MSF

Haydom:• All patients with

established treatment indications offered treatment

• Patients newly started on treatment for opportunistic infections included

• No selection based on long time follow up before treatment start

• Patients included even if no disclosure of HIV-status to others

MSF-Malawi (Thyolo):• Well developed home

based care system• Thorough screening of

patients for treatment• Exclusion of patients:

– Active opportunistic infections

– Not able to attend follow up regularly for several weeks prior to inclusion

– Not willing to disclose their HIV-status to family and contact persons in village

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Consequences of the differences between the programs at Haydom and

MSF-Malawi

Haydom:• All patients needing

treatment are offered treatment

• Difficulties with follow up due to – Lack of transport– Stigmatisation HIV-status not

shared with relatives

• High death rate due to– Nutritional problems– Opportunistic infections

• Resistance may develop due to poor adherence to treatment

• The program may be run by local health personnel

MSF-Malawi:• Good adherence to

treatment• Few lost to follow up• Low death rate among

those treated• Selection criteria favours

people with abundant economical and mental resources

• Higher cost per patient treated

• The program depends on extensive continued support

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Improvements

• Provision of transport to hospital

• Follow up seminars for patients every 4-8 weeks

• Mobile clinics – outreach program for follow up and drug delivery to patients at nearby village

• Nutritional support program for both in- and out-patients

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ConclusionMain challenges

• Education and motivation of patients

• Stigma and acceptance of the disease

• Necessary laboratory service

• Qualified health personnel

• Follow up – transport from remote villages

• Drug supply

• Government regulations

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HIV-treatment programs in developing countries

• Research projects– Completely staffed by skilled personnel

– Supply of modern equipment

– Run for a limited period

– Long term effect on local health service??

• Relief projects– Necessary skilled personnel brought in

– Some training of local staff

– Strictly necessary equipment

– Depend on continued support

• Development projects– Key personnel for limited periods

– Training of local staff aimed at take over

– Strictly necessary equipment