Lessons Learned from the Use of ARVs in Haiti

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• Lessons Learned from the Use of ARVs in Haiti
• Daniel Fitzgerald
• GHESKIO/Cornell University

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• Ministry of Health
• Henri Claude Voltaire
• Joelle Deas
• Partners in Health
• Paul Farmer
• Joia Mukherjee
• Fernet Leandre
• Serena Koenig
• Wesler Lambert

• GHESKIO
• Jean Pape
• Patrice Severe
• Paul Legere
• Ernest Barbot
• Renal GrandPierre

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Haiti

• Western third of Caribbean island of Hispanolia
• Population 8 million
• Per capita income 440/year (2002 World Bank)
• Human Development Index 150th out of 175
  countries listed (2003 UNDP)

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The HIV Epidemic in Haiti

• First documented AIDS case in Haiti1979
• Male female ratio 11
• Prevalence in adults 6 (2001 UNAIDS)
• Estimated survival from HIV infection to death
  pre-ARV
• adults 7.5 years
• newborns lt 1 year

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Distribution and Number of HIV Infections in
Haiti 2002 Total Number 287,908
Source Haiti Policy Project, 2002
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National HIV Seroprevalence in Haiti (1993-2003)
Pregnant women at 1st antenatal visit
MSPP/IHE/CDC/GHESKIO
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Rural Haiti ARV Experience Partners in Health

• 700 patients on therapy
• Patients followed in clinic by physician monthly
• Therapy monitored by clinical signs and symptoms
  and CD4 counts
• Adherence assured by daily directly observed
  therapy by community health workers

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Partners in Health Outcomes

• lt 5 lost to follow up
• 10 toxicity requiring change in medication
• 5 1 year mortality (mortality associated with
  very advanced disease at ART start)
• 86 of 65 patient subset had suppressed viral
  load with at least 3 month follow up

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Urban Haiti Experience GHESKIO

• 972 patients on ARV
• 75 of patients had clinical AIDS at ARV start
• Median CD4 was 114 cells/ml at ARV start
• Patient followed by physician every 3 months and
  by nurse monthly
• Therapy monitored by clinical signs and symptoms
  and CD4 count
• Adherence assured by peer counseling by people
  with AIDS, pharmacist counseling/pill counts,
  field worker visits prn

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GHESKIO ARV Follow up Schedule
IEC1General information about ARV,
patient/GHESKIO responsibility, guardian/contact
identification , contact update IEC2Signature
of at home visit authorization form, evaluation
of HIV reinfection risk level, risk reduction
planning FP method proposal - ARV counceling
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GHESKIO Outcomes

• 4 lost to follow up
• 6 deceased at one year (mortality associated
  with advanced disease)
• 10 drug toxicity requiring change in medication
  (anemia and rash the most common)

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Antiretroviral Therapy and Survival
Kaplan Meier Estimate of survival in 96 HIV
infected adults treated with antiretroviral
therapy (ART) by Gheskio compared to survival of
99 historical controls diagnosed with AIDS before
ART was available.
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National ARV Scale-up in Haiti

• Strong support of Haitian Government
• Established national guidelines
• PIH and GHESKIO are CDC/USAID Caribbean HIV/AIDS
  Regional Training (CHART) sites
• Strengthening primary care infrastructure at
  partner organizations is a key part of national
  scale up efforts

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Haiti National Guidelines for ARV Care

• Guidelines for HIV care were developed during
  November 2002 and April 2003 workshops in Haiti
  sponsored by MOH, PIH, and GHESKIO
• WHO recommendations are the starting point
• Local recommendations to improve adherence based
  upon experience in urban and rural areas
• Will be reevaluated frequently

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CHART Training Program at GHESKIO and PIH

• Training is both didactic and practical.
• Training by teams for teams Field workers,
  nurses, physicians, social workers, and
  pharmacists will train their peers.
• Follow up training/supervision will be done by
  mobile training teams.
• Establishing common national ARV treatment
  outcomes for performance based evaluation
• Trainees can see both the urban and rural models
  at GHESKIO and PIH and adapt these to their home
  institution.

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Strengthening Primary Care Infrastructure

• Partners in Health has established 5 satellite
  sites at neighboring public clinics strengthening
  TB, STI, and prenatal care, and providing HIV
  care.
• GHESKIO has established a national network of 20
  sites capable of providing an integrated package
  of primary care and HIV services (VCT, TB and STI
  management, womens health, MTCT, HIV care).

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Summary of activities for2003
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Lessons learned

• Government and non-government partnership (e.g
  Haitis Global Fund Country Coordinating
  Mechanism)
• Importance of combining research, service and
  training (e.g. documenting ARV outcomes)
• Benefit of local solutions for problems related
  to adherence (e.g DOT at PIH, PWA counseling at
  GHESKIO)
• Strengthening primary care infrastructure early
  on in scale up efforts (e.g Haiti now has 25
  sites ready to use ARV)

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Challenges

• Drug supply (e.g. order made in September and we
  have still not received all the drugs)
• Coordination by sponsoring agencies (e.g we have
  had employees at several VCT sites go unpaid for
  months due to delays in release of donor funds)
• Merging clinic based and community based care
• Adaptable training and re-training programs as
  treatment guidelines develop
• Developing a national drug resistance
  surveillance system