Paul Farmer, MD, PhD

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Global Health Equity

• Paul Farmer, MD, PhD
• Partners In Health
• Harvard Medical School
• Brigham and Womens Hospital
• University of Colorado 17 October 2005

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• Of all the forms of inequality,injustice in
  healthis the most shockingand the most
  inhumane.
• Dr. Martin Luther King, Jr.

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Lamptey 2002
Life expectancy in some countries in sub-Saharan
Africa with a high prevalence of HIV
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Meanwhile, in the United States
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Recent sound bitesfrom the published literature

• Two 2002 papers from The Lancet
• Data on the cost-effectiveness of HIV prevention
  in sub-Saharan Africa and on highly active
  antiretroviral therapy indicate that prevention
  is at least 28 times more cost effective than
  HAART.
• The most cost-effective interventions are for
  prevention of HIV/AIDS and treatment of
  tuberculosis, whereas HAART for adults, and home
  based care organised from health facilities, are
  the least cost effective.

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Introduction of HIV management and care at the
Clinique Bon Sauveur, Cange, Haiti

• 1986 First case of HIV in Central Plateau
• 1988 Free serologic testing to diagnose HIV
• 1990 Prevention efforts hampered by political
  violence and resulting migration, gender
  inequality, and poverty
• 1995 AZT to pregnant women in order to block
  mother-to-child transmission
• gt90 of women accepted HIV testing after AZT was
  made available free of charge
• 1997 Post-exposure prophylaxis with a three-drug
  regimen to all victims of rape or professional
  injury
• 1998 ART offered to a small number of patients
  with longstanding HIV disease who no longer
  responded to treatment of opportunistic infections

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The HIV Equity Initiative

• Provides directly observed therapy and social
  support free of charge to the sickest
  HIV-infected patients living in the Zanmi Lasante
  catchment area
• Programmatic approach based on successful TB
  control efforts
• Funding from the Global Fund, PEPFAR, private
  donors

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March 2003
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September 2003, six months later
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DOT-HAART supervised therapyfor advanced HIV
disease

• Programmatic approach based on successful TB
  control efforts
• gt8,000 HIV-positive people followed
• gt1,860 patients now being treated free of charge
  with directly observed HAART (DOT-HAART)
• Each DOT-HAART patient has an accompagnateur who
  observes ingestion of therapy at least once a day
• All patients have responded with weight gain,
  improvement of health
• Fewer than 5 of the patients have required
  changes in regimen due to serious adverse effects
• Reduction in hospitalizations and mortality
• Decreased AIDS-related stigma the Lazarus
  effect
• Improved staff morale
• Increased interest in HIV testing and counseling

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Annual per-patient ART cost, 2002
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Annual per-patient ART cost, 2005
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Saint-Marc
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Scale-up in Lascahobas, Haiti

• Population 55,000
• Agricultural market center
• Large and long-established town with a central
  square, a market, a public high school, a police
  station, a courthouse, several churches
• Extensive trade across the Dominican border

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Instituting the Four Pillarsin Lascahobas

• Introducing essential drugs to the formulary
• Establishing a laboratory
• Training and stipending community heath workers
• Complementing Ministry of Health personnel with
  PIH/ZL-trained staff
• Aggressive TB and STI case-finding and treatment

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Lascahobas after scale-up

• Fully functioning clinic, gt250 outpatient visits
  daily
• 15-bed hospital 6 TB isolation rooms with UV
  lights
• Staff doctors, nurses, nurse-midwife, nurse
  auxiliaries, laboratory technicians, pharmacist,
  administrative team
• Back-up generator for 24-hour electricity
• Well-stocked pharmacy, including ART
• High quality laboratory testing,including CD4
  capacity
• Extensive community network,with gt100
  accompagnateursworking in the surrounding
  villages
• TB case detection rate nearly 100
• Satellite for Internet connectivityand
  electronic medical records

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Patient visitsLascahobas, July 2002 - November
2003
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TB case detection Lascahobas, July 2002 -
November 2003
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HIV case detection Lascahobas, July 2002 -
December 2003
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Prenatal care visits Lascahobas, October 2002 -
December 2003
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VCT uptake Lascahobas, October 2002 - September
2003
Cange
Lascahobas
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Vaccine administration Lascahobas, January 2003
- December 2003
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HIV/AIDS care and treatment in Haiti

• Rather than siphoning resources from other health
  priorities, the focus on HIV has generated new
  investments in rebuilding public health
  infrastructure, improved drug procurement, and
  led to new interest in applying first-world
  diagnostics and therapeutics in developing-world
  settings.
• The chief barriers to scale-up have mostly been
  related to the poverty of the patients and to the
  poor quality of existing health infrastructures.

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What is the costof inaction?
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