ART in Khayelitsha 2001-2011

Achievements, lessons learned, way forward

Dr Gilles Van Cutsem
Medical Coordinator Mdecins Sans Frontires

10 years of ART in the public sector in Africa: Key successes and window into the future. Durban HIV Conference 2011

Model of care
1.

District-based planning and coordination between MSF, TAC, PGWC, City Early implementation of PMTCT Large scale HCT & treatment literacy Community condom distribution Decentralization of ART to all primary care clinics Nurse-led care including ART initiation TB/HIV integration as a one-stop service Male clinic & Youth clinics Three tier system for monitoring and evaluation Good secondary referral & support system Ongoing district-based training and mentoring Decentralised management of DR TB

2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

HIV Prevalence in pregnant women at first booking

Khayelitsha antenatal HIV prevalence 1999-2010

35% 30%

25%
20% 15% 10% 5% 0%

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

Prevalence 0.153
Tested

0.192 0.255 0.247 0.254 0.271 0.288 0.312 0.302 0.314 0.305 0.263

5325

4879

6816

7593

7172

8177

8601

8957

9258

10111 10303 9459

PMTCT
14.0%

Estimated mother to child HIV transmission rates

12.5%

12.0%

10.0%

8.0%

6.0%

4.0%

2.5%
2.0%

0.0% 2002 2003 2004 2005 2006 2007 2008 2009 2010

Children started on ART

160

140
120 100 80 60 40 20 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 CHCs City Clinics

 PITC Facility and out-of-facility HCT Awareness Campaigns

HCT
35 30 25 20 % infected

60000 50000 Number tested 40000 30000

15 20000 10000 0 2005 2006 2007 2008 2009 2010 10 5 0

Nmb tested

% HIV infected

Mass Community Condom distribution

Male Clinic

ART decentralization to all PHC clinics

CHC ARV clinics ART in 2008 ART in 2009 ART in 2010

Medecins Sans Frontieres

Nurse-based care

Monthly target mid 2010 Nov-10 Feb-10 May-09 Nov-08 Feb-08 May-07 Nov-06 Feb-06 May-05

City Clinic

CHC

Enrolment on ART

Total

Nov-04
Feb-04 May-03 Nov-02 Feb-02 May-01 50

450

monthly ART Enrollments

100

500

400

350

300

250

200

150

Earlier initiation
Median baseline CD4 adults 3 Khayelitsha CHC's
180
160 Median baseline CD4 140 131 120 100 80 60 40 20 PERCENTAGE 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 47 43 50 WHO 4 40 30 20 10 0 2002 2003 2004 2005 2006 2007 2008 2009 2010 85 74 60 103 112 148 162 152

WHO stage at the moment of ART initiation

WHO 1+2 WHO 3

TB/HIV integration

TB Case-finding 2003-2010
3,000 2,500 2,000 1,500 1,000 500 0

2003

2004

2005

2006

2007

2008

2009

2010*

Smear+

Smear-

Smear not done

EPTB

Decentralised DR TB care
Case detection
250 211 200 231 200

Location of treatment
Percentage of patients starting DR-TB treatment
Clinic Khayelitsha step-down facility Hospital

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 2006 2007 2008 2009 2010 15 19 58 74 71 85 81 42 19 6 14 15

Number of cases

157 150 118 100 58 50 14 0 2003/04 2005 2006 2007 2008 2009 2010

Time to treatment
80 70 60 50 50 40 40 30 20 10 0 2005 2006 2007 2008 2009 2010 33 72 71 71

Median Days

Challenges & Future

(Pre-)ART LTF
LTFU of treatment eligible preART patients in 2 Youth Clinics
80% 70% Site C Youth Site B Youth

60%
50% 40% 30% 20% 10% 0%

Q1-10 Q2-10 Q3-10 Q4-10

Community drug dispensing

Community ARV groups in Mozambique Decroo T et al, JAIDS 2010

Urban model: the Adherence Clubs in Khayelitsha

Groups of 30 stable patients Meet every 2 months Clinic & out-of-clinic Run by 1 or 2 lay health workers Clinical check + education session + drugs Clinician visit every 6 months

755 patients in 22 clubs Median 1029 days on ART at entry RIC at 1y. 99.2%, 2 y. 97.5% RIP 0.6%, LTF 1%, TFO 2.5% Transfer from club to clinic 6.2% Roll out in pilot sites in WC

Khayelitsha 10 Year Report, 2011.

Stabilisation of loss to care

RIP and LTFU after 12 months of ART
18.0% 16.0% 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% combined RIP and LTFU RIP Adherence Clubs

0.0%
2003 2004 2005 2006 2007 2008 2009

Adherence and drug options

Patients on second line ART with detectable VLs
18 16 14 12 10 8 6 4 2 0 17

9 4

currently detectable

VL re-suppressor

3rd line ART

30% re-suppressed after enhanced adherence support Cost of 3rd line: 1000-3000 R per month

Future

Start ART at CD4 500 and/or viral load threshold to further reduce infectiousness at community level (TASP)

Out-of-facility community base testing (in schools , taxi ranks... )

PREP targeting young females (? & older males) Development of new long acting ARV formulations (like TMC 278) combined with other bio-medical preventive interventions New drug formulations and technologies including:

Fixed dose combinations (FDC) Point of care (POC) viral load to monitor adherence and identify early treatment failures POC CD4 devices to reduce lost to follow-up pre-ART, mostly among adolescents

More robust and forgiving regimens, including drugs like darunavir,