Aids treatment on the field Experiences from CAMEROON Swiss AIDS platform Aidsfocus Bern, April 2004 Béata UMUBYEYI

Cameroon in 2000  Prevalence: 11% (0,5 % in 1987) 15% among soldiers 20% - 45% commercial sex workers  Failure of the prevention policy of last 15 years  Situation for ARV : chaotic access for the rich patients, no control of compliance AND risk of resistances  New will of governments / medical institutions to widen access  Civil society : No activism Still “negation” of the virus

MSF interventions : Not only MEDICAL  Psychosocial answer Counsellors for VCT, social workers, psychologists to support patients  Legal action National drugs patents, information on IP & TRIPS  Pharmaceutical implication Lowering prices, introducing generics, coordination of actors  Training National training cession with CNLS Regional MSF training courses  Empowerment of « civil society » ICAM: Cameroonian Initiative for the Access to drugs. Possible activism?

PARVY PRETIVI General objectives  Obtain the best clinical and biological effectiveness of ARV treatment. (PARVY)  Psychosocial environment to maximize adherence.  Contribute to the economical accessibility and availability of ARVs, OI treatments.  Adapt strategies to local conditions  Offer a “global” medical care to positive patients coming to MSF project. (PRETIVI)

Two projects, Two experiences Pilot project – ARV project Improvement of VCT – Psychosocial support First category hospital (Military hospital but 75 % patients civilians) Partnership MOH, research institute (IRD), Direction of Military Health PARVY Yaounde (January ) 260 patients already followed in PRESICA Treatment of OI already done by IRD Specific “AIDS service” in the hospital

Two projects, Two experiences PROJET Douala (October February 2003)  Improvement of VCT – Psychosocial support  Treatment of OI / STI PROJET PRETIVI (April 2003 –)  ARV treatment – global care  SIMPLIFICATION of the protocols  INTEGRATION in all services of the health structures (TB,AC, …) Douala: Step by step  Decentralization : district hospital / Sub-divisional medical center  Partnership : with medical staff and the COMMUNITY  Attempt of cost recovery

Achievements (March 2004) First patient under ARV Patients attending the project Patients under ARV Compliance Change of treatment needed Drop out PARVY 01 / % 10% - 5 % PRETIVI 04 / % 10,2 % - 5 %

Patients presently on HAART in PRETIVI project NB: Number of deaths: 12 A. Soria, MSF- CH Achievements: Rapid development

Achievements at a higher level  Simplification of protocols less pills (generic FDC by Cipla) less lab monitoring  ARV prices idea of accessibility for all  PLWA associations reinforcement involved in VCT counseling trainings  Demonstration MSF programs are effective = duplication less mortality rates under ARV good adherence thanks to accessibility and psychosocial support

Main difficulties  Global Care. Weak link with TB program. No PMTCT (or taken in charge by the national program). hepatisis co-infection  Small structure quickly over loaded (Douala)  Still many collateral effects on prevention, economic capacity  Nutrition  No real will from the managers and staff of public structures (« motivation ») MSF does everything  Problem of Substitution ?

CHALLENGES I: within MSF programs 1) How far in costs reduction ? NATIONAL FREE TREATMENT 2) Integration of an MSF program in a public structure 3) Decentralization BUT link with greater structures 4) Treat pregnant women AND children 5) Better link with TB program 6) Advocacy for cheaper monitoring tools and simplified protocols 7) Home based care?

CHALLENGES II : National Scaling up 1) FUNDING. WB – PPTE - Global Fund…. “The money from AIDS” 2) Global health infrastructures in need of funding even basic services are not working well HIV / AIDS = chronic care 3) Operational needs: input of more trained staff simplified monitoring real psychosocial support for adherence willingness of decentralized authorities

CHALLENGES III : still a long road … 1) Stigmatization: sensibilize health workers, employers, authorities 2) Maintain high prevention and show the link between treatment and prevention 3) HIV/ AIDS treatment is more than ARV ! Maintain information 4) Fear for resistance if chaotic scaling up 5) Multiplication of actors & care providers but close collaboration AND good coordination