Advances in care and treatment of AIDS, TB and other OIs through research capacity building in Haiti JEAN WILLIAM PAPE, MD Howard and Carol Holtzmann Professor of Clinical Medicine, Center for Global Health, Department of Medicine, Weill Cornell Medical College, New York, New York, USA Director, Les Centres GHESKIO, Port-au-Prince, Haiti Session: Ending AIDS through Research Training and Capacity Building in low and middle income countries IAS 2017, Paris, July 25, 2017 I have no conflicts of interest to declare

GHESKIO Centers and Haiti GHESKIO Centers: 1st comprehensive AIDS center dedicated to research, training, care (1982) Partnership: Ministry of Health and 116 local institutions Strong international collaboration: Cornell, F. Mérieux Continuous support from NIH (1983), Fogarty (1990) Haiti Profile: highest HIV prevalence outside of Africa Highest TB incidence in Americas Among the 5 most fragile countries in the world : UN Data analysis of >7,000 disasters 1995-2015 resulting in 1.35 million people disasters deaths 90% are from low/middle-income countries 1/6 of all deaths were in Haiti

Capacity Building by FIC 1989-1990: I was a Fogarty trainee 1990-1997: FIC grantee : AITRP, ICOHRTA, Framework, training grants for HPV/cervical cancer and MDRTB led to the training of 482 Haitians at the MDs, PhDs, Masters level, essential to: Conduct translational research on OIs, TB, AIDS care/RX leading to development of HIV prevention and care models Train >16,000 health workers (public, private sectors) Scale-up GHESKIO HIV, STI, TB, cholera at the national level Establish public health programs with local institutions Laboratory with the Ministry of Health Public Health Lab 1st MPH and NP with local institution (Quisqueya University) 5) Develop research network within the Americas: Trans Caribbean HIV/AIDS Network Initiative (TCHARI) Caribbean Central America South A. AIDS network (CCASAnet)

Chronic diarrhea and TB S/S : hallmark of AIDS in Haiti Establish the definitive epidemiology isosporiasis and cyclosporiasis as well as the treatment and prophylaxis with TMT-SMX

Pape JW et al: The Lancet 1993: 342 Isoniazid (INH) prevent active tuberculosis (TB) in persons infected by HIV and TB INH also delays the progression to AIDS Most cost-effective intervention in dually infected HIV-TB patients (WHO) Pape JW et al: The Lancet 1993: 342

Isoniazid post-treatment prophylaxis is effective to prevent TB Recurrence among HIV+ patients Kaplan-Meier estimate of proportion of patients with recurrent tuberculosis Proportion free of recurrent tuberculosis Population free of recurrent tuberculosis Time from completion of TB therapy (months) Fitzgerald D, Johnson WD Jr, Pape J.W. The Lancet 2000 356 : 1470-74

Factors associated with mortality in the 1st 6 months : Age Survival at 1 year = 90% Survival at 5 years - 75% Factors associated with mortality in the 1st 6 months : Age CD4 counts < 50/mm3 Malnutrition Hgb < 8.5gm) TB Leger P et al NEJM 2009;361:828-829

10-Year Survival on Antiretroviral Therapy in Haiti January 28, 2016 January 28, 2016 10-Year Survival on Antiretroviral Therapy in Haiti 70% of AIDS patients on ART in 2004 still alive today although 80% with advanced AIDS and severely underweight at ART start The 10-year survival rate estimate of AIDS patients on ART in Haiti is similar to that among patients on ART in the United States.  Long-term sustainability of international efforts to provide ART in resource-poor settings Pierre S, Jamat-Khat D, Pape JW, Fitzgerald D, McNairy ML. Ten year survival of patients with AIDS receiving antiretroviral therapy in Haiti. NEJM 2016; 374:397-398 January 28, 2016 DOI: 10.1056/NEJMc1508934

Mortality decreased fourfold and TB incidence decreased twofold when ART is initiated prior to AIDS or CD4 less than 200 Improved retention and outcomes with same-day HIV testing and treatment PLOS Medicine July 25, 2017 https://doi.org/10.1371/journal.pmed.1002357

Psycho/social workers Nurses / Nurses assistant GHESKIO Training 1992-2017 HIV counseling, prevention /care: OI, TB/MDRTB, ART, PMTCT, Malaria , Cholera, FP Healthcare providers 1992 -2009 2010-2013 2014- 2017 TOTAL Lab technicians 1,253 592 143 1,988 Psycho/social workers 1,165 216 100 1,481 Nurses / Nurses assistant 3,765 1,276 1,104 6,145 Physicians 2,774 866 643 4,283 Others 851 1,063 353 2,267 9,808 4,013 2,343 16,164 Community IEC 127,216 19,628 291,166 438,010 Specialized Training Programs 1. 1st MPH (2005) 2. 1st Nurse Practitioner (2009) 3. Laboratory Technicians in collaboration with MOH (2003)

National scale-up of the GHESKIO model in Haiti 1993–2017 ART in Haiti 31% of all ART patients in Haiti are in the GHESKIO network National HIV prevalence

Responses to Haiti 2010 earthquake: Acute care field hospital, refugee camp, clinics >10,000 refugees; 75% women and children

Response to Haiti 2010 Cholera epidemic 1. Cholera Treatment Centers (CTC) 2. Chlorine factory 3. Introduction of oral cholera vaccine

Summary National HIV, TB, cholera GHESKIO models scaled-up nationwide through FIC training . GHESKIO credited with “slowing the AIDS epidemic in Haiti” and serving as “a model for how poor countries with few resources can combat AIDS, TB,and diarrhea” (NY Times ) Long term ART complications Samuel Pierre, MD Oral cholera /Chikungunya vaccines Dosing MDRTB drugs in pediatric patients Karine Sévère, MD Vanessa Rouzier, MD Head of Pediatrics Nitazonamide (NTZ) forMDRTB HPV vaccination Cynthia Riviere, MD, Katey Walsh, MD