Improving the Use of Medications to Treat Complex Health Problems in Resource-Poor Settings: Community-Based Examples from Haiti and Peru Jennifer Furin, Paul Farmer, and Edward Nardell Partners In Health Division of Social Medicine and Health Inequalities, Brigham and Women’s Hospital, Boston, MA, USA

Objective and Methods Objective: To document factors associated with treatment program success for HIV and MDR-TB in resource-poor settings of Haiti and Peru Methods: Qualitative study from August 1996 to August 2003 in which a variety of ethnographic methods (including participant observation, key informant interviewing, and focus groups) were used to obtain data from programs and patients in rural Haiti and urban Lima, Peru

HIV Treatment Program in Haiti HIV Equity Initiative launched in 1999 Provides HIV care, including highly active antiretroviral therapy (HAART), to over 500 individuals Relies on the use of community health workers known as accompagnateurs 90% of patients have had a beneficial clinical response defined as weight gain, absence of opportunistic infections, or a rise in CD4 count None of the patients receiving HAART has died Program is expanding to 5 different sites in rural Haiti

Comparison of Outcomes Group A (HAART) Groups B and C n 100 200 [100 + 100] Mortality at end of study period 43 [14 + 29] Tuberculosis incidence 2 21/100* Number of opportunistic infections from start of interventions 0.24 3.3 Average weight change 10.3 kg increase 6.0 kg decrease Number of days in hospital from start of intervention to end of study period or death 23.4 ADL score for people surviving one year after the intervention Initial: 2 Final: 3.8 Initial: 2.7 Final: 2.3 *Data available only for Group B

“I was a walking skeleton before I began therapy “I was a walking skeleton before I began therapy. I was afraid to go out of my house and no one would buy things from my shop. But now I am fine again… My wife has returned to me and now my children are not ashamed to be seen with me. I can work again”.

MDR-TB Treatment Program in Peru Began in 1996 Has treated more than 1400 patients with MDR-TB Relies on the use of community health workers known as promoters Over 80% of the patients are cured or likely to be cured of the disease Has expanded to sites throughout the country

Cure rates for first cohort of MDRTB patients Cured, or in treatment and culture negative 85% In 1998, the first cohort of patients completed treatment. Cure rates exceeded 85%, better than the results seen at US hospitals and treatment centers. In July of that year, PIH invited international health experts and pharmaceutical manufacturers to Boston and presented our results. The long term outcome of this and subsequent meetings was a change in the WHO’s treatment recommendations and a dramatic reduction in the cost of MDRTB drugs. Cure rates for first cohort of MDRTB patients

Overarching Program Principles Community health workers provide daily supervision of treatment Close monitoring of patient progress and management of adverse effects Context-specific management protocols are in practice Measures in place to address socioeconomic conditions associated with poor health outcomes, including nutritional support, housing assistance, and job placement

Policy Agenda Complex health problems such as HIV and MDR-TB can be successfully treated, even in the most resource-poor settings Programs more likely to be successful if they have strong base in the community and if they address socioeconomic forces that place patients at risk for poor health outcomes

Future Directions Additional roles of community health workers Adapting protocols in different geographic and cultural settings Training of health workers Other program pillars of success