Paul Farmer, MD, PhD Partners In Health Harvard Medical School Brigham and Women’s Hospital Social Analysis 76 Global Health Challenges 8 November 2006 Community-based treatment of HIV Experience in Haiti, Rwanda, and Lesotho

UNAIDS 2002, 2004 HIV/AIDS in Haiti: situation in 1990s 280,000+ people living with HIV/AIDS Highest prevalence in the Western Hemisphere - 5% among asymptomatic women attending rural antenatal clinics - >10% among asymptomatic women attending antenatal clinics in urban slums 30,000 new cases annually “Generalized” epidemic Leading cause of death: 24,000-30,000 estimated HIV/AIDS deaths in late 1990s 200,000+ AIDS orphans

Introduction of HIV management and care at Clinique Bon Sauveur 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 - >90% 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

The HIV Equity Initiative Provides directly observed ART and social support free of charge to >2,500 patients in the Zanmi Lasante catchment area Programmatic approach based on successful TB control efforts Each pt has an accompagnateur who observes ingestion of therapy at least once a day All pts have responded with weight gain, improvement of health Reduction in hospitalizations and mortality Decreased AIDS-related stigma: the “Lazarus effect” Improved staff morale Increased interest in HIV testing and counseling

Annual per-patient ART cost, 2002

“Scaling up” in 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

Patient visits Lascahobas, July November 2003

TB case detection July November 2003 HIV case detection July December 2003 Prenatal care visits October December 2003 Vaccine administration January December 2003

IMB patient enrollment, May 2005-present

PIH-Lesotho: Bo-Mphato Litšebeletsong tsa Bophelo Launched March 2006 Goal: to improve comprehensive HIV prevention and treatment services in Lesotho, with a focus on patients living in the remote mountain regions Collaboration with the Ministry of Health and Social Welfare and the Clinton HIV/AIDS Initiative Other partners: Lesotho Flying Doctor Service, Mission Aviation Fellowship

Since July 18, 2006… 88 pts enrolled on ART, including 7 pregnant women and 3 children 182 pts in pre-ART care and awaiting CD4, on TB treatment, or not yet in need of ART 412 pts tested for HIV -300% increase in two months compared with last year -pMTCT outreach efforts during weekly antenatal clinics -Pediatric outreach efforts during weekly under-five clinics (qualitative PCR testing available) -All TB and STI pts encouraged to undergo testing -Testing also offered at two community workshops and in seven villages during village visits

Since July 18, 2006… Home visits and educational meetings held in 13 villages with VHWs, traditional healers, village chiefs 75 CHWs trained in HIV and TB management; of these, 40 are currently active in the program and have attended two monthly meetings One expert patient counselor and two translators/clerks hired and trained Waiting room constructed at Nohana TB program strengthened; >15 pts now on DOT Nutritional support for patients will be scaled-up in conjunction with the World Food Program and Catholic Relief Services

Workplan October: Training of staff and VHWs in Nkau November: Initiation of comprehensive HIV prevention and treatment services in Nkau January 2007: Begin construction on infectious disease clinic in Nohana; training of staff and VHWs in Bobete February: Initiation of comprehensive HIV prevention and treatment services in Bobete March: Training of staff and VHWs in Lebakeng April: Initiation of comprehensive HIV prevention and treatment services in Lebakeng