Department of Public Service and Administration (DPSA) Wellness Indaba – Durban 2007 Dr Stanley Moloabi & Dr Leon Regensburg & Mr. Rodney Cowlin

Disease Management Strategy as Part of Health Promotion in the Workplace – a Southern African Perspective

Agenda  Brief overview of Global HIV Infection Estimates  Introduction to aid for aids (AfA)  Benefits of early enrolment on the AfA programme  The positive impact early enrolment on HIV disease management programme has on HIV/AIDS related health costs  Impact of lack of disease management on productivity in the workplace  Work done by AfA beyond South African borders

Estimated adults & children living with HIV, end 2006 Total: 43.6 (36.7 – 45.3) million Western & Central Europe [ – ] North Africa & Middle East [ – 1.4million] Sub-Saharan Africa 28.6 million [26 – 31.2 million] Eastern Europe & Central Asia 1.9 million [ – 2.3 million] South & South-East Asia 8.2 million [5 – 13.3 million] Oceania [ – ] North America 1.2 million [ – 1.8million] Caribbean [ – ] Latin America 1.9 million [1.4 – 2.4 million] East Asia [ – 1.7 million] HIV infection estimates

Over new HIV infections a day in 2006  More than 95% occur in low and middle income countries  About 1500 occur in children under 15 years of age  About occur in adults aged 15 years and older

2006 Global HIV and AIDS estimates - Children (<15 years)  Children living with HIV:2.3 million [1.7 – 3.5 million]  New HIV infections in 2006: [ – ]  Deaths due to AIDS in 2006: [ – ]

Aid for AIDS  More than 9 years experience in providing HIV disease management solutions  More than patients currently registered  ART approved for over patients Introduction to Aid for AIDS

Aid for AIDS  Implemented HIV workplace programmes for a number of multinational companies in Southern Africa  Implementation of a donor funded treatment programme in rural South Africa  Experience in providing treatment programmes in a number of countries outside South Africa

Services offered  Epidemiological & Demographic surveys  Voluntary counselling and testing (VCT)  Financial Impact analysis  KAP (Knowledge, Attitudes and Practices) surveys  Education and awareness programmes.  Legal & Ethical Services  Workplace Policies  Clinical Disease Management Programme  Provision of comprehensive HIV/AIDS Treatment programmes

Clients  Partnerships with International Donor Funders for public sector treatment programmes  21 medical schemes contracted to AfA and administered by Medscheme  Bonitas, Medshield, Fedhealth, Protector, Liberty…  12 medical schemes contracted to AfA and administered by “other” administrators  GEMS, Nimas, Swazimed, Nampak, Randwater…  21 companies contracted to AfA for the provision of a workplace treatment programme:  De Beers, Nestle, Daimler Chrysler, BP Africa, Barloworld, Sun International …

Cost benefits of early enrolment Source: Aid for AIDS Database. Benefits of early enrolment on the AfA programme

Benefits of early enrolment on the AfA Programme  Patients should be on treatment before they develop opportunistic infections.  Patients who initiate ART at the optimal time have better survival prospects.

Comparative 24 month survival by CD4 count for patients on HAART – all patients Chan K et al 2002 AIDS 16(12) Hogg R et al 2001 JAMA 286(20)

CD4 count results relative to ART commencement – all patients

CD4 count results relative to ART commencement – PEPFAR (President’s Emergency Plan for AIDS Relief Partners) Treatment programme

Outcomes of MTCTP programme – all patients N Hlatshwayo, M S Hislop, M Cotton, G Maartens, L D Regensberg. Mother to child HIV transmission prevention (MTCTP) in a managed care setting in South Africa - no role for short-term antiretroviral therapy (ART)?. 15th World AIDS Conference, Bangkok Source: Aid for AIDS Database.

Direct & indirect costs, individual & organisational Insurance premiums Accidents due to ill and inexperienced workers Litigation over benefits, dismissals, etc. Direct CostsIndirect Costs Reduced on-the-job productivity Increased absenteeism Supervisor’s time Vacancy Lower productivity during replacement’s startup period Senior management time Production disruptions Loss of workforce morale Loss of experience and institutional memory Reduced returns to training investments Deteriorating labor relations Total Cost to Firm of HIV/AIDS in the Workforce Benefits payments Medical care Recruitment and training of replacement worker Individual (From one employee with HIV/AIDS ) Organisational (From many employees with HIV/AIDS) Boston University - Center for International Health and Development 2003 Impact of lack of disease management

Timing of Cases and Costs Progression of HIV/AIDS in the Workforce Cost to Company Morbidity begins (some early mortality, some long-term non-progressors). Employee becomes infected. Employee leaves workforce through death or disability retirement (some long-term survivors). Company hires replacement employee. No cost to company at this stage. Morbidity-related costs are incurred (absenteeism, productivity loss, supervisor’s time, medical care) End of service costs are incurred (death and disability benefits, management time, loss of morale, institutional memory, and experience) Turnover costs are incurred (vacancy, recruiting, training) Timeline Year 0 Year 2-8 Year 6-12 Employee remains asymptomatic and fully productive. No cost to company at this stage. Year 0-8 Boston University - Center for International Health and Development 2003

Impact of not having adequate Disease Management Programmes on the Workforce  Skills within the organisation are lost due to illness  Takes ~ 60% longer to replace skilled worker than unskilled worker  Takes ~ 6 times longer to replace a professional than a skilled worker  On-the-job training costs add to cost of replacing an employee

 Botswana Public Officers Medical Aid Fund  PULA Medical Scheme  Botswana Government Public / Private Sector HIV programme (joint venture with Associated Fund Administrators)  Debswana ( De Beers and Botswana) Treatment Programme Aid for Aids Beyond South African Borders

AfA in Af RIC A TUNISIA MOROCCO IVORY COAST NIGERIA EGYPT ZIMBABWE KENYA BOTSWANA ZAMBIA MALAWI NAMIBIA SOUTH AFRICA SWAZILAND TANZANIA ANGOLA ALGERIA

Conclusions  AfA facilitates effective access to comprehensive HIV management and enables extensive outcome data to be collected.  A key success component of HIV treatment is the ability to provide on-going patient support to ensure adherence to therapy.  Managed access to ART improves morbidity, but timing is critical - people are still presenting far too late.

Conclusions  Early managed access to ART improves clinical outcomes and reduces the cost of treating HIV/AIDS.  Managed access to ART should improve productivity in the workplace  Aid for AIDS has a proven track record and the expertise to provide comprehensive HIV treatment programmes which are flexible enough to be implemented in any setting.  Aid for AIDS is seeking to accelerate the work it does in conjunction with employer organisations – we have significant capacity and experience which could be shared.

Acknowledgements N Hlatshwayo, M S Hislop, M Cotton, G Maartens, L D Regensberg. Mother to child HIV transmission prevention (MTCTP) in a managed care setting in South Africa - no role for short-term antiretroviral therapy (ART)?. 15th World AIDS Conference, Bangkok Chan K et al 2002 AIDS 16(12) Hogg R et al 2001 JAMA 286(20) Boston University - Center for International Health and Development 2003 UNAIDS - Global summary of the HIV and AIDS epidemic, December 2006 World Health Organisation - Global summary of the HIV and AIDS epidemic, December 2006

“ Future generations will judge us by the adequacy of our response. ” Nelson Mandela