1. Treatment challenges of 2 nd /3 rd line HIV/AIDS, hepatitis-C in Seychelles BY DR LOUINE MOREL

2. Presentation outline Local Situation Treatment availability Advantages Challenges Way forward

3. Local Situation (source MOH Seychelles) SUMMARY HIV & AIDS FROM 1987 TO JUNE 2014 Cumulative HIV Cases 608 (356M/252F) Cumulative AIDS Cases 267 (165M/102F) Cumulative Deaths 125 (75M/50F) Cumulative HIV Positive Pregnancies 103 Living with HIV & AIDS 397 (226M/171F)

4. Cases on HAART 228 (124M/104F) Left Seychelles 86 (55M/31F) Cumulative Loss to Follow-Up cases 80 (53M/27F) Cumulative Drop-Outs on HAART 36 (19M/17F) Defaulter on treatment (>3 months) representing 14% of the HIV & AIDS clients eligible for treatment as per WHO recommended guidelines.

5. HEPATITIS C Since 2002 to June 2014 a cumulative of 440 cases of Hepatitis C of which 360(82%) were males and 80(18%) were females. Out of the 440 cases, 36 (27M/9 F) had HIV and Hepatitis C Co-infection and 13 (7M/6F) Hepatitis C related deaths. 99% of cases are injecting drug users. Minimal access to services Poor uptake on the Hepatitis B vaccination program

6. Treatment availability Antiretroviral 1 st Line(NNRTI Base): 38% 2 nd line(Protease Inhibitor base): 62% 3 rd Line: 0% 397 PLWHIV: 60% on treatment

7. Treatment Availability Hepatitis C management No treatment available Interferon gamma used for other diseases NO RIBAVIRIN at the moment Follow-up of Hepatitis C patients: Blood test 2 time per year/ Annual Liver Ultrasound Laboratories facilities: ill equipped: No genotyping no viral load available R50million needed to treat Hepatitis C(calculated end 2013)

8. Advantages No stock rupture One distribution point Quarterly monitoring of patient outcomes and ARV drug stocks 90% of patients on ART viral load undetectable Only 14% drop out on ART Resistance testing done: Minimal resistance One patient to this date resistant to all available ART in Seychelles

9. An overview of the challenges involved in ART drug management Increased number of different ARV formulations Increases the risk of stock outs Keeping the number of different ARV formulations as small as possible while maintaining adequate treatment options for the vast majority of patients Correctly forecasting the proportion of patients in need of changing of ART regimen Balancing minimum order v/s wastage

10. Ensure that adequate alternative and second-line ARVs are available (switching ARV regimens) Storage capacity in health facilities is limited Increase frequency of deliveries of ART to outer islands Similar challenges faced with the treatment for opportunistic infections LIMITED paediatric formulation ABACAVIR initiation FREE ART: Sustainability

11. Way forward Adopting 90% treatment target: As a means to reduce infection Increase usage of ABACAVIR Purchasing 3 rd line regimen Investing in fix dose regimen Stocking of ARVs on outer islands COST: SUSTAINING cost of ART

12. Thank you!