1. JNB/05 HIV/AIDS treatment - challenges in a remote rural area of Tanzania. Johan N. Bruun Department of Infectious Diseases Ullevål University Hospital Oslo, NORWAY

2. JNB/05

3. Haydom Lutheran Hospital

4. JNB/05

6. HIV/AIDS programme Haydom Lutheran Hospital Voluntary counselling and testing (VCT) –Local hospital initiative –NORAD supported project from 2002 planned in collaboration with Centre for International Health, Bergen HIV treatment Project planned and supported by: –Ullevål University Hospital, Oslo –Sørlandet Hospital, Kristiansand –NORAD support for drugs

7. JNB/05 Necessary conditions for starting HAART HIV-testing and counselling (VCT) –Established through NORAD project early 2003 Diagnostic procedures –Evaluation of immunodeficiency – CD4 cell counts –Diagnosis of opportunistic infections / WHO stage III-IV or CDC stage B (ARC) – C (AIDS) –Laboratory tests necessary for treatment follow up – detection of serious side effects Drug supply –Antiretroviral drugs –Drugs for treatment of opportunistic infections Free treatment Clinical skills for evaluation of patients

8. JNB/05 Problems with antiviral therapy A combination of drugs have to be taken every day –To be continued even if patient feels well Development of resistance –Insufficient drug combinations –Lack of adherence Side effects

9. JNB/05 Adherence problems Insufficient understanding of the disease, the effect of treatment and the risk of resistance Stigma – lack of openness towards family and surrounding society – lack of acceptance Side effects Difficulties with drug supply Follow up Problems with care and nutrition

10. JNB/05 Problems with follow up Long distance from hospital Cost of travel No one to care for family at home No one to provide food in hospital Stop of treatment and follow up when improved

11. JNB/05 Indications for starting HAART Pregnancy in order to prevent HIV transmission to the child Development of laboratory signs of immunodeficiency –CD4-cell count < 200x10 9 /L Symptomatic disease - Clinical signs of immunodeficiency –AIDS – CDC clinical stage C disease or WHO stage 4 disease –ARC (AIDS Related Complex) - CDC clinical stage B disease or WHO stage 3 disease

12. JNB/05 DOT – Directly Observed Therapy in HAART treatment Modified DOT regimen Initial phase – 14 days –Outpatients attend the HIV outpatient clinic once daily. The first daily dose to be taken at clinic – the second dose delivered to the patient to be taken in the evening –Blood sample at day 14 Initial phase - week 3 and 4 –Patients are given drugs for one week at the time – return of the bottle for pill count and new drugs once a week –Blood sample at day 28 Continuation phase –Patients are given drug for 4-5 weeks – return with the bottles for pill count and new drugs every 4 weeks –Blood sample at week 12 and then every 3 months

13. JNB/05 Preliminary results 01.01.200501.05.2005 Evaluated patients152300 Started on CART128139 Deaths 35 50 Lost to follow up 9 CART: Combination antiretroviral therapy

14. JNB/05 Differences between the Haydom project and relief projects by MSF Haydom: All patients with established treatment indications offered treatment Patients newly started on treatment for opportunistic infections included No selection based on long time follow up before treatment start Patients included even if no disclosure of HIV-status to others MSF-Malawi (Thyolo): Well developed home based care system Thorough screening of patients for treatment Exclusion of patients: –Active opportunistic infections –Not able to attend follow up regularly for several weeks prior to inclusion –Not willing to disclose their HIV-status to family and contact persons in village

15. JNB/05 Consequences of the differences between the programs at Haydom and MSF-Malawi Haydom: All patients needing treatment are offered treatment Difficulties with follow up due to –Lack of transport –Stigmatisation HIV-status not shared with relatives High death rate due to –Nutritional problems –Opportunistic infections Resistance may develop due to poor adherence to treatment The program may be run by local health personnel MSF-Malawi: Good adherence to treatment Few lost to follow up Low death rate among those treated Selection criteria favours people with abundant economical and mental resources Higher cost per patient treated The program depends on extensive continued support

16. JNB/05 Improvements Provision of transport to hospital Follow up seminars for patients every 4-8 weeks Mobile clinics – outreach program for follow up and drug delivery to patients at nearby village Nutritional support program for both in- and out-patients

17. JNB/05 Conclusion Main challenges Education and motivation of patients Stigma and acceptance of the disease Necessary laboratory service Qualified health personnel Follow up – transport from remote villages Drug supply Government regulations

18. JNB/05

19. HIV-treatment programs in developing countries Research projects –Completely staffed by skilled personnel –Supply of modern equipment –Run for a limited period –Long term effect on local health service?? Relief projects –Necessary skilled personnel brought in –Some training of local staff –Strictly necessary equipment –Depend on continued support Development projects –Key personnel for limited periods –Training of local staff aimed at take over –Strictly necessary equipment