1. Challenges in adapting chronic HIV/TB services to high mobile populations in Southern Africa Eric Goemaere, MD Médecins Sans Frontières IAS Washington, July 25 th 2011 OWN, SCALE-UP & SUSTAIN The 16 th International Conference on AIDS & STIs in Africa 4 to 8 December 2011, Addis Ababa www.icasa2011addis.org

2. High mobility, high HIV and TB prevalence High regional mobility Different patterns of migration Mobility = survival Chronic care designed for residents Migrants – Hardly attending health facility – Fear of deportation, health system barriers, xenophobia – Access to treatment often denied due to fears about adherence and continuity of care

3. Failure to identify migrants at ART initiation triggers a high rate of loss to follow-up Multivariate analysis -> AHR for LTFU in migrants at one year 6.69 ( 3.18-14.09) Trends in loss to follow-up among migrant workers on ART in a community cohort in Lesotho Helen Bygrave1*, and all, Plos One, October 2010 | Volume 5 | Issue 10 | e13198 14 % of migrants amongst ART initiations

4. Cd4 results collection among migrants testing HIV(+) Central Methodist Church, Johannesburg, 2009-2010 Central Methodist Church is a shelter for up to 3000 homeless mostly Zimbabwean migrants in central Johannesburg MSF opened a clinic in CMC in 2008 Cd4 testing was initially implemented in a traditional passive way After implementing a testing campaign and active case tracing, outcomes where significantly increased Central Methodist Church is a shelter for up to 3000 homeless mostly Zimbabwean migrants in central Johannesburg MSF opened a clinic in CMC in 2008 Cd4 testing was initially implemented in a traditional passive way After implementing a testing campaign and active case tracing, outcomes where significantly increased

5. Defining the problem HIV/TB care designed for resident population Mobility = survival for migrants Different treatment protocols in different countries Medications & documents frequently stolen or lossed during irregular crossings No cross-border information‘s on where and how to access services Fear of arrest /deportation Staff attitude towards migrants Illegal fees HIV/TB care designed for resident population Mobility = survival for migrants Different treatment protocols in different countries Medications & documents frequently stolen or lossed during irregular crossings No cross-border information‘s on where and how to access services Fear of arrest /deportation Staff attitude towards migrants Illegal fees

6. Establishing mobile HIV/Tb units, Establishing mobile HIV/Tb units, Musina border, Limpopo, South Africa  21,000 living on commercial farms along border  Circular seasonal migration  Decentralized MSF/DOH nurse based mobile clinics on farms, offering PHC services but referral for integrated HIV/TB initiation.  21,000 living on commercial farms along border  Circular seasonal migration  Decentralized MSF/DOH nurse based mobile clinics on farms, offering PHC services but referral for integrated HIV/TB initiation. SOUTH AFRICA MUSINA

7. Initial outcomes : continuum of HIV care in farms ART eligible 380 Pre- treatment steps CD4 results given 951 (44%) CD4 count sample provided 2171 Initiated ART 193 51% 95% CI 46%-56% HIV+ diagnosed population Testing to etsablish eligibility ART eligibility to ART initiation

8. Adapting services to integrated HIV/Tb care Adapting services to integrated HIV/Tb care

9. Adapted strategy for providing HIV/TB care to "migrant" patients

10. When time to go, issued with a ‘travel pack’

11. Impact of adapted strategy on continuum of HIV care ART eligible 380 226 Pre- treatment steps CD4 results given 951 (44%) 594 (81%) CD4 count sample provided 2171 735 Initiated ART 193 ( 51% ) 95% CI 46%-56% 188 83% 95% CI 78%-88% HIV+ diagnosed population Testing to etsablish eligibility ART eligibility to ART initiation 37% 32%

12. Preliminary ART outcomes,Musina TTFO n = 63

13. Conclusions

14. Acknowledgements Tambu Matambo, Helen Bygrave, Gilles Van Cutsem Mobile MSF/DOH teams in Musina Department of Health, Limpopo, South Africa People living with HIV in Musina