Meeting the Cost of HIV Treatment:Addressing Some of The Challenges –

Caribbean Perspective

Nicholas Adomakoh DTM&H, MRCP

Clinical Consultant

Medical Director, CHARTLadymeade Reference Unit

Adult HIV Prevalenceby Region (end of 2005)

6.1

1.6

0.8

0.5

0.5

0.4

0.3

0.2

Sub-Sahahran Africa

Caribbean

Eastern Europe & Central Asia

North America, Western and Central Europe

Latin America

Asia

Oceania

North Africa & Middle East

Data from UNAIDS Global Report 2006

Regional Statistics 2005

• 330 000 Persons living with HIV

• 37 000 New infections

• 27 000 Deaths

• M:F – 2:1

Background

• “Only universal access can keep this epidemic from engulfing the next generations. To fail now would be unforgivable.”– Peter Piot

Challenges

• Predictable and sustainable financing

• Affordable medicines, diagnostics and prevention commodities

• Target groups- S&D/ vulnerabilities

• Human resource and health systems management- Planning and coordination

Functioning Health Systems are fundamental to successful,

equitable and sustainable delivery of a continuum of HIV/AIDS

prevention, treatment, care and support

WHO HIV/AIDS Plan 2004/5

HIV/AIDS Estimates and Health Care in the Caribbean Region

1005912364.80.1Cuba

1885234251.5Jamaica

6412110182.71.5Barbados

25453855.21.9Suriname

7188295661.1Dominican Republic

391053003.72.5Belize

2848227122.4Guyana

N/A10610746.83.3Bahamas

1679428272.6Trinidad and Tobago

825541903.8Haiti

ARV coverage % (2004)

Physicians / 100000 pop (1990-2004)

Health expenditure per capita USD (2002)

Total PLWHA x 1000 (2005)

HIV Prevalence% (2005)

Country

Source: Marco Vitoria, WHO Dept of HIV/AIDS Dec2005/ UNAIDS Global report 2006

0 100,000 200,000 300,000 400,000 500,000 600,000

Effectively under ARV

Needs of ART

PLWHA

COUVERTURE EN ART COUVERTURE EN ART COUVERTURE EN ART COUVERTURE EN ART dans la Caradans la Caradans la Caradans la Caraïïïïbe be be be (mi octobre 2004)

ART coverage ART coverage ART coverage ART coverage in the Caribbean in the Caribbean in the Caribbean in the Caribbean (June 2005)

~16% of the needs covered

ART coverage ART coverage ART coverage ART coverage in the Caribbean in the Caribbean in the Caribbean in the Caribbean (June 2005)

Key Issues Faced

• How to develop the necessary health care infrastructure and capacity to make up for the shortfall, and in the process not lose the quality of care provided by the pilot programmes

• In particular to ensure adequate level of adherence to medications

“ Delivering essential services and achieving targets for universal access to HIV prevention, treatment, care and support depend vitally on a strong foundation of human resources. Developing innovative service delivery methods, scaling up to reach the most affected communities, promoting more supportive work environments to retain and motivate workers, and integrating HIV-related services into wider development services are key components of a successful strategy.”

Kemal Dervis ,, UNDP Administrator

Approach to Scaling –Up ART

• Maximising available human resources through training, expanding skill sets and rationalisingroles of different cadres of HCWs

• Intensifying involvement of the community and in particular of persons living with HIV

• Simplified, standardized regimens and protocols for managing clients

• Simplified and standardised record-keeping

People seeking orin need of services

“I need help to move on with my life”Psychosocial supportPersonal development

Centre, NGOs, Churches,

Welfare &Legal support

“I need treatmentand care”

HIV/AIDS Specialist Medical

Care @ LRU

“I need care and helpat home”

Domicilary/Community based

Care,Elroy Philips Centre.

“I need other medical services”

Surgical, Dental and Medical

Subspecialties

“I need help coping and changing to a healthier lifestyle”

Counseling/Education.

“I need informationand support”

HIV/AIDS Hotline436-2444 or436-AIDS

“I need to know my HIV status”

Community Voluntary Counseling & Testing

Care seeking/Providing

Active referral

HIV/AIDS Continuum of Care and Support

The Ladymeade Reference Unit

Summary of HIV and AIDS Cases and Deaths: 1984 -200 3

0

50

100

150

200

250

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

Year Diagnosed

Num

ber

of C

ases

HIV

AIDS

Deaths

HIV & AIDS Cases and Deaths in Barbados

Moving towards Universal Access

ARV SITE MODEL

CENTRAL LEVEL

Community Level

MobilisationIEC/ Prevention

Adherence Suppt.Psycho Social

Suppt.GIPA

NGO/ CBOHealth Promot.

VCT

LOW

VCTCounselling-Adherence-Nutrition

-Supportive-Prevention

-Social WelfarePMTCT

Intermediate

Staging of HIV+vef/u of stable HIV on Rx

f/u of HIV not on RxRoutine Repeat Rx

General MedicalRoutine Labs

Routine Adverse EffectsDental

STI

HIGH

ARV 4S’s/ TB /OI mgtPMTCT

M&ERemote SupportLink to support/

Tech Advice fromRegional/Overseas

M & E Technical Support

Data CollectionData Collection

Community Doctors

Nurses

Labs

Community Clinics

Pharmacies

Community Health Workers

QEH

LRU

Advanced Community Clinics/ QEH LRU SHIP

•Collecting data in a practical manner appropriate to the treatment setting

•Transforming and analysingdata into actionable information

Adapted from BroadReach Health care LLC

Cross-Cutting Issues

1. Planning2. Enabling public policy environment3. Involving and mobilising stakeholders4. Supply management of commodities5. Service delivery6. Human resources- Training and retention7. Infrastructure8. Costing and financing9. Management systems10. Information management and communication11. Monitoring and evaluation

Data Management

• Collecting data in a practical manner appropriate to the treatment setting

• Analysing and transforming data into actionable information

– Clinical decision support

– Adherence management and patient support

– M&E and programme decision support

A Regional Training Network for HIV/AIDS

Care & Treatment in the Caribbean

The Caribbean Region

GUYANA

NEVIS

BERMUDA

BELIZE

JAMAICA

CAYMAN IS.

ARUBA CURACAO

BONAIRE

TRINIDAD &TOBAGO

GRENADABARBADOS

ST. LUCIA

DOMINICA

ST. VINCENT

ST. EUSTATIUSSABA

MONTSERRAT

BR. VIRGINIS. ANGUILLA

ST. KITTS

ANTIGUA

BAHAMAS

TURKS &CAICOS IS.

SURINAM

CAREC Member CountriesCDC GAP Bi-Lateral ProgramsCDC GAP Regional OfficeCHART Centers of ExcellenceCHART Coordinating Center

Future CHART CentersFuture CHART CentersFuture CHART CentersFuture CHART CentersUSAID Regional Office

Emphasis on programme management training

• Commodity supply chain management

• Information management

• Improve responsiveness in the system to manage rapid scale up and need for rapid mobilisation of resources

Sustainability

• Critical to develop and capacitate a full continuum of care where knowledge transfer and learning as much as possible become a continuous process, and viewed as part of the job as opposed to a special distracting activity.

Resistance

• Variables– Universal access to ARVs

– CSME – wider movement of caribbeannationals within the region

– Time

– Prevention interventions

0

5

10

15

20

25

1996-97 1998-99 2000-01

NRTI anyNNRTI anyPI any primarytwo classesthree classes

Time Trends in Primary HIV-1 Genotypic Drug Resistance Among

Recently Infected Persons

JAMA. 2002 Jul 10;288(2):181-8.

% o

f res

ista

nt is

olat

es

Viral Resistance Laboratory

Engaging the clientele – KYS

Why do a HIV test?

• Because we are failing to reach thousands of PLWHA

• Most PLWHA do not know they are positive

• Entry point for both prevention & treatment

• You cannot tell by looking

P.Figueroa. Jamaica

Less than 10% of the world's

estimated 40 million HIV infected

are aware of their HIV status.

Knowledge of HIV status; Redressing the balance

Not accessing

testing

Accessing testing

Voluntary Counseling and Testing

Proportion of Newly Diagnosed HIV patients with Sim ultaneous, Delayed, and Deferred Diagnoses (M= 19. 1 months)

0

10

20

30

40

50

60

70

80

90

100

1997 1998 1999 2000 2001

Year of HIV Diagnosis

Per

cent Delayed

Deferred

Simultaneous

Responding to the HIV/AIDS Epidemic in the Caribbean

• An effective response to the HIV/AIDS epidemic depends primarily on the commitment, capacity and leadership at the national level

• The Regional response needs to ensure a favourable policy and legislative environment, adequate resources, good coordination, technical assistance and support for the countries

Challenges

• Slow progress with HIV policy & legislation• Continued strong stigma and discrimination• Weak national capacities • HIV prevention/interventions are inadequate• Universal access to ARV treatment• Inadequate response of education and other sectors• Unified system for Monitoring & Evaluation• Fragmenting approach of international agencies

Need to strengthen leadership at all levels, and Accountability for results

Obstacles are those frightful things you see when you take your eyes off

your goals.

Author Unknown

Thank you