Paul Farmer, MD, PhD

Partners In HealthHarvard Medical SchoolBrigham and Women’s Hospital

Social Analysis 76 • Global Health Challenges • 8 November 2006

Community-based treatment of HIVExperience in Haiti, Rwanda, and Lesotho

UNAIDS 2002, 2004

HIV/AIDS in Haiti: situation in 1990s

• 280,000+ people living with HIV/AIDS• Highest prevalence in the Western Hemisphere- 5% among asymptomatic women attending rural

antenatal clinics- >10% among asymptomatic women attending

antenatal clinics in urban slums• 30,000 new cases annually• “Generalized” epidemic• Leading cause of death: 24,000-30,000 estimated

HIV/AIDS deaths in late 1990s• 200,000+ AIDS orphans

Introduction of HIV management and care at Clinique Bon Sauveur

• 1986: First case of HIV in Central Plateau• 1988: Free serologic testing to diagnose HIV• 1990: Prevention efforts; hampered by political violence and

resulting migration, gender inequality, and poverty• 1995: AZT to pregnant women in order to block mother-to-child

transmission- >90% of women accepted HIV testing after AZT was made

available free of charge• 1997: Post-exposure prophylaxis with a three-drug regimen to

all victims of rape or professional injury• 1998: ART offered to a small number of patients with

longstanding HIV disease who no longer responded to treatment of opportunistic infections

The HIV Equity Initiative

• Provides directly observed ART and social support free of charge to >2,500 patients in the Zanmi Lasante catchment area

• Programmatic approach based on successful TB control efforts

• Each pt has an accompagnateur who observes ingestion of therapy at least once a day

• All pts have responded with weight gain, improvement of health

• Reduction in hospitalizations and mortality• Decreased AIDS-related stigma: the

“Lazarus effect”• Improved staff morale• Increased interest in HIV testing and

counseling

Annual per-patient ART cost, 2002

$10,

220

$701

$300

$10,

622

$577

$412

$0

$2,000

$4,000

$6,000

$8,000

$10,000

$12,000

Avg. wholesale price PIH price IDA price

Drug source

Pri

ce (

US

$)

d4T, 3TC, NVP

AZT, 3TC, NVP

“Scaling up” in Lascahobas

• Introducing essential drugs to the formulary

• Establishing a laboratory• Training and stipending

community heath workers• Complementing Ministry of

Health personnel with PIH/ZL-trained staff

• Aggressive TB and STI case-finding and treatment

Patient visitsLascahobas, July 2002 - November 2003

0

1000

2000

3000

4000

5000

6000

7000

Jul 0

2

Aug

02

Sep

02

Oct

02

Nov

02

Dec

02

Jan

03

Feb

03

Mar

03

Apr

03

May

03

Jun

03

Jul 0

3

Aug

03

Sep

03

Oct

03

Nov

03

Month

Nu

mb

er

of p

atie

nt v

isits

TB case detection July 2002 - November 2003

0

10

20

30

40

50

60

Jul

02

Aug

02

Sep

02

Oct

02

Nov

02

Dec

02

Jan

03

Feb

03

Mar

03

Apr

03

May

03

Jun

03

Jul

03

Aug

03

Sep

03

Oct

03

Nov

03

Month

Nu

mb

er

of T

B c

ase

s d

ete

cte

dHIV case detection

July 2002 - December 2003

0

5

10

15

20

25

30

35

40

Jul

02

Aug

02

Sep

02

Oct

02

Nov

02

Dec

02

Jan

03

Feb

03

Mar

03

Apr

03

May

03

Jun

03

Jul

03

Aug

03

Sep

03

Oct

03

Nov

03

Dec

03

Month

Nu

mb

er

of H

IV c

ase

s d

ete

cte

d

Prenatal care visits October 2002 - December 2003

0

100

200

300

400

500

600

Jul

y 02

Aug

02

Sep

02

Oct

02

Nov

02

Dec

02

Jan

03

Feb

03

Mar

03

Apr

03

May

03

Jun

03

Jul

03

Aug

03

Sep

03

Oct

03

Nov

03

Dec

03

Month

Nu

mb

er

of p

ren

ata

l ca

re v

isits

0

500

1000

1500

2000

2500

3000

Jan

03

Feb

03

Mar

03

Apr

03

May

03

Jun

03

Jul 0

3

Aug

03

Sep

03

Oct

03

Nov

03

Month

Nu

mb

er

of v

acc

ina

tion

s a

dm

inis

tere

d

Vaccine administration January 2003 - December 2003

IMB patient enrollment, May 2005-present

PIH-Lesotho:Bo-Mphato Litšebeletsong tsa Bophelo

• Launched March 2006• Goal: to improve comprehensive HIV prevention and

treatment services in Lesotho, with a focus on patients living in the remote mountain regions

• Collaboration with the Ministry of Health and Social Welfare and the Clinton HIV/AIDS Initiative

• Other partners: Lesotho Flying Doctor Service, Mission Aviation Fellowship

Since July 18, 2006…

• 88 pts enrolled on ART, including 7 pregnant women and 3 children

• 182 pts in pre-ART care and awaiting CD4, on TB treatment, or not yet in need of ART

• 412 pts tested for HIV- 300% increase in two months compared with last year- pMTCT outreach efforts during weekly antenatal clinics- Pediatric outreach efforts during weekly under-five

clinics (qualitative PCR testing available)- All TB and STI pts encouraged to undergo testing- Testing also offered at two community workshops and

in seven villages during village visits

Since July 18, 2006…

• Home visits and educational meetings held in 13 villages with VHWs, traditional healers, village chiefs

• 75 CHWs trained in HIV and TB management; of these, 40 are currently active in the program and have attended two monthly meetings

• One expert patient counselor and two translators/clerks hired and trained

• Waiting room constructed at Nohana• TB program strengthened; >15 pts now on DOT• Nutritional support for patients will be scaled-up in

conjunction with the World Food Program and Catholic Relief Services

Workplan

• October: Training of staff and VHWs in Nkau• November: Initiation of comprehensive HIV

prevention and treatment services in Nkau• January 2007: Begin construction on infectious

disease clinic in Nohana; training of staff and VHWs in Bobete

• February: Initiation of comprehensive HIV prevention and treatment services in Bobete

• March: Training of staff and VHWs in Lebakeng• April: Initiation of comprehensive HIV prevention and

treatment services in Lebakeng