Médecins Sans Frontières
in collaboration with
Treatment Action CampaignProvincial Government of the Western Cape
City of Cape TownUniversity of Cape Town, Infectious Disease Epidemiology Unit
Population = 500.000 Adult HIV prevalence: 32% in 2007 Highest TB case finding in the world:
1600/100.000 in 2006 Mostly informal housing;
unemployment rate ± 60%; highly mobile population; pop. density > 6000/km2; electricity 76% of households; high rates of crime and sexual violence.
0%
5%
10%
15%
20%
25%
30%
35%
40%
1999 2000 2001 2002 2003 2004 2005 2006 2007
Mean Prevalence (95 % CI)
1998: Creation of TAC1999: start of PMTCT programme2000: HIV care pilot project (3
clinics)2001: First patient started on ART2004: National HIV plan leads to
increased enrolment on ART2009: 12,000 people started on ART
at 9 sites
Existing ARV clincis
Extension 2006/07
ER1 :To develop a new model of care and to decentralise existing
HIV/AIDS dedicated services -including ART- to five peripheral clinics
Existing public health facilities
• 3 community health centers (day hospitals)
• 2 maternities (MTCT ante and peri-natal)
• 8 local clinics (STI, FP, TB, <5 health, post-natal MTCT)
• No hospital (under construction)
• 3 hospices – 1 only for DR TB
• “Home based care” NGOs
CHC based ARV clincis
New HIV clinics
2000: demonstrate feasibility of ART at primary health care level in resource-limited, peri-urban setting
2004: scaling up ART, TB/HIV integration, and integration into Provincial ART programme
2008: feasibility of achieving NSP targets, including “universal coverage” by 2011
80 % of needs ART coverage -> 800.000 to 1 million on Rx
80 % initiated and followed by nurses
50 % of children treated at PHC
Reduction of HIV transmission by 50%
1998: 450 people tested for HIV in Khayelitsha
Well functioning PMTCT programme since 1999
Vertical transmission = 3.5% in 2007
100% acceptance rate, formula feeding, AZT+NVP
Integration of ART provision within MOU since 2004
43 43 42
3734
31 30
2001 2002 2003 2004 2005 2006 2007
Khayelitsha: IMR, 2001-2007(Deaths of babies under 1 yr of age, out of 1,000 live births)
0
10000
20000
30000
40000
50000
60000
70000
80000
2001 2002 2003 2004 2005 2006 2007
To
tal
nm
b o
f vi
sits
0%
50%
100%
150%
200%
250%
300%
350%
400%
450%
Rat
io A
RT
/no
nA
RT
Tot ART Tot non ART Ratio
New patients 2006 2007 2008 2009 2010
2007 2008 2009 2010 2011
Enrolled 2,122 2,322
Target (new stage IV)* 3217 3485 3708 3847 3929
% needs covered 66% 67%
Remaining in care (%) 12 M 24 M 36 M 48 M
2001 83.4 81.2 78.0 73.82002 84.9 79.5 78.3 75.42003 86.4 81.7 77.3 73.5
2004 88.6 82.6 77.0 74.22005 87.8 82.6 77.62006 88.3 81.52007 86.6
Remaining in care (RIC) = (total initiated) – (deaths + loss to follow-up)
Adults
0
500
1000
1500
2000
2500
Adu
lts s
tart
ed o
n A
RT
Treatment naïve 82 206 389 1,063 1,647 2,122 2,322
Prior treatment or transferred in 9 7 18 66 229 304 168
2001 2002 2003 2004 2005 2006 2007
Children < 14 years
0
50
100
150
200
250
Adu
lts s
tart
ed o
n A
RT
Treatment naïve 33 37 63 98 127 101
Prior treatment or transferred in 6 24 39 64 56 35
2002 2003 2004 2005 2006 2007
Median baseline CD4 and IQR by year (Adults)
48 41.5
7385
105 112
0
50
100
150
200
2001 2002 2003 2004 2005 2006
Time eligible for ARV's to treatment start
05
01
00
150
200
2000 2001 2002 2003 2004 2005 2006 2007excludes outside values
Me
dia
n tim
e fro
m d
ate
elig
ible
to
sta
rtin
g tre
atm
en
t
Year eligible for treatmentSource: Louise Knight 2008, internal report
Expand providers: nurse based follow-up
Simplify follow-up routines: Fast track systems (clubs, “chronic
dispensing”) Limit number of follow-ups
Improve functioning of administrative section Blood results, data entry
Khayelitsha Monthly Total in Care
May2009
Total Adults Total Children TOTAL
% of total
Kuyasa 686 96 782 6,5M. Goniwe 1000 45 1045 8,7Michael M 3005 166 3171 26,5Nolungile 2527 238 2765 23,1Ubuntu 3702 278 3980 33,2Site C Youth 87 87 0,7Site B Youth 52 52 0,4Town II 89 89 0,7
Khayelitsha 11148 8231197
1
May2009
New Adults
New Childre
n
TFI Total (New)
Target % of total
Kuyasa 33 4 3 37 25 10,8M.Goniwe 38 1 4 39 35 11,3Michael M 85 1 1 86 75 25,0Nolungile 74 6 3 80 75 23,3Ubuntu 75 2 6 77 100 22,4Site C Youth 2 222 2 2 10 0,6Site B Youth 8 0 8 15 2,3Town II 15 0 0 15 ? 4,4
Khayelitsha
total
330 14 19 344 335
Facility based “clubs”▪ Green clinic: patient stable, > 12 months on ARV’s,
undetectable Community based “clubs”
▪ Functions : monthly support group meeting, clinical screening, drug distribution , data record.
▪ Management : community adherence counsellors ▪ Accountability : to the “mother clinic”▪ Supply : drugs “patient’ labelled, nutritional
support
Diagnosed DR-TB cases
All cases referred to Referral OPD
Severe clinical condition and XDR-TB admitted for intensive phase (or until culture conversion) 4-6 months
Others referred for clinic based treatment (intensive and continuation phase)
Continuation phase treatment, clinic based
Patients Started Tx = 52Patients started Tx in Hospital = 9Patients started Tx in Clinic = 43
Patients not Started Tx = 8
Initiation of Treatment Quarter 1 2009 (prepared May 27th, 2009)
Increase in HIV has been followed by increase in TB
70% of TB patients are HIV-infected in Khay.
Increase in smear-TB and EPTB
Increase in M/XDR-TB
Need for TB/HIV integration
Khayelitsha TB incidence 2002-2006
0
200
400
600
800
1000
1200
1400
1600
1800
2002 2003 2004 2005 2006
Incide
nce p
er 10
0 000
All TB New smear (+)TB New smear (-)TB EPTB
Khayelitsha: VCT in TB services
Proportion TB patients counselled
Proportion accepted testing
Proportion testing HIV +
2002 49% 89% 26%
2003 62% 84% 45%
2004 62% 87% 73%
2005 72% 91% 76%
2006 99% 95 % 67%
2007 99% 95 % 67%
TB/HIV juxtaposition: 1 folder, different admin & clinicians
Managerial integration: 1 folder & same admin, different clinicians and clinical pathway (Ubuntu).
True TB/HIV integration: ARV delivery integrated within TB programme: one-stop service with same staff (admin & clinical) and patient flow (Town 2).
1. ART in a poor public sector setting is feasible.2. Increased enrolment on ART has resulted in
decreased mortality.3. Saturation of large sites led to increased losses
to follow-up. There is a need for decentralisation of ART to the most peripheral clinics.
4. Success of nurse-based, doctor-supported strategy. Regulatory framework on the way.
5. TB/HIV integrated services led to quicker diagnosis and treatment of both diseases in co-infected patients.
6. Decentralized management of DR TB has led to increased diagnosis and number started on treatment.
7. Collaboration between MSF, CoCT, and PGWC was an essential condition for success.
Enrolment of children on ARTAdherence in youth and pregnant
womenEnhanced adherence strategiesFurther decentralizationRegulatory framework for
decentralised nurse-based careDR- TB: new diagnostic and
treatment options