Transcript Scaling up ART: Joint Clinical Research Centre (JCRC) Experiences Cissy Kityo Mutuluuza MBChB, MSc Deputy Director, Joint Clinical Research Centre Uganda January 4th, 2008 JCRC is Africa's Pioneer • use.

Scaling up ART: Joint Clinical
Research Centre (JCRC)
Experiences
Cissy Kityo Mutuluuza
MBChB, MSc
Deputy Director, Joint Clinical Research Centre
Uganda
January 4th, 2008
JCRC is Africa's
Pioneer
• use of ART in Africa
• HIV vaccine trials
JCRC ART SITES- December 2003
SUDAN
DEMOCRATIC
REPUBLIC CONGO
Soroti
Mbale
Buhinga
Jinja
Kampala
KENYA
Mbarara
Kalangala
Nyakibale
Kabale
TANZANIA
RWANDA
KEY
JCRC ACTIVE
JCRC Centre of Excellence
Timetable for the Regional Expansion of
Antiretroviral Therapy (TREAT)
TREAT Program started in Dec 2003, Funded by
USAID under PEPFAR
Objectives:
•Increasing access to ART
•Capacity building
– Infrastructure development
– Training
– Human Resource
• Logistics management
•Adherence to ART
•Communication
•M&E
The strategy for JCRC ART Rapid
scale up model
MOH Leadership
• Partnerships.
– Public and Private sector, NGO’s, Religious
organizations
• Commitment to quality and accountability
• Plan and address constraints as you progress:
– Infrastructure / Human resources / Logistics
Increasing Access to ART
From 6 ART sites in 2003 to
50 ART sites and 25 outreaches in 2007
Number of persons accessing ART increased
from 10,764 in 2004 to 54,501 by Sept 2007.
Where 6,819 are children and 47,682 adults
Serving 39 districts in Uganda.
Cumulative patients on ART from
JCRC supported centers, 2004-2007
60000
54501
47910
50000
# of patients
41380
40000
31708
30000
23699
14830
20000
10764
10000
0
2004
semi 05
2005
semi 2006
Year
2006
semi 2007
2007
Coverage of TREAT HIV care/ART services as of 31st October 2007
Treatment as a preventive tool :
• Promotion of VCT
– Cost Recovery Program
– Free ARVs
Voluntary Counseling and Testing:
Entry Point for HIV Care
Early medical care
including for
STIs and
tuberculosis
Family Planning
Prevention
•STI
•HIV Condoms
•Harm reduction
•Behaviour
change
HIV
Testing
and
Counselling
ARVs
Treatment for
Opportunistic
Infections
Social/ peer support
incl. for sex workers,
trafficked women
Normalize HIV/AIDS,
Reduction of stigma
Ease acceptance
of serostatus
and coping
PMTCT
Source: Adapted from WHO online VCT toolkit,
Trends of VCT utilization by AIC
region/branch over the years
45,000
40,000
VCT attendance
35,000
30,000
K'la
25,000
Jinja
Mb'ra
20,000
Mbale
Arua
15,000
10,000
5,000
2000
2001
2002
Years
2003
Disclosure
• Stigma & social discrimination
• Family disruption
• HIV infected children
• New relationships/companioship
• Need to have children
Appropriate Operational
Research
Joint Clinical Research
Centre, Kampala, Uganda
&
Academic Alliance, Mulago
Hospital, Uganda
MRC/Uganda Virus
Research Institute
Programme on AIDS,
Entebbe/Kampala, Uganda
&
TASO, Uganda
MRC CTU
Imperial
College
University of Zimbabwe,
Harare, Zimbabwe
Rockefeller
Foundation
MRC, UK
DfID, UK
Rock House
Foundation
GSK
Gilead
BoehringerIngelheim
Centre
Entebbe
Kampala
Harare ALL
Women in DART
685
893
578
2156
< 45 at enrolment
589
775
502
1866
Ever pregnant
85
65
48
198
Two pregnancies
12
4
3
19
Three pregnancies
1
0
1
2
Total pregnancies
99
69
53
221
Median follow up is 2.8 yrs
All pregnancies: incidence by age group
and time since enrolment
16
18-29 yrs
30-34 yrs
Incidence rate per 100 woman years
14
35-39 yrs
40-44 yrs
12
All women <45
10
8
6
4
2
0
0-6m
7-12m
13-18m
19-24m
Time since enrolment in DART
>24m
Positive Prevention
•
•
•
•
Link treatment to prevention
ABC strategy
Negative effects of ART on HIV risk behavior
Cross sectional study of 723 respondents at
JCRC compared sexual behavior in prior 6
months between ART experienced and ART
naïve patients
– No significant differences (one or more casual sexual
partners in addition to a main partner)
– The ARV-experienced respondents were more likely
to report consistent condom use with their spouses
than were ARV-naïve respondents (OR 2.82 95% CI
1.74–4.6).
– Similar to experiences from South Africa where a
Medicines san Frontiers project provided free ARVs
Adherence
• Studies done so far show high levels of
adherence
• Social barriers to Adherence
– Poverty
• Transport
• Food availability
– Carers of children/orphans
– Stigma
– Religion
– Traditional practioners
Adolescents in HIV/AIDS care
• Orphans
– School drop out
– Early pregnancies
– Prostitution
• Disclosure and stigmatization
• Concerns
– Relationships
– Marriage/Family
JCRC Adolescent clients
performing group
ART complimentary services
•
The killer side of AIDS is often
ignored
Opportunistic Infections (OIs)
• More expensive than ART
• More cumbersome to treat
• Fatal without ART.
• Nutritional Support
• School fees
• Specialised counseling for children
– JCRC has strengthened linkages with
organizations that can provide the services
Universal Access
• The most serious equity issue is lack of
universal access to ART!
• Unequal distribution of health services and
lack of access to ART
• Most of the ART clinics have been
established in main hospitals within the
towns in the regions.
• Limited access in rural areas served by
the lower health centers or units.
Mawokota North Constituency
Health Sub District in Mpigi District
10
JEZA
N
TIRIBOGO
MUSAALE-MAGALA
8
MALIMA
MUDUMA
11
9
15
12
LWAGWA
KYANJA
WARDD
KOLOLO
6
SEKIWUNGA
KIRINGENTE
KAVULE
KIKONDO
MAZIBA
13
KONKOMAKYALI
2
KAMMENGO
3
BUTOOLO
KAMENGO
LUWALA
M U SA
LUVUMBULA
MUTUBAGUMU
MUYIRA
KANYIKE
7
5
BUMOOZI KAKOOLA
WARDB
LWANGA
1
4
GANGU FOREST RESERVE
KAFUMU
LUGYO
MBAZZI
BULEREJJE
KISITU FOREST RESERVE
14
MPIGI TC
Key for Health Centres
1- Kampilingisa HC
2- Ggoli HC
3- Butooro HC
4- Kibanga HC
5- Katende HC
6- Sekiwunga HC
7- Epi Centre
8- Muduuma HC
9- Bujuuko HC
10-Jeza HC
11-Kibumbilo HC
12-Kafumu HC
13-Kyaali HC
14-Nswanjele HC
15-Konge HC
Best practices for ART roll out
• Community Mobilization
• Make your presence felt in the area Open with a bang!
• Use the launching occasion for IEC and
to “break” Stigma.
President Museveni opening
Rushere ART Clinic
First Lady during Itojo Launch
Minister of State for health opening
Mpigi Health Centre