A brief overview of ART services at QECH, Malawi

Kudzala Aub. MMEDsc. Student

Sr. Lead ART Clinician/ HIV Medicine Registrar

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•Current Challenges

•Genetic Barriers of Regimens

•Rationale for the clinical decision

Challenges

•Drug shortage problems

•Especially 3TC, NVP

•Laboratory back up

Challenges

Quantity versus Quality

Demand versus Supply

Shortage of health care personnel

Toxicity of the 1st line regime

Lancet 2000

- expensive- complicated- logistics- adherence

2000 1 clinician 25 patients Fee-paying

Malawi ART clinics 2002

TM&IH 2005

- Many lost to follow up- ATN - Poor adherence

Personal financeDrug shortage

2004 ART SCALE UP PROGRAMME

HIV Unit Ministry of HealthHIV Unit Ministry of Health

Global fund to fight AIDS-TB-Malaria

National ART Guidelines

Training of > 2000 clinicians and nurses

2004 ART SCALE UP PROGRAMME

HIV Unit Ministry of HealthHIV Unit Ministry of Health

Establishments of ART clinics within the existing HCS

PUBLIC HEALTH APPROACH TO ART

Large number of ART in RLS

Standardized than individualized

Simplified monitoring of treatment

Predominant use of Clinical Officers and Nurses

PUBLIC HEALTH PUBLIC HEALTH APPROACH TO ART APPROACH TO ART

ART to be free of charge

Follow experiences of the national TB programme

Standardised monitoring and reporting

PUBLIC HEALTH APPROACH TO ART

Quarterly supervision

Strong drug logistics

Harries et al - BMJ 2004

Cost of ARV drugs

Netherlands:

• Truvada®

• Stocrin®

USD 10,000 / year

Malawi: Triomune 30®

USD 100 / year

Malawi ART clinics 20082002

2010

5 377

270,000 patients started ART

9% children 9% children 60% females 60% females

• 93% on the same first line regimen

• 5% on alternative first line regimen

• <1% on second line regimen

Major Changes to the National ART Programme in 2011

PMTCT, Paediatric, Adult ART integration

Strategic phasing out of Stavudine

CD4 threshold increase

CHALLENGESCHALLENGES

Quantity versus Quality

Demand versus Supply

Shortage of health care personnel

Toxicity of the first line regime

CHALLENGESCHALLENGES

Early ART mortality

ART failure

ART delivery Infrastructure

Limited Laboratory Back up

DRUG SUPPLY DRUG SUPPLY CONTINUESCONTINUES

Possible reasons for the Drug Possible reasons for the Drug Shortage?Shortage?

•Increased # of clients on non standard regime.

•Inadequate financing or under-budgeting.

•Inefficiencies in supply and distribution chain.

SELECTED POINT SELECTED POINT EXAMPLES OF DRUG EXAMPLES OF DRUG

SUPPLYSUPPLY•Drug shortage is the main problem

•June 2010 3TC = 0, NVP = 117

•August 2010 3TC = 0, NVP = 0

•Sept. 2010 3TC = 55, NVP = 100

Conclusion Conclusion

Malawi ART Scale up Malawi ART Scale up Programme Programme

•Successful under difficult circumstances using public health approachLarge number of patients on ARTFavourable outcomes

• Many challenges

•Current Challenges

AcknowledgementsAcknowledgements

Joep van Oosterhout, M.D., PhD, Joep van Oosterhout, M.D., PhD, Associate Professor of Internal Associate Professor of Internal Medicine, University of Malawi, Medicine, University of Malawi, College of MedicineCollege of Medicine

AcknowledgementsAcknowledgements

James Blessings Mwambene, James Blessings Mwambene, Dip.Clin.Med, PGD(Mgt studies), Dip.Clin.Med, PGD(Mgt studies), The ART Outreach Coordinator, The ART Outreach Coordinator, Queen Elizabeth Central Hospital, Queen Elizabeth Central Hospital, MalawiMalawi

AcknowledgementsAcknowledgements

Cooper Nyirenda, M.D.,MMED, Cooper Nyirenda, M.D.,MMED, FRCP, Chief Govt. Physician, FRCP, Chief Govt. Physician, Queen Elizabeth Central HospitalQueen Elizabeth Central Hospital