Background

IAC Presentation on Selected Findings Community Access to Treatment, Care, and Support Study (CAT-S)Sushil Koirala, MA. MPH. Program Manager, APN+

Background National PLHIV Networks in Asia and the Pacific region consistently shared that the

national authorities do not adequately document and share the barriers/enablers to PLHIV’s access to treatment, care and support

Information gathered through health system delivery and ad-hoc studies were not adequate to capture the real problems faced by PLHIV in the community

In February 2010, a meeting among 11 National PLHIV Networks from Asia and the Pacific region identified a need to monitor, document and share information related to the level of access to effective HIV treatment, care and support services in the region.

Asia Pacific Network of People Living with HIV/AIDS (APN+) facilitated the submission of a Rd. 10multicounty (7contries) proposal to the The Global Fund

Of which a small portion (10%) was approved in February 2011 for the design and implementation of community centric, community driven and community led study that captures real life experiences that are hindering/enabling access treatment, care and support among PLHIV in the region

Study objectives The overall objective of this study is to monitor and

document the issues related to PLHIV's access to HIV treatment, care, and support services in Asia and the Pacific region Assess the HIV treatment-related issues such as access to

pre-ART care, ART, ART adherence, treatment literacy, disclosure and stigma, high risk behaviours health seeking behaviours, financial burden, etc.

Develop baseline to measure longitudinal changes in the key issues (identified through phase I) in access to HIV treatment, care and support

FrameworkBangladesh Lao PDR Nepal Pakistan Philippines Vietnam Indonesia Consolidate

d Sample size 600 530 1,598 525 1,320 1,615 1,655 7,843

Number of data collectors

15 11 14 11 14 15 18 98

Ethical approval

Medical Research

Council (BMRC)

Center for HIV/AIDS

and STI (CHAS)

Nepal Health Research

Council (NHRC)

Bridge Consultants Foundation

DOH Ethics Committee

(DREC)

Ha Noi School of

Public Health

AtmajayaUniversity

Start interview date

26-Nov-12 4-Jan-13 1-Oct-12 21-Nov-12 6-Nov-12 4-Dec-12 17-Nov-12 1-Oct-12

Latest interview date

30-Apr-13 7-Mar-13 29-Mar-13 4-Mar-13 7-May-13 21-Mar-13 31-May-13 31-May-13

Average time to complete question in minutes

71 69 64 77 57 69 53 64

Respondents- Place of enrollment (%)

Bangladesh Lao PDR Nepal Pakistan Philippines Vietnam Indonesia Total0

10

20

30

40

50

60

70

80

90

100

98.7

8.4 7.7

11.2

13.0

91.926.3 22.5

11.2

17.7

34.7 38.1

75.4

18.433.4

18.8

96.6

22.123.2

9.4

20.949.8

15.0

Community HealthServices Hospital Self-help group Others

Respondents- Gender (%)

Bangladesh Indonesia Lao PDR Nepal Pakistan Philippines Vietnam Total0102030405060708090

100

57.050.3

46.4

57.9

67.8

87.6

53.160.1

42.341.9

53.6 40.7 30.1 11.0 46.6 37.4

0.7 7.8 1.3 2.1 1.4 0.4 2.4

Male Female Transgender

Respondents- Risk classifications (main,%)

Bangladesh Indonesia Lao PDR Nepal Pakistan Philippines Vietnam0

102030405060708090

100

4.5 8.5

40.8

22.326.9

13.31724

13

3227

3744

75.8

MSM Sex workers Injecting drug users Domestic migrant workers International migrant worker

Reasons for HIV test (%)

Bangladesh Indonesia Lao PDR Nepal Pakistan Philippines Vietnam Consolidated0

10

20

30

40

50

60

70

80

90

100

23.23128

3429

25 27 2734

23

82

28 30 282921 25

40

11

52

23

3328

45.7

Overseas working Refer by a doctor Spouse/partner/children get sick/deathddue to /HIV infectionWant to know Risky behavior Never choose, got result from a doctor

Place of initial HIV test (%)


102030405060708090

100

11

24

85

34

51

33

4336

1915

4

1611

41

6

17

6

31

6

169 6

29

18

61

21

0

3430

3

1822

49

51 0

18

4 7

Government hospital Private hospital/ clinic VCT center in hospita VCT center in NGO Others


100

200

300

400

500

600

281259

180

363 367

281 292 292

229201

108

310 320

254 240 244

Mean Median

Average baseline CD4 count (cells/mm3)

WHO 2010

WHO 2013

Average baseline CD4 count (%)


102030405060708090

100

50

38

58

33 2938

4739

1813 13 13

23 22 17 1716

29

1523 22 21

1622

16 2015

3127

20 19 22

Less 250 251-350 350-500 500 and more

Baseline CD4 and clinical referral for HIV test (%)

Clinical referral for HIV test included;- Referred by a doctor due to suspected HIV-related symptoms or being sick- Husband/wife/partner/child tested positive- Illness or the death of husband/wife/partner/child


102030405060708090

100

56 5778

42 3649 53 52

16 11

6

13 2419 16 15

13 197

21 1817 15 17

15 13 925 22 15 17 17

Less 250 251-350 350-500 500 and more

Baseline CD4 and NON-clinical referral for HIV test (%)


102030405060708090

100

5971

81

50 47

7258 63

1610

5

1227

13

1412

1112 6

1911

9

13 12

14 8 919 15

614 12

Less 250 251-350 350-500 500 and more

HIV diagnosis & baseline CD4 count

Duration of HIV

diagnosisBanglades

h Indonesia Lao PDR Nepal Pakistan Philippines Vietnam Consolidation

<1 year 268 278 204 335 324 216 408 258

1-2 years 256 252 243 407 341 319 399 312

2-3 years 291 259 177 378 351 317 346 309

3 years or more 288 257 171 352 379 293 273 290

Total 281 259 181 361 367 281 292 292

No Viral Load Test (%)


20

40

60

80

10098.8

80.9

13.2

78.6

26.0

85.682.5

74.7

** 7.8% - cannot remember

No viral load test vs. change of ART regimen (%)


20

40

60

80

100 98

66

6

72

6

76 75

63

99

81

18

76

18

82 84

73

Changed ART regimen* Never changed ART regimen

Cost of health care

Sick Past 6 months (%) Required Hospitalization (%)

0

10

20

30

40

50

60

70

80

90

100

26

43

9

63

12

71

2835

27

41

28

48

20 2321

41

Bangladesh Indonesia Lao PDR NepalPakistan Philippines Vietnam Consolidated

Bangla

desh

Indon

esia

Lao P

DRNep

al

Pakis

tan

Philip

pines

Vietna

m

Conso

lidate

d0

50

100

150

200

250

300

350

400

5280

4423

43

274

23

89100 113 117

39

99

350

150 132

Associated cost (USD)/ Episode Average income (monthly) USD

HIV Treatment Literacy

ARV regimen Regimen N %

Stavudin + Lamuvudin + Nevirapine 494 8.3Stavudin + Lamuvudin + Efavirenz 298 5.0Ziudovudine + Lamuvudin + Nevirapine 2318 39.0Ziudovudine + Lamuvudin + Efavirenz 1367 23.0Ziudovudine + Lamuvudin + Lopinavir/Ritonavir 87 1.5Staudinger + Lamuvudin +Lopinavir/Ritonavir 21 0.4Lamuvudin+Tenofovir + Nevirapine 358 6.0Lamuvudin +Tenofovir + Efavirenz 579 9.7Lopinavir + Ritonavir + Tenofovir 28 0.5Others 154 2.6Don't know 241 4.1

5,945 100%

Still using Stavudin: Indonesia- 6.7%, Laos 16.7%, Nepal 29.4%, Pakistan 20.4%, Philippines 9% Vietnam 16.6%, Bangladesh 0%

Self-reported ART Adherence Countries % with > 95%

adherence % never missed a

dose

% missed an appointment of

HCP Bangladesh 99.6 78.8 2.6Indonesia 78.5 48.2 11.4Lao PDR 49.3 83.7 9.1Nepal 72.7 70.4 3.6Pakistan 83.3 63.6 18.1Philippines 88.2 58.2 9.9Vietnam 70.1 60.3 12.7Consolidated 76.3 62.9 9.7

Conclusions Low self initiated HIV testing, indication of late diagnosis, low CD4 at

diagnosis Monitoring of viral load is almost non-existent in 5 out of 7 countries Despite large scale funding- cost of care is still a burden Mixed level of treatment literacy, some countries have lower

treatment literacy levels than others. Self-reported adherence is lower than 80% in 4 out of seven

countries. Less than 50% self-reported adherence in Laos Stavudine is still used in 6 out of 7 countries

Ways forward Data driven specific and clear message to the stakeholders at the country level Use of data for prioritization and funding (esp. NFM) Continue expanding database- recognize and include community stories (things

that most designs skip but are very important) Expanding alert reporting, human right violations, service mapping and

monitoring of quality of care Continue to build an engagement platform for the community to interact, share

and learn Design country specific study for phase II and monitor “changes” over time

Acknowledgement Asar Alo Society, Bangladesh National Association of People Living with HIV, Nepal Pinoy Plus, Philippines Association of People Living with HIV, Pakistan Lao Network of People Living with HIV, Lao PDR Vietnam Network of People Living with HIV, Vietnam GWL- INA, Indonesia

Full report and presentation can be downloaded at apnmata.org For questions, comments etc get in touch at [email protected]@apnmata.orgThank you!

Documents

Background