Advocacy for improved medical care for HIV-positive persons

SolidarMed is working in rural remote regions within the national health systems of Mozambique, Tanzania, Zambia, Zimbabwe and Lesotho where people have only limited access to health care. Knowledge gained and lessons learnt in SolidarMed’s programmes are shared at different levels aiming at initiating discussion and ultimately change towards improvement of access to good quality health services.

In Lesotho, SolidarMed has been supporting the Ministry of Health since 2005 in the establishment and decentralization of antiretroviral treatment (ART) for HIV-positive patients. With 23.6 %, Lesotho has the third highest adult HIV prevalence worldwide (Demographic Health Survey 2009, MoHSW Lesotho). Despite massive national efforts in scaling-up ART-provision, only 57% of adults in need of treatment received ART in Lesotho by the end of 2009 (WHO/UNAIDS 2010). Lesotho therefore fell massively short of the UNGASS target of 80% treatment coverage by the end of 2010.

Evidence based advocacy

Getting patients on treatment is, however, not the only challenge in HIV programmes. With increasing numbers of patients on lifelong ART, the disease has become a chronic condition with also rising numbers of treatment failures. Identifying patients failing on first-line treatment and switching them to second line regimens is a question of life or death for these individuals – and a major challenge in ART programs in resource-limited settings. As a matter of fact, patients who are failing on a first-line regimen are often not or not timely switched to a second-line regimen. This leads to high mortality rates among patients who fail on first-line ART in resource limited countries (Keiser et al. Trop Med Int Health 2010, 15:251-258). The study on treatment failure, which is shortly described here, is an example of how SolidarMed achieved a change at national and local level for improved care of HIV positive patients.

Since SolidarMed started its HIV project SMART (SolidarMed antiretroviral treatment project) in Lesotho in 2005, more than 6100 patients have started ART in the catchment areas of the two long-lasting partner hospitals in the districts Butha Buthe and Thaba Tseka. 65% of these patients had still been under treatment by the end of 2011. These districts are rural and mountainous, and the majority of the population (about 132’000 persons) are poor subsistence farmers or migrant workers. Due to the decentralization of HIV services from hospitals to health centres and task shifting from physicians to nurses, the majority of patients are now able to access and continue HIV treatment at the nearest health centre. In this context, late detection of treatment failure has been recognized as a major challenge. This judgement was based on both observation of nurses’ performance during clinical consultations and on patient data: Since the beginning of the project, SolidarMed has monitored the clinical development of patients and progress of operations through routinely collected ART patient data.

To confirm treatment failure, a viral load measurement is required. Such viral load tests are relatively expensive (100 USD) and not available in Lesotho. In case of suspicion of treatment failure, the Ministry of Health in Lesotho provides funds for a limited number of viral load tests to be performed in a laboratory in South Africa. Having recognized the urgent need to identify patients who fail on first-line ART and to switch them timely on second-line, SolidarMed decided to conduct a study to assess a simpler and alternative clinical score to predict treatment failure (compared to the National guidelines). During the study, conducted in 2010, all patients who had been identified as fulfilling WHO failure-criteria (same as those in the national guidelines) received a blood measurement for HIV viral load. In case of confirmed treatment failure, clinicians have to write a request to a second-line committee headed by the Ministry of Health and Social Welfare of Lesotho. With permission of this committee, those patients can then be switched to second-line ART.

The study revealed not only a high number of patients with treatment failure that had not been detected and switched before. It also showed a high degree of uncertainty of WHO clinical or immunological criteria predicting “true” treatment failure as confirmed by viral load measurement (only 51% of suspects had confirmed treatment failure). Thus, the need for improved access to viral load testing to avoid delayed or unnecessary switch to 2nd line treatment became apparent. In addition, the study identified weaknesses in the process of switching patients, such as important time delays until the test result came back, and the lack of a standardized request forms for viral load testing.

Improvement of HIV services for the population

Results and lessons learnt of that study have been shared at facility and national level. At the hospitals, it has created awareness to more carefully assess patients for possible treatment failure and to develop routine procedures in requesting ARV 2nd line switches.

At national level, this issue has been discussed in meetings with the Christian Health Association of Lesotho (CHAL) and representatives of 8 out of 17 hospitals countrywide. The increased awareness has triggered a rise in viral load testing and of patients being switched to 2nd line regimens due to confirmed treatment failure. The study results have also been presented by the superintendent of one of the two partner hospitals in Lesotho at the International Conference on AIDS and sexually transmitted infections in Africa (ICASA) at Addis Abeba, Ethiopia.

In addition, SolidarMed and its partner CHAL organized a symposium in April 2012 with the participation of the Ministry of Health and main actors in HIV/AIDS in Lesotho (MSF, CHAI, Baylor, EGPAF, ICAP). It has resulted in an increased national awareness about the viral resistance problem, and in the development of standardized national procedures based on SolidarMed suggestions.

SolidarMed thus contributes to the improvement of HIV services for the population of Butha Buthe and Thaba Tseka districts in Lesotho by using different platforms and levels: Such as the here described study and symposium, but also through the collaboration within a research network (International Epidemiological Databases to Evaluate AIDS), through the presentation of its lessons learnt at ICASA and the World AIDS Conference, and, at least as important, the discussion of identified constraints and search for solutions together with its partners, national staff and patients at district, hospital and health centre level.

*Dr. Karolin Pfeiffer works as Desk Officer with Solidarmed in Lucerne, responsible for the Lesotho and Zimbabwe programme. http:/www.solidarmed.ch, Contact: k.pfeiffer@solidarmed.ch