HIV Prevention, Treatment, and Care program in northern Tanzania

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HIV Prevention, Treatment, and Care program in
northern Tanzania

• John A. Crump, MB, ChB
• Duke University Collaboration
• Moshi, Tanzania

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Overview

• Duke University collaboration in Tanzania
• Location
• Partners
• Research with service activities
• Current studies
• Cost-effectiveness of free VCT
• HIV staging
• Future studies

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Kibongtoto National Tuberculosis Hospital
Kilimanjaro Christian Medical Center
KIWAKKKUKI
Tanzania
Kilimanjaro Region
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Duke collaboration in Tanzania

• Mid-1980s Muhimbili National Hospital, Dar es
  Salaam
• Mid-1990s Kilimanjaro Christian Medical Centre,
  Moshi
• 2002 scale-up of activities
• Research with service
• HIV prevention, treatment and care

Kilimanjaro Christian Medical Center (KCMC)
KIWAKKUKI
Kibongoto National Tuberculosis Hospital
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Kilimanjaro Region

• Population 1,376,702
• 1,088,611 (79) rural
• Chagga, Pare, Maasai
• Moshi town 200,000
• Economy
• Subsistence agriculture
• Coffee, sugar cane, sisal, flowers
• Tanzanite
• Tourism
• HIV
• Seroprevalence 8

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Kilimanjaro Christian Medical Centre

• One of four national referral hospitals
• 600 beds
• Northern Zone population 12 million
• Kilimanjaro Christian Medical College
• HIV/AIDS services
• Newly constructed HIV clinic
• gt1,000 HIV patients under follow up
• PEPFAR, Global Fund

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Gates Biotechnology Laboratory

• On KCMC campus
• Opened in 2005
• Supports
• Joint Malaria Programme (LSHTM)
• HIV Prevention Trials Network site (Harvard)
• HIV treatment and care studies (Duke)

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Kibongoto Hospital

• Tanzanias National Tuberculosis Hospital
• Local routine TB service
• National complex TB service
• 150 inpatient beds
• 40 patients HIV-infected

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KIWAKKUKI

• Womens volunteer organization
• HIV voluntary counseling and testing
• Moshi
• gt200 clients per month
• 17 HIV-infected
• HIV home-based care
• Kilimanjaro Region
• gt600 clients

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Duke collaborative studies

• KCMC
• Adult and pediatric HIV database projects
• HIV staging study
• Northern Zone health facility survey
• Antiretroviral maladherence and resistance study
• KIWAKKUKI
• VCT database project and special studies
• HIV home-based care cohort study
• Kibongoto Tuberculosis Hospital
• FDC ZDV/LMV/ABC in TB co-infected patients

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Duke collaborative studies

• KCMC
• Adult and pediatric HIV database projects
• HIV staging study
• Northern Zone health facility survey
• Antiretroviral maladherence and resistance study
• KIWAKKUKI
• VCT database project and special studies
• HIV home-based care cohort study
• Kibongoto Tuberculosis Hospital
• FDC ZDV/LMV/ABC in TB co-infected patients

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Cost-effectiveness of Free HIV Voluntary
Counseling and Testing through a Community-based
AIDS Service Organization in northern Tanzania
Am J Public Health 2005 in press
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Background

• Voluntary Counseling and Testing
• Cost-effective
• Reduces high-risk behavior
• Prevents HIV transmission
• Universal VCT recommended
• Uptake low in Tanzania
• Is free VCT cost-effective?

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Methods

• VCT testing volumes
• 35 weeks
• June-November 2003
• Free VCT testing campaign
• Before
• During
• After

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Methods

• Estimated costs under three scenarios
• Standard fee schedule
• Free testing campaign
• Sustained free testing
• Cost-effectiveness model
• Number and cost HIV infections averted
• Number and cost Disability Adjusted Life Years
  (DALYs) gained

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Persons receiving VCT per day KIWAKKUKI VCT,
2003 n813
Mean daily volume prior to free testing
Mean 15.0 plt0.0001
Mean daily volume during free testing
Mean daily volume after free testing
Number of clients
Mean 7.1 plt0.0001
Mean 4.1
June
August
July
September
October
November
2003
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Estimated Testing Volumes and Costs with various
VCT scenarios
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Cost-Effectiveness of VCT
Based on previous estimates of cost-effectiveness
of VCT in Tanzania (Sweat M, et al. Lancet
356113-121, 2000), our observed seroprevalence
(16.7), gender mix (women 3.6x more likely to be
HIV-infected than men), and estimated costs
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Conclusions

• Free VCT
• Increases the number of persons testing
• Averts more HIV infections at lower cost per
  infection averted
• Gains more DALYs at lower cost per DALY

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Health Policy Implications

• Investing in VCT through existing organizations
  is cost-effective
• Widespread provision of free VCT should be
  considered
• Must balance against cost-effectiveness of other
  programs within national HIV prevention,
  treatment, and care program

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Evaluating Simple Low-Cost Predictors of CD4
Count lt200 for Scale-up of Antiretroviral Therapy
in Developing Countries
Conference on Retroviruses and Opportunistic
Infections, Boston, MA, 2005. Abstract 638a
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Background

• CD4-positive T-lymphocyte count
• Important for making HIV treatment decisions
• Thresholds of lt200 and lt350/mm3 critical
• Flow cytometry technically difficult, expensive
• Not widely available in developing countries
• Alternatives
• WHO staging criteria
• Other CD4 technologies

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Conditions difficult to ascertain in many
developing countries
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Aim

• To evaluate the utility of clinical staging
  criteria, anthropometry, and simple laboratory
  tests for predicting CD4 count lt200 in Tanzania

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Methods

• Recruitment
• Recently diagnosed HIV-infected adults
• VCT centers in Moshi
• Procedures
• History and examination for WHO staging
• Mid-upper arm circumference, skin fold thickness
  for total body fat estimation, body mass index
• Complete blood count and differential, ESR, CD4
  count

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Results

• Patient characteristics (n129)
• 94 (73) female
• Median age 39 years (range 19-65)
• 99 (77) primary school education
• 61 (48) farmers
• WHO stage
• Stage 1 15 (12)
• Stage 2 23 (18)
• Stage 3 44 (34)
• Stage 4 47 (36)

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Distribution of CD4 count by WHO stage
CD4 count mm3
WHO stage
Interquartile range, range
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Total lymphocyte count by CD4 count
Total lymphocyte count x109/L
CD4 count x109/L
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Erythrocyte sedimentation rate by CD4 count
Erythrocyte sedimentation rate mm/hr
CD4 count x109/L
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Bivariable analysis of factors associated with
CD4 count lt200
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Multivariable analysis of factors associated with
CD4 count lt200
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Receiver operator characteristics of combinations
of clinical and laboratory predictors of CD4
count
Sensitivity
1 specificity
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Conclusions

• Clinical, anthropometric, and simple laboratory
  tests useful
• Trade offs between sensitivity and specificty
• Combination of total lymphocyte count, ESR, and
  skin exam
• Identifies gt90 patients with CD4 count lt200
• More useful for predicting CD4 count lt200 that
  WHO staging criteria

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Future activities (funded)

• AIDS International Training and Research Program
  (AITRP)
• International Studies of AIDS Associated
  Co-Infections (ISAAC)
• Tuberculosis Mycobacterium bovis
• Bacterial infections Bloodstream infections
• Mycology Cryptococcus neoformans
• Female genital tract HPV and cervical cancer
• Pediatrics Disease staging
• Community cohort Disease incidence

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Future activities (competing)

• Comprehensive International Program of Research
  on AIDS (CIPRA)
• Antiretroviral therapy maladherence, resistance
• International AIDS Clinical Trials Group (IACTG)
• Antiretroviral therapy treatment trials
• Center for HIV/AIDS Vaccine Immunology (CHAVI)
• Participation in HIV vaccine development efforts

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Acknowledgements

• Division of Infectious Diseases and International
  Health, Duke University
• John A. Bartlett, MD
• Nathan M. Thielman, MD, MPH
• John D. Hamilton, MD
• G. Ralph Corey, MD
• L. Barth Reller, MD
• Susan C. Morpeth, MB, ChB
• Keren Z. Landman
• Helen Y. Chu, MD
• Terry Sandford Institute of Public Policy, Duke
  University
• Jan Ostermann, PhD

• Kilimanjaro Christian Medical Center
• John F. Shao, MD, PhD
• Humphrey J. Shao, MD
• Habib Ramadhani, MD
• Evaline M. Ndosi
• Francis P. Karia, MBA
• Ahazi T. Kulanga, MBA
• KIWAKKUKI
• Dafrosa K. Itemba
• Anna Mgonja
• Kibongoto Hospital
• Leonard O. Uiso

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