Raising the Bar: An Equity and Community Based Approach to Pediatric HIV in Haiti

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Raising the BarAn Equity and Community Based
Approach to Pediatric HIV in Haiti

• Joia S. Mukherjee, MD, MPH
• Medical Director, Partners In Health
• Assistant Professor, Harvard Medical School

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Childhood
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Health Statistics

• 12 million children under the age of five die
  every year
• 160 million children are severely or moderately
  malnourished.
• 1.4 billion people lack access to safe water
• 2.7 billion people lack adequate sanitation.

4
Social Milieu

• 30 million children are not in primary school
• 250 million children are engaged in some form of
  labor.
• 300,000 children served as soldiers in national
  armies.

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Causes of Child Mortality

• 54 of child mortality 4 diseases
• 19 pneumonia
• 17 diarrhea
• 10 neonatal sepsis
• 8 malaria
• Half of all under 5 deaths have underlying
  malnutrition

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Major causes of death among children under five,
world, 2000
Deaths associated with undernutrition 60
Sources For cause-specific mortality
EIP/WHO. For deaths associated with
malnutrition Caulfield LE, Black RE.
Malnutrition and the global burden of disease
underweight and cause-specific mortality. Paper
in preparation.
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Haiti Health Statistics

• Population7.5 million
• Urban Population36
• Population Growth Rate1.7
• Life Expectancy51.6 years
• Infant Mortality76 per 1,000 live births
• Under Five Mortality123 per 1,000 live births
• Maternal Mortality Rate520 per 100,000 live
  births
• GNP Per Capita480
• Percent of Population With AccessTo Safe
  Drinking Water46

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Water Poverty Index147 Countries
Rank 1
Rank 11
Rank 32
Rank 34
Rank 147
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Maternal Mortality per 100,000Live Births
Source PAHO 2002
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Haiti, Maternal Mortality Beyond Official
Statistics
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Affect of the AIDS Pandemic
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Trends in general mortality among children yrs by adult HIV prevalence rate, 1999
110
Zambia
105
HIV prevalence 19.9
100
Relative under-5 mortality (1981 100)
95
Kenya
HIV prevalence 14.1
90
Cameroon
85
HIV prevalence 7.7
80
80
82
84
86
88
90
92
94
96
98
Source Demographic and Health Surveys, Macro
International, USA
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Estimated Impact of AIDSUnder-5 Child Mortality
2010
with AIDS
per 1000 live births
250 200 150 100 50 0
without AIDS
Botswana
Kenya
Malawi
Tanzania
Zambia
Zimbabwe
Source US Bureau of the Census
UNAIDS 1 December 1999
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How are children affected??

• Orphaning
• Food
• School
• Insecurity

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AIDS Orphans

• By the end of 2000, 13 million children will be
  orphaned by AIDS
• More than 90 percent of the children orphaned by
  AIDS live in sub-Saharan Africa.
• One in every 3 children orphaned by HIV/AIDS is
  under age five. 19 sub-Saharan countries will
  have a combined 40 million orphans by 2010
• 35 countries have experienced a doubling,
  tripling, or quadrupling of the number of orphans
  between 1994 and 1997.
• Before AIDS, 2 percent of all the children in
  developing countries were orphaned. At the end of
  the 90's, 7, 9 and even 11 percent of children
  are orphaned int the hardest hit countries.

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Reduction in production in a household with an
AIDS death, Zimbabwe

• Crops Reduction
• Maize 61
• Cotton 47
• Vegetables 49
• Groundnut 37
• Cattle owned 29

Source Stover Bollinger, 1999
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Impact of HIV/AIDS on Urban Households, Côte
dIvoire
General population
Families living with AIDS
30 000 Francs CFA
25 000
Monthly income per capita
20 000
15 000
Monthly consumption per capita
10 000
5 000
Savings/Disavings
0
5 000
Source Simulation-based on data from Bechu,
Delcroix and Guillaume, 1997
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Estimated deaths in children (HIV/AIDS during 2000
Eastern Europe Central Asia Western Europe North America East Asia Pacific 1 000
North Africa Middle East 7 100
South South-East Asia 40 000
Caribbean 3 100
Sub-Saharan Africa 440 000
Latin America 3 000
Australia New Zealand Total 500 000
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How are children infected?

• 70-90 of the transmission occurs in the
  peripartum periodduring delivery rather than
  in utero
• Factors that increase transmission include
• Prolonged rupture of membranes
• High maternal viral load
• Low maternal CD4 count (independent of viral
  load)
• Babies of HIV postive mothers who are breast fed
  have a 16 additional risk of transmission.
• Poverty, lack of prenatal and maternity care,
  lack of antiretroviral medicines

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How are children infected?

• Mother to child transmission
• Transmission of HIV from mother to infant occurs
  in about 30 of births of untreated HIV positive
  mothers.
• AZT to mothers reduces the risk of transmission
  to less than 8
• ART combined with cesarean section and a
  reduction in duration of ruptured membranes
  lessens risk to ? 2
• Risk of transmission is less when mothers are on
  triple therapy
• No testing, no medicines

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Breast feedingin HIV positive womenKenya,
randomized trial (JAMA 2001 Nov
21286(19)2413-20)

• Mothers were randomly assigned either to use
  formula (n 186) or to breastfeed (n 185)
• Two-year estimated mortality rates
  formula-feeding and breastfeeding were 20.0 vs
  24.4
• No difference in the incidence of diarrhea or
  pneumonia
• Infection with HIV-1 was associated with a
  9.0-fold increased mortality risk (95 CI,
  5.3-15.3).
• HIV-1-free survival at 2 years was significantly
  higher in the formula arm.

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Breast feeding risk and duration of breast feeding

• Study of 499/2375 HIV-1positive women who breast
  fed their infants (East Afr Med J 2001
  Feb78(2)75-9)
• Overall risk of breast milk HIV-1 transmission
  16
• 47 of HIV-1 infections were attributable to
  breast feeding. (among breast feeding infants)
• Breast milk transmission risk was 21 when breast
  fed ? 3 months and 13 when breast feeding
  months.
• 702 infants (in a separate analysis) with breast
  feeding beyond 3-6 months had a late postnatal
  risk of HIV transmission of 4

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HIV in Adolescents
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Gender Inequality

• Financial or material dependence on men
• Often women cannot control when, with whom, and
  under what circumstances they have sex
• Many women have to exchange sex for material
  favors, for daily survival
• Domestic servitude

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HIV Diagnosis
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Diagnosing Pediatric Infection
-Difficult to know if the baby is HIV infected or
not -Transmission through breast milk accounts
for up to 30 of pediatric infections
Diagnosis ??
ELISA will be positive for 12-18 months
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Diagnosis Treatment in Children Diagnosis
ELISA will be positive for 12-18 months
Diagnostic test not available
Positive Virologic test
Symptomatic
Asymptomatic
Cotrimox. Prophylaxis 6 month or 1 year
Antibody at 12-15 mos ?Treat with HAART?
Not severely ill treat infections and defer HAART
AND
HAART if symptomatic
Retest ELISA at 18 months or if symptomatic
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Thanks to I-TECH
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• Foto test
• Foto

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Advantages to earlier diagnosis

• 15 HIV infected infants die within first 12
  months of life
• Ambiguous HIV status can lead to
• Uncertainty regarding when to start ART
• Uncertainty regarding differential diagnosis
• Unnecessary use of co-trimoxazole prophylaxis
• Concern for the parents

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Treatment
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Trends in Age-Adjusted Death Rate due to HIV
Infection,1982-1998
Using the age distribution of the projected
year 2000 US population as the standard.
Preliminary 1998 data
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The Outcome Gap
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Its too hard2000
It's 17 to 25 pills a day... Every two hours....
And you have to change the cocktail every three
or four months , or you can die from the toxicity
of the drugs.
'Many people in Africa have never seen a clock
or a watch their entire lives. And if you say,
one o'clock in the afternoon, they do not know
what you are talking about.'
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DOT-HAART Supervised Therapy for Advanced HIV
Disease, 2001

• Over 1500 HIV-positive people followed
• 60 patients treated with DOT-HAART
• Each DOT-HAART patient has an accompagnateur.
• Accompagnateurs observe ingestion of the therapy
  at least once a day.
• They all gained weight

Farmer, P et al. Lancet 2001 358
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Basing treatment on rights rather than ability to
pay 3 by 5
Mukherjee, JS The Lancet 363, 2004
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The drugs are too expensive
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IDA quality controlled 300 USD/pt/yr
Clinton Foundation 150 USD/pt/yr
Generic Prioprietary with WHO preapproval 800
USD/pt/yr
Concessional pricing, proprietary 1600
USD/pt/yr
Full price, proprietary 10,000 USD/pt/yr
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Original Covenants from UDHR

• Civil and Political Rights
• Vote
• Judiciary
• Free speech
• Privacy

• Social and Economic Rights
• Food
• Shelter
• Jobs
• Health Care

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• The Global Fund to Fight AIDS, TB, and Malaria
  was created to increase resources available to
  treat these diseases
• US 4.7 billion in financing 2001 to 2008.
• Committed US 1.5 billion in funding to support
  154 programs in 93 countries worldwide.

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AIDS treatment siphons resources from primary
care
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Integrated HIV Prevention and CareStrengthens
Primary Health Care
Walton, D et al. J.Pub Health Pol 25( 2), 2004
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Affect on General Medical CareNumber of
Ambulatory Visits per Day
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There isnt enough absorptive capacity
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From Directly Observed Therapy toAccompagnateurs
Behforouz, H et al CID 200438 (Suppl 5)
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Central Department pop 500,000
Clinic
Expected HIV 20,000 Expected active TB 1500
MD 15
RN, Pharm, Lab 40
Auxilliaire 100
Ajan Sante/Ajan Fanm 200
Accompagnateurs 500
Community
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Expansion Successes

• Over 8000 HIV-positive people followed
• 1500 patients now being treated with directly
  observed HAART (DOT-HAART).
• 6 public health clinics are operational in the
  central plateau now with 341000 ambulatory visits
  per year

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Efficacy of ART in Resource-Poor Settings

• ART treatment programs in resource-poor settings
  have efficacy rates similar to those reported in
  developed countries.
• The provision of medications free of charge to
  the patient is associated with a significantly
  increased probability of virologic suppression at
  months 6 and 12 of ART.

Ivers, L et al. CID 200541 (15 July)
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I like taking my medicines, because I love
school.
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