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OWN, SCALE-UP & SUSTAIN The 16 th International Conference on AIDS & STIs in Africa

Challenges in adapting chronic HIV/TB services to high mobile populations in Southern Africa Eric Goemaere , MD Médecins Sans Frontières IAS Washington , July 25 th 2011. OWN, SCALE-UP & SUSTAIN The 16 th International Conference on AIDS & STIs in Africa 4 to 8 December 2011, Addis Ababa

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OWN, SCALE-UP & SUSTAIN The 16 th International Conference on AIDS & STIs in Africa

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  1. Challenges in adapting chronic HIV/TB services to high mobile populations in Southern Africa Eric Goemaere, MD Médecins Sans FrontièresIAS Washington , July 25th 2011 OWN, SCALE-UP & SUSTAIN The 16th International Conference on AIDS & STIs inAfrica 4 to 8 December 2011, Addis Ababa www.icasa2011addis.org

  2. High mobility , high HIV and TB prevalence • High regional mobility • Different patterns of migration • Mobility = survival • Chronic care designed for residents • Migrants • Hardly attending health facility • Fear of deportation, health system barriers, xenophobia • Access to treatment often denied due to fears about adherence and continuity of care

  3. Failure to identify migrants at ART initiation triggers a high rate of loss to follow-up • Multivariate analysis -> AHR for LTFU in migrants at one year 6.69 ( 3.18-14.09) 14 % of migrants amongstART initiations Trends in loss to follow-up among migrant workers on ART in a community cohort in Lesotho Helen Bygrave1*, and all , Plos One , October 2010 | Volume 5 | Issue 10 | e13198

  4. Cd4 results collection among migrants testing HIV(+) Central Methodist Church, Johannesburg , 2009-2010 • Central Methodist Church is a shelter for up to 3000 homeless mostly Zimbabwean migrants in central Johannesburg • MSF opened a clinic in CMC in 2008 • Cd4 testing was initially implemented in a traditional passive way • After implementing a testing campaign and active case tracing, outcomes where significantly increased

  5. Defining the problem • HIV/TB care designed for resident population • Mobility = survival for migrants • Different treatment protocols in different countries • Medications & documentsfrequentlystolenorlossedduring irregular crossings • No cross-border information‘s on where and how to access services • Fear of arrest /deportation • Staff attitude towards migrants • Illegal fees

  6. Establishing mobile HIV/Tb units, Musina border, Limpopo, South Africa MUSINA • 21,000 living on commercial farms along border • Circular seasonal migration • Decentralized MSF/DOH nurse based mobile clinics on farms, offering PHC services but referral for integrated HIV/TB initiation . SOUTH AFRICA

  7. Initial outcomes : continuum of HIV care in farms HIV+ diagnosed population CD4 count sample provided 2171 CD4 results given 951 (44%) ART eligibility to ART initiation ART eligible 380 Pre-treatment steps Initiated ART 193 51% 95% CI 46%-56% Testing to etsablish eligibility

  8. Adapting services to integrated HIV/Tb care • ART and TB treatment initiation offered on the spot in farm • Point of care CD4 • Peer education network on farms (HIV awareness, linkage to care, adherence to ART/TB, defaulter tracing..)

  9. Adapted strategyfor providing HIV/TB care to "migrant" patients • Each visit, patient asked about travel plan and documented • Health passports + alternative treatment points

  10. When time to go , issued with a ‘travel pack’ • Temporary Transfer Out (TTFO): = plans to return (circular migration) • 3 months ARV supply + tail protection • If not intention to return, self addressed stamped envelope signed by receiving sites

  11. Impact of adapted strategy on continuum of HIV care HIV+ diagnosed population CD4 results given 951 (44%) 594 (81%) CD4 count sample provided 2171 735 ART eligibility to ART initiation ART eligible 380 226 Pre-treatment steps Initiated ART 193 ( 51% ) 95% CI 46%-56% 188 83% 95% CI 78%-88% 37% Testing to etsablish eligibility 32%

  12. Preliminary ART outcomes ,Musina TTFO n = 63

  13. Conclusions • HIV/TB care can be successfully adapted to migrant population pending : • clear regulations in terms of access to health care for non-nationals , including ART and TB • Access to be free of charge • Adapting health service to provide acceptable access • Harmonize ART practices, regimen & documentation -> Regional ART/TB health passport • Achievements of R9 global fund grant ( 12 M $) with SADC secretariat in Gaborone?

  14. Acknowledgements • TambuMatambo , Helen Bygrave, Gilles Van Cutsem • Mobile MSF/DOH teams in Musina • Department of Health, Limpopo , South Africa • People living with HIV in Musina

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