HIV Prevention, Treatment, and Care program in northern Tanzania. John A. Crump, MB, ChB Duke University Collaboration Moshi, Tanzania
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1 HIV Prevention, Treatment, and Care program in northern Tanzania John A. Crump, MB, ChB Duke University Collaboration Moshi, Tanzania
2 Overview Duke University collaboration in Tanzania Location Partners Research with service activities Current studies Cost-effectiveness of free VCT HIV staging Future studies
3 Kibong toto National Tuberculosis Hospital Kilimanjaro Christian Medical Center KIWAKKKUKI Tanzania Kilimanjaro Region
4 Duke collaboration in Tanzania Kilimanjaro Christian Medical Center (KCMC) Kibong oto National Tuberculosis Hospital KIWAKKUKI 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
5 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%
6 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 >1,000 HIV patients under follow up PEPFAR, Global Fund
7 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)
8 Kibong oto Hospital Tanzania s National Tuberculosis Hospital Local routine TB service National complex TB service 150 inpatient beds 40% patients HIV-infected
9 KIWAKKUKI Women s volunteer organization HIV voluntary counseling and testing Moshi >200 clients per month 17% HIV-infected HIV home-based care Kilimanjaro Region >600 clients
10 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 Kibong oto Tuberculosis Hospital FDC ZDV/LMV/ABC in TB co-infected patients
11 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 Kibong oto Tuberculosis Hospital FDC ZDV/LMV/ABC in TB co-infected patients
12 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
13 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?
14 Methods VCT testing volumes 35 weeks June-November 2003 Free VCT testing campaign Before During After
15 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
16 Persons receiving VCT per day KIWAKKUKI VCT, 2003 n= Mean 15.0 p< Mean daily volume prior to free testing Mean daily volume during free testing Mean daily volume after free testing Number of clients Mean 7.1 p< Mean June July August September October November 2003
17 Estimated Testing Volumes and Costs with various VCT scenarios No Free VCT Free VCT Campaign Sustained Free VCT Cost (USD) Cost per client (USD) Cost (USD) Cost per client (USD) Cost (USD) Number Clients Tested 966 1,864 3,915 Cost per client (USD) Economic Parameters Building rent , Telephone , Power Advertising , Labor 8, , , Lab supplies , HIV test kits 2, , , Other , consumables Total cost 12, , ,
18 Cost-Effectiveness of VCT No free VCT Free VCT campaign Sustained free VCT Infections averted Cost per infection averted (USD) DALYs gained 1, , ,597.2 Cost per DALY (USD) Based on previous estimates of cost-effectiveness of VCT in Tanzania (Sweat M, et al. Lancet 356: , 2000), our observed seroprevalence (16.7%), gender mix (women 3.6x more likely to be HIVinfected than men), and estimated costs
19 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
20 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
21 Evaluating Simple Low-Cost Predictors of CD4 Count <200 for Scale-up of Antiretroviral Therapy in Developing Countries Conference on Retroviruses and Opportunistic Infections, Boston, MA, Abstract 638a
22 Background CD4-positive T-lymphocyte count Important for making HIV treatment decisions Thresholds of <200 and <350/mm 3 critical Flow cytometry technically difficult, expensive Not widely available in developing countries Alternatives WHO staging criteria Other CD4 technologies
23 Conditions difficult to ascertain in many developing countries
24 Aim To evaluate the utility of clinical staging criteria, anthropometry, and simple laboratory tests for predicting CD4 count <200 in Tanzania
25 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
26 Results Patient characteristics (n=129) 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%)
27 Distribution of CD4 count by WHO stage 1400 CD4 count mm 3* Stage 1 Stage 2 Stage 3 Stage 4 WHO stage *Interquartile range, range
28 Total lymphocyte count by CD4 count Total lymphocyte count x10 9 /L TLC 1.2x10 9 /L TLC >1.2x10 9 /L CD4 count x10 9 /L
29 Erythrocyte sedimentation rate by CD4 count Erythrocyte sedimentation rate mm/hr ESR >80 mm/hr ESR 80 mm/hr CD4 count x10 9 /L
30 Bivariable analysis of factors associated with CD4 count <200 OR 95% CI p-value Sensitivity % Specificity % Total lypmhocyte count 1.2x10 9 /L < Total white blood cell count <3.5x10 9 /L < Age 25 years Hematocrit <38% male, <35% female < Papular pruritic eruption < Eryhrocyte sedimentation rate >80mm/hr < Bicipital skin fold thickness 12mm male, 16mm female Minor mucocutaneous manifestations HIV wasting syndrome Bedridden for all or part of the day WHO stage Weight loss >10% Body mass index 21kg/m
31 Multivariable analysis of factors associated with CD4 count <200 OR 95% CI p-value Sensitivity % Specificity % Total lypmhocyte count 1.2x10 9 /L < Papular pruritic eruption < Eryhrocyte sedimentation rate >80mm/hr <
32 Receiver operator characteristics of combinations of clinical and laboratory predictors of CD4 count 2 of TLC 1.2, ESR>80 or PPE 1 of TLC 1.2, ESR>65 or PPE WHO 2002 Stage 4 or Stage 2/3 + TLC of TLC<2, ESR>80 or PPE 1 of TLC 1.2, ESR>80 or PPE WHO 2004 Stage 3 or 4 or Stage 2 + TLC 1.2 Sensitivity specificity
33 Conclusions Clinical, anthropometric, and simple laboratory tests useful Trade offs between sensitivity and specificty Combination of total lymphocyte count, ESR, and skin exam Identifies >90% patients with CD4 count <200 More useful for predicting CD4 count <200 that WHO staging criteria
34 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
35 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
36 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 Kibong oto Hospital Leonard O. Uiso
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39 Transparency Index Rank Country 1 Finland 2 Iceland 3 New Zealand 4 Singapore 11 United Kingdom 18 USA Tanzania 106 Zimbabwe 113 Uganda
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