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Patrice Joseph, MD,MSCI XIX International AIDS Conference July 22-27, 2012 Washington DC, USA

Patrice Joseph, MD,MSCI XIX International AIDS Conference July 22-27, 2012 Washington DC, USA. GHESKIO’ Experience and Impact in Global Health in Haiti. Outline. GHESKIO’s mission GHESKIO’s expanded mission Future directions Acknowledgments.

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Patrice Joseph, MD,MSCI XIX International AIDS Conference July 22-27, 2012 Washington DC, USA

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  1. Patrice Joseph, MD,MSCIXIX International AIDS ConferenceJuly 22-27, 2012Washington DC, USA GHESKIO’ Experience and Impact inGlobal Health in Haiti

  2. Outline GHESKIO’s mission GHESKIO’s expanded mission Future directions Acknowledgments

  3. Haitian Study Group on Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO) • Oldest institution in the developing world dedicated to the fight against HIV/AIDS (May 2 1982) • Mission: Operational research, services and training in HIV/AIDS and associated diseases • Partnership with: • The Haitian Ministry of Health,a founding member of GHESKIO • The Haitian Medical Association and 116 local institutions • Cornell, Fondation Mérieux and 12 international institutions • Continuous support from NIH (1983), Fogarty (1988), and Fondation Mérieux (1998) • Granted status of “Utilité Publique” by the Haitian government (2000)

  4. AIDS Challenges 1982-2012 • 1982-1990: Define the disease AIDS • Can the common OIs be treated? • What are the modes of HIV transmission? • 1991-2002: Can the AIDS epidemic be controlled? • Can a model for prevention and care be developed? • Can antiretroviral therapy be introduced? • 2003-present: Nationwide scale-up of comprehensive care model • Support from UN Global Fund and PEPFAR • 2010-present: Earthquake, cholera, and the national elections 1984-2012: political turmoil with departure of the Duvalier in 1986 followed by long period of instability and 2 foreign occupations

  5. Characteristics of the Acquired Immunodeficiency Syndrome (AIDS) in Haiti Jean W. Pape, Bernard Liautaud Franck Thomas , Jean-Robert Mathurin, Marie-Myrtha A. St. Amand, Madeleine Boncy, Vergniaud Pean , Moliere Pamphile, A. Claude Laroche , Warren D. Johnson Jr. NEJM 309:945-950, 1983 “The first description of AIDS in the developing world” • Clinical manifestations • Gastrointestinal • Dermatological • Pulmonary • 88% were males

  6. Tuberculosis and HIV: Findings with direct impact on clinical services and public heath • Can TB disease be prevented in those co-infected with HIV and TB? Yes Pape JW et al: The Lancet 342: 1993 • Can TB be cured in patients with AIDS?YesDesvarieux M et al: AMJPH 1997 • But recurrence rate is high but can be prevented Fitzgerald D et al; The Lancet 2001;375 • Rate of TB in persons seeking HIV testing is very highBurgess A et al, AIDS:15: 1875-1879 2001

  7. T Diarrhea and AIDS

  8. 1.9% for women on HAART Noel F et al PloS ONE 2008; 3 11; 1-10

  9. Elimination of congenital syphilis in Haiti Decentralize syphilis testing The national HIV network that makes it possible to couple syphilis with HIV testing Cases of congenital syphilis decreased from 1/ week to 1/4 months Use of rapid tests evaluated at GHESKIO: bioline. Goal: >95% of prenatal clinics to provide standard of care of same day testing and treatment for syphilis Herring et al A Multi-centre Evaluation of Nine Rapid, Point of Care Syphilis Tests Using Archived sera STI2006

  10. Mortality in HIV-infected children < 12 months old of PMTCT mothers Bactrim, formula HAART for Mothers with AIDS PCR/p-24 for early diagnosis and HAART in babies

  11. With ART 90% alive at 1 year When ART start early: 4 X less deaths and 2 X less TB

  12. Cornell-GHESKIO VCT model with integrated services Post-HIV exposure Counseling and HAART STI Management Pre-test Counseling HIV, Syphilis, Tuberculosis, Malaria Post-Test Counseling Reproductive Health Services (family planning and prenatal care) HIV+ women Prevention HIV MTCT with HAART Same day TB screening / Rx / Px • Care to HIV infected individual / affected family • OI Rx/Px • HAART for AIDS or CD4 count <350 • Nutritional support • Psychosocial support • Microcredit, jobs opportunity Rx = Treatment Px = Prophylaxis Peck R, et al : JAIDS:33;470-475, 2003

  13. GHESKIO Training: HIV (counseling,prevention/care of OI, ART, PMTCT), TB, Malaria , FP 3 other Spec. Training • (MPH) (2005) • Nurse Practitioner (2009) • Laboratory Technicians in collaboration with LNSP of Ministry of Health (2003)

  14. National Scale-up of Ministry of Health-GHESKIO Integrated Prevention and Care Model (2003-2012)

  15. ART care in the MOH-–GHESKIO Network • 38,029 on ART actively being followed in Haiti; about 40% in the MOH-GHESKIO network (56% at GHESKIO centers alone) • EMRs developed by GHESKIO are critical for care/retention : • Lab EMR: CD4, VL, resistance testing; • Clinic EMR: schedule visits, weight curve ; • Pharmacy EMR: drug adherence, change • Other tools to increase care/adherence • Multidisciplinary team approach (HIV-positive peer counselors, accompagnateurs, social workers, field workers • Communication tools : (cell phones/prepaid phone cards, GPS, contact list of team members, home visits) • Nutritional support and transportation fees • Educational material • Microfinance Source: Mesi May 2012

  16. GHESKIO Second Center Warren D Johnson Medical Center Rodolphe Merieux Laboratory February 9, 2009

  17. Earthquake impact on GHESKIO • 4 Staff members dead, 70 lost 1 or more family members • 65% of GHESKIO buildings damaged or destroyed Blvd Jean Jacques Dessalines Main Commercial Center

  18. New Tasks and Opportunities • Earthquake-related: • Acute Field Hospital and Rehabilitation Center • TB lab and TB treatment • Complete care for “tent city population” • Cholera • Treatment • Prevention

  19. GHESKIO Centers TB Cases: 2009-2011 The number of AFB screening smears: 18,700 (2009), 24,700 (2010) and 29,300 (2011) The number of MDRTB cases: 9 (2009), 30 (2010) and 61 (2011)

  20. GHESKIO’s BSL-3 Laboratory

  21. GHESKIO TENT City interventions Creation of 15 member Committee (11 men and 4 women) in charge of daily operations with support of 40 volunteers Census: 5,913 persons; 57% women; 20.5% children < 5 yrs. Daily inquiry on 4 symptoms/signs: cough, fever, diarrhea, skin disease. Those reporting one of these S/S are referred to dedicated medical team/clinic Immunization-Nutrition: pregnant/breastfeeding women/children 0-5 years ; Prenatal care; Prevention gender violence; STI control Jobs: 512 people employed for daily cleaning of the camp, in construction, in water management, for security Creation of a maternal and primary school for 300 children Creation of vocational school (construction work): 500 enrolled Creation of three soccer teams and youth club Creation of a group of women leaders .

  22. Cholera Interventions • Set up Cholera Treatment Centers (CTC) and Oral Rehydration Points (ORPs) • Training of health care personnel and community health workers • Improve water treatment and distribution of (ORS, Soap,jerry can, Aquatabs ect..) • Improve sanitation and hygiene through health promotional agents • Active screening of cholera in the slums through community agents • Conduct cholera prevention in market places and IDP camps • Conduct a compete census of the population in five huge slums • Set up a chlorine factory • Conduct with the MOH a pilot campaign on Oral Cholera Vaccination • Development of a model of prevention and care in the slums

  23. GHESKIO Centers expanded mission • Largest HIV/TB/STI care, training and research institution • Since quake: • Acute care Hospital with HHS followed by Rehab Unit: 16,000 patients up to May 2012 • Increasing TB and MDRTB care (4 x more TB in children) • Vocational school (400 trained in construction work) • Primary school for 400 chlildren • Global health program for internally displaced persons: lessons learned being implemented in large surrounding slums • Since Cholera • Running CTC s, CTUs, ORPs • Provided with MOH Oral Cholera Vaccine to 50,000 at risk persons in surrounding slums • Set-up of chorine factory • Rebuilding better: New Training Unit, new primary school, new MDRTB hospital, new Family Nutrition center

  24. GHESKIO Rebuilds New MDRTB Hospital in construction Family Nutrition Center in construction Prince Albert Primary School completed

  25. Future directions • GHESKIO mission will continue as the technical arm of the Ministry of Health in the control and prevention of infectious diseases such as AIDS, other sexually transmitted diseases, tuberculosis, and more recently cholera. • However, since the earthquake and the cholera epidemic, GHESKIO’s scope of work has broadened to include: • Global health (expand micro credits, primary school, nutrition) • Interventions to prevent (HPV vaccines ) and treat cervical cancer • TB control (MDRTB care/TB vaccines)

  26. Acknowledgements • Our patients • Our heroic staff • Our collaborators • Our donors

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