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DOTS in HIV/AIDS Services: An Essential Strategy for Treatment Adherence

Learn why Directly Observed Treatment, Short-Course (DOTS) is needed in HIV/AIDS services, its components, and the benefits of implementing DOTS in antiretroviral therapy. Explore community-based treatment models and the feasibility of DOT-HAART programs.

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DOTS in HIV/AIDS Services: An Essential Strategy for Treatment Adherence

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  1. Why there is a need for DOTS in HIV/AIDS services? Papa Salif SOW MD, MSc Department of Infectious Diseases Dakar University Teaching, Senegal 4th Meeting TB/HIV Working Group, Addis Ababa 20-21 september 2004

  2. Introduction • DOT short course revolutionized control of TB • Standardization of therapy with a reduction of morbidity and mortality • Patient dropout declined • Increase of cure and survival rates • Decrease of occurrence of MDRTB

  3. Components of the DOTS strategy in TB • Sustained of political commitment • Access to quality-assured diagnosis • Standardized short-course chemotherapy for all cases with direct observation of treatment • Uninterrupted supply of drugs • Recording and reporting system • A similar strategy for the control of the HIV epidemic is needed in HIV/AIDS services

  4. Antiretroviral for PLWHA • Increase access to ARV in resources-limited countries • Existing scaling up ARV programmes • “3 by 5” initiative • Then adherence to ARV regimens is essential • For therapeutic success • Reduction of resistant HIV strains in the community • Innovative approaches to adherence are required • DOT for HAART must accommodated to HIV

  5. Tuberculosis TB is curable Treatment is finite TB treatment can be mandated HIV infection HIV infection is not curable Treatment is lifelong HIV treatment is voluntary Tuberculosis versus HIV

  6. DOTS for antiretroviral therapy • Pilot studies were performed • DOT HAART • DAART: directly administered ARV therapy • MDOT : modified DOT • DOT for antiretroviral drugs required • Simplified ARV regimens • The sites of DOT provision • Identification of the ARVs DOT providers

  7. DOT for antiretroviral drugs • DOT HAART for marginalized HIV populations • Homelessness • Alcohol abuse • Drugs addiction • Prisoners • DOT HAART for HIV / TB patients • DOT HAART for the general HIV populations • Not marginalized and not HIV TB patients

  8. Community-based treatment of advanced HIV diseases: introducing DOT-HAART (directly observed therapy with highly active antiretroviral therapy Paul Farmer, Fernet Léandre, Joia Mukherjee, Rajesh Gupta, Laura Tarter, Jim Yong Kim Bull, WHO, 2001, 79 (12)

  9. DOT-HAART in Haiti • Providers: community health workers experienced in TB DOT • HAART was delivered at the HIV patients home • Results of the DOT-HAART project • Effective according to clinical and virological data • Reduces mortality • Lessens AIDS-related stigma • Improves medical staff morale • Boosts interest in HIV testing and counseling: contributes to prevention

  10. The Feasibility of a Community-Based Directly Administrated Antiretroviral Therapy Program Amy Rock Wohl, Wendy H.Garland, Kathleen Squires, Mallory Witt, Robert Larsen, Andrea Kovacs, Shannon Hader, Paul J. Weidle Clin Infect Dis 2004:38 (Suppl 5) S388-S392

  11. DAART in Los Angeles Country • For 6 months, trained community workers observed ingestion of 1 of 2 daily HAART doses, 5 days per week • Homeless population • Preliminary results showed • DAART was feasible in low income HIV patients • Effective communication is essential between • The DAART staff • The HIV patient

  12. Directly Observed Therapy (DOT) for Individuals with HIV. Jennifer Adelson Mitty, Grace Macalino, Lynn Taylor, Joseph Harwell, Timothy P. Flanigan Medscape General Medicine 5 (1), 2003

  13. The DOT-HAART program • Program focus on hard-to-reach populations • Active substance abusers • Social instability such as homelessness • Mental health disorders • HAART DOT provided by an outreach worker • Therapy is observed on 5 or 7 days of the week • This strategy had a significant impact on: • Improvement of quality of life • Morbidity and mortality reduction

  14. DOT for HAART: one element for a holistic approach • DOT for HAART in these population need to be integrated into a package: • Food support • Social support • Drugs (HAART and for opportunistic infections ) • Friendly environment with « a big smile » = DOTS-S: DOTS with smile! Gerald L.Baum and Joel Lefaire Intern J Tuberc Lung Dis 2003, 7(2):198-201

  15. DOT for antiretroviral drugs • DOT for marginalized HIV populations • Homelessness • Alcohol abuse • Drugs addiction • Prisoners • DOT HAART for HIV TB patients • DOT HAART for the general HIV populations • Not marginalized and not HIV TB patients

  16. HAART in TB patients 1.HIV Testing and counselling for all TB patients eligible for ARV. 2. The two programmes to collaborate to provide ARVs to HIV positive TB patients, each year

  17. ARV and TB: WHO guidelines

  18. Aim for TB and HAART: “3 by 5” Initiative To identify a new approach for TB programmes to act as an entry point for about 400,000 HIV-related TB patients, and gain access to ARV treatment, each year.

  19. A pilot study of once-daily antiretroviral therapy integrated with tuberculosis directly observed therapy in a resource-limited setting Jack Christopher, Lallo Umesh, Karim Quarraisha Abdool, Karim Salim Abdool, El-Sadr Wafaa, Cassol Sharon, Friedland Gerald JAIDS 2004, 36(4): 929-934

  20. Methods and results • Pilot study in TB clinic in South Africa • HIV testing and counseling for TB patients • Twenty TB and HIV patients received • Standard TB therapy • HAART once-daily: ddI (400mg) + 3TC (300mg) + Efavirenz (600 mg) • After TB therapy, patients were referred to HIV clinic • 17/20 completed combined TB and HIV therapy • TB was cured in 89 % of the patients • 88 % had viral load less 50 copies/ml • CD4 count increase of 148 cells/ml

  21. DOT for antiretroviral drugs • DOT for marginalized HIV populations • Homelessness • Alcohol abuse • Drugs addiction • Prisoners • DOT HAART for HIV TB patients • DOT HAART for the general HIV populations • Not marginalized and not HIV TB patients

  22. Is it possible to provide DOT HAART for HIV asymptomatic patient? • An adapted model in this context is needed • HIV treatment is lifelong • Patient no longer feels ill • Good results were obtained with ARV self-administered programmes • ARV education strategy • Multidisciplinary approach: social workers, pharmacists, community and family members

  23. Adherence to HAART and its principal determinants in a cohort of Senegalese HIV adults Isabelle Laniece, Mounirou Ciss, Alice Desclaux, Karim Diop, Fatou Mbodji, Bara Ndiaye, Omar Sylla, Eric Delaporte, Ibrahima Ndoye AIDS 2003, 17 (suppl 3): S103-S108

  24. The Senegalese approach • HIV patient education programme for ARV • Physician • Pharmacist • Social workers • Peer support group discussion • HAART self-administration • Adherence rate was high: more than 85 %

  25. Observance mensuelle moyenne en fonction de la durée de traitement chez 159 patients suivis de novembre 1999 à octobre 2003 médiane de suivi = 21 mois Observance moyenne mensuelle : 90% (IQR : 96 -100%)

  26. Main factors to influence adherence to HAART • Cost of the ARV regimen • Adherence better when cost is subsidized: no financial problem • Type of ARV combinaison • Adherence better in once-daily than other regimens • Financial problems when frequent transportation from home to the ARV clinic • DOT for HARRT may be inadequate and may not be useful for a majority of patients in this context

  27. The Senegalese strategy for improving adherence • Simplified ARV regimens • ARV Education programme • Self-administrated HAART at home • HIV testing, CD4 cells counts and ARV are free of charge: gratuity • 2 months ARV supply for motivated HIV patient

  28. Challenges for DOT HAART implementation in HIV services • Simplified ARV regimen: once-daily • Standardized ARV regimens: 1st / second line • Geographical accessibility of the DOT centre • Patient privacy • Issue of confidentiality within the DOT centre • Accessibility in time (opening hours) • Social stigma and discrimination • DOT adaptation to the patient’s lifestyle

  29. In Summary • DOT HAART with supervision must be indicated • For hard-to-reach HIV populations • And during co-administration anti-TB and ARV • Self-administration for HIV asymptomatic patient • Therapeutic education program • Adapted to the lifestyle of the patient

  30. Conclusions • Collaboration between TB and HIV programmes at all levels is needed • Strategy to increase adherence to HAART must be adapted to the HIV context and to the target HIV population • Additional operational research questions • Model of delivery • The best ARV combinaisons for DOT • The community involvement • The category of the provider • The location of DOT-HAART: community versus health centres

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