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| HIV Care & Support |
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| Pakistan has an estimated 97,400 HIV cases (<0.1% general population prevalence NACP and UNAIDS estimations ) and the epidemic is rapidly progressing in risk groups such as injecting drug users, male sex workers. |
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The National and Provincial AIDS Control Programs under the leadership of the Ministry of Health and with full support of the Government of Pakistan have established 15 HIV Treatment and Care centers nationwide. These centers provide comprehensive HIV care services including free antiretroviral therapy, free advanced HIV diagnostics such as CD4 and HIV Viral load testing, management of HIV related opportunistic infections and counseling services to HIV positive people of Pakistan. To date nearly 3983 HIV positive people are receiving care and of these 1725 are on life saving antiretroviral therapy. |
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In HIV more so than other diseases quality of care determines good patient compliance. Without rigorous patient compliance and follow up, ART fails and the consequences are detrimental to the individual. HIV highlights the critical necessity of improving quality of health services through: improving our health delivery systems, strengthening community and out-reach linkages, building multisectoral responses at all levels, and simply better coordination. |
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| Role / Objective |
- To provide comprehensive HIV treatment and care services for adults and pediatric cases including free antiretroviral therapy, management of opportunistic infections, voluntary counseling and testing (VCT) services and management of acute/chronic care of HIV related infections to HIV + people and their families.
- Follow up and monitor treatment related adverse effects, toxicities and provide medical and psychological support in understanding both the disease and treatment demands.
- Provision of integrated PPTCT interventions in MCH facilities for all HIV+ women and their families including risk screening, counseling and safe infant feeding options.
- Availability and access to advanced HIV diagnostics such as CD4 and HIV viral load testing.
- Promote linkages with referral services (hospital based services), community organizations/NGOs and people living with HIV/AIDS (PLWHA) to enhance access to care and other support services (i.e. nutritional, financial, social)
- To reduce stigma of HIV through acceptance of HIV + people and create awareness of HIV as a treatable chronic medical condition.
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| Activities |
- Medical Care
- HIV/AIDS related medical care (acute and chronic management of HIV/AIDS)
- Management of Opportunistic infections
- Provision of Antiretroviral therapy (ART)
- In-patient ward admission facility
- Referral to specialist services (i.e. medical, surgical, pediatric, obstetrics-gynecology, psychiatric, dental etc)
- Pediatric care
- PPTCT interventions including C-section, safe delivery, infant feeding counseling, and ARV prophylaxis
- Counseling Services
- Pre-test counseling
- Post-test counseling
- Individual, couples, family and group counseling
- Out-reach peer counselors (PLWHA volunteers)
- Referral to COs/NGOs for social support services and PLWHA groups
- Laboratory/Diagnostics
- HIV ELISA
- CD 4 and HIV viral load PCR testing ( only available at PIMS, Shaukat Khanum Hospital and Sindh Services Hospital)
- General laboratory diagnostics
- Radiological support
- Facility to send out specialized tests to NIH reference laboratory
- Pharmacy
- Inventory of Antiretroviral medicines
- Medications for opportunistic infections & STIs including some common antibiotics
- Nutritional Counseling
- Daily caloric requirements
- Efficient utilization of resources to meet caloric requirements
- Healthy lifestyle choices
- Educational materials
- Referral to nutritional support opportunities if needed
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| Antiretroviral therapy (ART) |
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Antiretroviral therapy (ART) is the best available treatment for patients with AIDS. It
increases survival (for decades at times) and quality of life (to nearly normal) and may
even limit epidemic transmission. Availability of such treatment frequently improves the
conduct of prevention services by giving hope to people affected or infected with HIV.
Although governments have to weigh costs incurred on this expensive treatment against
other public health issues, global evidence suggests that this treatment is cost effective in
the long run.
Pakistan has successfully established HIV treatment in all provinces via a clinic based
model with locally and internationally trained staff. People Living with HIV (PLHIV) are
supported by NGOs and other support systems such as medicine and commodities
procurement and supply, monitoring, quality assessments etc are being developed or
refined.
While the clinics have been founded, 2 major gaps remain. One is that the quality of care
as measured by treatment failures remains suboptimal and secondly there has been
insufficient community based support for PLHIV. Sub-optimal quality of care rendered is
probably the most important reason for treatment failures. In part this is because the
system relies on junior physicians for care. Intermittent failures of support systems such
as medicine supplies have also contributed to the treatment failures. The other major gap
has been a lack of support network for many PLHIV that provides such support as
counselling, nutrition and logistics. Finally there are a few centres that are in place and
many of the PLHIV travel far to reach them.
In order to address the issues of poor quality of care by junior doctors, this proposal is
incorporating the involvement of more senior doctors to be provided in the medical
facility (large public sector teaching hospitals). In order to address this gap, a small
consultancy amount will be paid to senior doctors to participate in patient care in the HIV
care centres. Community support is addressed by provisions of small grants that allow
NGOs to support PLHIV in the communities they live in. |
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| HIV Treatment and Care Coordination Unit. |
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The main role of the NACP is to
coordinate the HIV care across the country and to develop and ensure quality standards.
The NACP will also procure anti-retroviral drugs (ARVs) and other supplies related to
HIV care in all of the country in order to benefit from bulk purchasing and economy of
scale. These responsibilities will be conducted by an “HIV Treatment Coordination Unit”
at the NACP, that will bring together many of the current NACP personnel already
working in these capacities. An HIV/AIDS specialist who is well versed in clinical
aspects of HIV treatment and its public health application will lead the unit. As there are
very few such individuals in the country (the Infectious Diseases Society estimates that
there are fewer than 15 trained Infectious Diseases specialists in Pakistan and only 1-2 of
these have expertise in public health), this position is to be filled at market based salary.
This arrangement is already in place and will be continued. NACP’s regular staff will
provide finance, logistics and procurement support related to HIV care.
The HIV care model being implemented in Pakistan is comprehensive and involves following modalities: |
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| ARV medicines |
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| ARVs are functionally divided into a primary regimen or 1st
line medicines and the second line medicines or secondary therapy. 1st line
medicines are those that are used for most patients and are the safest and/or the
cheapest. 2nd line medicines are equally potent, but work even when the virus in
a person’s body learns to resist the primary medicines. These are usually quite a
bit more expensive.
ARVs are to be procured using the computation that about 90% of the patients
will require primary regimen and 10% will need secondary regimens. Keeping
in view of the global annual rate to treatment failures, it is anticipated 10% of
the patients will fail primary regimens annually and require secondary regimen.
However the overall proportion remins about constant since patients requiring
secondary regimen have increased mortality; therefore the increase in the
number of patients requiring second line therapy will be offset by those who
expire. On the other hand, the decrease in the number of patients on primary
therapy will be offset by identification of new AIDS patients who will require
primary therapy. At the moment about 650 patients are receiving ARVs
nationwide from the NACP. Based on the newer case detection methodologies
now being used, this number is expected to increase by about 30% annually. |
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| Opportunistic infection medicines |
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A proportion of those who are first
identified as having transitioned from HIV to AIDS stage will develop a set of
unique infections that are collectively called opportunistic infections
(pneumocystis, fungal infections and to some extent tuberculosis). It is
anticipated that based on the anticipated results of the case finding system
(using the results of the pilot by one NGO for IDUs in 4 cities of Punjab),
approximately 2000 HIV+ individuals will be identified in year 1 and about
30% of these will have AIDS and therefore require drug therapy for
opportunistic infection prevention. An annual increase in detected cases of 30%
is anticipated based on current experience. |
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| STI medicines |
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Condoms
Since HIV+ patients have sexual intercourse (including risky behaviours), some
provision is made for STI treatments (to about 10 patients per centre annually)
and STI/HIV prevention (Positive Prevention) in the HIV care centres. This
will be in the form of condoms (about 10 condoms monthly to about half the
patrons). Furthermore, since many centres are frequented by people wishing to
know their HIV status (a consistent observation during the past 2+ years of
operation of these centres), some support (training of the staff in VCT and provisions of some rapid testing kits) is provided for VCT at the centres. |
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| CD4-T-Lymphocytes count |
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HIV Viral Load measurement tests
Treatment efficacy and monitoring are essential for the success of HIV care of
patients with AIDS. This monitoring is done using measurements of CD4-TLymphocytes
and HIV Viral Load, both specific tests of the effects of the virus on the body that are altered by treatment. |
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Pneumococcal vaccines
The standard of care today is to identify and treat Viral Hepatitis among HIV+
patients and to inoculate against certain infections that cause avoidable
morbidity or mortality – in turn reducing the overall cost of treatment of HIV+
individuals in the long run. In this regard, pneumococcal vaccine is being made
available in the clinic via a GFATM grant and the policy will be continued
during this project. Treatment of Viral hepatitis will be sought from the Prime
Minister’s Programme for Hepatitis via a linkage mechanism. A maximum of about 3000 patients are anticipated to receive these services. |
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