Center for Global Development Marie M H Deschamps,MD Deputy Director, GHESKIO Centers WDC,December 4,2009
Outline Background and Context GHESKIO Mission and impact GHESKIO expansion of services and IMIS Perspectives
Haiti Population: 9,400,000 Maternal mortality rate: 642/100,000 Majority (80%) of women deliver outside a health care setting Infant mortality rate: 74/1,000 HIV vertical transmission rate estimate at 30% without intervention. Life expectancy at birth: 60.78 yrs 50% of population earns less than $2.00/day MD/10,000 inhabitants ratio : 2.5
Background It is the most affected country by HIV after those in Sub-Saharan Africa. It is estimated that there are up to 235,000 adults and as many as 11,800 children are living with HIV/AIDS. Approximately 3% of the women visiting prenatal clinics are HIV (+)
HIV Prevalence (%) National HIV Seroprevalence studies in Haiti (1993 2006) 18.0% 16.0% 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% National HIV and syphilis Seroprevalence 1993-2003* 7.6% 6.1% 5.6% 6.2% 6.0% 3.5% 4.5% 3.1% 1993 1996 2000 2003 HIV SYPHILIS *Pregnant women at 1 st prenatal visit National HIV seroprevalence: DHS (2005-2006)** 3 2.5 2 1.5 1 0.5 0 Urban Rural Total Women Men Both * *5250 women and 4855 men
Profile of GHESKIO Centers Institution Created in 1982 Recognized as Public Utility in 1996 Strong partnership with public sector and other private institution (Universities, other NGO) National Referral Center for HIV/AIDS/TB/STI/F.P Mission: Provide services, training of medical and paramedical personnel, and operational research
GHESKIO/MOH comprehensive model with integrated services STI Management Post-HIV exposure Counseling and HAART Pre-test Counseling HIV, Syphilis, Tuberculosis Reproductive Health Services (family planning and prenatal care) HIV+ women Prevention HIV MTCT with HAART Post-Test Counseling Same day TB screening / Rx / Px Rx = Treatment Px = Prophylaxis Care to HIV infected individual / affected family OI Rx/Px HAART for AIDS or CD4 count 200 Nutritional support Psychosocial support
Map of greater PORT-AU-PRINCE GHESKIO GHESKIO
The GHESKIO Institute of Infectious Diseases and Reproductive Heath (GHESKIO-IMIS) February 10, 2009
Heterosexual Transmission of HIV infection in 475 Discordant Couples 8 7 6 5 4 3 2 1 0 5.4 Yes Sexual Activity 0 No 1 Yes 6.8 No 7.6 Female Condoms Clinical Disease in Index 4.8 Male 6.82 Gen. Ulcers 2.89 Ser. Syphilis STI in HIV - Spouse 2.58 Gen. Discharge Deschamps MM, Pape JW, Hafner A and Johnson WD Jr. Heterosexual Transmission of HIV in Haiti. Ann Intern Med;125:324-330, 1996.
Source: Deschamps, M. et al. HIV infection in Haiti: Natural History and Disease Progression. AIDS 2000, 14:2515-2521. Background and Context Haiti and HIV AIDS in Haiti characterized by rapid progression 0 1 2 3 4 5 6 7 8 Seroconversion 0 years Clinical AIDS 5.2 years CD4<200 6.8 years Death 7.4 years
Individuals New individuals tested for HIV at 35000 GHESKIO (VCT Center) 30000 25000 23313 24116 24691 26921 28780 20000 21279 15000 10000 5000 7987 8757 10310 13245 16087 0 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Years
HIV prevalence among new individuals tested for HIV at GHESKIO (VCT Center) Percentage 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 33% 67% 34% 66% 29% 71% 26% 74% 23% 77% 19% 81% 19% 81% 17% 83% 17% 17% 16% 83% 83% 83% 15% 13% 12% 85% 87% 88% 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Negative Positive Years
Individuals New individuals tested for HIV at GHESKIO (VCT Center) by sex 20000 18000 16000 14000 12000 10000 8000 6000 4000 2000 0 4859 3108 5468 3288 6684 3625 8809 4436 10726 5355 15574 14110 7167 7734 15832 8282 16312 8379 18284 8637 18421 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 8671 Female Male
Individuals New youth people* tested for HIV at GHESKIO (VCT Center) 10000 9000 8000 7000 6000 5000 4000 3000 2000 1000 0 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Years *Individuals from 10 to 24 years old Population Women Men
Percentents HIV Prevalence among new youth people* tested for HIV at GHESKIO (VCT Center) 100% 95% 14% 10% 11% 10% 9% 9% 8% 6% 6% 5% 90% 85% 80% 86% 90% 89% 90% 91% 91% 93% 94% 94% 95% 75% 1999 2000 2001 2002 2003 2004 2005 2006 2007 2007 Negative Positive Years *Individuals from 10 to 24 years old
Percentage HIV Prevalence among people tested at GHESKIO (VCT Center) 35% 30% 25% 20% 15% 10% 5% 0% 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Males Years Females
Percentage Syphilis prevalence among Adolescents and young adults* tested at GHESKIO (VCT Center) 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Years Males Females Population *From 10 to 24 years old
Prevalence of HIV among street children examined at GHESKIO, per age group Age Group Women Men Total (Year) % % % 15-19 19 5.5 10.4 20-24 24.2 22 24 Total 15 5.6 9.2
Knowledge and Behavior of the Youth visiting the GHESKIO Centers n=4,113 85 % were self referred 67% of the boys and 56% of the girls are in secondary school 85% of them are informed of HIV/AIDS through radio and TV broadcasts 48% of the boys and 74 % of the girls had their first sexual experience when they were 15-19 years old. Only 19 % of the girls and 21% of the boys used a condom during their first sexual experience.
Knowledge and Behavior of the youth visiting the GHESKIO Centers ( cont.) 90% of both boys and girls know that condoms protect. Only 9 % of the girls and 25% of the boys regularly use condoms 38% of the boys and 5 % of the girls had more than one sexual partner during the last 6 months 24% of the boys and 33 % of the girls had a previous STI Only 14% of the boys and 9% of the girls think they are at risk for HIV.
Behavioral Changes among Young Adults in Haiti 15 19 Y/O 15 19 Y/O 20-24 Y/O 20-24 Y/O Males Females Males Females 1999 2003 1999 2003 1999 2003 1999 2003 Excellent Knowledge of AIDS 24 54 26 45 29 60 33 54 Sex with occasional Partner 50 12 31 2 60 20 52 2 Condom use at last Contact 50 52 37 25 48 63 36 88
Survival and Response to ART 12 month survival Viral load <50 Adults (910) Children (191) Adolescents (146) 87% 81% 87% 76% 56% 49% Severe et al. N Eng J Med 2005; 353:2325-34. George et al. J Infect Dis 2007; 185:1411-8. Charles et al. 2007; Submitted.
Individuals Pregnant woman tested for HIV at GHESKIO (VCT Center) 3500 3000 2915 2500 2521 2000 1500 1658 1909 1970 2079 1000 964 977 500 0 480 95 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Years Pregnant women
Individuals HIV prevalence among Pregnant woman tested at GHESKIO s VCT center 18.0% 16.0% 14.0% 12.0% 10.0% 16.4% 16.4% 12.1% 10.9% 10.4% 15.2% 14% 11% 8.0% 6.0% 4.0% 2.0% 0.0% 2001 2002 2003 2004 2005 2006 2007 2008 Years Prevalence (%)
Individuals Syphilis prevalence among Pregnant woman tested at GHESKIO s VCT center 14.0% 12.0% 10.0% 8.0% 12.2% 10.1% 8.3% 10.6% 9.1% 7.4% 7% 6.0% 4.0% 5% 2.0% 0.0% 2001 2002 2003 2004 2005 2006 2007 2007 Years Prevalence (%)
PROGRESSION ANNUELLE DE LA PRISE EN CHARGE DES VICTIMES DE VIOLENCE SEXUELLE DANS LES CENTRES GHESKIO De 2001 à juin 2009 600 500 503 481 2001 2002 400 372 337 2003 2004 300 272 2005 2006 200 164 2007 2008 100 42 58 67 2009 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 N.B.: 2298 victimes de 2001 à Juin 2009 soit 22 mâles et 2276 femelles
Women s empowerment Micro credit was introduced in 2005 to women visiting GHESKIO s reproductive health unit in collaboration with the MIF institution (ACME), support of UNFPA and Merieux Foundation. The objective is to empower women and develop income generating activities. A fixed interest rate of 2%/month was granted. 688 (42%) of the 1638 beneficiaries were HIV+, and 269 (39%) of the HIV Positive beneficiaries had AIDS and receiving HAART. The majority 1474 (90%) of the women had no other income. The capacity to repay the loan was used to evaluate the impact.
Loan portfolio as of July 2009 2879 loans to 1638 individuals Loan Cycle Number of Loans HIV Positive HIV Negative Loan Amount in HTGS Loan Amount in US Dollars First 1638 688 950 10,194,500 254,862.50 Second 717 316 401 6,422,000 160,550.00 Third 296 166 130 3,282,500 82,062.50 Fourth 104 76 28 1,309,000 32,725.00 Fifth 60 46 14 931,500 23,287.50 Sixth 40 31 9 850,000 21,250.00 Seventh 19 12 7 553,500 13,837.5 Eight 5 4 1 290,000 7,250 Total 2676 --------- --------- 23,833,000 595,825.00 One US Dollar is equal to 40 HT Gourdes: 1638 individuals received 2879 loans
Reimbursement rate of the portfolio by clinical status - March 2005 July 2009 Total Non AIDS AIDS First Loan 93% 89% 97% Second Loan 88% 83% 93% Third Load 97% 97% 97% Fourth Loan 98% 99% 97% Fifth Loan 88% 89% 87% Sixth Loan 86% 90% 82% Seventh Loan 84% 90% 78% Average 91% 91% 91% *Among 688HIV(+) 264 (38%) had AIDS and are receiving HAART
GHESKIO National Expansion services for Prevention and Care of HIV/AIDS/TB/Malaria (MOH/GHESKIO network) 43 HIV sites supervised by GHESKIO - PEPFAR - FM 11 Malaria sites GHESKIO Centers Multidisciplinary mobile teams essential for supervision, monitoring and continued on the job training
Interventions (as of 12/2008) NATIONAL GHESKIO Tested and counseled for HIV and syphilis 1,692,614 517,395 Tested for HIV 1,272,688 447,622 HIV-infected 99,143 44,425 Tested for syphilis 880,590 379,685 Serology + for syphilis 52,991 23,817 Pregnant women tested for HIV and syphilis 781,329 178,986 HIV-infected pregnant women 14,802 5,396 Patients treated for STIs n/a 48,579 HAART 18,558 9,054
ART Network MOH and Gheskio Sept, 2009 All HAITI (www.mesi.ht) MOH/Gheskio Network % # Patients placed on ART # Active Patients 30, 886 15,576 50% 24, 655 12,490 51%
CSW and HIV prevalence Haiti N=352 Prevalence HIV+ 16 / 352 (5%) RPR+ 22/352 (6%) GRA+ 34/352(9.6%)
Cost per sex exchange Haiti site Haiti site recruitment areas: n=5 Payment per sexual contact (Range :US) Port au Prince $0.50 - $2.40 Delmas $2.40 - $6.00 Carrefour $0.50 - $2.40 Croix Bouquets $ 0.50-$2.40 Pétion -Ville $2.40 - $6.00
Distribution of Sex Workers according to their worked areas N = 293 Non défini N = 11 (3.8%) *** 2 HIV+ Croix-des-Bouquets (Plaine) N = 10 (3.4%) Carrefour N = 127 (43.3%) *** 2 HIV+ Port-au-Prince N = 104 (35.5%) *** 10 HIV+ Delmas N = 28 (9.6%) *** 1 HIV+ Pétion-Ville N = 13 (4.4%)
Summary/Perspectives Women, Adolescents, CSW, particularly young girls are the most vulnerable : Lack of education-poverty. There is the need for national scale up services for FP services, ARV, antenatal care to decrease MM and prevention of HIV, syphilis, unwanted pregnancy, cervical, breast cancer.. GHESKIO women s health clinic will be created to focus those needs with the MOH in collaboration with partners.