Missing the Target North Africa :  Barriers to Access to HIV  Treatment in Six Countries  of North Africa                 ...
About ITPCITPC: Worldwide coalition of PLWHIV and their supporters and advocates. Uses a community based approach to achi...
North Africa ContextMENA region has the lowest coverage rate of access to HIV treatment in the world : 11%No data on Nor...
Objectives of the researchIdentify barriers to access to HIV treament from Civil Society and PLWHIV perspectiveDevelop c...
MethodologyIncountry research teams:  all community activists  including 2 PLWHIV  Mauritania, Morocco, Algeria, Tunis...
Research Template Epidemiological situation in the country Organization of testing Organization of care for PLWHIV Nat...
Key Findings
Voluntary Counseling and Testing Limited offer of voluntary testing facilities:   Low in numbers and Geographical inquet...
Voluntary Counseling & Testing Centralized confirmation of positive results:   1 site in most countries, delays in confi...
Organization of care  Country                               Number of care centers for PLWHIV  Mauritanie                 ...
Access to ARV TreatmentCountry      Number of PLWHIV on ARV        Coverage rateMauritanie                  1.621         ...
ARV Treatment1st line treatment and at least one 2nd line option available in all countriesProblem of patients in treatm...
ARV AvailabilityMorocco offers the highest choice of ARVs, followed by Tunisia and Maritania.Very limited choice of ARVs...
Biological TestsOnly Morocco and Tunisia offer satisfying biological follow up (CD4, VL, resistance test)Algeria, Lybia,...
Prevention and treatment of OIIn general: lack of medicinesTreatment free for inpatients, otherwise at charge of PLWHIV ...
Treatment Education and LitteracyOnly Morocco and Tunisia have treatment education program (problem of human ressources i...
Impact of stigma and discriminationNegative on testingRefusal of care by health workersBreach of confidentialityHigh l...
Impact of Intellectual Property Rights Most countries use generic versions of ARVs (1st line non  patented drugs) Lack o...
Summary Access to HIV status (Testing) remains a major obstacle BUT several gaps in the existing treatment programs    ...
Aknowledgements               Research team:Nadia Rafif, Souheila Bensaid, Fatimata Ball,  Abdullah Turki, Skander Soufi, ...
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Mtt north africa

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Mtt north africa

  1. 1. Missing the Target North Africa : Barriers to Access to HIV Treatment in Six Countries of North Africa AMANI MASSOUD, EIPR OTHMAN MELLOUK, ITPC
  2. 2. About ITPCITPC: Worldwide coalition of PLWHIV and their supporters and advocates. Uses a community based approach to achieve universal access to treatment, prevention and all health care services for PLWHIV and those at-risk.The treatment monitoring and advocacy project (TMAP): produces « Missing the Target » reports series that identify barriers to delivery of AIDS services and holds national governments and global institutions accountable for improved efforts.
  3. 3. North Africa ContextMENA region has the lowest coverage rate of access to HIV treatment in the world : 11%No data on North Africa as sub-region (North Africa different from Middle East)Country data available but only quantitative (number of PLWHIV on ART) Officially: HIV Treatment is available and free for all BUT problem of testing
  4. 4. Objectives of the researchIdentify barriers to access to HIV treament from Civil Society and PLWHIV perspectiveDevelop capacities of community activists in: research, data collection & analysis and their use in advocacySet priorities for advocacy in the sub-region with the goal to reach Universal Access to HIV treatment
  5. 5. MethodologyIncountry research teams:  all community activists  including 2 PLWHIV  Mauritania, Morocco, Algeria, Tunisia, Libya and EgyptStandardized research template for data collectionRevue and analysis of available litterature  articles, publications, national reports etc.Interviews with key stackeholders:  NAP, bi and multilateral cooperation, health professionals, social workers, AIDS activistsInterviews and focus-groups with PLWHIV
  6. 6. Research Template Epidemiological situation in the country Organization of testing Organization of care for PLWHIV National treatment guidelines Treatment coverage Availability of ARVs Lab tests Prevention and treament of opportunistic infections Co-infections Treatment litteracy and education Impact of stigma and discrimination Impact of intellectual property protection Role of Civil society
  7. 7. Key Findings
  8. 8. Voluntary Counseling and Testing Limited offer of voluntary testing facilities:  Low in numbers and Geographical inquetities Countrty VCT Centers NGO VCT Estimated 1 Test/Nbre Centers Tests / Year Habitants Mauritania 22 3 7.738 426 Morocco 44+8 mobiles 44+8 55.451 561 Algeria 54 1 12.589 2.859 Tunsisia 19 - 8.000 1.325 Libya 0 0 - - Egypt 14+9mobiles 4 5-6.000 13.300
  9. 9. Voluntary Counseling & Testing Centralized confirmation of positive results:  1 site in most countries, delays in confirmation, problem for linkage to care « Anarchic testing » in private labs  no link with national system of reference  no counseling  no confirmation of positive results Compulsory testing still widely existing:  Inmates at admission, Algeria  « Populations with a special risk of danger »?, foreigners, prenuptial tests, some professions (Canal de Suez Org, General prosecuter), Egypt  Hospitalization, Libya  Army, majority of countries HIV testing not targetted toward MARPs  Ex: in Tunisia PUD represent 2,6% of VCT clients, while PUD represent 25% of HIV+ cases. Weak involvement of civil society (with exceptions) No voluntary testing in Libya
  10. 10. Organization of care Country Number of care centers for PLWHIV Mauritanie 4 Maroc 10 Algérie 8 Tunisie 4 Libye 2 Egypte 5 Limited offer of care facilities for PLWHIV Several centers not equipped or non-functionnal (Morocco, Algeria) Geographical distribution:  In pocket travel fees  Delays , treatment interruptions linked to travel (Algeria, Egypt+++) Good example: 2 guest houses for PLWHIV in Morocco: Agadir, Casablanca Weak involvement of civil society: No links between NGOs and treatment centers (Except Morocco++, Algeria and Tunisa+)
  11. 11. Access to ARV TreatmentCountry Number of PLWHIV on ARV Coverage rateMauritanie 1.621 25%Maroc 3.356 28%Algérie 1.526 13%Tunisie 402 10%Lybie 2.600 ?Egypte 538 10% • Countries have updated treatment guidelines (WHO 2010) except Libya • ARV treatment available and free in all 6 countries • No official waiting list BUT because of CD4 interruptions PLWHIV can wait several months before accessing treatment (Mauritania++)
  12. 12. ARV Treatment1st line treatment and at least one 2nd line option available in all countriesProblem of patients in treatment failure: Egypt++In 2010-2011: ARV stock-outs reported in ALL countries (Algeria++)  Stock outs during revolutions (2months in Tunis, NOW in Libya++)High number of people lost from care system (40% in some centers in Algeria) and Libya
  13. 13. ARV AvailabilityMorocco offers the highest choice of ARVs, followed by Tunisia and Maritania.Very limited choice of ARVs in EgyptSpecific case Egypt: regular change of regimens based on availability causing drug resitanceTreatment not optimized: choice of ARV motivated by financial constraints and not benefits to PLWHIVProblem of availability of pediatric formulations: Morocco++
  14. 14. Biological TestsOnly Morocco and Tunisia offer satisfying biological follow up (CD4, VL, resistance test)Algeria, Lybia, Egypt: follow up based on CD4 only, viral load non availableLab tests available in 1 site only: travel fees, delays to obtain resultsCD4 counters often « out-of-service »PLWHIV need to go to private labs: Expensive!
  15. 15. Prevention and treatment of OIIn general: lack of medicinesTreatment free for inpatients, otherwise at charge of PLWHIV (treatment & prevention): Egypt, Libya, Tunisia +++NGO support for OI medicines in Morocco (ALCS) and aids with « disability status » in TunisiaCo-infections:  TB treatment available,  None of the countries offer treatment for Hepatitis
  16. 16. Treatment Education and LitteracyOnly Morocco and Tunisia have treatment education program (problem of human ressources in Tunisia)Sporadic activities in Algeria and MauritaniaSome informations by health workers and pharmacists in Libya and EgyptOnly Tunisia has an updated manual on treatment for PLWHIV (but in french)Non outdated manuals in Mauritania and MoroccoStrong opposition to allow CSO and PLWHIV (non medical) to run treatment education activities (Egypt, Tunisia)
  17. 17. Impact of stigma and discriminationNegative on testingRefusal of care by health workersBreach of confidentialityHigh level of stigma for excluded populations: sex workers, MSM, PUD, migrants…Higher in Egypte and Libya
  18. 18. Impact of Intellectual Property Rights Most countries use generic versions of ARVs (1st line non patented drugs) Lack of 2nd and 3rd line linked to their high price (patented in producing countries: India) Same for some OI drugs (antifungicals) and HepC treatment Morocco: supply of Tenofovir delayed several months because of patent status (even if not patented) Recent disturbing developments:  5 of 6 countries (except Mauritania) excluded from the Gilead/Medicines Patent Pool (MPP) licence (june 2011)  Also the recent Johnson&Johnson voluntary licence (dec 2011)
  19. 19. Summary Access to HIV status (Testing) remains a major obstacle BUT several gaps in the existing treatment programs  Geographical distance  Lack of treatment optimization  Availability of 2nd and 3rd line regimens  Failing biological monitoring: maintenance problems, stock-outs of reagents  Stock outs of ARVs: failing procurement & supply channels, complicated procurement procedures, monitoring  Lack of medicines for OI  Inaccessibility of information on treatment  Stigma and discrimination  Intellectual property rights
  20. 20. Aknowledgements Research team:Nadia Rafif, Souheila Bensaid, Fatimata Ball, Abdullah Turki, Skander Soufi, Ragia El Guerzawy The FORD Foundation

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