Amisi, T

Chan, K

Culbert, Heather

Ellman, Tom

Ford, N

Mills, C

O'Brien, Daniel P

Shanks, L

Tu, D

English

MSF Field Research

1
Comprehensive HIV care and Anti-Retroviral Therapy in a conflict setting--
outcomes, experiences, and lessons learned from Bukavu, Democratic 
Republic of Congo
David Tu1,  H. Culbert1, T. Amisi2,  L. Shanks2, D. O’Brien1, T. Ellman1, C. Mills1, N. Ford1 , K. Chan3
1MSF Holland, Amsterdam, Netherlands; 2MSF DRC, Bukavu, DRC; 3BCCfE, Vancouver, Canada
www.msf.ca/aids2006
Bukavu ART-LINC ART-CC
Baseline 
Median 
CD4 count 
(cells/ml)
123 
[IQR 57 –
195]
108 
[IQR 37 –
210]
106 
[IQR 43 –
180]
6.4% 
(95% CI 5.1 
–7 . 7 )
15% (active)
19% 
(passive)
234 
[IQR 98 -
380]
12 month 
Mortality
7.9% 
(95% CI 
3.6–12.1) 
1.8% 
(95% CI 
1.5 – 2.2)
12 month 
Loss to 
follow-up
5.4% 
(95% CI 
3.2-7.5)
6 month 
Median 
CD4 gain 
(cells/ml)
163
[IQR 82 –
232]
103 
[IQR 32 -
192]
Conflict & HIV/AIDS Care Conflict & HIV/AIDS Care
• •Breakdown of health care institutions Breakdown of health care institutions
• •↑ ↑ poverty poverty
• • ↓ ↓ access to care and prevention    access to care and prevention   
(e.g. STI Rx, Condoms, etc.) (e.g. STI Rx, Condoms, etc.)
• •Persistence into  post Persistence into  post- -conflict conflict
• •Limited human resources Limited human resources
• •Program and Population Instability   Program and Population Instability  
⇒ ⇒? Adherence, ? Resistance ? Adherence, ? Resistance
• •1996  1996 – – 2006 : Chronic War 2006 : Chronic War
• •3.2 million internally displaced  3.2 million internally displaced 
• •3.8 million war related deaths  3.8 million war related deaths 
• •Estimated DRC HIV prevalence 4% Estimated DRC HIV prevalence 4%
Background
DRC
Bukavu
Patients 
started 
on ART
494 / 
1868 
(26%)
Women
328 
(66%)
Median 
Age
37 
Years
Median 
Weight 51 Kg
% CD4 
< 200 70%
Outcomes
Factors Supporting ART 
Adherence in Episodes of Acute 
Conflict
1.Plan for acute instability
2.Patient Education
3.Defined roles/responsibilities for 
staff
4. Communication Networks
4. Emergency Drug 
Stocks/Washout Medications 
5. Secure Drug Storage
6. Decentralization of Care
7. Cooperation with Neighbouring 
HIV treatment facilities
8. Treatment Information Cards 
Advantages to ART in Conflict  Advantages to ART in Conflict 
Settings Settings
• •Reduces HIV related sickness and  Reduces HIV related sickness and 
death death
• •Improved morale of health care  Improved morale of health care 
providers and PLWHA providers and PLWHA
• •Re Re- -establish Health Infrastructures establish Health Infrastructures
• •Allows for more rapid scale up  Allows for more rapid scale up 
during post during post- -conflict period conflict period
May 2004: Episode of acute 
conflict in the city of Bukavu
• Pre-acute conflict there were 66 
patients on ART
• Only 5 patients had interruptions 
of their ART> 4 days 
• No patients were lost to follow up; 
all eventually returned to 
treatment
Comparison or ART outcomes with  ART-
LINC & ART-CC Collaboration* • Conflict creates many obstacles 
to providing comprehensive HIV 
care and ART
• Bukavu ART outcomes are very 
satisfactory and  comparable to 
those found in non-conflict 
settings.
• With adaptation, HIV 
comprehensive care can be 
effectively administered in a 
setting of chronic conflict.  
• The key to successful provision 
of ART in conflict settings is 
preparation for disruption.
Lessons Learned
MSF  MSF intervention in Bukavu intervention in Bukavu
• •HIV project started in 2000. HIV project started in 2000.
• •ART started in October 2003:  ART started in October 2003: 
• •Free Medications and care Free Medications and care
• •generic Fixed Dose Combination  generic Fixed Dose Combination 
ARVs  ARVs 
• •Use of a comprehensive care  Use of a comprehensive care 
model  model 
*Lancet 2006; 367: 817-24
Median Time 
on ARV
4.5  Months [IQR 3 – 6.7]
ART adherence 
rate 
99%
Six month Twelve 
month
Median weight 
gain (kg) [IQR]
2.5
[0-5.5]
N=363
4.3
[1.0-8.0]
N=82
Median CD4 
gain (cells/ml) 
[IQR]
163
[82 – 232]
N=118
132
[37 – 213]
N=26
Mortality Rate 
(95%CI)
4.9%
(2.6%-7.0%)
7.9 %
(3.6% -12.1%)
ARV Treatment Outcomes (N=494)
5%
6%
87%
1%
Surviving on First
Line Therapy
Overall Deaths
Lost to Follow Up
 Clinical Failures
(switched to
second line)
Experiences

Comprehensive HIV care and Anti-Retroviral Therapy in a conflict setting-outcomes, experiences, and lessons learned from Bukavu, Democratic Republic of Congo

Comprehensive HIV care and Anti-Retroviral Therapy in a conflict setting-outcomes, experiences, and lessons learned from Bukavu, Democratic Republic of Congo

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