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Department of Public Service and Administration (DPSA) Wellness Indaba – Durban 2007
Dr Stanley Moloabi & Dr Leon Regensburg & Mr. Rodney Cowlin
Disease Management Strategy as
Part of Health Promotion
in the Workplace –
a Southern African Perspective
Agenda
Brief overview of Global HIV Infection Estimates
Introduction to aid for aids (AfA)
Benefits of early enrolment on the AfA programme
The positive impact early enrolment on HIV disease
management programme has on HIV/AIDS related health
costs
Impact of lack of disease management on productivity in
the workplace
Work done by AfA beyond South African borders
Estimated adults & children living with HIV, end 2006
Total: 43.6 (36.7 – 45.3) million
Western & Central Europe
744 000744 000[590 000 –915 000][590 000 –915 000]
North Africa & Middle East578 000578 000
[271 000 – 1.4million][271 000 – 1.4million]
Sub-Saharan Africa28.6 million28.6 million[26 – 31.2 million][26 – 31.2 million]
Eastern Europe & Central Asia1.9 million 1.9 million
[990 000 – 2.3 million][990 000 – 2.3 million]
South & South-East Asia8.2 million8.2 million[5 – 13.3 million][5 – 13.3 million]
Oceania81 00081 000
[45 000 – 120 000][45 000 – 120 000]
North America1.2 million1.2 million
[650 000 – 1.8million][650 000 – 1.8million]
Caribbean327 000327 000
[220 000 – 551 000][220 000 – 551 000]
Latin America1.9 million1.9 million
[1.4 – 2.4 million][1.4 – 2.4 million]
East Asia970 000970 000
[496 000 – 1.7 million][496 000 – 1.7 million]
HIV infection estimates
Over 11 000 new HIV infections a day in 2006
More than 95% occur in low and middle income countries
About 1500 occur in children under 15 years of age
About 10 000 occur in adults aged 15 years and older
2006 Global HIV and AIDS estimates - Children (<15 years)
Children living with HIV: 2.3 million [1.7 – 3.5 million]
New HIV infections in 2006: 530 000 [410 000 – 660 000]
Deaths due to AIDS in 2006: 380 000 [290 000 – 500 000]
Aid for AIDS
More than 9 years experience in providing HIV
disease management solutions
More than 36 000 patients currently registered
ART approved for over 24 000 patients
Introduction to Aid for AIDS
Aid for AIDS
Implemented HIV workplace programmes for a number of
multinational companies in Southern Africa
Implementation of a donor funded treatment programme in
rural South Africa
Experience in providing treatment programmes in a number
of countries outside South Africa
Services offered
Epidemiological & Demographic surveys
Voluntary counselling and testing (VCT)
Financial Impact analysis
KAP (Knowledge, Attitudes and Practices) surveys
Education and awareness programmes.
Legal & Ethical Services Workplace Policies
Clinical Disease Management Programme
Provision of comprehensive HIV/AIDS Treatment programmes
Clients
Partnerships with International Donor Funders for public sector
treatment programmes
21 medical schemes contracted to AfA and administered by
Medscheme
Bonitas, Medshield, Fedhealth, Protector, Liberty…
12 medical schemes contracted to AfA and administered by
“other” administrators
GEMS, Nimas, Swazimed, Nampak, Randwater…
21 companies contracted to AfA for the provision of a workplace
treatment programme:
De Beers, Nestle, Daimler Chrysler, BP Africa, Barloworld, Sun
International …
Cost benefits of early enrolment
-6 -3 0 3 6 9
R 0
R 1,000
R 2,000
R 3,000
R 4,000
R 5,000
R 6,000
Per
pati
en
t p
er
mo
nth
co
st
Months relative to enrolment
CD4 > 350
CD4 < 50
Source: Aid for AIDS Database.
Benefits of early enrolment on the AfA programme
Benefits of early enrolment on the AfA Programme
Patients should be on treatment before they
develop opportunistic infections.
Patients who initiate ART at the optimal time have
better survival prospects.
Comparative 24 month survival by CD4 count for patients on HAART – all patients
0%
20%
40%
60%
80%
100%
200 - 349 50 - 199 0 - 49
CD4 count (cells/µL) at HAART commencement
24 m
on
th s
urv
ival
(%
)
British Columbia Drug Treatment Programme
Aid for AIDS programme
Centers for Disease Control USA
Chan K et al 2002 AIDS 16(12)
Hogg R et al 2001 JAMA 286(20)
CD4 count results relative to ART commencement – all patients
0
50
100
150
200
250
300
350
400
450
500
0 1 3 6 12 18 24 30 36 42 48 54 60 66 72 78
Months relative to ART commencement
CD
4 C
ou
nt
cel
ls/µ
L
CD4 count results relative to ART commencement – PEPFAR (President’s Emergency Plan for AIDS Relief Partners) Treatment programme
0
50
100
150
200
250
300
350
CD4_00 CD4_06 CD4_12
Ave
rag
e C
D4
cou
nt
Outcomes of MTCTP programme – all patients
N Hlatshwayo, M S Hislop, M Cotton, G Maartens, L D Regensberg. Mother to child HIV transmission prevention (MTCTP) in a managed care setting in South Africa - no role for short-term antiretroviral therapy (ART)? . 15th World AIDS Conference, Bangkok 2004.
25.0%
5.1%
1.2%
0%
5%
10%
15%
20%
25%
30%
NO ART MONO ART HAART
% m
oth
er t
o c
hil
d H
IV
tran
smis
sio
n
Source: Aid for AIDS Database.
Direct & indirect costs, individual & organisational
• Insurance premiums• Accidents due to ill and
inexperienced workers• Litigation over benefits,
dismissals, etc.
Direct Costs Indirect Costs
• Reduced on-the-job
productivity• Increased absenteeism• Supervisor’s time• Vacancy• Lower productivity during
replacement’s startup period
• Senior management time• Production disruptions• Loss of workforce morale• Loss of experience and
institutional memory• Reduced returns to training
investments• Deteriorating labor relations
Total Cost to Firm of HIV/AIDS in the Workforce
• Benefits payments• Medical care• Recruitment and
training of replacement worker
Individual
(From one employee with HIV/AIDS )
Organisational
(From many employees with HIV/AIDS)
Boston University - Center for International Health and Development 2003
Impact of lack of disease management
Timing of Cases and Costs
Progression of HIV/AIDSin the Workforce
Cost to Company
Morbidity begins (some early mortality, some long-term non-progressors).
Employee becomes infected.
Employee leaves workforce through death or disability retirement (some long-term survivors).
Company hires replacement employee.
No cost to company at this stage.
Morbidity-related costs are incurred(absenteeism, productivity loss, supervisor’s time, medical care)
End of service costs are incurred (death and disability benefits, management time, loss of morale, institutional memory, and experience)Turnover costs are incurred (vacancy, recruiting, training)
Timeline
Year 0
Year 2-8
Year 6-12
Year 6-12
Employee remains asymptomatic and fully productive.
No cost to company at this stage.Year 0-8
Boston University - Center for International Health and Development 2003
Impact of not having adequate Disease Management Programmes on the Workforce
Skills within the organisation are lost due to illness
Takes ~ 60% longer to replace skilled worker than unskilled worker
Takes ~ 6 times longer to replace a professional than a skilled worker
On-the-job training costs add to cost of replacing an employee
Botswana Public Officers Medical Aid Fund
PULA Medical Scheme
Botswana Government Public / Private Sector HIV
programme (joint venture with Associated Fund
Administrators)
Debswana ( De Beers and Botswana) Treatment
Programme
Aid for Aids Beyond South African Borders
AfA in AfRICA
TUNISIA
MOROCCO
IVORY COAST
NIGERIA
EGYPT
ZIMBABWE
KENYA
BOTSWANA
ZAMBIA
MALAWI
NAMIBIA
SOUTH AFRICA
SWAZILAND
TANZANIAANGOLA
ALGERIA
Conclusions
AfA facilitates effective access to
comprehensive HIV management and enables
extensive outcome data to be collected.
A key success component of HIV treatment is
the ability to provide on-going patient support
to ensure adherence to therapy.
Managed access to ART improves morbidity,
but timing is critical - people are still presenting
far too late.
Conclusions
Early managed access to ART improves clinical outcomes and
reduces the cost of treating HIV/AIDS.
Managed access to ART should improve productivity in the
workplace
Aid for AIDS has a proven track record and the expertise to
provide comprehensive HIV treatment programmes which are
flexible enough to be implemented in any setting.
Aid for AIDS is seeking to accelerate the work it does in
conjunction with employer organisations – we have significant
capacity and experience which could be shared.
Acknowledgements
• N Hlatshwayo, M S Hislop, M Cotton, G Maartens, L D Regensberg. Mother to child HIV transmission prevention (MTCTP) in a managed care setting in South Africa - no role for short-term antiretroviral therapy (ART)? . 15th World AIDS Conference, Bangkok 2004.
• Chan K et al 2002 AIDS 16(12)• Hogg R et al 2001 JAMA 286(20)
• Boston University - Center for International Health and Development 2003
• UNAIDS - Global summary of the HIV and AIDS epidemic, December 2006
• World Health Organisation - Global summary of the HIV and AIDS epidemic, December 2006
“ Future generations will judge us by the adequacy of our response. ”
Nelson Mandela