Overview of activities targeting the objectives of the

Presentation – Global Campaign for Microbicides

Dr Ian Sanne,

19 June 2008

About Right to Care (RTC)

• RTC is a non-profit, Section 21 company specialising in HIV disease management, (company registered 23 January 2003; PBO registration 2004)

• Funded by the US Presidents Emergency Programme For Aids Relief through USAID

• Clinicians of RTC have a long track record of ARV and TB research with NIH funding

ACTG, CIPRA, R01’s, and are members of the WHO and South African guideline

committees for adult and paediatric treatment. • Diversified management structure compliant with empowerment criteria• Corporate governance – much attention has been paid to Corporate Governance

Vision: • All HIV positive patients receive high quality treatment, care and support improving

their quality of life, productivity and survival

Mission: • To facilitate access and build capacity to deliver innovative HIV treatment, care and

support services • To develop HIV treatment capacity both in the public and private sectors

Funding level employed:• Total of $35 Million PEPFAR funding spent to date • Current funding levels $27 Million for BY 08 ending Sept 08; $35 Million budget 09.

Overview of Right to Care

Structure for treatment provision

• HPTN Foundation• NIH Foundation• K401 Trust/Foundation

• Administration and billing • Service provider networks• Claims processing and payment• Financial and outcome reporting

• Accredited provider network• Prevention trial accredited• Management, Lab., Pharmacy

etc.

Funding arrangement- actuarial calc.

- Cell captive, Foundation Medical Scheme

Administration

Treatment implementation

Practical Implementation of our Clinical Services

• Patient visits doctor of choice• Doctor sends medical report to

RTC• Doctor can prescribe treatment• RTC processes script and offers

education

• Patient visits doctor of choice• Doctor sends medical report to

RTC• Doctor can prescribe treatment• RTC processes script and offers

education

• Clinical case managers enter data onto IT Platform

• System programmed to alert potential problems

• Clinical case managers enter data onto IT Platform

• System programmed to alert potential problems

• Patient can decide where drugs must be delivered for confidential collection

• Patient can decide where drugs must be delivered for confidential collection

• Case manager proactively support patient treatment

• Specialist physicians review GP medical report and lab results; and confirm script for processing

• Case manager proactively support patient treatment

• Specialist physicians review GP medical report and lab results; and confirm script for processing

• Medical and psychological support available via 24 hour call centre

• Medical and psychological support available via 24 hour call centre

• Doctor can send blood sample to any certified lab

• Lab sends result to Doctor and RTC

• Doctor can send blood sample to any certified lab

• Lab sends result to Doctor and RTC

RTCMedical Experts

• RTC sends script to courier pharmacy for distribution to patient

• RTC sends script to courier pharmacy for distribution to patient

GP

Patient

Lab

RTC Data Entry

Advice & Counseling

Collection

Distribution

Implementation of Clinical Services

TherapyEdge-HIV developments at RTC 2007-08

TherapyEdge-HIV

Rapid data capture

Implementation as “Live” system

Data outputs

PEPFAR and DORA

Export to SAS™

Paediatric Module

TB Management Module

Cervical dysplasiaHPV

Laboratory IntegrationLancet, Toga, NHLS

Request Result

Data transfer for patient Mx

Down referral

Pharmacy supply chain management

Private sectornetwork

Beta Testing

Development

Implemented

Reports Referral

VCT Module

HIV Epidemiological

information

Link Genotype to Therapy

Virologists

ViroScore Suite

HIV virologicalinformation

Linking genetic information with clinical outcomeTo measure impact of therapeutics and

patients disease management

CliniciansData capturers

TherapyEdge

HIV clinicalinformation C

ore

DB

M+EEpidemiologists

Statisticians

PEPFAR indicators

DORA

Paediatric data capture

Resistance testing

Red bar indicates drugs with known resistance, green bar indicates no resistance. Note decrease in viral load after resistance is detected and correct treatment implemented

HIV ViroScore – TherapyEdge™

Used to develop six treatment models

• Support for the Department of Health CCMT sites – responsible for 38 government sites in five provinces

• Direct access to specialist care – drug resistance and complex opportunistic infections seen at Helen Joseph Hospital Site. Access to new and unregistered antiretroviral drugs for salvage therapy on section 21 approval.

• Foundation funded community programs – funded by Oprah Winfrey Foundation and Housing for HIV

• Community Clinics model – support six clinics with over 6000 patients on treatment,

• SMME treatment model – area based clinic to provide the employer funded model to SMME’s

• Private practitioners treating indigent patients – capitation fee model for the VCT and ARV treatment

• Workplace model – Direct AIDS Intervention (DAI in partnership with Alexander Forbes Health Management Solutions)

Q1 Monitoring Evaluation -Treatment target

ARVTREATMENT # ARV treatment outlets during year

109 119 109%

# patients on ART since start of funding (cumulative)

60,000 48,353 81% 66,458 111%

# patients on ART at year end (current) 44,350 38,413 87% 52,503 118%

subset: # newly initiated patients during year

23,600 6,079 26% 24,105 102%

subset: # paeds on ART at year end (current)

1,610 2,165 134%

# people trained in ART during year500 117 23%

% patient attrition21%

% of attrition due to default/LTF49%

% of new cumulative patients retained as current

78%

Government treatment sites

• RTC sites are responsible for over 10% of all ART patients in SA• Themba Lethu Clinic at Helen Joseph Hospital

– Largest and most efficient in South Africa

– Over 11,000 patients initiated on ART since April 2004

– A further 5000 pre-ART patients

– Development site for TherapyEdge, TB Focal Point, Down Referral, Laboratory Integration

– CHRU research site

• Public Private Interaction MOU’s – Gauteng, Mphumalanga, Northern Cape, Free State, Western Cape

• 38 government sites

RTC supports government through…

• Needs assessments at the sites included in the MOU• Recruitment and seconding personnel – currently over 700

employee seconded to DoH• Training of personnel – in-house HIV training program

responsible for over 3500 health care workers trained in 2007• On-site expertise – preceptors trained by RTC brought to site to

increase confidence and capacity of on-site personnel• Provision of the TherapyEdge data system to DoH sites

throughout the country• Infrastructure assessment and capacity building – over R35M

spent in 2007 on department of health sites• Access to specialized laboratory testing not accessible to DoH

e.g. Resistance testing

Partnerships with Community Organisations (1)

• CHRU– Strategic founding partner of Right to Care– 12 Year track record of phase 2 and 3a and 3b clinical trials (ART, TB,

MDR TB and opportunistic infections). Currently there over 500 patients participating in 35 clinical trials

– Strong Epidemiology and Public Health Evaluation Agenda using the large database of Therapy Edge

• ACTS– Based in the Masoyi Tribal Area near White River– 95% adherence rate

• Rea’phela– An initiative of Right to Care, situated in Wynberg– Fastest growing clinic with a focus on ARV’s

• Witkoppen Health and Welfare Centre– Services Diepsloot, Zevenfontein, Lion Park & Kya Sands– Over 250 patients on ART with 90% adherence rate

Partnerships with Community Organisations (2)

• Ndlovu Medical Trust– Situated in Elandshoorn, Mpumalanga, servicing

30,000 – 40,000 people.– Initiate a number of community upliftment programmes

• Babesi Medical Trust– Situated close to the Kruger National Park – Servicing a population of 100,000 people

• Refilwe Community Project– Initially a palliative care centre– Focus on OVC

• Care Organisations:– Community AIDS Response (CARE)– Friends for Life– Vuselela Ulwazi Lwakho (Vuselela)

Public-Private Partnerships

• Direct AIDS Intervention (DAI)– Partnership with Alexander Forbes Health Management Services

– Reaches over 32 corporate organisations in South Africa

– Over 78,000 employees covered

– (see program slides below)

• Thusong Community Treatment Programme– Provides ART services via independent GP’s and GP networks

– Active in 5 provinces, 14 participating GP’s

Partnerships with Foundations

• Oprah Winfrey Foundation – Provision of home based testing and treatment to community members

• Housing for HIV – provision of home-based HIV testing, treatment and management of treatment to low-income home owners. This program is linked to the Home Loan Guarantee Company to underwrite lender risk in low income populations

RTC Measured Performance

• In-house monitoring evaluation team focused on site performance

• Strong Public Health Evaluation and Epidemiology Research Group developing research agenda – Treatment outcomes

– Interactions between HIV and TB

– Social science agenda including loss to initiation, loss to follow-up

– Economics research agenda – health cost economics and macro-economic impact of HIV on society

Q1 Monitoring Evaluation Results Period Dec 07

Program Indicator Target Actual % TargetAnualized

% Annual

VCT# VCT outlets during year 104 101 97%

# people tested and given test results during year

110,000

23,194 21% 92,272 84%

# TB patients tested and given results during year

10,000 0 0%

# people trained in VCT during year 200 44 22%

HIV CARE & SUPPORT # HIV Care outlets during year 114 130 114%

# patients given HIV Care during quarter (current)

96,000 55,082 57% 67,996 71%

# people receiving PEP 100 67 67%

# people trained in HIV Care during year 600 241 40%

TB/HIV# TB outlets during year 16 13 81%

# HIV/TB patients given TB Tx during year 5,350 1,926 36%

# people trained in TB/HIV during year 200 85 43%

Q1 Monitoring Evaluation -Treatment target

ARVTREATMENT # ARV treatment outlets during year

109 119 109%

# patients on ART since start of funding (cumulative)

60,000 48,353 81% 66,458 111%

# patients on ART at year end (current) 44,350 38,413 87% 52,503 118%

subset: # newly initiated patients during year

23,600 6,079 26% 24,105 102%

subset: # paeds on ART at year end (current)

1,610 2,165 134%

# people trained in ART during year500 117 23%

% patient attrition21%

% of attrition due to default/LTF49%

% of new cumulative patients retained as current

78%

Direct AIDS Intervention: A partnership with Alexander Forbes – Employer Funded Treatment Programs

It can be economically viable to treat a single HIV+ employee…

Do-nothing costsDo-nothing costs

Delaying an employee’s termination

by 7 years, and avoiding absenteeism

costs saves R171k

NPV for a R10’600/m employee

R200k R400k

yr 1

yr 3

yr 5

yr 7

yr 9

yr 11

yr 13

yr 15

yr 17

yr 19

Sick leaveProductivityDeath benefitRecruit & trainOp drugsHAART

55 days additional sick leave over 2 yrs

55 days additional sick leave over 2 yrs

25% productivity

drop for 2 yrs

25% productivity

drop for 2 yrs

3 months salary cost to recruit & train

3 months salary cost to recruit & train

HIV related disease

AIDS sick

HIV contracted

R100k R200k

Treated costsTreated costs

7 year productive life extension due to HAART drugs

Cycle of demise excludes absenteeism costs

Diseaseprogressionmonitoring

Patient not identified

Direct AIDS Intervention (DAI)

• Workplace programme in partnership with AFHMS

• 300 Doctors supported by ETP

• Programme covers over 130,000 employees of 38 companies

• Many employers are moving to funding family members

RTC role in DAI program

• Initial program design and negotiation with service delivery partners – Dr Ian Sanne, Chris Barker

• Modeling of HIV risk and funding by company profile – Dr Ian Sanne and Chris Barker

• Public and Boardroom presentations of the program – Dr Ian Sanne, presented to over 300 companies

• Development of all clinical protocols and VCT protocols• On-site VCT for companies• Development of TherapyEdge-HIV™• Development of case management division in RTC• Reporting of clinical outcomes • Rightmed Provision of ART in selected populations and

programs

• Since Dr Strydom left less interaction with Alexander Forbes

Pricing scenarios – uptake 20%Scenario: 20.0% 25.0% 30.0% 35.0% 40.0%

Quote/employee/year (341.7) (343.6) (345.5) (347.4) (349.3) Administration (HMS) (130.7) (130.7) (130.7) (130.7) (130.7)

24hr call centre (Access Health) (48.0) (48.0) (48.0) (48.0) (48.0) Clinical counselling (ICAS) (31.2) (31.2) (31.2) (31.2) (31.2)

Data hosting (R2C) (6.0) (6.0) (6.0) (6.0) (6.0) Actuarial & auditing (AF) (3.0) (3.0) (3.0) (3.0) (3.0)

Payroll synch (First connect) (3.0) (3.0) (3.0) (3.0) (3.0) Cell Captive fee (excl education) (19.8) (21.7) (23.7) (25.6) (27.5)

Education (100.0) (100.0) (100.0) (100.0) (100.0)

Estimated costs/empl/yr (273.7) (321.6) (369.4) (417.3) (465.2) VCT (52.0) (52.0) (52.0) (52.0) (52.0)

Pre-test counselling (8.0) (8.0) (8.0) (8.0) (8.0) Pathology VCT (20.0) (20.0) (20.0) (20.0) (20.0)

Post-test counseling (24.0) (24.0) (24.0) (24.0) (24.0) Treatment (221.7) (269.6) (317.4) (365.3) (413.2)

Doctor (11.6) (14.5) (17.4) (20.3) (23.2) Drug (90.4) (113.0) (135.6) (158.2) (180.7)

STI treatment (30.0) (30.0) (30.0) (30.0) (30.0) Micronutrients for HIV+ (13.3) (16.7) (20.0) (23.3) (26.6)

Vaccines for HIV+ (new HIV+ only) (14.7) (18.3) (22.0) (25.6) (29.3) Lab (treated bloods) (23.2) (29.0) (34.8) (40.6) (46.3)

Lab (HIV+ monitoring) (7.1) (8.9) (10.6) (12.4) (14.2) Drug delivery (11.6) (14.5) (17.4) (20.3) (23.2)

Scripting expertise (19.9) (24.8) (29.8) (34.7) (39.7)

Total req (est/empl/yr) (615.3) (665.1) (715.0) (764.8) (814.6)

NegotiableEssentialOptionalEssentialOptionalN/AEssentialNegotiable

OptionalOptionalOptional

OptionalEssential

Pricing scenarios – uptake 50%Scenario: 20.0% 25.0% 30.0% 35.0% 40.0%

Quote/employee/year (356.3) (361.1) (365.9) (370.7) (375.5) Administration (HMS) (130.7) (130.7) (130.7) (130.7) (130.7)

24hr call centre (Access Health) (48.0) (48.0) (48.0) (48.0) (48.0) Clinical counselling (ICAS) (31.2) (31.2) (31.2) (31.2) (31.2)

Data hosting (R2C) (6.0) (6.0) (6.0) (6.0) (6.0) Actuarial & auditing (AF) (3.0) (3.0) (3.0) (3.0) (3.0)

Payroll synch (First connect) (3.0) (3.0) (3.0) (3.0) (3.0) Cell Captive fee (excl education) (34.4) (39.2) (44.0) (48.8) (53.6)

Education (100.0) (100.0) (100.0) (100.0) (100.0)

Estimated costs/empl/yr (639.1) (758.9) (878.6) (998.4) (1'118.1) VCT (130.0) (130.0) (130.0) (130.0) (130.0)

Pre-test counselling (20.0) (20.0) (20.0) (20.0) (20.0) Pathology VCT (50.0) (50.0) (50.0) (50.0) (50.0)

Post-test counseling (60.0) (60.0) (60.0) (60.0) (60.0) Treatment (509.1) (628.9) (748.6) (868.4) (988.1)

Doctor (29.0) (36.2) (43.4) (50.7) (57.9) Drug (226.0) (282.4) (338.9) (395.4) (451.9)

STI treatment (30.0) (30.0) (30.0) (30.0) (30.0) Micronutrients for HIV+ (33.3) (41.6) (50.0) (58.3) (66.6)

Vaccines for HIV+ (new HIV+ only) (36.6) (45.8) (55.0) (64.1) (73.3) Lab (treated bloods) (57.9) (72.4) (86.9) (101.4) (115.9)

Lab (HIV+ monitoring) (17.7) (22.1) (26.6) (31.0) (35.4) Drug delivery (29.0) (36.2) (43.4) (50.7) (57.9)

Scripting expertise (49.6) (62.0) (74.4) (86.8) (99.2)

Total req (est/empl/yr) (995.4) (1'120.0) (1'244.5) (1'369.0) (1'493.6)

NegotiableEssentialOptionalEssentialOptionalN/AEssentialNegotiable

OptionalOptionalOptional

OptionalEssential