HIV/AIDS
Review of 2003
HA8
Wellness Programme:
A Wellness Programme was introduced in 1999 to extend the productive life of HIV-infected employees as far as possible. Long-term follow up of HIV-infected employees is undertaken on an out-patient basis as is customary for other chronic diseases. There the patients' disease status is monitored, and their physical and psycho-social well-being is addressed through counselling and lifestyle education, and prevention treatment is instituted. The process is as follows:
·
Employees who receive an HIV positive result and who elect to join the Wellness Programme receive further counselling and an initial baseline health assessment is conducted.
·
After two weeks, there is a follow-up visit during which the results of the tests taken are reviewed to decide whether to start preventative treatment against opportunistic infections and/or to start ART (as of November 2002).
·
Thereafter the patient is reviewed every six months or sooner if he/she is ill, or is suffering any side-effects.
·
Patients who take advantage of ART will also be seen more frequently.
Opportunistic infections are managed by prescribing prophylaxis against tuberculosis (TB) and other diseases. Opportunistic diseases are identified early and suitable treatments prescribed during regular check-ups at the Wellness Clinics. In addition, annual medical surveillance at the Occupational Health Centre, regular chest X-rays at the medical stations and 24-hour access to health care services are available.
Employees have unlimited hospitalisation benefits for AIDS-related illnesses, as required by the prescribed minimum benefits under the Medical Schemes Act. AngloGold also provides HIV positive employees with nutritional and lifestyle counselling as well as psychosocial support. By the end of 2003, 2,903 employees (2,074 in 2002) had enrolled in the Wellness Programme.
Community programmes
Community-based prevention interventions target high-risk populations in the two regions surrounding AngloGold mines. An example of this is the Mothusimpilo programme, a jointly funded partnership with Gold Fields Limited, Harmony Mines and the Gauteng Department of Health. The project provides male and female condoms, peer education and curative and preventative treatment for STIs to an estimated 4,000 commercial sex workers in Carletonville. In 2002, AngloGold initiated a similar project in Orkney. A situational analysis has confirmed the urgent need for such an intervention. Funding for implementation as well as evaluation has been committed by local AngloGold and Harmony mines.
Home-based care
AngloGold provides home-based care through a wide range of partnerships, particularly in rural areas.
TEBA home-based care: Home-based care is provided through a service level agreement with TEBA that covers approximately 45% of AngloGold's labour-sending areas. The service provides palliative care for the dying with links to primary care and assistance for bereaved families to access welfare support for both the incapacitated, terminally ill person and the orphans who are left behind. From April 2002 to December 2003, 1,106 ex- AngloGold employees availed themselves of this service. (See case study on page HA15)
Carletonville Home and Community Based Care: This is a multi-stakeholder programme involving public, private, civic, NGO and faith-based sector participation in partnership with the local community. AngloGold has provided more than just financial support. It has seconded a programme manager and a part-time accountant, provides IT support and supports income-generating activities. Carletonville Home and Community Based Care successfully cares for a monthly average of 35 bed-bound patients, 190 ambulant people with AIDS and terminal illnesses, and 501 orphans, 154 of whom are living in child-headed households.
Bambisanani: Similarly, AngloGold has seconded a nurse and donated the use of a vehicle to the Bambisanani Home-Based Care Project in the Eastern Cape.
St Bernard's Hospice - Duncan Village East London
HIV/AIDS
Case studies
HA11
South Africa
7.1 The delivery of ART to employees
Following extensive consideration, AngloGold's ART programme was cautiously implemented in three phases.
·
The first phase started in August 2002 and ran until October 2002. This preparation phase focused on developing protocols, guidelines and data systems; recruiting and training; and negotiating contracts with suppliers and service providers.
·
The second pilot phase ran from November 2002 until March 2003, to test-run the new treatment programme. In this phase 100 patients were randomly selected off the database from each of AngloGold's two Wellness Clinics and invited to the clinics to begin ART. In addition, any patient with full-blown AIDS who needed ART as a life-saving measure was offered the treatment. The pilot phase recruited 129 patients onto ART. Overall adherence to treatment ranged from 81% to 88%. Operational problems identified were minor.
·
The third phase, or full roll-out, started in April 2003, and made the treatment available to any employee who is both medically eligible and who has undergone HIV testing to confirm his or her HIV status.
By the end of December 2003, 688 patients had been offered or been considered for ART; 31 were reassessed by their physicians as not being ready for treatment, and 78 refused treatment for fear of side effects, reluctance to have blood taken frequently for testing, concern about the frequent follow-up visits required, or were unconvinced about the benefits of ART.
Of the 534 that had started treatment, by year-end 484 were still on treatment. 50 patients stopped treatment because of the side effects that had presented, their own failure to collect repeat scripts, forgetting to take treatment, or death. During this period 12 severe adverse events (SAEs) occurred. This means that these patients experienced health problems that may be attributed to the drugs and/or other underlying or concurrent disease processes
8
. On the whole, patients that are on
treatment return to work and show clinical improvement as evidenced by recovering CD4 counts and diminishing viral loads.
8
SAEs are health problems of such a severe nature that they result in death or disability, birth defects or hospitalisation, and as a consequence need to be
reported to the Medicines Control Council.
Practical experience in the delivery of ART
In April 2003, AngloGold announced the rollout to all employees of its groundbreaking ART intervention programme, following an eight- month implementation project.
The implementation project, which was driven by AngloGold Health Service (AHS), was aimed at developing an understanding of, and finding solutions to, the challenges inherent in the provision of ART in the mining industry. It identified the operational requirements of providing ART, particularly around supporting patient adherence to the drug regimen.
Says Dr Petra Kruger, manager of AngloGold's HIV/AIDS programme, "The implementation project was imperative. Never before had ART been taken to such a huge population. We were pushing new boundaries in that we were taking ART out of the constraints of specialist care and into the domain of primary health care. We also had to assess if there was any impact on a patient's capacity to carry out his or her duties, particularly in underground working conditions, and we had to monitor drug sensitivity. In short it required the development of an unprecedented level of sophistication in our health care delivery."
During the implementation project Aurum Health Research, a subsidiary of AHS, finalised the clinical guidelines, established a specialist clinical and laboratory support consortium, secured a drug supply chain necessary to negotiate Africa access priced drugs, developed training materials and courses, and formulated an evaluation protocol based on rigorous data management which made provision for an economic study of the cost benefit of ART. During this time intensive training was given to 16 doctors, 22 nurses and 25 lay counsellors.
AngloGold and Anglo American also established an ethics forum, chaired by Dr Lyn Horn, an independent ethicist, to provide advice on a range of ethical questions that arose during the planning of the project. These included questions around, for example, the selection of volunteers, ensuring patients' consent is genuinely an informed consent, and matters relating to the treatment of dependents and of stopping treatment when an employee leaves the company and no longer has access to the internal health service. With the decision by the South African government to make ART available to all, the latter two issues have become easier to resolve in respect of those employees and their dependents who are South African citizens.
HIV/AIDS
Case studies
HA12
ART becomes medically indicated when a patient's CD4 count falls below 250 or if he or she has suffered an AIDS-defining illness. It is estimated that 25% of AngloGold HIV-infected employees meet these medical eligibility criteria.
Eligible employees are invited to participate in the ART programme. They are given detailed information about the programme and the nature of the treatment, including the possible side effects, the patient's own obligations while receiving the medication and the extent of the company's commitments. Each person is then given two weeks to consider his or her participation.
Says Dr Petra Kruger, "One of our biggest concerns when starting to administer ART was the issue of adherence. We were worried that some of our patients might not keep up with taking their pills at specified times each day thus putting themselves at risk of becoming resistant to the drugs. We have been very encouraged by the way the patients have strictly adhered to what is a very demanding schedule. Admittedly early reports indicate that careful counselling and patient preparation is working."
Self-reported drug adherence has been observed at 90%. This will be validated through for instance demonstrating a reduction in viral load once a body of follow-up data becomes available.
But, although the initial phase of the programme has yielded very promising results, Dr Petra Kruger cautions against complacency. "There is still a long way to go and a number of issues that we have to grapple with," she says.
Included amongst these challenges are the possible emergence of serious side effects associated with the long-term use of anti- retrovirals. The one that is most likely to cause difficulties amongst mineworkers is what is known as peripheral neuropathy, which is the loss of sensation in the extremities such as hands and feet.
"I am also concerned that adherence rates will fall over time as employees become more complacent about their health. And there is always the danger that those receiving treatment will revert to risky sexual behaviour. That is why it is so important for us to keep up our education and training efforts."
Aurum will monitor and evaluate the clinical outcomes and the economic impact of the ART programme during its first three years.
What is ART and how does it work?
Antiretrovirals are drugs that act against viruses such as HIV. HAART stands for Highly Active Anti-retroviral Therapy and refers to a cocktail of three or more drugs, which in combination are strong enough to reduce viral loads to very low levels.
When an individual contracts HIV, the HI virus enters the cells of the body's immune (or defence) system where it multiplies before killing that cell and moving on to infect other cells. The most important cell that the virus enters is known as the CD4 cell.
As the virus destroys increasing numbers of CD4 cells, the individual reaches a point where his or her defence systems are no longer capable of withstanding attack from other diseases. At this point he or she becomes susceptible to certain infections and cancers against which the immune system would ordinarily have guarded the body - in other words, the HIV- infected person becomes AIDS-ill. These opportunistic infections - including TB - become more frequent and more severe and, in most cases, eventually lead to death.
ART works by stopping the virus from entering or multiplying itself in the immune cells of the body. These drugs do not completely remove HIV from a person's body, but they reduce both the amount of the virus in the blood and the damage that HIV can do to the body's immune system.
Many people with HIV who have taken these drugs have been able to lead longer healthier lives. While these drugs cannot cure HIV/AIDS, they do interrupt the progression of the disease allowing AngloGold employees to remain productive and to enjoy a vastly improved quality of life.
HIV/AIDS
Case studies
HA13
South Africa
7.2 Caring for the community - Carletonville Home and Community Based Care
The town of Carletonville and its environs in South Africa's Gauteng Province, comprises some 250,000 inhabitants. Most of its economically active population is employed within the mining industry. The most reliable estimates of the region's HIV levels indicate a prevalence rate in the adult population of about 35%. That is why the role of the Carletonville Home and Community Based Care project is so important.
(See AngloGold AIDS report 2001/2002).
The project remains focused on
four key areas, namely:
·
Palliative care by volunteer care givers providing home-based care to the bed-ridden;
·
Support groups for people living with HIV/AIDS but who are still mobile;
·
Income generation and poverty alleviation programmes; and
·
The sourcing of welfare grants, food parcels, schooling and day-care for orphaned children and youth, particularly those from child-headed households.
The project came about as a result of the dire need to provide palliative care to people dying as a result of AIDS. This spurred a local retired nurse, Ma Montjane, to mobilise volunteers in the community to provide such assistance as far back as 1998.
HIV/AIDS
Case studies
HA16
East and West Africa
7.4 Adopting best practice at Geita Gold Mine
Located some 20km west of Lake Victoria, adjacent to the town of Geita in Tanzania, is the Geita Gold Mine, which was established in May 1999. The mine currently has an expected life of about 14 years. Geita employs 2,200 people (600 employees and 1,400 contractors), of which about 90% are local Tanzanians. The population of the town of Geita has grown from 30,000 in 1999 to nearly 57,000 in 2002.
Although Geita is a very young mine, its early HIV interventions have already begun to pay off. The programme has as its overriding vision to improve the health of mineworkers at Geita and surrounding communities through a sustainable programme of health promotion and disease control measures. The sustainability of the programme is particularly important given the fact that the mine will, at some stage in the future, cease operations.
Establishing a baseline
In 2001, a prevalence survey was conducted by the African Medical and Research Foundation (AMREF)*, in collaboration with the National Institute of Medical Research (NIMR), in Mwanza, Tanzania, and the London School of Hygiene and Tropical Medicine.
The survey confirmed the pre-existence of a local HIV epidemic in the community: 19% of men, 16% of women and 39% of high-risk women were found to be HIV positive. Mineworkers surveyed had a comparatively lower HIV prevalence of 4%. (This is probably an unreliable result, however, since the prevalence is expected to be similar to that in the surrounding area.)
Despite these results, both the community members and mineworkers demonstrated that they were at high risk of becoming HIV positive because:
·
All groups reported very high rates of STIs in the previous 12 months;
·
All groups had high rates of positive syphilis serology;
·
35% of mineworkers indicated that they had had multiple sexual partners in the previous three months;
·
54% of mineworkers had paid for sex in the previous 12 months; and
·
30% did not always use condoms during these paid encounters.
Rapid intervention needed
It was clear that without rapid intervention the HIV prevalence amongst mineworkers could rapidly escalate (estimated to between 20 and 40%) within the life-span of the mine. Although a detailed financial assessment of the potential impact was not conducted, it was felt that this increase would constitute a significant threat to the mine's continued profitability.
Geita's proposed interventions focused on:
·
Preventing the escalation of the local epidemic, and
·
Providing care and support for those who were already HIV positive.
Employee HIV/AIDS policy at Geita
The Employee HIV/AIDS policy at Geita
provides for: ·
Non-discrimination: - Employees will not be dismissed on
grounds of their HIV status
- Employees will undergo a medical
examination prior to employment, but the examination does not include an HIV test
·
Confidentiality and disclosure: - Employees are not required to disclose
their HIV status.
- If an employee discloses his or her
HIV status, this information remains confidential without written consent
·
Medical benefits: - Medical benefits are provided for
employees and their spouse and children registered upon entry into employment
- Employees and contractors have
access to the Geita clinic
- Geita covers the cost of dependents of
employees when they access services from the Geita Government hospital (including referrals)
·
Termination: - When an employee
is deemed
medically incapacitated the medically affected employee policy is enacted
- The employee is entitled to sick leave
(three months on full pay and three
months on half-pay)
- If the employee is still medically
incapacitated as determined by a multi-disciplinary team including representatives from Human Resources, management and the medical department, his/her employment is terminated
- Upon termination of service the
employee receives six months full salary but medical services become the responsibility of the employee
·
Contractors: - Contractors are not required to adhere
to Geita's HIV policy
* AMREF is an independent non-profit, non-governmental organisation (NGO) whose mission is to
improve the health of disadvantaged people in Africa as a means for them to escape poverty and
improve the quality of their lives.
HIV/AIDS
Case studies
HA17
Voluntary Counselling and Testing
In July 2001, Geita signed a memorandum of understanding establishing a three- year contract with AMREF to provide workplace and community HIV/AIDS services as part of a comprehensive community programme. The programme was divided into two related parts:
·
Workplace prevention programmes including top management advocacy, peer health educators, free condom distribution, syndromic STI management and HIV Voluntary Counselling and Testing (VCT) and awareness workshops. In 2003, preparation for the provision of ART was begun.
·
Community prevention programmes focused on developing community health educators, targeted interventions for high-risk women and their male clients, condom social marketing and Sexual and Reproductive Health (SRH) services. A community HIV information centre providing VCT and SRH services was established in March 2002.
Geita's budget for both workplace and community-based programmes over a three-year period (2002 to 2004) is US$325,000 funded by the main stakeholders, the owners of the mine (AngloGold and Ashanti Goldfields), the main contractor (DTP Terrassement), Stanley Mining Services and other contractors. The programme also receives in-kind donations - the Community HIV Information Centre, for example, is located in facilities provided by the District Council, and District Health Workers frequently act as facilitators during training.
The mine also finalised its Employee HIV/AIDS policy in January 2002, superseding the informal policy that had been in place since January 1999. The policy provides for non-discrimination, confidentiality and non-disclosure, benefits, termination and the role played by contractors.
(See box).
There is an
ongoing formal process of meetings to refine and develop the process to culminate in the provision of ART.
Community intervention
programmes at Geita
Geita's influence on the community surrounding the operation is one which is viewed seriously and responsibly by the company. The company started funding community prevention programmes in July 2001, extending the AMREF programmes launched in June 2000. Elements of the programme include the following:
Prevention and awareness: ·
Community educators: 60 community educators trained (1 to 500) in three villages surrounding the mine. These part-time volunteers are trained to carry out clearly defined health education activities with ongoing support and supervision provided at monthly support meetings facilitated by project staff. Activities conducted by the community educators include visiting homes, distributing health learning materials, demonstrating the use of condoms and recruiting clients for the HIV Information Centre.
·
Focused interventions for high-risk women. This was launched in August 2001. The programme trained 23 women in respect of life skills. These women in turn conduct social marketing of male and female condoms and distribute tokens to their peers and male clients entitling them to a full range of free SRH services at the AMREF HIV Information Centre.
·
Sexual and Reproductive Health services. This started in March 2002. Services are available at the community HIV Information Centre located in the centre of Geita town. It was launched at a public event with guest speakers including Geita's Chief Executive Officer and the Executive Director of the Tanzanian Commission for AIDS, Major General Lupogo and with the Regional Commissioner for Mwanza as Guest of Honour. Services are available to anyone for free (with the exception of VCT) and clients are encouraged to take advantage of multiple services.
Community intervention programmes
at Geita (continued)
Voluntary Counselling and Testing
VCT services were initiated in March 2003 at the community HIV Information centre. The service is available to everyone in the community for US$1 per visit, Geita subsidising US$2.50 of the total US$3.50 cost of the test. Six VCT counsellors are drawn from the district health personnel and local community members that have been trained by AMREF. Post-test counselling includes a personal risk reduction strategy, referrals where necessary and an offer to join the Post-test Club to obtain ongoing emotional support, as well as home-based care.
HIV status is assessed through parallel rapid tests of a finger prick sample. Since the launch, through 11 December 2003, 2,730 people had accessed the service, 11.5% of whom were employees. 10.7% of those who have been tested are HIV positive.
In addition, 2,252 people have undergone STI treatment (901 of those have come in for repeat/follow-up visits) 2,252 syphilis screenings have been conducted and 442 family planning sessions have been held as part of the Sexual and Reproductive Health Service.