NextBillion - An Initiative of the William Davidson Institute at the University of Michigan

Monday, December 5, 2005

In South Africa, where 6.5 million people are HIV positive and more than 500,000 would benefit from immediate anti-retroviral (ARV) therapy, a U.S. company is using private-sector efficiency and information technology to expand access to the life-saving drugs.

BroadReach Healthcare, founded in 2002 to increase access to health care around the world, received $4.1 million in 2005 and will receive a similar amount in 2006 from the U.S. President’s Emergency Plan For AIDS Relief (PEPFAR) to implement an innovative large-scale ARV program in South Africa, where 28 percent of the population is affected by HIV/AIDS. (See President Bush’s HIV/AIDS Initiatives.)

In the company’s Cape Town offices, Dr. John Sargent, president and chief operating officer, describes the company’s approach to large-scale ARV programs in terms of Henry Ford’s first automobile assembly line.

“Before Henry Ford came up with the concept of the Model T Ford and the assembly production line,” Sargent said, “the automobile industry was a cottage industry. Tons of little shops everywhere were producing automobiles of variable quality at variable costs.”

Ford took a systems approach, joining operations and protocols with the technology of the day to create a car that could be produced in mass quantities and consistent in quality.

That’s what BroadReach has done with ARV treatment for AIDS patients, based in part on experience gained in Botswana’s national ARV program, Masa. The Botswana program is one of the largest public-sector HIV/AIDS treatment programs in Africa, with nearly 40,000 people now on ARV therapy.

In South Africa, BroadReach formed an international joint venture with Cape Town-based Aid for AIDS (AfA), the world’s largest HIV/AIDS disease-management company.

The joint venture, called ARVCare, is a treatment-management system for HIV/AIDS programs. The system is allowing BroadReach to help South Africa move ARV drug delivery from a cottage industry – most government and private-sector treatment facilities are single hospitals or clinics that can treat 1,000-3,000 patients – to quality-conserving mass production.

“We have life-saving technology – ARVs – that can make a difference in people’s lives,” Sargent said. “The reality is, how do you get them out to 6.5 million people?”

Initially, the BroadReach program was what Sargent calls “an emergency stop-gap measure” for people in rural areas who are not being helped by the South African government’s HIV/AIDS treatment program. That program faces a variety of challenges across the country: there are not enough trained AIDS doctors, government clinics are too busy or far away, provincial governments have not fully scaled up their programs.

To serve rural people better, BroadReach has moved away from a single-clinic model and recruited a network of 4,500 community-based private general practitioners (GPs) and other health care professionals, private laboratories and a national mail-order pharmacy system. The BroadReach program initiated comprehensive doctor and patient education, support and monitoring; and, thanks to PEPFAR funding, delivers ARV drugs, at no charge, to people who need them.

Since June, when the company received its 2005 PEPFAR funding, BroadReach has established 27 treatment sites in eight communities across three provinces (Gauteng, KwaZulu-Natal and Mpumalanga).

More than 800 patients have been educated, more than 500 have started ARV therapy, and more than 200 program facilitators have been educated in sessions on treatment literacy and ARV-adherence support.

HOW IT WORKS

At the BroadReach offices in Cape Town is a central facility (remote center) with a 50-member staff of AIDS doctors, case managers, nurses, pharmacists and data-entry specialists. The staff uses a secure, computerized, patient information management system linking the network of GPs, laboratories, pharmacies and patients.

All the processes – for patients, doctors, labs, pharmacies and AfA and BroadReach team members – are standardized. Education programs (including Internet-based training) for doctors and patients are standardized and treatment supporters and volunteers also undergo a standard training curricula.

All patients are introduced to the four steps of ARV treatment:

Education: Complete ARV treatment sessions.

Doctor: Visit your doctor to find out if you can start treatment.

Support: Participate in community support and buddy program.

Medicines: Pick up medicines and start treatment as prescribed by your doctor.

Colorful, useful patient instruction booklets are in English and South African languages, including Zulu, Tswana and, soon, Xhosa.

The computerized ARVCare system allows the remote center in Cape Town to know if patients have not picked up their drugs or if a doctor has prescribed the wrong drugs. Problems are addressed in a timely manner.

GPs, who are not AIDS specialists, can consult with doctors at the remote center to ensure consistent quality of care. Patients can call anonymously to a support line with questions or problems.

“During implementation and ongoing operations, there’s a very consistent approach and methodology,” Sargent said. “You have to account for local variation, but for the most part it’s all codified process information.

“Every time I launch a site,” he added, “I’ve got a site manual that walks everyone through their roles and responsibilities.”

BroadReach wants to prove, Sargent said, “that with this system we can have many, many sites with consistent quality.”

NEW PARTNERSHIP

Today, 100 percent of BroadReach’s funding is from PEPFAR and the company is looking for ways to assume more of the cost burden in the future with the South African government and increase funding from other sources.

One new program, which began November 28, is South Africa’s first public-private partnership. BroadReach is working with the Northwest Province and a hospital that operates the province’s flagship ARV program. The hospital is treating 3,000 public-sector ARV patients and is at its limit.

“A lot of these 3,000 patients are doing well and are stable,” Sargent said, “so the idea is to take those stable patients and down-refer them to our community-based GPs. This will open up a lot more new slots in the hospital, which can then take on new patients.”

In the new program, the provincial government pays for ARV drugs and laboratory costs, and BroadReach helps pay for doctors and patient education.

“It’s exciting because this is the only way that any large-scale program in government hospitals can see more patients,” Sargent said.

“For us, it’s very promising because I think this is the right model,” he said. “It’s in complete partnership with the government and because of that it’s sustainable, and it gives us a precedent and opportunity to take this model to other provinces and perhaps to other countries.

“It’s part of our whole approach,” Sargent said, “which is finding innovative solutions to provide scalable programs.”

(The Washington File is a product of the Bureau of International Information Programs, U.S. Department of State. Web site: http://usinfo.state.gov)