Department of Public Service and Administration ( DPSA) Wellness Indaba – Durban 2007

1. Department of Public Service and Administration (DPSA) Wellness Indaba – Durban 2007 Dr Stanley Moloabi & Dr Leon Regensburg & Mr. Rodney Cowlin

2. Disease Management Strategy as Part of Health Promotion in the Workplace – a Southern African Perspective

3. 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

4. Eastern Europe & Central Asia 1.9 million [990 000 – 2.3 million] Western & Central Europe 744 000 [590 000 –915 000] North America 1.2 million [650 000 – 1.8million] East Asia 970 000 [496 000 – 1.7 million] North Africa & Middle East 578 000 [271 000 – 1.4million] Caribbean 327 000 [220 000 – 551 000] South & South-East Asia 8.2 million [5 – 13.3 million] Sub-Saharan Africa 28.6 million [26 – 31.2 million] Latin America 1.9 million [1.4 – 2.4 million] Oceania 81 000 [45 000 – 120 000] Total: 43.6 (36.7 – 45.3) million HIV infection estimates Estimated adults & children living with HIV, end 2006

5. 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

6. 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]

7. Introduction to Aid for AIDS 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

8. 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

9. 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

10. 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 …

11. Benefits of early enrolment on the AfA programme Cost benefits of early enrolment Source: Aid for AIDS Database.

12. 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.

13. Comparative 24 month survival by CD4 count for patients on HAART – all patients Chan K et al 2002 AIDS 16(12) Hogg R et al 2001 JAMA 286(20)

14. CD4 count results relative to ART commencement – all patients

15. CD4 count results relative to ART commencement – PEPFAR (President’s Emergency Plan for AIDS Relief Partners) Treatment programme

16. 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. Source: Aid for AIDS Database.

17. Impact of lack of disease management Direct & indirect costs, individual & organisational Direct Costs Indirect Costs • Benefits payments • Medical care • Recruitment and training of replacement worker • Reduced on-the-job productivity • Increased absenteeism • Supervisor’s time • Vacancy • Lower productivity during replacement’s startup period Individual (From one employee with HIV/AIDS ) • Insurance premiums • Accidents due to ill and inexperienced workers • Litigation over benefits, dismissals, etc. • Senior management time • Production disruptions • Loss of workforce morale • Loss of experience and institutional memory • Reduced returns to training investments • Deteriorating labor relations Organisational (From many employees with HIV/AIDS) Total Cost to Firm of HIV/AIDS in the Workforce Boston University - Center for International Health and Development 2003

18. Timeline Progression of HIV/AIDS in the Workforce Cost to Company Year 0 Employee becomes infected. No cost to company at this stage. Year 0-8 Employee remains asymptomatic and fully productive. No cost to company at this stage. Year 2-8 Morbidity begins (some early mortality, some long-term non-progressors). Morbidity-related costs are incurred (absenteeism, productivity loss, supervisor’s time, medical care) Year 6-12 Employee leaves workforce through death or disability retirement (some long-term survivors). End of service costs are incurred (death and disability benefits, management time, loss of morale, institutional memory, and experience) Year 6-12 Company hires replacement employee. Turnover costs are incurred (vacancy, recruiting, training) Timing of Cases and Costs Boston University - Center for International Health and Development 2003

19. 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

20. Aid for Aids Beyond South African Borders • 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

21. ALGERIA AfA inAfRICA TUNISIA MOROCCO EGYPT NIGERIA KENYA IVORY COAST ANGOLA TANZANIA ZAMBIA MALAWI NAMIBIA ZIMBABWE BOTSWANA SWAZILAND SOUTH AFRICA

22. 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.

23. 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.

24. 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 Ket al 2002 AIDS 16(12) • Hogg Ret 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

25. “ Future generations will judge us by the adequacy of our response. ” Nelson Mandela