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Community models of ART delivery in Southern Africa MSF Regional experience

Community models of ART delivery in Southern Africa MSF Regional experience E . Goemaere , Medecins Sans Frontieres IAS Washington , July 26 th 2012. A long road to decentralisation. Decentralisation : referral down <> initiation Impact of HC on community approach

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Community models of ART delivery in Southern Africa MSF Regional experience

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  1. Community models of ART delivery in Southern Africa MSF Regional experience E. Goemaere , Medecins Sans Frontieres IAS Washington , July 26th 2012

  2. A long road to decentralisation • Decentralisation : referral down <> initiation • Impact of HC on community approach • Task shifting -> Nimart • Clinical appointment spacing for stable patients • Pill refills -> not only for high prevalence countries ?

  3. Spacingclinicalvisitsevery 6 months for stable patients , Chiradzulu , Malawi • District Chiradzulu 26,330 patients sous TARV • Adultes stables (> 95% compliance, CD4 >300, plus de 12 mois sous TARV • Visite clinique tous les 6 mois et appro ARV ts les 3 mois • 97% de rétention a 12 mois McGuire et al MOPE 436 , IAS Rome 2011

  4. Eligibility criteria

  5. Youths clubs, Khayelitsha , South Africa

  6. Impact of community based activity on the whole ‘seek, test, treat, retain’ cascade ? HIV Testing Eligibility ART Long term adherence CAG

  7. Impact of community based activity on the whole ‘seek, test, treat, retain’ cascade ? HIV Testing PMTCT coverage Eligibility ART PMTCT Long term adherence Undetectable VL PRE- ART CAG CAG POC VL CAG

  8. Discussion Challenges Advantages Patient perspective : Burden on stable/adherent patients who only need refills Promotes self- management, empowerment development of community networks -> activism Health services perspective Burden on health facilities health services accountability Likely more cost effective Further task shifting • Patient perspective : • Unfair balance of responsibility • Quality of medical monitoring • HIV trivialization • Disclosure <> stigma • Health services perspective • Excludes the high risk of LTFU • Stretches further the drug supply chain • Requires well functioning and simplified monitoring and supervision

  9. Discussion : An option for all and where not to go ? • Tete: ~50% , Khayelitsha ~ 30 % eligible cohort->not a replacement for health services • Bottom-up initiative <> top down • While ‘ going back to Alma Ata , let’s learn from experience and avoid repeating same strategic mistakes’

  10. Acknowledgements • MSF teams in Zimbabwe , Malawi , South Africa & DRC • Nathan Ford, Tom Decroo , Lynne Wilkinson , Gilles van Cutsem, Helen Bygrave, Tom Ellman, Marc Biot • All PLHA’s for their energy in setting up such ART groups/clubs

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