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Models of care to reach and retain more people Is there a role for the community?

Models of care to reach and retain more people Is there a role for the community?. Tom Decroo 1 , Luisa Cumba 2 1 Médecins Sans Frontières 2 Ministry of Health, Mozambique. HIV and ART in Sub Saharan Africa. 23.200.000 PLWHA in SSA 10.500.000 need ART (with CD4 350 criteria)

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Models of care to reach and retain more people Is there a role for the community?

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  1. Models of care to reach and retain more peopleIs there a role for the community? Tom Decroo1, Luisa Cumba2 1 Médecins Sans Frontières 2 Ministry of Health, Mozambique

  2. HIV and ART in Sub Saharan Africa • 23.200.000 PLWHA in SSA • 10.500.000 need ART (with CD4 350 criteria) • 6.000.000 on treatment • Attrition at 3 years ART up to 48% • When not on treatment, and in phase of AIDS, life expectancy is less then 1 year • The proportion of PLWHA eligible for treatment will increase • Aging of cohorts • More inclusive protocols : PMTCT B +, CD4 500, ..., test and treat? • Roll out ART in resource constrained context: • Who will do the job? • How to absorb increasing caseloads? • How to bridge distances between clinics and rural communities?

  3. Community Participation: • Resources that can be found in the community: • Community Health Worker (CHW) • PLWHA • Networks of PLWHA (social capital) • HIV = chronic disease • self – management is only sustainable treatment strategy for long term adherence • Peer – support = known promoter for adherence

  4. Example of Malawi, Thyolo district • Community participation accompanied process of roll out and integration of HIV care into small peripheral HF's • > 80% of coverage of ART needs was reached

  5. Example of Uganda • Community Based ART (CBART) • CHW deliver ART in community, provide psychosocial support, and refer sick people to the clinic • equipped with motorbikes, cell phones

  6. Example of Kenya • Community Based ART (CBART) • Peer - CHW deliver ART in community, provide psychosocial support, and refer sick people to the clinic • Equipped with cell phones, and mobile device (personal digital assistant) • Were perceived by PLWHA as their advocates, and use their experience of living with HIV to resolve practical barriers to adherence

  7. Example of CBART in Mozambique, Tete province • PLWHA self-form groups of maximum six • CAG members are registered on a group card • CAG members meet monthly in the community • Verify adherence • Fill in group card • Chose a representative to go the clinic • Share transport costs (if any) • The representative at the clinic • Reports about the other members • Receives refill for all members • Has a routine consultation • Back in the community the representative delivers the refill to the other members • Members support each other, and refer other community members to the clinic when sick

  8. Community ARTGroups (CAG) - DYNAMIC 4th Annual IAS/IAC Pre-conference Meeting: HIV and Health Systems: Strengthening Health Systems for an AIDS-free Generation – July 20-21, 2012 8

  9. Results of CBART in Mozambique, Tete province • 5229 members enlisted in 1139 CAG: • Median FU time: 16 months, IQR [9-27] • Mortality: 2,3 / 100 person-years • LTFU: 0,1 / 100 person-years

  10. Challenges • CBART and STIGMA? • CBART is not without cost: • Training • Supervision • Equipment • Salary / Incentive • Need functional referral system • Community participation = bottom-up • NOT to fill GAPS defined by provider

  11. Conclusion • CBART • Can be effective • Increases affordability and accessibility of ART • Potential to increase trustworthiness (proximity) of ART • Accompany with health system strengthening • Voluntarily involvement PLWHA versus professional lay provider? • Sustainable treatment strategy for chronic disease care? • Peer networks: potential to boost motivation (confidence / importance), and circulation of information

  12. Future applications for community participation? • VCT? Self testing? • Point of care Hb, CD4, VL? • ART stocks? • Combine models of care described above? • Network of PLWHA engaged in the care for their chronic condition • Linked with CHW for VCT, CD4, VL, ARV, sputum sample collection, and reporting • Refer patients who need clinician to the clinic

  13. Models of CBART

  14. References Decroo T, Telfer B, Biot M, et al. Distribution of antiretroviral treatment through self-forming groups of patients in Tete province, Mozambique. Journal of acquired immune deficiency syndromes. 2011;56(2):39-44. Decroo T, Van Damme W, Kegels G, et al. Are Expert Patients an Untapped Resource for ART Provision in Sub-Saharan Africa ? Aids Research and Treatment. 2012; 749718 Garnett GP, Baggaley RF. Treating our way out of the HIV pandemic: could we, would we, should we? Lancet. 2009;373:9-11. Gifford AL, Groessl EJ. Chronic disease self-management and adherence to HIV medications. Journal of acquired immune deficiency syndromes. 2002;31 Suppl 3:S163-6. Jaffer S, Amuron B, Foster S, et al. Rates of virological failure in patients treated in a home-based versus a facility-based HIV-care model in Jinja, southeast Uganda:a cluster-randomised equivalence trial. Lancet. 2009;374:2080-9. Mermin J, Were W, Ekwaru JP, et al. Mortality in HIV-infected Ugandan adults receiving antiretroviral treatment and survival of their HIV-uninfected children: a prospective cohort study. Lancet. 2008;371:752-9. Morgan D, Mahe C, Mayanja B, et al. HIV-1 infection in rural Africa: is there a difference in median time to AIDS and survival compared with that in industrialized countries? AIDS. 2002;16(4):597-603. Van Damme W, Kober K, Kegels G. Scaling-up antiretroviral treatment in Southern African countries with human resource shortage: how will health systems adapt? Social science & medicine. 2008;66(10):2108-Kober K, Damme WV. Scaling up access to antiretroviral treatment in southern Africa : who will do the job ? The Lancet. 2004;364:103-107. 21. Rasschaert F, Pirard M, Philips MP, et al. Positive spill-over effects of ART scale up on wider health systems development: evidence from Ethiopia and Malawi. Journal of the International AIDS Society. 2011;14 Suppl 1:S3 Selke HM, Kimaiyo S, Sidle JE, et al. Task-Shifting of Antiretroviral Delivery From Health Care Workers to Persons Living With HIV/AIDS: Clinical Outcomes of a Community-Based Program in Kenya. Journal of acquired immune deficiency syndromes. 2010;55(4):483-90. Wandeler G, Keiser O, Pfeiffer O, et al. Outcomes of Antiretroviral treatment in Rural Southern Africa. Tropical Medicine and International Health. 2012;59(2): e9-e16. Wools-Kaloustian KK, Sidle JE, Selke HM, et al. A model for extending antiretroviral care beyond the rural health centre. Journal of the International AIDS Society. 2009;12(1):22. World Health Organization (WHO). Global HIV/AIDS response: epidemic update and health sector progress towards universal access. Progress Report 2011 Zachariah R, Teck R, Buhendwa L. How can the community contribute in the fight against HIV/AIDS and tuberculosis? An example from a rural district in Malawi. Transactions of the Royal Society of Tropical Medicine and Hygiene. 2006;100(2):167–75. 

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