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

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 ?

Spacing clinical visits every 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

Recruited patients 2486

Female (%) 1715 (69)

Median time on ART prior to enrollment (IQR) 27.2 (17.2-44.2)

Median CD4 at SMA enrollment ( IQR) 534 ( 420-692)

Median follow in SMA ( IQR) 14.7 ( 8.3-18.7)

Location Model of community ART care

Start date

Nbrpatients

ART provider Frequency of ART dispensing

Frequency of clinic visits

Cumulative Retention*

Mozambique, Tete

Community ART groups

2008 4410900 CAGS

Expert patient

1 monthly 6 monthly 97% after average FU time of 16 months

Malawi, Thyolo

Community health posts

2009 925 CHW ( HSA) 3 monthly 3 monthly 98% at15 months

Malawi, Chiradzulu

Community ART refills

2008 3343 CHW 3 monthly 6 monthly 97% at 1 yr 93% at 2 years*

Malawi, Chiradzulu

Community ART refills

2008 4,000 CHW ( HSA) 3 monthly 6 monthly 97% at 2 years

South Africa, Khayelitsha

Adherence clubs

2007 3000110 clubs

CHW 2 monthly 6 monthly 97.5 % at 1y97.5 % at2 y

Kinshasa, DRC

Community ART points

2010 -- Expert patient

-- -- --

Eligibility criteria

05

1015202530354045

March April May

Ineligible Newly Init Stable on ART

Youths clubs, Khayelitsha , South Africa

HIV Testing

HIV Testing EligibilityEligibility ARTART Long term

adherenceLong term adherence

CAGCAG

Impact of community based activity on the whole ‘seek, test, treat, retain’ cascade ?

HIV TestingPMTCT

coverage

HIV TestingPMTCT

coverageEligibilityEligibility ART

PMTCTART

PMTCTLong term adherenceLong term adherence Undetectable

VLUndetectable

VL

CAGCAGCAGCAG

POC VLPOC VL

PRE- ARTPRE- ART

CAGCAG

Impact of community based activity on the whole ‘seek, test, treat, retain’ cascade ?

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

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’

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