Community models of ART delivery in Southern Africa MSF Regional experience
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Transcript of 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 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
-- -- --
05
1015202530354045
March April May
Ineligible Newly Init Stable on ART
Youths clubs, Khayelitsha , South Africa
HIV Testing
Eligibility ART Long term adherence
CAG
Impact of community based activity on the whole ‘seek, test, treat, retain’ cascade ?
HIV TestingPMTCT
coverageEligibility ART
PMTCTLong term adherence Undetectable
VL
CAGCAG
POC VL
PRE- ART
CAG
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’