Long Acting Injectable ARVs for

Adolescents: Considerations for

Health Systems and Service Delivery

Nandita Sugandhi

October 3, 2019

Overview

• Health systems and introduction of of long-acting

injectable ARVs (LAI)for treatment of HIV

• Service delivery considerations for adolescents

– Demand creation

– Dosing schedule

– Location

– Provider

– User fees

– Choice

Introduction of new ARVs at the health system level

Policy/Guidelinechange

Procurement Implementation

• Regimen• Formulation• Eligibility• Registration

• Quantification• Budgeting• Availability• Distribution

• Demand creation• Training• Monitoring

• Revision of national HIV treatment guidelines takes time

• Need to assess impact on other programmatic changes

• Sequencing needs to be considered over a lifetime and through future periods of transition

• Data challenges

• Funding constraints

• Supply of new ARV products is often constrained

• Timeline for new pipeline products is uncertain making planning a challenge

• Healthcare workers need to be trained

• Viral load monitoring is not widely available or reliable to enable timely decision making

• Registers and forms need to be updated

• Transition “fatigue”

General Implementation Considerations

for LAI for HIV Treatment

1. Eligibility criteria– Prioritization v. equal access

– Adherence requirements

– Completion of lead-in period

– Special populations (TB,

pregnancy, children)

2. HCW training– Identifying eligible patients

– Providing patient information

– Following lead-in, monitoring

and discontinuation protocols

3. Infrastructure– Reliable supply chains for oral and

injectable ARVs

– Refrigeration/cold chain

– Laboratory monitoring (VL,

monitoring for liver or kidney

toxicity, resistance testing)

– Access to supplies and safe

injection practices

4. Accessibility – Decentralization

– Integration into other health

services

Differentiated Service Delivery:

One Size Does Not Fit All

http://itpcglobal.org/wp-content/uploads/2018/11/ITPC-DSD-Youth-Chapter-Nov-2018.pdf

Introduction of LAI for adolescents and young people

• How do you want to hear about it?

• Where do you want to get it?

• When do you want to get it?

• Who do you want to provide it?

• What kind of support will you need

to adhere to it?

• How much will it cost for you?

• Is this right for everyone?

HOW should demand for LAI be created?

• Healthcare workers should be able to provide explanation in

terms that young people understand

• Peers and youth leaders can share information

• Social media platforms can spread helpful information (but also

fake news!)

• Role models

Information should be shared by sources that

adolescents and young people can TRUST

When do you want to get it?

• Injections required every two month

– 7 day “window” period

– Discontinuation increases risk of resistance

• Females using injectable contraception need to balance an injection every 3 months with another injection every 2 months

• Can injections be timed with school holidays or be given on weekends to avoid interruption of your schedule

Where should LAI’s be delivered

Facility level

• ART clinic

• Family Planning clinic

• OPD

• Mobile clinic

Community level

• School

• Church

• Home

• Community setting

WHO do you want to administer it

• HCW (Doctor, Nurse)

• Community Health Worker

• Peer who has been trained

• Parent/Caregiver

What kind of support will help with adherence?

• SMS reminders

• Peer support and coordinated visit days

• Radio/Media messages

• Treatment buddy

• Reminders on phone

• Home visits

Will you only need

adherence support when

you are due for an

injection or is ongoing

support needed?

How much will it cost for you?

• Intramuscular injections require:

– The drug

– Sterile syringe

– Sterile needle

– Antiseptic

– Cotton wool

– Bandage/tape

– Gloves

Is this right for everyone?

• Lead in period requires adherence to daily ARVs for several

months

• Visits every 2 months may too frequent for some

• Needle phobia is real!

• Dependence on HCW to provide injection may feel like a loss of

control over one’s own health

• Changes in pregnancy intention

What choices do you want

and what information do

you need to make a choice

that is right for you?

Thank you!

• Long-acting injectable ARVs are potentially a game changer for HIV treatment

• Health systems need to consider a number of issues to adopt any new drug or new drug delivery systems

• Health systems should also consider want young people want before introducing LAI

• Your voice is needed and it needs to be heard

Acknowledgments

• Jessica Rodrigues

• Marissa Vicari

• Yannis Hodges-Mameletzis

• Shenaaz Pahad