Models of care to reach and retain more people

Is there a role for the community?

Tom Decroo1, Luisa Cumba2

1 Médecins Sans Frontières2 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)• 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?

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

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

Volunteers Home Based Care, including drug distribution (CTX, TB), psychosocial support, referral

PLWHA Sensitization, psychosocial support and tracing

CHW Participate in care provision at the HF (Reception, VCT, Pharmacy)

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

Mortality 95 % reduction (before – after CBART)

Orphanhood 93% reduction (before – after CBART)Effectiveness CBART = Facility based ARTNr of clinic visits 75% reduction for CBARTCost CBART slightly less expensive

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

Effectiveness CBART = Facility based ARTNr of clinic visits Reduction w 50% for CBART cohort

4th Annual IAS/IAC Pre-conference Meeting: HIV and Health Systems: Strengthening Health Systems for an AIDS-free Generation – July 20-21, 20127

• 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

Example of CBART in Mozambique, Tete province

Community ART Groups (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

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

Results of CBART in Mozambique, Tete province

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

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

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

Models of CBARTUganda (Jaffar, 2009)

Kenya(Selke, 2010)

Mozambique(Decroo, 2011)

Who? CHW Peer CHW PLWHA in support groups

Salaried? Y Y N

Equipment Motorbikes, cell-phones

Cell-phones, mobile device

N

Study population Rural, 859 patients, from 0 m on ART

Rural, 96 patients, from 3 m on ART

Rural, 1301 patients, from 6 m on ART

Routine clinic visit Every 6 m Every 3 m Every 6 m

Outcomes Attrition at 12 m:CBART: 12%Control:13%

VL < 500 at 12 m:CBART: 84% Control: 83%

Attrition at 12 m:CBART: 6%Control:3%

VL undet. at 12 m:CBART: 89% Control: 86%

Attrition after median of 16 months FU in CBART: 2,4%

References

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