M. Bemelmans, S. Baert, E. Goemaere, L. Wilkinson, M. Vandendyck, G. Van Cutsem, C. Silva, S. Perry, E Szumilin, R. Gerstenhaber, L. Kalenga, M. Biot, N. Ford
MSF OCB Scientific day 2014
Community-supported models of care for people on HIV treatment in sub-Saharan Africa
Peter Casaer
STABLE patient on ART
Monthly clinic visit for
consultationand ART refill
How to deal with a
growing cohort of
stable patients on ART?
Peter Casaer
Mozambique
MalawiDR Congo
South Africa
Community-supported models of care
Project Chiradzulu, Malawi
Khayelitsha, South Africa
Kinshasa, DR Congo
Tete, Mozambique
Context Rural Urban Urban Rural
ART refill 3-monthly 2-monthly 3-monthly Monthly
Mode Individual Group Individual Group
Where Health facility Health facility or community venues
Community distribution points
Patients’ homes
Led by Lay worker Lay worker Lay worker of network of PLHIV
Self-formed group of patients
Clinical consultation
6-monthly Yearly Yearly 6-monthly
Blood drawing Yearly viral load Yearly viral load Yearly CD4 6-monthly CD4
Project Chiradzulu, Malawi
Khayelitsha, South Africa
Kinshasa, DR Congo
Tete, Mozambique
Context Rural Urban Urban Rural
ART refill 3-monthly 2-monthly 3-monthly Monthly
Mode Individual Group Individual Group
Where Health facility Health facility or community venues
Community distribution points
Patients’ homes
Led by Lay worker Lay worker Lay worker of network of PLHIV
Self-formed group of patients
Clinical consultation
6-monthly Yearly Yearly 6-monthly
Blood drawing Yearly viral load Yearly viral load Yearly CD4 6-monthly CD4
Project Chiradzulu, Malawi
Khayelitsha, South Africa
Kinshasa, DR Congo
Tete, Mozambique
Context Rural Urban Urban Rural
ART refill 3-monthly 2-monthly 3-monthly Monthly
Mode Individual Group Individual Group
Where Health facility Health facility or community venues
Community distribution points
Patients’ homes
Led by Lay worker Lay worker Lay worker of network of PLHIV
Self-formed group of patients
Clinical consultation
6-monthly Yearly Yearly 6-monthly
Blood drawing Yearly viral load Yearly viral load Yearly CD4 6-monthly CD4
Project Chiradzulu, Malawi
Khayelitsha, South Africa
Kinshasa, DR Congo
Tete, Mozambique
Context Rural Urban Urban Rural
ART refill 3-monthly 2-monthly 3-monthly Monthly
Mode Individual Group Individual Group
Where Health facility Health facility or community venues
Community distribution points
Patients’ homes
Led by Lay worker Lay worker Lay worker of network of PLHIV
Patients
Clinical consultation
6-monthly Yearly Yearly 6-monthly
Blood drawing Yearly viral load Yearly viral load Yearly CD4 6-monthly CD4
What are the benefitsbenefits
for patientspatients and health health systemssystems
across these community-supported modelsmodels?
MethodsMethods
• Assessing 4 approaches to manage stable patients on ART
• From a patient and health system perspective
• Reviewing routinely collected programme data as well as published studies
ResultsResults
“The advantage of being in a CAG is that you can do other
small jobs when you know that a group member will collect
ART for you. This makes things easier “
CAG Group member, Tete, Mozambique
Rasschaert, 2014
Transportation costs
3x less at PODI versus hospital
Jocquet, 2011
Time spent for ART collection
14 minutes at PODI versus
85 minutes at hospital
Billaud, 2014
69% reduction in ART 69% reduction in ART refill visits refill visits
Project data, Chiradzulu, 2013Luque-Fernandez, 2013Kalenga, 2013Preliminary data, Tete, 2014
High retention in careHigh retention in care
Project data, Chiradzulu, 2013Luque-Fernandez, 2013Kalenga, 2013Preliminary data, Tete, 2014
Eligible & joined
Eligible & did not join
Better retention than in Better retention than in conventional careconventional care
“… belonging to a group strengthens people. Moreover, being united people become mentally stronger during treatment compared to those who do it individually.”
CAG leader, Tete, Mozambique
Rasschaert, 2014
Lower Service
Provider Costs
Cost per patient per year
Adherence club 58 US$
Conventional care 109 US$
Bango, 2013
Samantha Reinders
Strong publication and dissemination efforts
Major impact on national & international policy
What is MSF’s responsability
in national roll-outs?
Critical enablers
André Francois
Brendan Bannon
Brendan Bannon
Miguel Cuenca
Recognition of lay workers
Robust drug supplyReliable monitoring system
Acces to quality clinical managementRealistic planningFlexible adaptations
ConclusionConclusion
• Community supported models respond to the needs of a growing cohort of stable patients on ART and their health care workers
• Adaptation of these models is ongoing to include other HIV+ patients and allow for a wider application to other diseases
• Further analysis and advocacy is needed to ensure models are adapted to contexts and critical enablers are in place
André Francois
AcknowledgementsAcknowledgements
André Francois
• Patients living with HIV in sub-Saharan Africa
• MSF and Ministry of Health staff in our projects in sub-Saharan Africa
• Co-authors
Extra’s
Project Chiradzulu, Malawi
Khayelitsha, South Africa
Kinshasa, DR Congo
Tete, Mozambique
Start 2008 2007 2010 2008
Nr patients joined
8566 5900 2162 8181
% active ART cohort
20% 23% 43% 50%
samumsf.org
3168 tested for HIV
8,6% HIV + 40% joined CAG
42% eligible for ART
89% eligible and started ART
Improve testing & linkage to care
Project data Changara, 2013