The CQUIN Learning Network

Patients at High Risk: Innovations and Experience

Lucas Molfino

Medecins Sans Frontieres – MSF Mozambique July 17-19, 2017

Harare, Zimbabwe

ChamanculoProjectBackgroundCRAM-IntermediaryReferralCenter-

ü  MaputoPop:1.240.000Pop.ü  HIVprevalence:16,9%ü  ARTCoverage:94%ü  3formerHealthAreas(newadministraOveprocesson-going)EachareahaveHospital+Primaryhealthcenters.ü  MSFsupporOngChamanculoHealthareainHIV/TBcaresince2001.2003-ScaleupofHIVcaretroughverOcalapproach2006-DecentralizaOonofHIVcaretoPHC2009-CreaOonofReferralcenterofAltoMae(CRAM)duetolackofHospitalinChamanculoarea.2010-CreaOonofKaposiUnitinCRAM

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CRAMAimCRAM:

1.  toprovideasafetynetfortheHCforclinicalmanagementofcomplicatedHIVpaOentsthatdonotrequirehospitalizaOon

2.  toreducetheworkloadofMaputo’sreferralhospitalsCharacterisOcsofCRAM:-  6outpaOentconsultaOonrooms-  1HospitalizaOonroom(3bed-dayCareUnit)-  KaposiUnit(PreparaOonroom&chemotherapyadministraOonroom)-  Labpla_orm(Samedayresult)-PoC’s,RDT,biochemistry,RouOneVL--  Technicalpla_orm(ProceduresLP,pleural/peritonealtap,fibroscan)-  QualifiedstaffMoH&MSF(IDMD’s,Psy,CO’s,counselors).-  SOP’sforCRAMacOviOes.-  Referral’sandcontra-referral'scriteriabetweenPHC–CRAM–Hospital-  Pla_ormtoimplementOR/PiloOngnewstrategies/training.

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Admission&DischargeCriteriav Admission-CD4<50Cells/mlwithsignsofOI(WHOIII/IV)-  SuspicionsofARTtreatmentfailureorneededof2nd/3rdARTline.-  KSeligibleforChemotherapy(T1)-  Pediatricscomplexcases(treatmentfailures,comorbidiOes)-  SevereARTsideeffects-  HIV&comorbidiOes(PWID/HCV,HBV,MHdiseases)-  PaOentsincriOcalhealthcondiOon,lackingcomplementaryexaminaOons,

andinneedofmorespecializedcareorinvasivemedicalprocedures.v Discharge-  ART1stline>6M-  CD4>200cells/ml-  UndetectableHIVVL-  FuturedecentralizaOonofstable2ndlineARTpaOentstoPHC

v LinkagetoHospital

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PackageofcareatCRAM(I)v CommonpackageforallHIVpa:ents-  Screening&treatmentofTB(orIPTifindicated)-  ScreeningforHBV/HCVandcervicalcancer(VIA)-  IntegraOonofNCD&HIV(mainlyMentalHeathdiseases)-  NutriOonalassessment&support.-  PaOentsupportholisOcapproach(EducaOon,EAC&psychologicalcare)-  Homebasecare&palliaOvecare(medicalprogram)-  TracingsystemforthoseLTFUthroughphonecalls-  LinkedwithcommunityCSO’s(hospice,orfanate,PWIDnetwork)-  Adherenceclub’s(2ndlinecohort)&familyapproach.-  MulOdisciplinaryteamdiscussionsforcomplicatedpaOents.

v PackageforKaposiSarcomapa:ents.-  Chemotherapy(MoHstandardofcare–Bleo/vincrisOne/doxorrubicine)(IntroducOonofPLD–Doxoliposomal-Greatsuccess!!)-  EducaOon,counsellingandpsychologicalsupport.-  LinkedwithMaputocentralhospitalfor2ndlinechemotherapy.

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PackageofcareofCRAM(II)

v AdvanceHIVdiseases-DeepclinicalexaminaOon&comprehensivenursingcare.-ScreeningforCryptoAnOgen(pre-empOvetherapy&CCMtreatment-selectedcasesfordayhospital-)-Screening&treatmentofTB–MolecularMethods,TBLAM--RapidiniOaOonofART&Intensivefollowup-CTX&OIprophylaxis

v SuspicionofARTtreatmentfailure-EACcounselling&Switchto2ndART/ARTcommioee-Fasttrackswitchto2ndLine.(LowCD4orOI)-AccesstoHIVgenotype&switchto3rdARTLine/ARTcommioee-AdvanceARTmanagementwithDrugsresistancedonebyIDMD

v KeyPop(PWID-HIV/HCVprevalence-)-  Specialcare&CRAMfocalpointforthistargetpopulaOon.-  Care&treatmentforHCV(newDAA’s)-  StronglinkwithCSO’sworkingwithPWID.

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CRAMataglancev  CRAMacOvecohort:2513paOents(8%children)-1°ART-1089/2°ART1380/3°ART44-Averageof900admissions/year&2000consultaOons/month.-68CD4cells/mlmedianatadmission.-64%male&60%receivingART.v  HIVadvancediseasesub-group-Averageof270admission/year-31CD4cells/mlmedianatadmission-50%male&50%receivingART.

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Reasonofadmission 2016 2015 2014

HIVAdvancedisease 239(25%) 308(34%) 269(35%)KaposiSarcoma 254(27%) 234(26%) 290(37%)ARTTreatmentFailure 350(37%) 315(35%) 62(8%)Other 108(11%) 46(5%) 138(18%)

GrandTotal 951 903 775

CRAM–2ndlineARTcohort

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•  GoodRetenOonincareinrecentyears(Includingchildren-10%cohort-)•  22%ofcohort>1000cop/mlaser6monthonARTormore.•  45Adherenceclubs(60%cohort)•  DecentralizaOonprocessplanfornearfuturetoPHC.

CRAM-Kaposicohort

-  PoorretenOonincare-AcOvecohortof608paOents/183onchemoox.-  1803paOentstreated(ABV)since2010/40%complete-parOalremission-  IdealsetngtointroducePLD(feasibilitystudyongoing)

At6months,63%ofparOcipantshadcomplete/parOalremission,andanother16%hadstabledisease

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AdvanceHIVdiseasecohort

-PoorRetenOoninCare(Mortality>LTFU)-  SystemaOcscreeningforOI(TBLAM&cripto)-  AmbulatorytreatmentofCCMforselectedpaOents.-  TB,CCM,wasOngsyndrome,anemiamainreasontohospital

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HIV/HCVPWID

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I.

II.

III.

HEPATITISCdiagnosis,enrolmentandtreatment

71VHCRDTsPositive 5HIVneg

61CVresult3waitingtocollect5waitingresults

1LFU1dead

51CVdetected(85%)88%GNT1a

38patientsenrolled

10CVnotdetected4HIVneg1dead

Among35HIV+enrolled,14wereinitiatedontreatmentsince

Dec2016(12patientsJan-June2017)

Among 14 patients initiated on treatment 2 SVR12 (cured)

2 finished treatment 10 are still on treatment

Ø12male,2female-MedianAge:32yearsØ12ex-drugusers;1activedruguser;1non-druguser(druguserpartner)Ø3patientsF3-F4byFibroscanØMedianCD4:211cel/mm3(range169-1034)

Patientnoteligiblefortreatment*3willstartinJuly*3onTBtreatment;*2withKS*1patientwithcomorbidities*5onTARV<6months*3workingoutofarea*3activeDUnonadherent*1inprison

Challenges&limitaOons-  Latearrivals&highmortality-  LackofawarenessofdangersignsofpaOents-  HighaoriOonrateinspecificgroupsKS,advancedisease-  HighVLdetectabilityrates(adherence/resistance?)-  ScreeningofothersOI(Toxo,CMV)-  ManagementofpaOentwithpreviousexposuretoART-  ImplementaOonofOIProphylaxis(IPT,Extendedprophylaxis)-  DecentralizaOonof2ndlineARTcohort(stablepaOents)-  IntegraOngHIV&NCDservices(CVD,DBT)-  PaOentswithacuteclinicalcondiOonsthatneedshorttermobservaOon.àNotcapacityfor24/7funcOoningforobservaOon.-  LinkagetomainHospitalàReferralbetweenCRAM&Hospitals.àLinkagetoCRAMaserhospitaldischarge.-Lackofsupportofdonors/partnersinvolvedinHIVadvancecare.

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CRAMasamodelofcareforAdvanceHIV

disease?AddedvalueofCRAM–intermediaryfacility-inaurbansetngwith

highHIVprevalence?

OngoingDebate…Sustainability

cost-effecOvenessproporOonofpaOentsthatneedshortperiodofhospitalizaOon

geographicallocaOonofthisfacilityspectrumofacOviOesbeyondHIV.

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