Community-supported models of care for people on HIV treatment in sub-Saharan Africa

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