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The CQUIN Learning Network
Patients at High Risk: Service Delivery for Unstable HIV Patients
Dr Daniel Mwamba, MD
Centre for Infectious Diseases Research in Zambia July 17-19, 2017
Harare, Zimbabwe
Background
• CIDRZsupports233sitesin4provinces• Implemen7ngdifferen7atedservice
delivery(DSD)modelssince2015– Communityadherencegroups(CAGs)– Urbanadherencegroups(UAGs)
• AsofJune2017:– 763CAGsand16UAGsformed– 5,062pa7entsonregularfollowup
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CurrentEligibilityCriteriaforCIDRZDSDModels
• Individuals>14yearsstableonART:– CD4≥200– Noac7veOI(noWHOstage3or4condi7on)– ReceivingARTfor≥6months– Viralload<1000copies/ml
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LessonsLearntfromDSDforStablePa7ents
• Highyieldindextes7ngcomparedtodoor-to-door– 12.3%posi7vityand>90%linkagetocare
• 12monthreten7on:97%comparedto76%ofpa7entsreceivingstandardofcare.
• Highlyacceptabletoallstakeholderspar7cularlypa7ents
• Pa7entsareunhappytoleaveDSDcareserviceswhenup-referredtoclinicbasedcareforeitherOIordetectableVL
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Thelast90,Zambiastatus
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90:90:90inZambiaDatafromZAMPHIA
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DSDfor“Unstable”Pa7ents
• Understandingbarrierstoengagementandreten7oniskeyinformula7ngstrategiestoimprovepa7entoutcomes
• Barrierstopa7entengagementandul7matelyVLsuppressioninclude:– LowHIVliteracy– S7gma/denialofdiagnosis/tradi7onalbeliefs– Mentalhealthdisorders– PrimaryHIVdrugresistance/drugtoxicity– Incorrectdosing/impaireddrugabsorp7on
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Mostcommonpa1ent-reportedreasonsforstoppingcare(N=603).Be>erinfoStudy
363739404646515155555862
7190
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0 20 40 60 80 100 120 140
IcametobelieveIdonotactuallyhaveHIVIhadfamilyobliga1ons
Movedtoanewplace,nomen1onifARTavailableThestaffdidnottreatmewithrespect
ItwastakingtoolongtostartARTIlostmycardforARTCare
IwasafraidclinicwouldscoldmeformissingmyHadhighCD4anddidn'tseeareasontoa>end
IintendedtogobutwastoolazyImovedandtherewasnocareavailableinthis
Ispenttoomuch1meatclinicA>endingclinicriskeddisclosuretosomeoneI
IfeltwellandthoughtIdidn’tneedcareorTransporta1onwastoodifficultorexpensive
Workrequirementsinterferedwithpickingup
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0% 20% 40% 60% 80% 100%
Structural Psychosocial Clinic
StrategiesforImprovingOutcomes
Targe7nginterven7onsaddressing:1. Clinic/Facilitybasedbarriers• Lackofdedicatedcliniciantooverseecare• Qualityofcare/respectfromproviders• Longwait7mes
2. Psychosocialbarriers• S7gma• Culturalbeliefs
3. Structuralbarriers• Distance/Access• Workdemands
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ProposedInnova7on:Include“Unstable”ClientsinCAGModel
• RevisedEligibility:– >14years– OnART>6months– RegardlessofVLorWCS
• Anynewlyiden7fiedunstableclientsinalreadyestablishedtradi7onalDSDmodelswillbeeligibletoreceivecareunderthismodelwhilebeinginaCAG
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Ra7onaleforInclusionof“Unstable”ClientsintheCAGmodel
• ThehypothesesisthatDSDforsuchpa7entswillprovideanintegratedclinicalandcommunitycarepackagetoimproveadherenceandaddressassociatedbarriersthatmayhavecontributedtoadetectableviralloadwhilemanagingallcomorbidi7es.
• Thisstrategyaimtoajainthelast90oftheUNAIDStargetsinabidtoendtheHIVepidemic
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Clinic-basedCareforClientsatHighRisk
• Dedicatedmul7disciplinaryclinicalteamtrainedinmanagementofpa7entswithcomplicateddisease-doctor,nurse,pharmacist,laboratorytechnician
• Dedicatedadvancedtreatmentdiseaseclinic(stakeholderstodecidewhichday/7mebestforall)
• Reliablelaboratorysupportwith72hrVLresultturnaround7me
• HIVgenotypeasrequiredwithrapidTAT(14-21days)• Enhancedcounselingservices(HIVliteracy,mentalhealthscreening,sexualreproduc7vehealth)
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Community-basedCareforClientsatHighRisk
• Treatmentsupporterled• Psycho-socialsupport/counseling–bothathomeatingroupadherencemee7ngs
• Homedrugdeliverywithsimplesymptomscreen(h/ofevers,nightsweats,weightloss,cough,headaches)–monthlyorperphysiciansrecommenda7on
• DBSVLcollec7onevery3months• Appointmentremindersperclinicianrecommenda7on• Groupadherencemee7ngswithincommuni7esatagreedintervals(e.g.every4or8weeks)
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M&E
• DevelopSOPstoguidefacility-basedandcommunity-basedac7vi7es
• Adoptcurrentna7onaldatacollec7ontoolsforbothfacilityandcommunityac7vi7eswithsomerevisionsincommunitytoolstoincludehomedeliveryofART,symptomscreenandresultfeedback
• TraincliniciansinmanagementofunstableHIVpa7ents
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Thankyou
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