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Long Acting Injectable ARVs for
Adolescents: Considerations for
Health Systems and Service Delivery
Nandita Sugandhi
October 3, 2019
Overview
• Health systems and introduction of of long-acting
injectable ARVs (LAI)for treatment of HIV
• Service delivery considerations for adolescents
– Demand creation
– Dosing schedule
– Location
– Provider
– User fees
– Choice
Introduction of new ARVs at the health system level
Policy/Guidelinechange
Procurement Implementation
• Regimen• Formulation• Eligibility• Registration
• Quantification• Budgeting• Availability• Distribution
• Demand creation• Training• Monitoring
• Revision of national HIV treatment guidelines takes time
• Need to assess impact on other programmatic changes
• Sequencing needs to be considered over a lifetime and through future periods of transition
• Data challenges
• Funding constraints
• Supply of new ARV products is often constrained
• Timeline for new pipeline products is uncertain making planning a challenge
• Healthcare workers need to be trained
• Viral load monitoring is not widely available or reliable to enable timely decision making
• Registers and forms need to be updated
• Transition “fatigue”
General Implementation Considerations
for LAI for HIV Treatment
1. Eligibility criteria– Prioritization v. equal access
– Adherence requirements
– Completion of lead-in period
– Special populations (TB,
pregnancy, children)
2. HCW training– Identifying eligible patients
– Providing patient information
– Following lead-in, monitoring
and discontinuation protocols
3. Infrastructure– Reliable supply chains for oral and
injectable ARVs
– Refrigeration/cold chain
– Laboratory monitoring (VL,
monitoring for liver or kidney
toxicity, resistance testing)
– Access to supplies and safe
injection practices
4. Accessibility – Decentralization
– Integration into other health
services
Differentiated Service Delivery:
One Size Does Not Fit All
http://itpcglobal.org/wp-content/uploads/2018/11/ITPC-DSD-Youth-Chapter-Nov-2018.pdf
Introduction of LAI for adolescents and young people
• How do you want to hear about it?
• Where do you want to get it?
• When do you want to get it?
• Who do you want to provide it?
• What kind of support will you need
to adhere to it?
• How much will it cost for you?
• Is this right for everyone?
HOW should demand for LAI be created?
• Healthcare workers should be able to provide explanation in
terms that young people understand
• Peers and youth leaders can share information
• Social media platforms can spread helpful information (but also
fake news!)
• Role models
Information should be shared by sources that
adolescents and young people can TRUST
When do you want to get it?
• Injections required every two month
– 7 day “window” period
– Discontinuation increases risk of resistance
• Females using injectable contraception need to balance an injection every 3 months with another injection every 2 months
• Can injections be timed with school holidays or be given on weekends to avoid interruption of your schedule
Where should LAI’s be delivered
Facility level
• ART clinic
• Family Planning clinic
• OPD
• Mobile clinic
Community level
• School
• Church
• Home
• Community setting
WHO do you want to administer it
• HCW (Doctor, Nurse)
• Community Health Worker
• Peer who has been trained
• Parent/Caregiver
What kind of support will help with adherence?
• SMS reminders
• Peer support and coordinated visit days
• Radio/Media messages
• Treatment buddy
• Reminders on phone
• Home visits
Will you only need
adherence support when
you are due for an
injection or is ongoing
support needed?
How much will it cost for you?
• Intramuscular injections require:
– The drug
– Sterile syringe
– Sterile needle
– Antiseptic
– Cotton wool
– Bandage/tape
– Gloves
Is this right for everyone?
• Lead in period requires adherence to daily ARVs for several
months
• Visits every 2 months may too frequent for some
• Needle phobia is real!
• Dependence on HCW to provide injection may feel like a loss of
control over one’s own health
• Changes in pregnancy intention
What choices do you want
and what information do
you need to make a choice
that is right for you?
Thank you!
• Long-acting injectable ARVs are potentially a game changer for HIV treatment
• Health systems need to consider a number of issues to adopt any new drug or new drug delivery systems
• Health systems should also consider want young people want before introducing LAI
• Your voice is needed and it needs to be heard
Acknowledgments
• Jessica Rodrigues
• Marissa Vicari
• Yannis Hodges-Mameletzis
• Shenaaz Pahad