Models of care to reach and retain more people Is there a role for the community?

1. Models of care to reach and retain more peopleIs there a role for the community? Tom Decroo1, Luisa Cumba2 1 Médecins Sans Frontières 2 Ministry of Health, Mozambique

2. HIV and ART in Sub Saharan Africa • 23.200.000 PLWHA in SSA • 10.500.000 need ART (with CD4 350 criteria) • 6.000.000 on treatment • Attrition at 3 years ART up to 48% • When not on treatment, and in phase of AIDS, life expectancy is less then 1 year • The proportion of PLWHA eligible for treatment will increase • Aging of cohorts • More inclusive protocols : PMTCT B +, CD4 500, ..., test and treat? • Roll out ART in resource constrained context: • Who will do the job? • How to absorb increasing caseloads? • How to bridge distances between clinics and rural communities?

3. Community Participation: • Resources that can be found in the community: • Community Health Worker (CHW) • PLWHA • Networks of PLWHA (social capital) • HIV = chronic disease • self – management is only sustainable treatment strategy for long term adherence • Peer – support = known promoter for adherence

4. Example of Malawi, Thyolo district • Community participation accompanied process of roll out and integration of HIV care into small peripheral HF's • > 80% of coverage of ART needs was reached

5. Example of Uganda • Community Based ART (CBART) • CHW deliver ART in community, provide psychosocial support, and refer sick people to the clinic • equipped with motorbikes, cell phones

6. Example of Kenya • Community Based ART (CBART) • Peer - CHW deliver ART in community, provide psychosocial support, and refer sick people to the clinic • Equipped with cell phones, and mobile device (personal digital assistant) • Were perceived by PLWHA as their advocates, and use their experience of living with HIV to resolve practical barriers to adherence

7. Example of CBART in Mozambique, Tete province • PLWHA self-form groups of maximum six • CAG members are registered on a group card • CAG members meet monthly in the community • Verify adherence • Fill in group card • Chose a representative to go the clinic • Share transport costs (if any) • The representative at the clinic • Reports about the other members • Receives refill for all members • Has a routine consultation • Back in the community the representative delivers the refill to the other members • Members support each other, and refer other community members to the clinic when sick

8. Community ARTGroups (CAG) - DYNAMIC 4th Annual IAS/IAC Pre-conference Meeting: HIV and Health Systems: Strengthening Health Systems for an AIDS-free Generation – July 20-21, 2012 8

9. Results of CBART in Mozambique, Tete province • 5229 members enlisted in 1139 CAG: • Median FU time: 16 months, IQR [9-27] • Mortality: 2,3 / 100 person-years • LTFU: 0,1 / 100 person-years

10. Challenges • CBART and STIGMA? • CBART is not without cost: • Training • Supervision • Equipment • Salary / Incentive • Need functional referral system • Community participation = bottom-up • NOT to fill GAPS defined by provider

11. Conclusion • CBART • Can be effective • Increases affordability and accessibility of ART • Potential to increase trustworthiness (proximity) of ART • Accompany with health system strengthening • Voluntarily involvement PLWHA versus professional lay provider? • Sustainable treatment strategy for chronic disease care? • Peer networks: potential to boost motivation (confidence / importance), and circulation of information

12. Future applications for community participation? • VCT? Self testing? • Point of care Hb, CD4, VL? • ART stocks? • Combine models of care described above? • Network of PLWHA engaged in the care for their chronic condition • Linked with CHW for VCT, CD4, VL, ARV, sputum sample collection, and reporting • Refer patients who need clinician to the clinic

13. Models of CBART

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