Community based ART adherence Clubs: A community model of care for ART delivery Suhair Solomon, Phumelele Trasada, Gabriela Patten, Fanelwa Gwashu, Lillian Twentiey, Lynne Wilkinson Good morning, my name is Suhair Solomon, I will be presenting on behalf of my colleagues at MSF and Western Cape DoH, on a community model of care for ART delivery piloted in Khayelitsha, Cape Town.

Background ~ 6.4 million HIV positive ~ 2.5 million on ART Expansion of ART eligibility, CD4 500 Leaky Cascade - A lot has changed in last 10 years with a fair focus on scale up of ART programs, advances in regiments, increases in median CD4 count for ART start, decresaes morbidity and mortality and a form of prevention, SA guidelines changes over time, The proportion of those who access and stay on art, we know there are challenges with retain along the cascade, as this slide shows, we lose patients at each stage of the cascade, of those who know they on treatment, reduced number on treatment, and estimated that in SSA, only 29% have a suppressed VL All benefits of treatment are dependent on adherence and retention in care, given what we know about this leaky cascade, retaining these patients is where our challenge lies With change in elibigiblity where more of our patients initiating on ART are well, the old model of a doctor centred service, of long waiting queue with sick or unwell patients who really require additional clinical support will not work for them. We need to explore alternative options for these patients in order to keep them in care Boulle, A. 2014

Setting Khayelitsha, Cape Town Population ~ 500,000 12 health facilities providing HIV care 29,192 pts on ART (2014) 8,552 at Site B CHC (Ubuntu Clinic) A brief background to the context we find ourselves in, in Khayelitsha, Cape Town, with an estimated population of 500k, 12 health facilities providing HIV care, over 29k on ART 92014 data) and at the clinic we have piloted our model from, has 8.5k patients.

ART Adherence Clubs Stable patients on ART Lay health worker-led Number of patients retained in Adherence Clubs and % of RIC in club across the Cape Metro ART Adherence Clubs Stable patients on ART On ART >12-months 2 suppressed viral load No condition requiring frequent clinical consultation Lay health worker-led ~30 stable patients Meets 5 times/year Receives pre-packed ART Clear referral pathway for clinical support A brief overview of the AC: criteria at time of pilot was stable adult patients, with 12m on treatment, 2 undetectable VL, and otherwise well with no clinical diagnosis that requires additional clinical monitoring. Groups are counselor or equivalent led, receiving pre-packed treatment 5 times a year (with longer dispensing over the festive season, synonomous with circular migration. Endorsed by City and provincial health, the rollout of the facility based adherence club model has been at a steady pace, with this graph showing implementation across all subdistricts in facilities that have clubs in the Cape Metro between Jan 2011 – November 2014. 50 facilities, 1100 clubs, > 30 000 patients in facility club care, showing 30% retained in club care. Club M&E data courtesy of Dr. Beth Harley

Community Models of Care Facility Community venue - close to facility Community venue close to / in patient home It is important to understand the distinction between different types of community models out there. Groups can meet at facility, community venue close to/across the road from the facility, community close to or in patient home. It is

Intervention: community based club Same club model Key differences Patient selected home or venue close to home Members are from same area Club facilitator collects treatment at facility or alternative delivery site Blood visit managed differently Referral pathway exists but not immediate/dependent on uptake While same eligibility criteria was followed for entry into a community club, the CC model moved these clubs from clinic facility to community Club facilitators (lay health worker) Blood visit, either blood taking is done at alternative site, with results being delivered to facility, or patients were given a voucher indicating they were due for blood taking and presenting at a time convenient to them at the clinic to have their blood drawn before their next club visits

Methodology All patients enrolled in CCs in Ubuntu clinic’s feeder areas: May 2012 - November 2014 Collected patient baseline characteristics; longitudinal VL data, retention in care outcomes (incl. club care) LTFU = no recorded clinic/club visit >3m. - - We collected patient…..

Results Total enrolled in community clubs 203 Club size 10 – 38 Female (%) 158 (78%) Median age at club enrolment (IQR) 36.7 (32.2 - 42.8) Median time on ART (IQR) 3.6 (2.2 - 5.5) Median time in community clubs in days 336 (224 - 728) At least 1 year of follow-up time 101 (50%) Used buddy for drug pickup at least once 124 (61%) Used buddy more than once 50 (25%) Club size varied depending on venue size (venues ranged from patients homes to community and church halls). Can see wide use of buddy’s, which shows this is a valuable flexibility of the model, and doesn’t detract from model. Add #home and # community venue (fanelwa)

Results: all patients ever enrolled in community clubs - Of the 203 enrolled in CC between May 2012-Nov 2014, 97 % were retained in care, here we made the distinciton between club and clinic care, where 85% were retained in CC, 11% in clinic care, and just 1 % transferred to another clinic. Given this time period we followed VL results, for those who were due for their first VL, 95% of them suppressed, and those in club for over a year due for their second VL, 93 % had suppressed VL. Of those who returned to clinic care, 4/22 had a high viral load (18%), others either because they missed a visit, chose to return to clinic, clinically unstable, 2 confirmed in transferred care

Results: patients with 1-year follow-up in community clubs Patients 1 year follow-up = 101 LTF 1 (1%) Retained in ART care 100 (99%) Community Club Care 95 (94%) Clinic Care 5 (5%) Among patients with at least 1 year of follow-up time in the community club, 100(99%) were retained, of which 95 (94%) were in CC care, 89 have had one or more VL, 100% suppressed 5 (5%) in clinic care 1 had a high VL, 3 missed appt, 1 referred back for clinical reasons, and 1 (1%) was LTF. Due VL 93 (98%) At least 1 VL completed 89 (96%) VL suppressed: 89 (100%)

Conclusion Homes and community spaces are feasible options Improves access to ART for patients close to home High retention and adherence rates Reduces patient load at health facilities, Empowers patients through self-management Reduces community stigma. People comes to peoples homes to request club membership, and to ask about testing/HIV - CCs work for the patients that want them

Recommendations Close to home clubs should be considered for rollout elsewhere Requiring resource planning and management on a reliable drug supply, suitable monitoring systems, trained and supported lay healthcare workers, effective referral systems and adequate funding Consider options for community club scale out (CBO) CC work for those who want it

If considering rolling out AC/CC, we can accommodate training your trainers https://www.msf.org.za/msf-publications/how-to-keep-art-patients-long-term-care-art-adherence-club-report-and-toolkit