Dr. Roger Teck - MSF WHO Satellite Meeting ICASA 2015 - Harare Reducing frequency of ARV pick-ups for HIV patients stabilised on ARV treatment Realistic in Africa ? What do we need to make that work ? MSF Perspective Dr. Roger Teck - MSF WHO Satellite Meeting ICASA 2015 - Harare

Monthly clinic visit for consultation STABLE ART patient Monthly clinic visit for consultation and ART refill Health Services: How to deal with a growing cohort of stable patients on ART? Let me first introduce you to Mamotsileli, a young HIV positive woman from Lesotho. Mamotsileli travels miles every month to pick up her drugs at the closest health facility. She takes 3 hours to get there and spends a full day waiting in the queue with other healthy patient on ART, just to pick up her drugs from a nurse who is struggling to deal with the huge patient load. Many other stable patients on ART and their health care workers face the same challenges as Mamotsileli and led MSF to question on how to deal with a growing cohort of stable patients on ART. Peter Casaer Peter Casaer

Peer support recognised as a facilitator for adherence/RIC Self management as part of any chronic care disease model

Drug dispensing for ART pickup “Bottleneck” for patients’ retention in care and for capacity of HIV treatment services

Task shifting in dispensing from pharmacists to nurses and lay workers

Reducing frequency of ARV pick-ups for HIV patients stabilised on ARV treatment WHO recommendation: Less frequent ARV medication pick ups should be recommended for patients stable on ART

Frequency of ARV pick-ups Country Number of re-fill month allowed by country guidelines Number of months re-fill Arguments for non –allowing Mozambique 3 1 Buffer stock - Supply stability South Africa 3 months supplies not opposed by government circular. Medicines Act restricting re- scripts to 6 months 1-2 Cash cycle - Supply stability Lesotho No specification Storage space, adherence, storage conditions Malawi 3 months for stable and adherent patients ; 6 - 12 months for travelling patients Willingness to move to 6 months Zimbabwe 3 (exceptionally 6-12 months for travelling patients ) Supply stability DRC 1-3 No argument from DoH [1]

3 monthly supplies of ART and Cotrimoxazole Delinking Clinical Visit from ART refill for Stable Patients on ART adult dose V Few points we feel are key to all these approaches Fundamental concept is to make clear guidance on how often it is needed to see a clinician versus the need for the patient to collect chronic ART refills Clear definition of stability with “ temporary clinic follow up” as and when problems arise Appointment Spacing 3 monthly supplies of ART and Cotrimoxazole Clinical appointment once every 6 months to once every year (routine VL monitoring)

« Differentiated » care for stable patients on ART Range of models implemented in MSF programmes for stable patients on ART Range from facility based through to community based models and all have one characteristic in common: that they delink clinical consultation from ART ref Ill All these models looked at on how often it is needed to see a clinician versus the need for the patient to collect ART refills and used a clear definition of stability with “ temporary clinic follow up” as and when problems arise For ex in Zimbabwe we managed to get to 3 monthly supplies of ART and Cotrimoxazole. If routine VL: clinical appointment once a year If no routine viral load: clinical appointment every 6 months. The way how these drugs then get collected is difference between these models. Patient centred - context adapted – patient’s choice – local ownership

Health facility or community venues Community distribution points Context Urban & rural Urban Rural ART refill 1 to 3-monthly 2-monthly 3-monthly 1 to 3 Monthly Mode Individual Group Where Health facility Health facility or community venues Community distribution points Patients’ homes Led by Lay worker Lay worker of network of PLHIV Patients Clinical consultation Yearly Blood drawing Yearly viral load A first more health sercvice driven strategy called appointment spacing and fast track drug refill was implemented in several urban and rural settings Patients individually attend monthly to 3-monthly for drug refill at the health facility where they get the drugs dispensed directly from a lay worker, meaning they no longer need to pass by the nurse. Patients only attend 6 monthly or yearly for a clinical consultation and 6 monhtly for CD4 or yearly for viral load. Brendan Bannon

Health facility or community venues Community distribution points Context Urban & rural Urban Rural ART refill 1 to 3-monthly 2-monthly 3-monthly 1 to 3 Monthly Mode Individual Group Where Health facility Health facility or community venues Community distribution points Patients’ homes Led by Lay worker Lay worker of network of PLHIV Patients Clinical consultation Yearly Blood drawing Yearly viral load A second model called adherence clubs, were piloted in urban Khayelitsha in South Africa. In this approach patients gather 2-monthly as a group in the health faciliy or at a community venue, where a lay worker distributes ART. Patient attend yearly to the health facility for a clinical consultation and viral load. Samantha Reinders

Health facility or community venues Community distribution points Context Urban & rural Urban Rural ART refill 1 to 3-monthly 2-monthly 3-monthly 1 to 3 Monthly Mode Individual Group Where Health facility Health facility or community venues Community distribution points Patients’ homes Led by Lay worker Lay worker of network of PLHIV Patients Clinical consultation Yearly Blood drawing Yearly viral load Moving further along the continuum towards more patient driven strategies, we come accross the community ART distribution points, also called PODI in french. This strategy was launched in urban Kinshasa, in DR Congo which is a context of very low ART coverage with only few health facilities offering ART and high stigma. Patient individually present 3 monthly to community distribution points that are managed by a network of PLHIV. Lay workers of this network dispense ART to the patients. Patients attend yearly for a clinical consultation and VL at the health facility.

Health facility or community venues Community distribution points Context Urban & rural Urban Rural ART refill 1 to 3-monthly 2-monthly 3-monthly 1 to 3 Monthly Mode Individual Group Where Health facility Health facility or community venues Community distribution points Patients’ homes Led by Lay worker Lay worker of network of PLHIV Patients Clinical consultation Yearly Blood drawing Yearly viral load A last model is the community ART groups that were piloted in rural Tete, Mozambique. In this model patients formed groups in the community and the group members monthly take turns to attend the health facility for the pick up of ART for the group. At the return of one of the group members from the clinic, drugs are dispensed to the other members in a patient’s home. Goup member get a yearly consultation and blood drawing for viral load. Overall, in setting where viral load is not implemented, patients get a 6 monthly clinical consultation and blood drawing for CD4

Reduce burden for patients “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 Reduce burden for patients Patient costs at community ART distribution points: Time spent for ART collection:14 minutes vs. 85 minutes at hospital Transportation costs: 3x less at ART distribution point First of all from a patient perspective community models reduce costs for patients. This member of a community ART group in Tete told during an interview the following:…. The time spent to travel and wait in the clinic is thus used to attend other duties and enable patients to lead a regular life again. This was also shown with the community ART distribution points blabla Rasschaert, 2014 Jocquet, 2011

Better retention than in conventional care Improve health outcomes Better retention than in conventional care Another benefit of these models are patient’s improved health outcomes. By end 2013, ~ 22.000 in 8 MSF supported countries received ART through Community supported models. In this graph we looked at retention in care of patients who joined these different community-supported models represented in the coloured bars- versus their peers who were also eligible but opted not to join –represented in the patterned bars. Although the follow-up time in care is different for the models analysed, it does show us a trend of high retention, ranging from 82% at 24 months in DR Congo in the PODI’s, to 97% in the adherence clubs at 40 months follow-up time in South Africa. And we observe that patients in community-supported models show a better retention in care than patients with same characteristics that opted not to join and stayed in conventional care Adapt Prelimin data tete 2015: 95% in CAG vs 77% CAG elgible at 36 months Prelim data Thyolo 2015: 97% in cag vs 95 % eligible at 24 months- but carol prefers this not to be cited as too selective Eligible & joined Eligible & did not join Project data, Chiradzulu, 2013 Luque-Fernandez, 2013 Kalenga, 2013 Preliminary data, Tete, 2015

“… belonging to a group strengthens people “… 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 Another added value of these approaches for patients is the availability of peer support, be it from their group members or the lay worker. This peer support can be facilitator for adherence. A CAG leader in Tete, Mozambique explains it as follows: quote… Rasschaert, 2014

Lower Service Provider Costs Cost per patient per year Adherence club 58 US$ Conventional care 109 US$ Another benefit for health systems is their lower service provider cost. In Khayelitsha, South Africa the cost/patient/year was 58 US$ for patients in an adherence clubs versus 109 US$ for patients who stayed in conventional care. Samantha Reinders Khayelitsha Cape Town Bango, 2013

59% reduction in ART refill visits in Thyolo, Malawi Community Supported models also have advantages for health care workers. An study conducted in Thyolo, malawi evaluated patient’s clinic attendance before and after joining CAGs. We found a reduction of 59% of ART visit and an overall reduction of 43% in HIV patients visitis. The reduction in visits can be translated in reduction in health staff patients load. Billauld 2014

Putting patients at the centre of the supply chain Key barrier: stockouts Empty shelves; come back tomorrow ARV stockouts undermine efforts to fight HIV Medecins Sans Frontières November 2015 MSF experience 4 November 2015

Supply chain Innovations targeting Monitoring & Evaluation Systems measuring ART stock(out) and cohort data at patient level Pharmacy based cohort monitoring Mobile health technology Quality control and/or lacking data through patient reporting « Last Mile Delivery » Flexible supplies closer to patients Chronic disease dispensing and distribution systems with community pickup points (PEP stores, churches, ..) Patient lead community pharmacies Fast Track (Quick Pick up) systems PODI, Kinshasa

What is needed for regular supply In-country and international planning and support in ‘critical periods’ when regimens change (…..DTG, EFV 400mg) Global coordination of demand vs supply security for critical medicines Planning and support for introduction multiple-months refill Phased introduction (per drug / per geographical area/ fased eligibility) Optimal coordination needed Country wide introduction Push for 3-6 month supplies to all clinics

Reducing frequency of ARV pick-ups for HIV patients stabilised on ARV treatment Reduces burden for these patients - Reduces workload in health services Choice of strategy acc to multiple factors: Patients' barriers to adherence Rural & urban Extent of decentralisation Capacity of health services / staff Regulatory constraints to ART delivery / TS Social frabic Stigma

Reducing frequency of ARV pick-ups is realistic De-linking clinical visits from ARV pick-ups Differentiated models of care Regular Supply: avoid stockouts !!!