M. Bemelmans, S. Baert, E. Goemaere, L. Wilkinson, M. Vandendyck, G. Van Cutsem, C. Silva, S. Perry, E Szumilin, R. Gerstenhaber, L. Kalenga, M. Biot, N. Ford MSF OCB Scientific day 2014 Community-supported models of care for people on HIV treatment in sub-Saharan Africa

Peter Casaer STABLE patient on ART Monthly clinic visit for consultation and ART refill How to deal with a growing cohort of stable patients on ART? Peter Casaer

Mozambique Malawi DR Congo South Africa Community-supported models of care

ProjectChiradzulu, Malawi Khayelitsha, South Africa Kinshasa, DR Congo Tete, Mozambique ContextRuralUrban Rural ART refill3-monthly2-monthly3-monthlyMonthly ModeIndividualGroupIndividualGroup WhereHealth facilityHealth facility or community venues Community distribution points Patients’ homes Led byLay worker Lay worker of network of PLHIV Self-formed group of patients Clinical consultation 6-monthlyYearly 6-monthly Blood drawingYearly viral load Yearly CD46-monthly CD4

ProjectChiradzulu, Malawi Khayelitsha, South Africa Kinshasa, DR Congo Tete, Mozambique ContextRuralUrban Rural ART refill3-monthly2-monthly3-monthlyMonthly ModeIndividualGroupIndividualGroup WhereHealth facilityHealth facility or community venues Community distribution points Patients’ homes Led byLay worker Lay worker of network of PLHIV Self-formed group of patients Clinical consultation 6-monthlyYearly 6-monthly Blood drawingYearly viral load Yearly CD46-monthly CD4

ProjectChiradzulu, Malawi Khayelitsha, South Africa Kinshasa, DR Congo Tete, Mozambique ContextRuralUrban Rural ART refill3-monthly2-monthly3-monthlyMonthly ModeIndividualGroupIndividualGroup WhereHealth facilityHealth facility or community venues Community distribution points Patients’ homes Led byLay worker Lay worker of network of PLHIV Self-formed group of patients Clinical consultation 6-monthlyYearly 6-monthly Blood drawingYearly viral load Yearly CD46-monthly CD4

ProjectChiradzulu, Malawi Khayelitsha, South Africa Kinshasa, DR Congo Tete, Mozambique ContextRuralUrban Rural ART refill3-monthly2-monthly3-monthlyMonthly ModeIndividualGroupIndividualGroup WhereHealth facilityHealth facility or community venues Community distribution points Patients’ homes Led byLay worker Lay worker of network of PLHIV Patients Clinical consultation 6-monthlyYearly 6-monthly Blood drawingYearly viral load Yearly CD46-monthly CD4

benefits What are the benefits patientshealth systems for patients and health systems models across these community- supported models?

Methods Assessing 4 approaches to manage stable patients on ART From a patient and health system perspective Reviewing routinely collected programme data as well as published studies

Results “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 Rasschaert, 2014

Transportation costs 3x less at PODI versus hospital Jocquet, 2011 Time spent for ART collection 14 minutes at PODI versus 85 minutes at hospital

Billaud, % reduction in ART refill visits

Project data, Chiradzulu, 2013 Luque-Fernandez, 2013 Kalenga, 2013 Preliminary data, Tete, 2014 High retention in care Improve health outcomes

Project data, Chiradzulu, 2013 Luque-Fernandez, 2013 Kalenga, 2013 Preliminary data, Tete, 2014 Eligible & joined Eligible & did not join Better retention than in conventional care Improve health outcomes

“… 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 Rasschaert, 2014

Lower Service Provider Costs Cost per patient per year Adherence club58 US$ Conventional care109 US$ Bango, 2013 Samantha Reinders

Strong publication and dissemination efforts

Major impact on national & international policy What is MSF’s responsability in national roll-outs?

Critical enablers André Francois Brendan Bannon Miguel Cuenca Recognition of lay workers Robust drug supplyReliable monitoring system Acces to quality clinical management Realistic planning Flexible adaptations

Conclusion Community supported models respond to the needs of a growing cohort of stable patients on ART and their health care workers Adaptation of these models is ongoing to include other HIV+ patients and allow for a wider application to other diseases Further analysis and advocacy is needed to ensure models are adapted to contexts and critical enablers are in place André Francois

Acknowledgements Patients living with HIV in sub- Saharan Africa MSF and Ministry of Health staff in our projects in sub-Saharan Africa Co-authors

Extra’s

ProjectChiradzulu, Malawi Khayelitsha, South Africa Kinshasa, DR Congo Tete, Mozambique Start Nr patients joined % active ART cohort 20%23%43%50%

samumsf.org

3168 tested for HIV 8,6% HIV +40% joined CAG 42% eligible for ART 89% eligible and started ART Improve testing & linkage to care Project data Changara, 2013