1. Expert Patients and AIDS Ministry of HealthMSF-OCB Mozambique CDC From Field Operational Research to National Roll Out of CASG in Mozambique

2. Mozambique Context 10 provinces, 23 million of habitants HIV Prevalence: 11,5% 30% Population without access to Health 1 in 5 HFs has ART (245 Total ART HFs) Need for 7 X more HRH 30 % ART coverage ~ 50 % LTFU at 3 years for ART

3. CASG Context Community Adherence Support Groups Tete Province: April 2009, MoH Partner initiative – Retention 97,6/ 100 pt yrs – Average time in CASG: 13,2 months* – Nr of. Active members in CASGs in 7 districts: 3720, 915 groups on October 2011 Task Force Group in March 2011 * Decroo T et al., J Acquir Immune Defic Syndr 2011; 56: 39

4. Strategy Secondary Objectives 1.To improve access, retention and adherence of patients on ART. 2.To enhance the quality of the services and follow-up of patients at the HF. 3.To establish a system of early surveillance to triage medical conditions and situations related to LTFU. 4.To reduce the number of clinical appointments and the workload at the HF. 5.To reinforce the psychosocial support among ART and pre-ART patients. 6.To strengthen the link between the HF and the community. Primary Objective To improve retention in care of patients on ART through increasing patient involvement in Mozambique

5. Strategy Home January FebMarAprMayJun GAAC in the community ReceptionConsultationPharmacy Laboratory Counselor A B C D E Health Facility CASG member 1 goes to HF every six months for clinical consultation, psychosocial counseling, lab tests and to pick up monthly CASG ARVs Member 1 returns to community and distributes ARVs to other 5 CASG members 2 1 Members 2, 3, 4, 5 and 6 conduct trips to HF during the following five months 3

6. National Pilot: Methods Pilot HF selection 3 Health Facilities in each province selected – 1 health facility from each of three patient volume categories:  > 1000 patients  500-1000 patients  <500 patients Each health facility required to provide a minimum package of services  ART program for more than 6 months  One clinician trained in ART provision  One nurse  Access to CD4 testing  TB services

7. Patient Inclusion Criteria  On ART for at least 6 months  Age ≥ 15 years OR children on adult ART dosage  Knowledge and understanding of their HIV serostatus  CD4 count ≥ 200 cel/ul.  Interest in involvement in CASG  Adherence to clinical consultations and ARV pick-ups during the previous 6 months  Clinical stability and without an active III or IV WHO condition National Pilot: Methods

8. Criteria for Group Formation  At least two members and a maximum of six  Group is established according to social or cultural affinities related to location, employment or other kind of relationship  Group members must be registered at the same HF where they receive ART  Each group will be form by members that select a Focal Point responsible for some of the main activities of the group  All the members execute the tasks related to the group in a rotating manner National Pilot: Methods

9. 1.Group Focal Point (within each group) 2.Group Members 3.CASG Focal Point at the HF National Pilot: Roles

10. Monitor adherence to the treatment of each group member Conduct monthly meetings with his group (the day before going to the HF) Do a search of group members who were absent or discontinue treatment Remind group members to go to the HF every 6 months for clinical and laboratory monitoring To refer patients whose condition requires medical attention Stimulate the group to create a fund to support travel to the HF 1. Main Tasks of CASG Focal Point

11. Be representative of the group every 6 months for: Take stock of ARV's in the HF and distribution to the members, report the information on adherence and health status of group members to the HF To have a medical appointment and routine analysis every 6 months Support group members for adherence to treatment Inform the group in case of change of residence or travel Promote HIV prevention and education within the family and community 2. Tasks of CASG Members

12. Sensitize patients for the creation of CASG State the potential group members to assess the clinical eligibility criteria for creating a group Train the members of the CASG on HIV/AIDS, and OI, interpretation of CD4, filling out forms, and other aspects of the management group Monthly follow up and monitoring the adherence on the CASG Monitor and follow up of patients with low CD4 counts, poor adherence, anemia and other aspects relating to ART Ensure the existence of the file of patient groups in the HF Providing all the recording instruments to each group focal point 3. Tasks of CASG Focal Point at the HF

13. Tools 1.ARVs Control Register: To register monthly patient pill-counts and report warnings of potential OIs (filled out in the community) 2.GAAC Register Book: To register and follow up information about the group members (including basic demographic and treatment follow- up information) 3.GAAC Monthly Report: To track CASG expansion and trends in patient retention at the HF, district, provincial and national level Monitoring & Evaluation

14. ARVs Control Register

15. CASG Register Book

16. Where we are? During this Semester: Clinical Workshop in Tete Province Distribution of the National Strategy to the provinces National Meeting at MoH central level Conjoined visits of MoH and MSF to the provinces By November 2011: It was already implemented in all the provinces

17. Total of Groups in the Country by 30 th Nov 2011: 330 31 5 27 41 17 31 84 44 38 12

18. Next Steps Central Level Workshop in December Quarterly evaluations Visits of an experienced MoH/MSF mobile team to the districts according to the implementation needs during 2012 Monitoring and Supervision visits to the Provinces Quantitative, Qualitative and Cost-effectiveness studies

19. Conclusions This strategy has shown promising results on provincial scale in improving adherence to treatment Partners can be synergic with national MoH and the willingness to pilot stepwise innovative ideas

20. Thank you! Amesegenalehu!