1. Scaling up Access to HIV treatment What can we learn for NCDs?
Dr Helen Bygrave
MSF Southern Africa Medical Unit
LSHTM 02/09/16

2. 17 million on Treatment Multisector response
Problem of the name NCDs – not specific have to have champion for each disease
Lessons are for management of chronic disease

3. The Value of Targets
Once a year we go for clinical check up and viral load
Point to make – drives governments
NCD targets now in sustainable development goals
Needs to speak to people on the ground
Once a year we go for clinical check up and viral load

4. Guideline Development
Evidence based
Pragmatic
When and What to Start
* New 2013/16 How to do it
Service delivery guidance
Operational research agenda to assess the quality and cost effective models of care
Points
Leadership WHO
Setting clear PICOS
Clinical and service delivery now
Level of pragmatism – evidence but also realism
Funding to lead in country process to translate these into country guidance plus need for further simplifcation for job aids etc

5. Simplification

6. Fixed Dose Combinations
WHO Guidance for 1st Line treatment
2006
8 choices
2013 /2016
1 first line choice
Fixed Dose Combinations
Adherence
Procurement
Transport
Storage
Simplified the choice of ART
FDC – what options for NCDS – polypill for primary and secondary prevention – what about in Rx if 6/10 will need 3 drugs for hypertension why not to start with FDC of at least 2 drugs ? What OR needed to look at this
Heat Stable Formulations

7. MONITORING Once a year Viral Load Minimal toxicity monitoring
Working with companies to overcome feasibility and cost barriers
Example VL in South Sudan
Role of POC ( Xpert DRC , CAR )
Simplification of lab monitoring
What is the minimum we are OK to accept – what’s the evidence in terms of outcomes /risk

8. Simplifying ART delivery

9. Differentiate ART delivery The three elements
Differentiate ART delivery according to clin needs , subpopulation , context

10. The building blocks
Consider the when , where ,who and what needed to provide ART
Each of these questions addressed in PICO question in WHO Guideline Development

11. The building blocks Implementation Science to Support recommendations
Reduce Visits to 3-6 mthly
Decentralise to primary care and further to the community
( Kredo et al : Cochrane review; Nachega et al 2016 systematic review community strategies ) V
Task Shift to Non physician Clinicians
Refills by lay cadres
( Kredo et al Cochrane review ; STRETCH Study)
Consider the when , where ,who and what needed to provide ART

12. Community ART Groups: Mozambique, Zimbabwe, Malawi, SA, Lesotho
Where?
We Meet in each other’s houses
Who ?
Our group leader helps us to complete the community refill checks
What ?
Every three months we meet together and check we are healthy
One of us then goes to collect all the drugs
Once a year we go for clinical check up and viral load
When?
We meet every 3 mths
Self forming Groups (4-12) Stable Adults
Collecting ART for each other

13. Community ART Groups: Mozambique, Zimbabwe, Malawi, SA, Lesotho
Mozambique Retention in CAG : 98% and 96% at 12 and 24 mths
Decreased Clinic Visits
Benefits of Peer Support
Income Generating Activities
Mobilisation for testing in their community
20-45% of cohort in CAGS
Outcomes

14. Allowed Continued ART Distribution During Mozambique Flooding
CHW delivered to group representative at agreed meeting point
How community models can help in these situations
Allowed Continued ART Distribution
In unstable contexts DRC , CAR

15. Facility-based group refills
Adherence Clubs
Facility-based group refills
CHW-led
~30 stable patients
Meets 5 times/year
Receive pre-packed ART

16. 34,000/130,000 clients receiving ART in this model
Fernandes et al PloS One 2013
34,000/130,000 clients receiving ART in this model
97% of club patients remained in care compared to 85% of other patients.
Club participation reduced loss to care by 57% ( HR % CI )
South Africa National Roll Out aiming for 100,000 clubs by next year

17. Medication Adherence Clubs
(20-30 clients; facility based; lay worker led)
Where?
Most Meet At facility in the afternoons after work or Saturday morning
When?
Every 3 months
HIV and NCD patients Together
Explain integrated approach
Add reference Kibera outcomes /qual
Kibera: Kenya
Integrated Approach = HIV and NCDs
Venables et al : Integrating HIV and NCD patients in adherence clubs in Kibera, Kenya: a qualitative study

18. Medication Adherence Clubs
(20-30 clients; facility based; lay worker led)
Offloaded 2,208 consultations from routine outpatient care
Loss to follow up 3.5%
1432 enrolled into 47 clubs
71% HIV positive
29% have Diabetes or Hypertension
Explain integrated approach
Add reference Kibera outcomes /qual

19. NCDs and HIV come Together
Integrated screening strategies ( HIV , TB , Malaria, BP, Diabetes) outreach and door to door testing
WHO 2016 : Assess CVS and depression risk in all HIV positive patients
Concept of “ Chronic Care Clinic” ( Wroe et al: leveraging HIV platforms to work toward comprehensive primary care in rural Malawi : the Integrated Chronic Care Clinic)

20. Key Messages
Targets that talk to politicians, donors, clinicians and patients
Leadership from WHO on development of evidence based guidelines not only on what to do but HOW to do it – with support for country adaptation
Keep it simple ! What are the opportunities and evidence needed to simplify drugs used, laboratory monitoring and service delivery

21. What Really Made it Work ?
End point on activism and funding - accountability