1. Differentiated service delivery for ART
SAMU SUMMARIES SEPTEMBER 2017
samumsf.org

2. Objectives of session
To be aware of the global guidance on differentiated service delivery for ART
To explain the main principles of differentiated models of ART delivery for stable adult patients and specific populations
To be able to decide what differentiated ART delivery strategies would best suit your setting
The objectives of this presentation is :
To be aware of the global discussions on differentiated service delivery for HIV
To explain the main principles and outcomes of differentiated models of ART delivery for stable adult patients and specific populations
To be able to decide what differentiated ART delivery strategies would best suit your setting

3. Consensus definition 2016 : WHO , UNAIDS, Global Fund, CDC, USAID, OGAC, Gates Foundation, MSF
Differentiated care is a client-centred approach that simplifies and adapts HIV services across the cascade to reflect the preferences and expectations of groups of people living with HIV (PLHIV) while reducing unnecessary burdens on the health system.
In 2016 a consensus definition of differentiated care was agreed by the agencies listed
Important points to emphasise in the definition is that differentiated care should be client-centred and in fact it can be applied across the cascade and not just for ART delivery . Although it also aims to reduce the burdens on the health system it should not be seen as a “ cheap” option and is ultimately about improving the quality of care for our clients

4. Differentiated Testing Differentiated Initiation
The principles of differentiated care can be applied across the HIV care and treatment cascade with a number of guidelines now describing strategies for differentiated testing , initiation and ART delivery that aim to support the acheivement of the targets.
Differentiated Testing
Differentiated Initiation
Differentiated ART delivery

5. Differentiated Care in International Guidance
At international level the global fund released a toolkit for differentiated care in December 2015 , WHO includes the principles of differentiated care within their chapter on service delivery and an interagency technical work released the framework for differentiated ART delivery in 2016
Dec 2015 Global Fund
Kenya, Uganda, Senegal
WHO
2016
GF, WHO, OGAC, USAID, CDC, GATES, MSF 2016

6. National Guidance
Several national guidelines have also embraced the concepts of differentiated care and have endorsed a range of ART delivery models within their guidelines

7. Differentiated service delivery The Three Elements
Clinical Characteristics
Context
Specific population
To structure how we think about designing differentiated service delivery models for ART we can consider three elements
The specific population – are we designing a model for an adult , child or adolescent, pregnant or breastfeeding woman or key population
What is the context we are working in – is it high or low prevalence , an urban or rural setting
What are the clinical characteristics of the client – are they stable or presenting with advanced disease or have other co-morbidities or co-infections

8. Differentiated service delivery The building blocks
Once each of these elements has been identified a model of differentiated ART delivery can then be built using the building blocks
When is ART delivered : What is the timing of the clinic and how frequently are clients being seen for clinical review and medication refill
Where is ART delivered: Is ART decentralised , is it available from the facility or also community structures
Who delivers ART : Is there a role for task sharing to support scale up of ART
And What package of services needs to be delivered during a clinic or refill visit
Evidence for Each of these building blocks reviewed in WHO Guideline

9. An example of using elements and building blocks for ART delivery
Subpopulation: Adults
Clinical characteristic :Stable
Context: High prevalence / stable
Building Blocks for fast track model
This is an example of using the elements and building blocks to build a model for ART delivery
This is a model for stable adults in a high prevalence setting :
ART delivery is every 3 months any time during opening hours, it is collected directly from the dispensing point at the facility, the client only sees the ART dispenser and receives ART and CTX refills

10. When is ART delivered?
In the service delivery chapter of the 2016 WHO guidelines evidence for a recommendation on each of the building blocks is given
“ Differentiation” should be made between the clinical visit and the need to collect medication for a client who is stable
WHO recommends for stable clients both less frequent clinical visits ( 3-6 months) and less frequent medication pick ups ( 3-6 months). Already in some MSF programmes and in some national guidelines ( South Africa and Zimbabwe) an annual clinical review has been endorsed in contexts where viral load is available. Many settings now are providing a 3 month supply of ART with some discussing providing 6 months of drugs. V

11. Move further towards community delivery ? Mentorship/supervision
Where is ART Provided?
Move further towards community delivery
? Mentorship/supervision
Supply chain
WHO has endorsed decentralisation of ART delivery in previous guidelines. However what is new in the 2016 guideline is the strong recommendation that maintenance of ART may be provided at the community level including outside health facilities.
There is good evidence that taking ART services closer to clients’ homes support improved retention however consideration must be given for the ongoing mentorship support required to ensure quality care and the drug supply and M and E systems that are required for decentralisation
Decentralising HIV treatment in lower- and middle-income countries.
Kredo T1, Ford N, Adeniyi FB, Garner P. Cochrane review 2013

12. Who is providing ART delivery?
The importance of task sharing
Community health workers able to dispense ART between regular visits
WHO has also endorsed task sharing of ART delivery in previous guidelines but the 2016 guideline now gives a strong recommendation that community health workers can dispense ART between clinical visits

13. Who is a stable patient?

14. Definition of Stable WHO Swaziland Zimbabwe Kenya Tanzania Time on ART
1 year
6 mths
6 mths ; only first line
Age
Not specified
> 18
> 20 years
> 5 years
Current Illness
None
No other medical condition requiring frequent visits
No current OIs
No active OIs or TB in last 6 mths; completed 6 mths of IPT
No active OIs for the past 6 months or uncontrolled NCD
Pregnancy No
Not mentioned
Evidence of treatment success
2 VL < 1000
2 consec VL < 1000 with last one within 6 mths
Last VL < 1000
Where no VL CD4 > 200
Most recent VL < 1000
VL < 50 copies
? And /or
CD4 350 and above
Other adherence
Understanding of adherence
Has had at least 2 ART visits at facility
Adhered to scheduled appts in last 6 mths
95% adherence
Attended appointments in last 6 mths
Other
BMI>18.5
Not injecting PWID
Definition of Stable
Differentiated ART delivery is not just for stable clients but this presentation is focusing on the models where a definition of stability has been used for entry into the model
WHO has defined a stable client as someone who is one year on ART , has no adverse drug reactions requiring monitoring , has no current illneses , a good understanding of adherence and evidence of treatment success shown by 2 consecutive undetectable viral loads or in the absence of VL monitoring a rising CD4 or CD4 > 200 cells/mm3
During country adaptation the definition of stability has been adapted including the reduction of time on ART to 6 months , using just one VL < 1000 copies/ml and including stable clients on second line therapy.

15. Facility-based individual Community based individual
Using the building blocks of differentiated service delivery 4 types of model have been implemented in MSF programmes
The models can be divided into those where ART is collected by clients at the facility and models where clients meet or collect ART in the community
The models are also divided according to whether the client collects the ART as an individual or in a group
Health care worker-managed group
Community based Client-managed group

16. 2. Individual Community ART Refill ( Outreach/ community pharmacy)
Kinshasa
Time for refill reduced 14 mins v 85 mins
Transport costs 3x less when collection at distribution points
Individual Facility ART refill-
fast track
Chiradzulu district Malawi 3mth refills ; 6 mth clinical
50% in fast track
at 36 months 94% of clients in fast track retained v 83% of clients with same eligibility criteria staying in conventional care (Mguire et al 2011)
An example of an individual facility model is the fast track – documented by MSF France in Chiradzulu Malawi. Clients receive 3 monthly refills but see a clinician once every 6 months. In the refill visit the ART is distributed by a lay provider directly from the pharmacy.
To date 50% of the cohort receive their care via the fast track model and retention data is high.
An example of a community based individual refill model are the PODIs set up in Kinshasa DRC. These are community sites staffed by peer lay workers. Clients are able to collect their ART refills from the sites with a substantial reduction in the time taken to collect ART and reduction in transport costs. The lay workers also provide HIV testing from these community distribution points

17. Health care worker led group refill “Adherence Clubs”
(20-30 clients: South Africa, Kenya)
When?
Every 2- 3 months
Takes minutes
After work
Saturdays
Where?
Most Meet At facility
Works better in urban settings
Who ?
Facilitated by lay worker
An example of the facility based, health care worker led group model are the adherence clubs originally started in Khayelitsha in South Africa
The groups meet every 2-3 months ( dependant on the maximum duration of ART refill available) at a fixed time and place usually at the facility.
The group is facilitated by a nurse or lay worker. Clients are asked as a group if they have any clinical problem and if so are directed to attend for a consultation in the clinic. The nurse or lay worker then facilitates group discussion and distributes the ART to the group members. Depending on the setting the ART may need to be pre-packed by the pharmacy first. The meeting last between minutes dependant on how much discussion the group would like to have.

18. Adherence Clubs in Cape Town
Wilkinson et al, TMIH, 2016
Data as of June 2016:
N=53,523– 36% of the cohort
Outcomes
12 months: 95.2% retention & 97% virally suppressed
24 months: 89.3% retention & 96% virally suppressed
As of June % of the cohort in the western cape clinics had opted to receive their refill as part of an adherence club. In general this model has been more successful in urban settings and in high volume clinics.
Analysis of retention within the group shows that almost 90% remain in the groups after 2 years and of them 96% were virologically suppressed

19. Mozambique, Zimbabwe, Malawi, SA, Lesotho , Kenya
Community ART Groups
Mozambique, Zimbabwe, Malawi, SA, Lesotho , Kenya
Who ?
Our group leader helps us to complete the community refill checks
Where?
We Meet in each other’s houses
Generally more often in rural settings
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
Finally the community based, client led group ART model- most commonly known as the community ART groups ( CAGS)
These are groups of between clients who live near each other and choose to disclose to each other – ideally the groups are self forming but some facilitation may be needed to form the groups by the health care worker.
The group meets every 3 months ( determined by the maximum refill duration available ) in a community venue or one of their houses. The group has a simple form to complete including asking each other a few simple health questions such as screening for TB
The group then nominates one member to collect ART from the facility. That member attends the facility and sees the nurse who dispenses ART for all the group and completes whatever necessary paperwork for the group refill
The nominated member then returns to the group and distributes the ART
Once or twice a year the group attends the facility together to have their clinical review and laboratory monitoring
Self forming Groups (4-12) Stable Adults
Collecting ART for each other

20. Community ART Groups: Mozambique, Zimbabwe, Malawi, SA, Lesotho
Mozambique Retention in CAG 91% at 48 mths
20-45% of cohort in CAGS
Qualitative
Income Generating Activities
Time and money saving
Benefits of peer support
“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 “
CAGS have now been implemented in a number of MSF programmes and have also been endorsed by a number of national programmes e.g Mozambique, Zimbabwe and Kenya
Overall experience has demonstrated that between % of the cohort opt to receive ART via this model. In general it is more successful in rural settings where clients are often having to travel long distances to the clinic .
Outcome data has showed promising retention data and several qualitative studies have also demonstrated advantages such as the benefits of peer support and time and money saved by the model
Outcomes
(Decroo et al ; Rasschaert, 2014; Vandendyck 2015)

21. Reduction in ART refill
59% reduction in refill visits in Thyolo Malawi
Community supported models also have advantages for health care workers.
A study conducted in Thyolo, Malawi evaluated patient’s clinic attendance before and after joining CAGs. A reduction of 59% of ART visits and an overall reduction of 43% in HIV patients visits was found.
Billauld 2014

22. Tools samumsf.org http://www.differentiatedcare.org/
All the toolkits for the models described can be found in the implementation section of the differentiated ART delivery resource section of the SAMU website
Further information and tools from governments and other NGOS can be found at

23. Differentiated ART for stable Children and adolescents

24. International Guidance
In July 2017 WHO issued a key considerations document for the provision of differentiated ART delivery for specific populations including children , adolescents , pregnant and breast feeding women and key populations
This was accompanied by a decision framework developed to guide how to differentiate ART delivery is differentiated for children and adolescents which includes specific field examples

25. WHO Eligibility criteria
< 2 years should be seen monthly
> 2yrs differentiated models ( including family group refills) if
On ART >12 months
Same ART regimen > 3 months
No current illnesses (incl. malnutrition)
1 VL < 1000 copies/ml in last 3 months
No adverse drug reactions requiring regular monitoring
Caregiver orientated on importance of engaging in age appropriate disclosure process
Eligibility criteria for less frequnet clinical and refill visits are outlined in the next slides
Children less than 2 years should be seen monthly to adjust their doses
Children more than 2 years may then be seen less regularly if they fulfill these definitions of stability
On ART >12 months
Same ART regimen > 3 months
No current illnesses (incl. malnutrition)
1 VL < 1000 copies/ml in last 3 months
No adverse drug reactions requiring regular monitoring
Caregiver orientated on importance of engaging in age appropriate disclosure process

26. WHO : criteria for clinical visit
When:
6 monthly
Aligned with family members visits
Consider timing to minimize school/work absences
Where (minimal):
PHC/mobile outreach from PHC (with drugs/scale to manage dose adjustments)*
*In low burden settings clinical review could be considered at higher level facility
Who (minimal):
Nurse
What:
Clinical review per guidelines including but not limited to: TB screen, Adherence support & Disclosure support
Labs (VL annual or if not available CD4 6-monthly)
Dosage check and possible adjustment
Borderline weight gain (growth) = pre-emptive dose adjusting if possible
Re-scripting (6 month script)
Children more than 2 years may be seen for a clinical visit every 6 months and should be seen together with their mother

27. WHO criteria for refill visits
When:
3-6 monthly*
Aligned with family members visits
Consider timing to minimize school/work absences
* Promote use of LPV/r pellets (syrup = 2 month shelf-life)
Where:
PHC or out-of-facility
Who:
Trained lay providers
Collection can be done by caregiver without child present
What:
ART refill
Adherence check (caregiver report/self-assessment)
Referral check - Is child well/coughing/TB in the household?
Disclosure support
For children more than 2 years of age refills may be given 3-6 monthly , again aligned with the mother’s refill dates
Mother and young children may also be booked on the same day to form groups in order for the mothers / caregivers to benefit from peer support and for the children to play together

28. Teen/ Youth Clubs Provision of ART refill Peer support SRH education
Life skills
Adolescents may be booked to collect refills on the same say in groups , often referred to as teen clubs.
Adolescents and young adults should be grouped according to age (e.g 10-14, 15-19, 20-24). The group meeting is similar to the adherence club except specific topics and activities are discussed that are relevant to this age group. Of great importance is the inclusion of SRH education for this group
The youth clinic in Khayelitsha has produced a report and toolkit of it’s experience which is available in the paediatric resource sections

29. Critical enablers Critical enablers Recognition of lay workers
André Francois
Brendan Bannon
Recognition of lay workers
Acces to quality clinical management
Finally is must be noted that for any of these differentiated models of ART delivery to function and be sustainable several critical factors must be functioning within the health system.
For many of these models lay workers have played a vital role in their implementation. Currently many of these lay-workers are funded through partners and are not recognised within the ministry’s establishment list. Ministries will need to find ways to implement these models also in the abscence of such lay cadres
Clients who become unwell at any point must be able to access quality clinical services. Differentiated ART for clients with advanced disease is dealt with in the advanced disease resource section
Finally a robust drug supply and a reliable monitoring system both form the foundation of a successful ART programme into which these models may be built
Brendan Bannon
Miguel Cuenca
Reliable monitoring system
Robust drug supply

30. Key Messages
Differentiated service delivery is about putting the patient at the centre of our planning
Differentiated service delivery spans across the cascade of care and is not just for stable adults
Use the elements and building blocks to build the model of ART delivery
The model chosen will be context specific to answer local challenges
Having the key enablers in place is a foundation for providing successful differentiated ART delivery