1. What’s ahead on the differentiated care agenda
Tom Ellman
MSF
PUT MONEY IN PHONE
Thoughts at start….
-we come a long way
-where is the gap
Key themes:
Reduce burden on health facilities and allow focus on most in need by reducing unnecessary time spent in ‘’professional’’/patient contact
Improve patient experience by doing same
Improve patient outcomes by doing same
Minimise patient exposure to abusive or unnecessary contacts with HFs
Empower patients to resist and change health system abuses through tx literacy, mutual/peer support, self-mx, and community-based monitoring and accountability holding
Ensure this applies to those most at-risk and most in need (harm reduction principle over best quality principle….nothing to lose)
Separate elements (drug, lab, clin, safety net, and support) and approaches (one size all v indiv/popn specific and all tasks fit one v multiple p/t cadres) to find best balance and efficiency
Professional v peer

2. MSF’s Differentiated Care Agenda
Differentiate where the need is greatest:
2nd line
Advanced disease
Hard to reach/Excluded populations
Low coverage settings
Areas of new focus
Supply chains
Self-testing, Peer-led testing, and PEP/PREP
Investment in targeted patient support
Advanced disease is about ensuring the community side of hospital care….tracing post-dx, screening and referral, and certain tools like cd4/crypto
Hard to reach is key pops and men
Unstable is 2nd line and adherence support without referral out of diff care model
Low coverage is rural low burden high stigma focussed on mitigation of stigma with long refills
Supply chains for all settings to ensure long refill and no stockout incl 2nd line and dx tools using community pharmacy/monitoring etc
Tools is developing things for different levels…most advanced maybe most necessary at community level ie Omni… self-test improvements too
Support is counselling, tracing

3. What are the outstanding research questions?
Limits of ‘demedicalisation’
Peer experience versus professional experience
Role of new tools in facilitating task-shifting
Risks and benefits of ‘remedicalisation’
Mortality/morbidity after return from CAGS to SOC
Efficacy of safety nets in identifying high risk
Parallel or integrated services for excluded populations
Few highlights:
Demedical is ‘how low can you go’’- bring harm reduction principle alongside quality expectations…ie peer led initiation, CD4 screening etc
Remedicalise is ‘is it better to return to SOC or have enhanced support in club/cag etc when VL is high or CD4 is low’’?
Lump together or study elements one by one (too slow)….what is counterfactual in harm reduction comparative study?
Of course cost and model it all
Tools adapted to differentiation go here: peer-led or self-mx…specifically screening- HIV (with confirmation), failure (CD4, TB, crypto), ROTF (VL) either fully poc or easy sample take/transport/result
Not sustainability but fungibility…how to convince for govt …and safety and cost-efficacy of safety net..
Evidence for unstable in diff care…specifically comparing outcomes of those gone back to normal care with those staying in…
POTENTIAL FOR DIFF CARE TO REDUCE MORTALITY AND INCREASE TEST/LINK….UP ADHERE IN FAILURES, HOSPITAL LINK, CADRES FOR SCREEN, REFER, TREAT THE SICK?, TOOLS FOR THAT? x

4. What are the implications of differentiated care beyond HIV?
TB and MDR-TB
Non-Communicable Disease
SRH
Family Planning and Termination of Pregnancy
Population-specific approaches
Alternative provision for excluded populations
Patient-centred demedicalised health care
Empowerment of peers and communities
in order of increasing hubris…
Similar diseases…model or morb/mort….TB….NCD….FP/TOP
Patient-centred public health and greater investment in demedicalisation or at least transforming nature of professionalised care
Counter to small government neo-liberalism with a realistic citizen-provider-accountability….both improving qualitycare and mitigating its absence…includes best sector to fund/manage…is it the health sector?

5. What I hope we’re talking about a year from now
Not second-line!
Capacity to sustain differentiated care
Peer cadres
Community-level across cascade
Proposed definition: High risk of POOR OUTCOMES
Advanced disease at presentation
CD4 < 200 and/or WHO 3-4
Uncontrolled NCD and other comorbidities not considered WHO 3-4
On ART (or defaulted)
CD4 < 200, WHO 3-4 and/or High Viral Load > 6 month
Children < 15 yrs.
How to improve identification of
Retain CD4 at baseline and targeted in high VL patients or sick patients à Malawi plan to come back and re-install CD4…..!
Consider POC VL for patients with low CD4 or WHO 3-4
Improve VL result utilization à what works to ensure usage of VL???
Use existing mentors to ensure facility programs to track advanced disease patients
Emphasize tracking/flagging systems using current M&E systems whether paper or electronic
Empower community involvement in the continuum of care
Patients empowerment and service seeking behaviour
Outreach and community cadres to be trained on identification of clients at high risk
Establish/boost VL program review system (dashboard, facility and program level
TB LAM to be scaled-up in several of the present countries
Model of care for people with advanced disease:
MSF Maputo, advance/late/unstable clinic from Malawi; use of POC VL and impact on patients care (lighthouse) – safe-referral system in Kenya (Univ of Meryland program) were presented! Some TB LAM experience
Role of telemedicine? à to be followed in next meetings
Role of morbidity and mortality meetings? Need pilot/sharing experiences  
Research gaps
Cost-effectiveness of different models used in different countries
Situation analysis and gaps in implementation of DSDM in each country
Clients perspectives
Men in DSDM
Reversibility of models
Decentralization of advanced disease Dx tools
Ways forward:
Define the role of Lab-based and POC CD4, and define financial implications
Cost studies will help to make decisions
Advanced disease should not be included in DSD models?????? but patients with high VL/children yes
Standardize psychosocial and mental health support in our programs
Re-focus on HIV/TB integration and IPT
M&E harmonization workshop for DSDM à late 2017/2018