1. Closer to home: Use of decentralized models of treatment and care Eric Goemaere Southern African MSF medical unit School of public health , UCT

2. Main MSF models of differentiated ART delivery Aim: reduce burden for patients AND health care workers
Delinking clinical consultation from ART refill for stable patients on ART
Range of models implemented in MSF programmes for stable patients on ART
Range from facility based through to community based models and all have one characteristic in common: that they delink clinical consultation from ART ref
Ill
All these models looked at on how often it is needed to see a clinician versus the need for the patient to collect ART refills and used a clear definition of stability with “ temporary clinic follow up” as and when problems arise
For ex in Zimbabwe we managed to get to 3 monthly supplies of ART and Cotrimoxazole. If routine VL: clinical appointment once a year
If no routine viral load: clinical appointment every 6 months.
The way how these drugs then get collected is difference between these models.

3. Designing the appropriate model: logical framework
Environmental context : Urban <> rural
Low prevalence
<> High prevalence
Subpopulation
Adult
Paeds
Pregnant and BF
Key populations
MEDICAL NEED
Routine
Intense
Stable <> unstable

4. Better retention than conventional care
Eligible & joined
Eligible & did not join
Another benefit of these models are patient’s improved health outcomes.
By end 2013, ~ in 8 MSF supported countries received ART through Community supported models.
In this graph we looked at retention in care of patients who joined these different community-supported models represented in the coloured bars- versus their peers who were also eligible but opted not to join –represented in the patterned bars. Although the follow-up time in care is different for the models analysed, it does show us a trend of high retention, ranging from 82% at 24 months in DR Congo in the PODI’s, to 97% in the adherence clubs at 40 months follow-up time in South Africa. And we observe that patients in community-supported models show a better retention in care than patients with same characteristics that opted not to join and stayed in conventional care
Adapt
Prelimin data tete 2015: 95% in CAG vs 77% CAG elgible at 36 months
Prelim data Thyolo 2015: 97% in cag vs 95 % eligible at 24 months- but carol prefers this not to be cited as too selective
Project data, Chiradzulu, 2013, Luque-Fernandez, 2013,Kalenga, 2013,Preliminary data, Tete, 2015

5. Moving towards the front end of the cascade Community VL ( > 1000cp/ml),KZN , South Africa 2013 community survey
Adapted linkage to care strategies
Adapted Community testing strategies ( Fixed, MISS, D2D,)
Most important slide from Epicentre survey: who is running in the community with high VL !!
Moving from community VL to a concept of infectiousness ( High VL x sexual activity ) -> young women/men represent more than their % seen young sexually active population.
To evaluate the effectiveness (positivity rates, linkage-to-care) of different community-based HTC to reach our priority targets
Orange bars : aware of their status but not in care -> investigate barriers and define socio-demographics to see if we can adapt model of care to suit their living priorities
Red bars : untested . Define as well their socio- demographic status to see how to organize our community testing strategies -> What community testing strategy and site brings highest yield from our ‘key population’ between fixed sites , chaps, mobile DOH, MiSS ( school, child grant meeting point , market, farms, factory , home ..)

6. Differentiated care at front end of cascade, Bending the curves project, Eshowe , KZN 2016
TUPEE461: Demographic reach and costs associated with 3 models of community HIV testing in rural KwaZulu-Natal, R.Bedell and all

7. Policy and ressources: critical enablers
André Francois
Brendan Bannon
Miguel Cuenca
Recognition of lay workers
Robust drug supply
Reliable monitoring system
Acces to quality clinical management
Especially as experience so far shows that there are a number of critical enablers for these models to function well.
First of all lay workers play play an key role in performing tasks that support these models such as the establishement and facilitation of groups, ART dispensing and such. These cadres is often lack recognition and finacing in the countries where we operate.
Secondly acces to quality clinical management is needed with clear referral mechanism to ensure a minimum follow-up of patients.
Monitoring and evaluation are essential parts of any community supported model to ensure accountability as well as a troubleshooting capacity when confronted with patient or groups’ problems.
Finally a robust drug supply is crucial as supply chain weaknesses undermine the advantages of these models for patients.
Realistic planning and flexible adaptations to ensure these enablers are in place, are crucial otherwise shortcomings of the health system risk to be carried over to community care.
Cost per patient /year
Adherence club
300 US$
Conventional care
374 US$
Cost-effectiveness and access analysis from Khayelitsha Adherence clubs Funeka Bango and all , UCT Health Economics Unit

8. Food for thoughts
Individual <> Collective models ? Importance of social fabric / collective responsibility ?
Expanding these models across
the cascade of care
population sub-types
co-morbidities ( NCD ) <> NCD patients
Policy and resourcing barriers ?
Flexible regulatory issues around drug delivery
Reinforced supply chain
Electronic adapted M & E
Comes at an ( additional) cost

9. Aknowledgments
- Community health workers/expert patients in Mozambique ,SA, DRC, Malawi, Zimbabwe, Guinea
MSF Field teams
SAMU team mates i.e. Helen Bygrave, Saar Baert
Could also put this slide at the end