1. Absorption, Retention and Empowerment
Addressing the Root Causes of Attrition Through Scale-up of Community Adherence Support Groups

2. Mozambique Population: 23.4 million (2011)
Human Development Index (165/169)
Life expectancy 48.4 years
Mean years of schooling: 1.2
- 33% adult men and 63% adult women illiterate
Limited human resources and physical infrastructure
> 830,000 births per year, ~65% in health facilities
50-60% DO NOT have access to health care
Many clinics and hospitals lack continuous access to water (63%), electricity (74%)
Poor roads, seasonal flooding
>70% rural
Mozambique is one of PEPFAR’s 15 focus countries. Situated on the east coast of Africa, and with a coastline twice the length of California, it has a populaton of about 20 million people, 54% of whom live on less than a dollar a day,
Population
23 million people
44% children <5 chronically malnourished
Ranked 165th of 169 on UNDP’s Human Development Index
36% of the population lives within 30 minutes of a health facility
60% of the population lives on less than $1.25/day
In 2004 reported as the world’s 7 the poorest country according to UNDP’s Human development index rating scale.
It is also recovering from a 16 year civil war which ended in 1992,
Apart from poverty, emerged from a 16 year civil war in 1992.
Extreme poverty, and the after effects of war, make Mozambique one of the worlds 25 worst affected countries by the global Health worker shortage with 3 physicians per 100,000 population
UNDP) human development index (HDI) listings, which arranges countries according to their overall level of human development, ranks Mozambique 168th out of a total of 174 nations. The HDI, a composite index (one that assesses more than one variable) that measures life expectancy at birth, adult literacy rate, school enrollment ratio, and GDP per capita, is indicative of a country's general social and economic wellbeing. As such, Mozambique's HDI ranking demonstrates that the country is one of the least developed in the entire world.
The one used:

5. National and USG-supported ART coverage through 2013
Coverage estimates fell in 2009 and 2011 though absolute numbers on treatment increased throughout the last 10 years because of changing eligibility criteria (CD4<200 prior to 2009, CD4< , CD4< > for adults, children <12 months in 2009 and <24 months in 2011 (as well as various CD4 threshold changes))
* Coverage estimates are calculated as those on ART at end of reporting period (MOH - Dec 31, USG - Sep 30), divided by midyear Spectrum estimates from 2012 Demographic Impact Report USG targets are as proposed in COP12.

6. Absorptive Capacity
The public health system in Mozambique is currently straining to serve the needs of the population
3 physicians/100,000 inhabitants
21 clinical officers/100,000 inhabitants
40 MCH nurses/100,000 inhabitants
1.4 million infected
603,375 eligible for treatment
273,561 alive and on treatment
Model of HIV care must be adapted
Add some data here on the HSS impact of HIV on MZ public health sector
Discuss the chronic care model in broad strokes here.

7. Traditional Retention Strategies
Pre-ART/ART counseling
Care package
Peer educators
Support groups
Defaulter tracing
Community health workers
SMS messaging
The point here is that none of these strategies, with the exception of the care package, address the root causes of why patients are lost to follow-up.
They are ex-post facto approaches that are simply not effective and likely far more costly than alternative approaches that do address the reasons why patients default

8. A Different Approach Community adherence support groups (CASG)
Establish treatment groups with up to 6 members
One representative from the group visits the health facility every month and does the following:
Clinical assessment and CD4 count
Provides feedback to the health facility about the five other members of the group
Obtains lab results for other members
Collects one month’s worth of ARV’s for each group member

9. Results from MSF-Tête Pilot
Cohort of 1384 ART patients in 12 health facilities in Tête Province
291 groups formed
12-month retention: 97.5%
Mortality: 0.2%
LTFU: 2.3%
Median follow-up time: 12.9 months
Between February 2008 and May 2010, 1384 members were enrolled into 291 groups. Median follow-up time within a group was 12.9 months (IQR 8.5–14.1). During this time, 83 (6%) were transferred out, and of the 1301 patients still in community groups, 1269 (97.5%) were remaining in care, 30 (2%) had died, and 2 (0.2%) were lost to follow-up.
Data is available for 78% of patients
Decroo, T., Telfer, B., Biot, M., Maïkéré, J., Dezembro, S., Cumba, L. I., Dores, C. D., et al.; Distribution of antiretroviral treatment through self-forming groups of patients in Tête province, Mozambique; Journal of Acquired Immune Deficiency Syndromes, February 2011

10. Patient Level Characteristics
Median CD4 count at ART initiation: 176 cells/mm3
Median amount of time on ART prior to CAG: 22.3 months
Median age: 36 years
70% female
Median CD4 count gain: cells/mm3

11. Before the Monthly Clinic Visit
All members convene at a place of their choosing to do the following:
Discuss their health and any other issues that may arise
Pill counts
Basic negative screening tool

12. After the Monthly Clinic Visit
All members of the group reconvene at a place of their choosing to do the following:
Report lab results
Distribute medications
Convey any health messages received during the clinic visit

13. Impact at Health Facility
Reduce number of stable ART patients accessing the health facilities
Increase capacity of a health facility to enroll new patients
Increase amount of time staff can dedicate to sick or complex patients
Decrease congestion at the pharmacy
Decrease acuity of consultations and admissions due to earlier access to health services
Improved reporting on patient outcomes
Note: HAI article re: pharmacy overload and the impact that has upon clinical care and retention

14. Impact on patient Decreased number of health facility visits
Improved self-monitoring of clinical conditions
Improved psycho-social support
Stigma reduction
Early warning system for illness
Improved monitoring and resources to address adherence problems
Social safety net
Income generation
Family testing
Community education

15. Scale-Up
Government of Mozambique piloting the model in all 11 Provinces
3-6 health facilities per Province
3 tiers
>1000 patients
patients
<500 patients
12-month pilot with national scale-up pending the results of retrospective evaluation
Outline the criteria:
ART > 6 months
3 tiers
>1000 patients
patients
<500 patients
Describe the process of making scale-up happen.

16. 6 Months of Progress PROVINCE NUMBER OF GROUPS NUMBER OF PATIENTS
Cabo Delgado 51
229
Gaza
121
552
Inhambane
159
727
Manica 94
318
Maputo Cidade 87
152
Maputo Provincia
123
561
Nampula 84
310
Niassa 41
150
Sofala
132
492
Zambezia
189
813
Grand Total
1081
4304

17. Who is currently eligible
Non-pregnant
Stable
Adult (or at least adult doses of ARVs)

18. Who could be eligible? Pre-ART populations Pregnant HIV-infected women
Children
Defaulters
TB infected patients
HIV/TB co-infected patients

19. Challenges Allowing for a flexible dynamic Phased implementation
Perception of strategy as a panacea
Staff ownership
CD4 count monitoring
Demand creation
Urban settings
Links with other adherence and retention strategies
Patients with the most need may not have access

20. “The most important aspect of self-management is the realization that people with a chronic condition are those that have the most comprehensive expertise in dealing with that condition.”
-Katarina Kober & Wim Van Damme

21. Obrigado!

22. Acknowledgements
HIV-infected and affected Mozambicans Aleny Couto (MISAU) Vania Macome (MISAU) Armando Bucuane (MISAU) Joe Lara (MISAU) Tom Decroo (MSF-B) Sergio Dizembro (MSF-B) Inacio Malimane (CDC) Paula Samo Gudo (CDC) Lisa Nelson (CDC)