1. Community models of ART delivery in Southern Africa MSF Regional experience E. Goemaere, Medecins Sans Frontieres IAS Washington, July 26 th 2012

2. A long road to decentralisation Decentralisation : referral down <> initiation Impact of HC on community approach Task shifting -> Nimart Clinical appointment spacing for stable patients Pill refills -> not only for high prevalence countries ?

3. Spacing clinical visits every 6 months for stable patients, Chiradzulu, Malawi District Chiradzulu 26,330 patients sous TARV Adultes stables (> 95% compliance, CD4 >300, plus de 12 mois sous TARV Visite clinique tous les 6 mois et appro ARV ts les 3 mois 97% de rétention a 12 mois McGuire et al MOPE 436, IAS Rome 2011 Recruited patients2486 Female (%)1715 (69) Median time on ART prior to enrollment (IQR)27.2 (17.2-44.2) Median CD4 at SMA enrollment ( IQR)534 ( 420-692) Median follow in SMA ( IQR)14.7 ( 8.3-18.7)

5. LocationModel of community ART care Start date Nbr patients ART providerFrequency of ART dispensing Frequency of clinic visits Cumulative Retention* Mozambique, Tete Community ART groups 20084410 900 CAGS Expert patient 1 monthly6 monthly97% after average FU time of 16 months Malawi, Thyolo Community health posts 2009925CHW ( HSA)3 monthly 98% at15 months Malawi, Chiradzulu Community ART refills 20083343CHW3 monthly6 monthly97% at 1 yr 93% at 2 years* Malawi, Chiradzulu Community ART refills 20084,000CHW ( HSA)3 monthly6 monthly97% at 2 years South Africa, Khayelitsha Adherence clubs 20073000 110 clubs CHW2 monthly6 monthly97.5 % at 1y 97.5 % at2 y Kinshasa, DRC Community ART points 2010--Expert patient --

6. Eligibility criteria

7. Youths clubs, Khayelitsha, South Africa

8. HIV Testing Eligibility ART Long term adherence CAG Impact of community based activity on the whole ‘seek, test, treat, retain’ cascade ?

9. HIV Testing PMTCT coverage HIV Testing PMTCT coverage Eligibility ART PMTCT ART PMTCT Long term adherence Undetectable VL CAG POC VL PRE- ART CAG Impact of community based activity on the whole ‘seek, test, treat, retain’ cascade ?

10. Discussion Challenges Advantages Patient perspective : – Burden on stable/adherent patients who only need refills – Promotes self- management, empowerment – development of community networks -> activism Health services perspective – Burden on health facilities – health services accountability – Likely more cost effective – Further task shifting Patient perspective : – Burden on stable/adherent patients who only need refills – Promotes self- management, empowerment – development of community networks -> activism Health services perspective – Burden on health facilities – health services accountability – Likely more cost effective – Further task shifting Patient perspective : – Unfair balance of responsibility – Quality of medical monitoring – HIV trivialization – Disclosure <> stigma Health services perspective – Excludes the high risk of LTFU – Stretches further the drug supply chain – Requires well functioning and simplified monitoring and supervision Patient perspective : – Unfair balance of responsibility – Quality of medical monitoring – HIV trivialization – Disclosure <> stigma Health services perspective – Excludes the high risk of LTFU – Stretches further the drug supply chain – Requires well functioning and simplified monitoring and supervision

11. Discussion : An option for all and where not to go ? Tete : ~50%, Khayelitsha ~ 30 % eligible cohort->not a replacement for health services Bottom-up initiative <> top down While ‘ going back to Alma Ata, let’s learn from experience and avoid repeating same strategic mistakes’

12. Acknowledgements MSF teams in Zimbabwe, Malawi, South Africa & DRC Nathan Ford, Tom Decroo, Lynne Wilkinson, Gilles van Cutsem, Helen Bygrave, Tom Ellman, Marc Biot All PLHA’s for their energy in setting up such ART groups/clubs