1. Providing Treatment, Restoring Hope Community Health & Treatment Support Programs AIDSRelief Gabou Mendy, MD, MPHTM Martine Etienne, DrPH

2. Slide 2 AIDSRelief Service Areas Mostly rural and “para-urban” Problematic access to care Limited infrastructure Significant logistical difficulties in terms of both transport and procurement systems

3. Slide 3 Proposed Solution Community based service model to ensure maximum access

4. Slide 4 Community Oriented Primary Care versus Traditional Primary Care COPCTPC Community as PatientIndividual Patient 1. Subjective evaluation SimilarityCommunity's perceived needChief complaints DifferenceProvider selects the community and conducts an opinion survey to define the perceived health issues Patient comes to provider for help 2. Objective evaluationEpidemiologic dataHistory, physical and laboratory data 3. TreatmentIntervention programSpecific treatment of identified problem 4. Subsequent careOngoing evaluation and feedback, with appropriate modifications Follow-up HRSA, HAB SPNS Project, 2000

5. Slide 5 Community Oriented Primary Care (COPC) Dialogue in systemic planning and developmental process Difference in program and target population Changes exemplifying sound public health principles and practices Identify and eliminate existing and potential barriers

6. Slide 6 Continuum of Care Key Elements  Clinical Care  Adherence and Treatment Support  Health Literacy, Promotion, and Education Package of Services  Entry Point For HIV Prevention and Care  Clinical Care (PMTCT/VCT, ART, PC/OVC, CATS)  Community Involvement

7. Slide 7 Overview The AIDSRelief Model - Expansion Into the Community 38/7 Targeting Everyone Sooner Fighting HIV/AIDS - An Effective Public Health Approach

8. Slide 8 Overview Provided over 160,000 patients with HIV care and support; 74,000 on ART 152 non-faith based and faith based facilities Rapid scale up yet cautious in an effort to maintain the integrity and quality of the programs

9. Slide 9 Why the community health support program is so important Due to increased access to antiretroviral therapy Few community based structured strategies to support patients on treatment and continuity of care Various treatment models used to support patients on ART with sites developing innovative ways to ensure and support adherence

10. Slide 10 Why the community health support program is so important Due to limited viral load and lack of resistance testing As strategies used to support prevention with positives Critical for continued successful scale up in resource limited settings, where communication infrastructure is often deficient and poverty is prevalent

11. Slide 11 Expansion of the treatment support programs into the community Increase in community support groups Increase in use of PLHIVs for training and continuous support of other patients Increase in community mobilization activities that target religious leaders, traditional healers, community officials

12. Slide 12 Phases of the AIDSRelief Community Health & Treatment Support Model I.Thorough treatment preparation for patients and family II.Intensive treatment support during initiation of therapy III.Long-term treatment support and continuity of care within the community (including patient support groups)

13. Slide 13 Phases of the AIDSRelief Community Health & Treatment Support Model Treatment Preparation includes: A thorough patient assessment and individualized and/or group patient education Assessment of social factors that influence patient adherence (disclosure, geographical distance, risk behaviors, etc..) Inclusive of patient support network (i.e. preparation of patient family, support system, guardian) Extensive emphasis on prevention and reduction of risk behaviors

14. Slide 14 Phases of the AIDSRelief Community Health & Treatment Support Model Intensive Treatment Support during Initiation of Therapy Make contact with the patient within the first 2 weeks of treatment  Modified DOT or WOT  Home Visits Early recognition of treatment complications  Effective communication between community health workers and community nurse Appropriate identification of social hindrances to optimal ART adherence

15. Slide 15 Phases of the AIDSRelief Community Health & Treatment Support Model Long-term Treatment Support & Continuity of Care Engaging patients in the program Linking patients to support groups Reduces the burden on the clinic and staff Continuous patient education and secondary prevention Continuous follow-up and support Home visits targeting other family members

16. Slide 16 Clinic Regional Community Nurse Adherence Officer Adherence Officer CHW CHW- Patient CHW- Patient CHW- Patient CHW- Patient CHW Support Groups Patients and Families Regional Community Nurse Regional Community Nurse

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18. Slide 18 Does the AIDSRelief Model Works?

19. Slide 19 Retrospective review of patients enrolled in the AIDSRelief program treatment sites between Aug 2004-June 2005. Loss to follow up (ltfu) data was aggregated from the quarterly grant reports. Loss to follow up data is cumulative over time for each program in each country, and programs are tiered according to their particular components Tier II Adherence counseling plus a structured treatment preparation plan * Tier III Tier I plus Tier II plus home visits conducted by non medical staff and/or volunteers * Tier IV Tier III plus community health nurses supervising Tier III staff & supporting patients at home Tier I Adherence Counseling only Prior to Starting ART * This is developed by the site with specific guidelines from AIDSRelief

20. Slide 20 (within first 12 months of AR - Guyana, Haiti, Kenya, Nigeria, Rwanda, Tanzania, Uganda, Zambia)

21. Slide 21 38/7- Targeting Everyone Through Community Mobilization Increase testing, reduce stigma PLHIV advocates for primary and secondary prevention Increase in support of men

22. Slide 22 38/7- Targeting Everyone Through Community Mobilization Increase the visibility of the PLHIVs in the community Collaborate with surrounding partners (CBOs, NGOs) in adherence and prevention training to effectively support our patients

23. Slide 23 38/7- Targeting Everyone Through Community Mobilization Increased efforts in strategies for community mobilization: Facilitate change within the community altering social patterns in ways that will improve the quality of life within the community Change the everyday environment in communities in ways that will result in better outcomes for everyone living within a designated geographic area. This crucial difference in strategy poses a new and complex set of challenges and at the same time multiplies and complicates the issues that need to be addressed by those evaluating the initiatives.

24. Slide 24 How much does this all cost?

25. Slide 25 Cost per patient of selected sites & tiers (inclusive of staff salaries, excludes RVs) <20002001-40004001-7000 Total patient Capacity by Tier

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27. Slide 27 Public Health Implications - What have we learned? Consider AR model as priority for programs seeking optimal treatment success Integration of the community into the treatment program is crucial Prevention with positives can be achieved best by the use of other PLHIVs within the program and in the community

28. Slide 28 Community mobilization strategies using people living with HIV/AIDS help decrease stigma within the community Support groups made up of patients and their families provide comprehensive & continuous support of the community Public Health Implications - What have we learned?

29. Slide 29 Engaging Community: Capacity Utilisation vs Capacity Building “The process of engaging community leaders happens when they use their social interpretations of reality, their way of communicating it to others and build on their social remedies. Capacity utilisation should not be viewed as an exclusively external process but as a process that builds on what keeps that community going, their social capital, to use the sustainable livelihood language.” Chabu Kangale, International HIV/AIDS Alliance, Zambia Country Office

30. Slide 30 THREE SAMARITANS 'The sweetness of hunger, misery and despair is found when the eyes close in an eternal sleep.' Vidho Lorville