1. Models of care to reach and retain more people Is there a role for the community? Tom Decroo 1, Luisa Cumba 2 1 Médecins Sans Frontières 2 Ministry of Health, Mozambique

2. HIV and ART in Sub Saharan Africa 23.200.000 PLWHA in SSA 23.200.000 PLWHA in SSA 10.500.000 need ART (with CD4 350 criteria)10.500.000 need ART (with CD4 350 criteria) 6.000.000 on treatment6.000.000 on treatment Attrition at 3 years ART up to 48%Attrition at 3 years ART up to 48% When not on treatment, and in phase of AIDS, life expectancy is less then 1 yearWhen not on treatment, and in phase of AIDS, life expectancy is less then 1 year The proportion of PLWHA eligible for treatment will increase The proportion of PLWHA eligible for treatment will increase Aging of cohortsAging of cohorts More inclusive protocols : PMTCT B +, CD4 500,..., test and treat?More inclusive protocols : PMTCT B +, CD4 500,..., test and treat? Roll out ART in resource constrained context: Roll out ART in resource constrained context: Who will do the job?Who will do the job? How to absorb increasing caseloads?How to absorb increasing caseloads? How to bridge distances between clinics and rural communities?How to bridge distances between clinics and rural communities?

3. Community Participation: Resources that can be found in the community: Resources that can be found in the community: Community Health Worker (CHW)Community Health Worker (CHW) PLWHAPLWHA Networks of PLWHA (social capital)Networks of PLWHA (social capital) HIV = chronic disease HIV = chronic disease self – management is only sustainable treatment strategy for long term adherenceself – management is only sustainable treatment strategy for long term adherence Peer – support = known promoter for adherence Peer – support = known promoter for adherence

4. Example of Malawi, Thyolo district Community participation accompanied process of roll out and integration of HIV care into small peripheral HF's Community participation accompanied process of roll out and integration of HIV care into small peripheral HF's > 80% of coverage of ART needs was reached > 80% of coverage of ART needs was reached Volunteers Home Based Care, including drug distribution (CTX, TB), psychosocial support, referral PLWHA Sensitization, psychosocial support and tracing CHW Participate in care provision at the HF (Reception, VCT, Pharmacy)

5. Example of Uganda Community Based ART (CBART) Community Based ART (CBART) CHW deliver ART in community, provide psychosocial support, and refer sick people to the clinicCHW deliver ART in community, provide psychosocial support, and refer sick people to the clinic equipped with motorbikes, cell phonesequipped with motorbikes, cell phones Mortality 95 % reduction (before – after CBART) Orphanhood 93% reduction (before – after CBART) Effectiveness CBART = Facility based ART Nr of clinic visits 75% reduction for CBART Cost CBART slightly less expensive

6. Example of Kenya Community Based ART (CBART) Community Based ART (CBART) Peer - CHW deliver ART in community, provide psychosocial support, and refer sick people to the clinicPeer - CHW deliver ART in community, provide psychosocial support, and refer sick people to the clinic Equipped with cell phones, and mobile device (personal digital assistant)Equipped with cell phones, and mobile device (personal digital assistant) Were perceived by PLWHA as their advocates, and use their experience of living with HIV to resolve practical barriers to adherenceWere perceived by PLWHA as their advocates, and use their experience of living with HIV to resolve practical barriers to adherence Effectiveness CBART = Facility based ART Nr of clinic visits Reduction w 50% for CBART cohort

7. 4th Annual IAS/IAC Pre-conference Meeting: HIV and Health Systems: Strengthening Health Systems for an AIDS-free Generation – July 20-21, 20127 PLWHA self-form groups of maximum six CAG members are registered on a group card CAG members meet monthly in the community Verify adherence Fill in group card Chose a representative to go the clinic Share transport costs (if any) The representative at the clinic Reports about the other members Receives refill for all members Has a routine consultation Back in the community the representative delivers the refill to the other members Members support each other, and refer other community members to the clinic when sick Example of CBART in Mozambique, Tete province

8. Community ART Groups (CAG) - DYNAMIC 4th Annual IAS/IAC Pre-conference Meeting: HIV and Health Systems: Strengthening Health Systems for an AIDS-free Generation – July 20-21, 20128

9. 5229 members enlisted in 1139 CAG: 5229 members enlisted in 1139 CAG: Median FU time: 16 months, IQR [9-27]Median FU time: 16 months, IQR [9-27] Mortality: 2,3 / 100 person-yearsMortality: 2,3 / 100 person-years LTFU: 0,1 / 100 person-yearsLTFU: 0,1 / 100 person-years Results of CBART in Mozambique, Tete province

10. Challenges CBART and STIGMA? CBART and STIGMA? CBART is not without cost: CBART is not without cost: TrainingTraining SupervisionSupervision EquipmentEquipment Salary / IncentiveSalary / Incentive Need functional referral system Need functional referral system Community participation = bottom-up Community participation = bottom-up NOT to fill GAPS defined by provider NOT to fill GAPS defined by provider

11. Conclusion CBART CBART Can be effectiveCan be effective Increases affordability and accessibility of ARTIncreases affordability and accessibility of ART Potential to increase trustworthiness (proximity) of ARTPotential to increase trustworthiness (proximity) of ART Accompany with health system strengtheningAccompany with health system strengthening Voluntarily involvement PLWHA versus professional lay provider? Voluntarily involvement PLWHA versus professional lay provider? Sustainable treatment strategy for chronic disease care?Sustainable treatment strategy for chronic disease care? Peer networks: potential to boost motivation (confidence / importance), and circulation of informationPeer networks: potential to boost motivation (confidence / importance), and circulation of information

12. Future applications for community participation? VCT? Self testing? VCT? Self testing? Point of care Hb, CD4, VL? Point of care Hb, CD4, VL? ART stocks? ART stocks? Combine models of care described above? Combine models of care described above? Network of PLWHA engaged in the care for their chronic conditionNetwork of PLWHA engaged in the care for their chronic condition Linked with CHW for VCT, CD4, VL, ARV, sputum sample collection, and reportingLinked with CHW for VCT, CD4, VL, ARV, sputum sample collection, and reporting Refer patients who need clinician to the clinicRefer patients who need clinician to the clinic

13. Models of CBART Uganda (Jaffar, 2009) Kenya (Selke, 2010) Mozambique (Decroo, 2011) Who?CHW Peer CHW PLWHA in support groups Salaried?YYN EquipmentMotorbikes,cell-phonesCell-phones, mobile device N Study population Rural, 859 patients, from 0 m on ART Rural, 96 patients, from 3 m on ART Rural, 1301 patients, from 6 m on ART Routine clinic visit Every 6 m Every 3 m Every 6 m Outcomes Attrition at 12 m: CBART: 12% Control:13% VL < 500 at 12 m: CBART: 84% Control: 83% Attrition at 12 m: CBART: 6% Control:3% VL undet. at 12 m: CBART: 89% Control: 86% Attrition after median of 16 months FU in CBART: 2,4%

14. References Decroo T, Telfer B, Biot M, et al. Distribution of antiretroviral treatment through self-forming groups of patients in Tete province, Mozambique. Journal of acquired immune deficiency syndromes. 2011;56(2):39-44. Decroo T, Van Damme W, Kegels G, et al. Are Expert Patients an Untapped Resource for ART Provision in Sub-Saharan Africa ? Aids Research and Treatment. 2012; 749718 Garnett GP, Baggaley RF. Treating our way out of the HIV pandemic: could we, would we, should we? Lancet. 2009;373:9-11. Gifford AL, Groessl EJ. Chronic disease self-management and adherence to HIV medications. Journal of acquired immune deficiency syndromes. 2002;31 Suppl 3:S163-6. Jaffer S, Amuron B, Foster S, et al. Rates of virological failure in patients treated in a home-based versus a facility-based HIV-care model in Jinja, southeast Uganda:a cluster-randomised equivalence trial. Lancet. 2009;374:2080-9. Mermin J, Were W, Ekwaru JP, et al. Mortality in HIV-infected Ugandan adults receiving antiretroviral treatment and survival of their HIV-uninfected children: a prospective cohort study. Lancet. 2008;371:752-9. Morgan D, Mahe C, Mayanja B, et al. HIV-1 infection in rural Africa: is there a difference in median time to AIDS and survival compared with that in industrialized countries? AIDS. 2002;16(4):597-603. Van Damme W, Kober K, Kegels G. Scaling-up antiretroviral treatment in Southern African countries with human resource shortage: how will health systems adapt? Social science & medicine. 2008;66(10):2108-Kober K, Damme WV. Scaling up access to antiretroviral treatment in southern Africa : who will do the job ? The Lancet. 2004;364:103-107. 21. Rasschaert F, Pirard M, Philips MP, et al. Positive spill-over effects of ART scale up on wider health systems development: evidence from Ethiopia and Malawi. Journal of the International AIDS Society. 2011;14 Suppl 1:S3 Selke HM, Kimaiyo S, Sidle JE, et al. Task-Shifting of Antiretroviral Delivery From Health Care Workers to Persons Living With HIV/AIDS: Clinical Outcomes of a Community-Based Program in Kenya. Journal of acquired immune deficiency syndromes. 2010;55(4):483-90. Wandeler G, Keiser O, Pfeiffer O, et al. Outcomes of Antiretroviral treatment in Rural Southern Africa. Tropical Medicine and International Health. 2012;59(2): e9-e16. Wools-Kaloustian KK, Sidle JE, Selke HM, et al. A model for extending antiretroviral care beyond the rural health centre. Journal of the International AIDS Society. 2009;12(1):22. World Health Organization (WHO). Global HIV/AIDS response: epidemic update and health sector progress towards universal access. Progress Report 2011 Zachariah R, Teck R, Buhendwa L. How can the community contribute in the fight against HIV/AIDS and tuberculosis? An example from a rural district in Malawi. Transactions of the Royal Society of Tropical Medicine and Hygiene. 2006;100(2):167–75. Zachariah R, Teck R, Buhendwa L. How can the community contribute in the fight against HIV/AIDS and tuberculosis? An example from a rural district in Malawi. Transactions of the Royal Society of Tropical Medicine and Hygiene. 2006;100(2):167–75.