1. 3 rd South African AIDS Conference, Durban 2007 Plugging the leaky cascade, Rome IAS, July 2011 Plugging the Leaky Cascade: Programmatic adjustments for specific target populations Dr Eric Goemaere Regional TB/HIV Advisor MSF South Africa

2. 3 rd South African AIDS Conference, Durban 2007 Plugging the leaky cascade, Rome IAS, July 2011 Testing Staging/ Eligibility Staging/ Eligibility ART Post – initiation Long Term survival The low hanging fruits Increased coverage/Higher Cd4 threshold Triage and fast track PHC decentralised care, nurse based CHW supported Patient friendly regimen Patient self management

3. 3 Specific targets, specific strategies Adult males 43 % of male testing at site C are less than 25 yrs

4. 4 Recruiting eligible males: have a look at TB clinic Source : Fuchia bulletin (OCB) N= 54.679 Source: Town II TB clinic, Khayelitsha= 188

5. 5  Median CD4 count = 218 Baseline retention on pre-ART in SA ( CD4 monitoring within 12 months ): 31-45% ART ineligible enrolled1828 Recorded CD4/visit within 8m prior to end of study/starting ART 8m Active in care %61.9 Requested transfer out % 4 Deceased %10.28 LTFU %23.85 Factors Influencing Retention in Care after Starting Antiretroviral Therapy in a Rural South African Programme. Boyles TH, Wilkinson LS, and all, 2011 PLoS

6. 6 Weekly peer educator led HIV Care Group (Pre-ART+ART)  group support and education  CD4 count monitoring  weight + symptom screening  pregnancy referrals  ART prep/ counselling  Bactrim dispense CD4 <500  IPT refills  pap smear monitoring  nutrition  defaulter tracing referrals Comprehensive care for pre-ART Effective referral system btw HIV care group and clinic Accessible CD4/VL results to peer educator Provision of ART/Cotri/IPT refills to HIV care group M&E system at community level – simple mobile options? Effective referral system btw HIV care group and clinic Accessible CD4/VL results to peer educator Provision of ART/Cotri/IPT refills to HIV care group M&E system at community level – simple mobile options?

7. 7

8. 8 Specific targets, specific strategies Adolescents Denial Stigma /parental judgment Peer pressure Outreach testing Reduce time/number prep sessions Mixing positive and negative ones Not Peer supporter <> counselor 1:1 guidance across all initial step Intensive emotional support

9. 9 ART for youth and adolescents in Khayelitsha, IAS poster THPE 0170 Van Cutsem G 1, 2, Knight L 1, Abrahams M 1, Kerschberger B 1, Malavazzi C 1, Ford N 1, Boulle A 2 0.00 0.10 0.20 0.30 0.40 0612182430364248 Months on ART 10-24>=25 Kaplan-Meier: Virological failure by age group Remaining in care at 24 mths: Children 95.4 % <> Adolescents 81.6 % ( p=0.007) Youth 78.7 % <> Adults : 83.3% ( p=0.008) Virological suppres.@24mths children 80.4 % Adolescents:87.0 % Youth : 74.5 % Adults : 88.2 % ( p <0.001)

10. 10 Multivariate analysis -> AHR for LTFU in migrants at one year 6.69 ( 3.18-14.09) Helen Bygrave1*, Katharina Kranzer2, Katherine Hilderbrand3,4, Jonathan Whittal3, Guillaume Jouquet1,Eric Goemaere3, Nathalie Vlahakis1, Laura Trivin˜o1, Lipontso Makakole5, Nathan Ford3,4, Plos One, October 2010 | Volume 5 | Issue 10 | e13198

11. 11 Mobile clinic one stop shop for the HIV/TB co-infected patient HCT, POC CD4 at mobile points Each visit, patient asked about travel plan and documented Health passports + alternative treatment points Temporary Transfer Out (TTFO): = plans to return (circular migration) 3 months ARV supply + tail protection If not intention to return, self addressed stamped envelope signed by receiving sites

12. 12 Acknowledgments MSF teams in South Africa, Lesotho and Zimbabwe South African Medical Unit & CAME Gilles Van Cutsem, Guiseppe Demola, Daniela Garone, Katherine Hilderbrand, Nathan Ford Staff and patients who are driving these new ideas Dedicated to Babalwa