1. Community ART groups: distribution of ARVs through self-forming groups in Tete province, Mozambique Tom Decroo, Barbara Telfer, Jacob Maïkéré, Sergio Dezembro, Carla das Dores, Marc Biot and Nathan Ford DIRECÇÃO PROVINCIAL DE SAÚDE TETE

2. Background - HIV in Tete province HIV prevalence 13% in 2007 (11%-21%) 1 HIV prevalence 13% in 2007 (11%-21%) 1 Gap Human Resources for Health 2 Gap Human Resources for Health 2 National ART coverage of 31% 3 National ART coverage of 31% 3 Up to 1 on 5 on ARV is lost to follow up, 50% dead 4 Up to 1 on 5 on ARV is lost to follow up, 50% dead 4 Barriers to access ARV 5 : Barriers to access ARV 5 : distances/ transport distances/ transport waiting times in Health Facility waiting times in Health Facility social obligations social obligations

3. Self management and expert patients Use day-to-day experience of patients Use day-to-day experience of patients Train them to assume standardized functions such as ARV provision Train them to assume standardized functions such as ARV provision Kober & Van Damme 6

4. Community ART groups (CAG) Objective: improve retention by Addressing patient reported barriers 5 Addressing patient reported barriers 5 Involvement of patients Involvement of patients Distribute ARVs in community Distribute ARVs in community Assess adherence & outcomes Assess adherence & outcomes Dissociate care & ARV refills Dissociate care & ARV refills

5. Method (1/2): implementation of CAGs Consult stakeholders Consult stakeholders Patients self form groups of six Patients self form groups of six Inclusion criteria: 1st line, time on ART, CD4 Inclusion criteria: 1st line, time on ART, CD4 Inscription on a group monitoring form Inscription on a group monitoring form Monthly: group-refill by representative Monthly: group-refill by representative 6 monthly: consult, CD4 and training 6 monthly: consult, CD4 and training

6. Method (2/2): descriptive analysis Sources for monitoring and verification: Group monitoring forms Group monitoring forms Clinical files Clinical files Observation of patient at CAG meetings Observation of patient at CAG meetings Home visits Home visits Data entered and analyzed in Excel and STATA Data entered and analyzed in Excel and STATA

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8. Results 1. Characteristics of 1384 members in 291 CAGs on 31/05/10 Nr [IQR] [IQR] Median age (years) at enrolment 36 [30 - 43] Median months on ART pre CAG 22 [10 – 34] [10 – 34] Median CD4 at ART initiation (nr = 1298) 176 [105 - 247] [105 - 247] Median months in CAG 13 [9 – 14] [9 – 14] Members > 9 months in CAG With a last CD4 in last 9 months Median CD4 1069836479 [314 - 642]

9. Results 2. Outcomes of 1384 members in 291 CAGs on 31/05/10 Nr% total - Dead - Lost to follow up - Retained in CAG 13013021269 100 % 2.3 % 0.2 % 97.5 % 97.5 % 1384 members > 14 years of age 1384 members > 14 years of age 83 transferred out (35 to another HF) 83 transferred out (35 to another HF) remain 1.301 remain 1.301

10. Discussion – limitations Difficult to compare with ART cohorts in conventional care Difficult to compare with ART cohorts in conventional care Limited follow up time of 13 months Limited follow up time of 13 months Reduced contact with clinicians Reduced contact with clinicians Potential for abuse Potential for abuse

11. Conclusion ART retention possible with patients as partners in care delivery ART retention possible with patients as partners in care delivery Patients in Community ART groups can: Patients in Community ART groups can: Support each other Support each other Distribute ARVs Distribute ARVs Monitor adherence & outcomes Monitor adherence & outcomes Way forward: Way forward: Evaluation of the CAG model Evaluation of the CAG model MOH promoted implementation MOH promoted implementation

12. Acknowledgements Patients Patients Vision: Wim Van Damme Vision: Wim Van Damme Tete authorities: Luisa Isabel Cumba, Carla dos Dores and Azélia Novéla Tete authorities: Luisa Isabel Cumba, Carla dos Dores and Azélia Novéla Implementation: Mariano, Helena, Natasha, Laura, Déolinda, counselors (Augusto, Dinda, Sonia, Ana, Raja, Julio, Marcelino, Jose, Lourenco, Maria, Viola) Implementation: Mariano, Helena, Natasha, Laura, Déolinda, counselors (Augusto, Dinda, Sonia, Ana, Raja, Julio, Marcelino, Jose, Lourenco, Maria, Viola) Technical advice: Kathryn Chu and Katharina Hermann Technical advice: Kathryn Chu and Katharina Hermann Film: Eliane Beeson, Paul Kelso Film: Eliane Beeson, Paul Kelso

13. References 1. Grupo técnico multisectorial de apoio a luta contra o HIV/SIDA em Moçambique. Ronda de Vigilância. Epidemiológica do HIV de 2007. Republica de Moçambique, Ministério da Saúde, Direcção Nacional da Assistência Medica. Programa Nacional de Controle das ITS/HIV/SIDA. Maputo, Fevereiro de 2008. 2. UNAIDS/WHO. Epidemiological Fact Sheet on HIV and AIDS. Mozambique. September 2008. 3. Oooms, G., Van Damme, W., Temmerman, M. (2007). Medicines without Doctors: Why the Global Fund must fund salaries of health workers to expand AIDS treatment. PLoS Medicine, Vol 4; Issue 4: 605-608. 4. Caluwaerts, C., Maendaenda, R., Maldonado, F., Biot, M., Ford, N., Chu, K. (2009) Risk factors and true outcomes for lost to follow-up individuals in an antiretroviral treatment programme in Tete, Mozambique. International Health, 1: 97-101. 5. 5. Posse, M. & Baltussen, R. (2009). Barriers to access to antiretroviral treatment in Mozambique, as perceived by patients and health workers in urban and rural settings. AIDS patient care, Vol 23, no.10: 867-875. 6.Kober, K. & Van Damme, W. (2006) Expert patients and AIDS care. A literature review on expert programmes in high-income countries, and an exploration of their relevance for HIV/AIDS care in low-income countries with severe human resource shortages. In Eldis. (Ed.) (pp. 1-27). Antwerp: Eldis. www.eldis.org/hivaids/fulltext/kober-vandamme.pdf

14. Thank you, Obrigado, Merci, Tatenda