Kebba Jobarteh

Report
Absorption, Retention and
Empowerment
Addressing the Root Causes of Attrition
Through Scale-up of Community Adherence
Support Groups
Mozambique
• Population: 23.4 million (2011)
• Human Development Index
(165/169)
• Life expectancy 48.4 years
• Mean years of schooling: 1.2
- 33% adult men and 63% adult women
illiterate
• Limited human resources and
physical infrastructure
₋ > 830,000 births per year, ~65% in
health facilities
₋ 50-60% DO NOT have access to health
care
₋ Many clinics and hospitals lack
continuous access to water (63%),
electricity (74%)
₋ Poor roads, seasonal flooding
• >70% rural
National and USG-supported
ART coverage through 2013
400,000
60%
53%
51%
49%
Patients on Treatment
48%
320,000
44%
280,000
45%
240,000
30%
32% 32%
34%
27%
160,000
20%
18%
120,000
10%
80,000
40,000
2%
50%
40%
37%
200,000
45%
8%
30%
On Treatment
(USG - FY)
Coverage (%)
360,000
On Treatment
(National - CY)
20%
National
Coverage (USG
direct support)
10%
National
Coverage
(MOH)
4%
2%
0%
0
0%
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
* Coverage estimates are calculated as those on ART at end of reporting period (MOH - Dec 31, USG - Sep 30),
divided by midyear Spectrum estimates from 2012 Demographic Impact Report. 2012-13 USG targets are as
proposed in COP12.
Absorptive Capacity
• The public health system in
Mozambique is currently
straining to serve the needs of
the population
–
–
–
–
–
–
3 physicians/100,000 inhabitants
21 clinical officers/100,000
inhabitants
40 MCH nurses/100,000 inhabitants
1.4 million infected
603,375 eligible for treatment
273,561 alive and on treatment
• Model of HIV care must be
adapted
Traditional Retention Strategies
–
–
–
–
–
–
–
Pre-ART/ART counseling
Care package
Peer educators
Support groups
Defaulter tracing
Community health workers
SMS messaging
A Different Approach
• Community adherence support groups
(CASG)
– Establish treatment groups with up to 6 members
– One representative from the group visits the
health facility every month and does the
following:
• Clinical assessment and CD4 count
• Provides feedback to the health facility about the five
other members of the group
• Obtains lab results for other members
• Collects one month’s worth of ARV’s for each group
member
Results from MSF-Tête Pilot
Cohort of 1384 ART patients in 12 health
facilities in Tête Province
–
–
–
–
–
291 groups formed
12-month retention: 97.5%
Mortality: 0.2%
LTFU: 2.3%
Median follow-up time: 12.9 months
Decroo, T., Telfer, B., Biot, M., Maïkéré, J., Dezembro, S., Cumba, L. I., Dores, C. D., et al.; Distribution of antiretroviral
treatment through self-forming groups of patients in Tête province, Mozambique; Journal of Acquired Immune Deficiency
Syndromes, February 2011
Patient Level Characteristics
• Median CD4 count at ART initiation: 176
cells/mm3
• Median amount of time on ART prior to
CAG: 22.3 months
• Median age: 36 years
• 70% female
• Median CD4 count gain: 478.5 cells/mm3
Before the Monthly Clinic Visit
• All members convene at a place of their
choosing to do the following:
– Discuss their health and any other issues that
may arise
– Pill counts
– Basic negative screening tool
After the Monthly Clinic Visit
• All members of the group reconvene at a
place of their choosing to do the
following:
– Report lab results
– Distribute medications
– Convey any health messages received during
the clinic visit
Impact at Health Facility
• Reduce number of stable ART patients accessing
the health facilities
• Increase capacity of a health facility to enroll
new patients
• Increase amount of time staff can dedicate to
sick or complex patients
• Decrease congestion at the pharmacy
• Decrease acuity of consultations and admissions
due to earlier access to health services
• Improved reporting on patient outcomes
Impact on patient
•
•
•
•
•
•
•
•
•
•
Decreased number of health facility visits
Improved self-monitoring of clinical conditions
Improved psycho-social support
Stigma reduction
Early warning system for illness
Improved monitoring and resources to address
adherence problems
Social safety net
Income generation
Family testing
Community education
Scale-Up
• Government of Mozambique piloting the
model in all 11 Provinces
– 3-6 health facilities per Province
– 3 tiers
• >1000 patients
• 500-10000 patients
• <500 patients
• 12-month pilot with national scale-up
pending the results of retrospective
evaluation
6 Months of Progress
PROVINCE
Cabo Delgado
Gaza
Inhambane
Manica
Maputo Cidade
Maputo
Provincia
Nampula
Niassa
Sofala
Zambezia
Grand Total
NUMBER OF
GROUPS
NUMBER OF
PATIENTS
51
121
159
94
87
229
552
727
318
152
123
84
41
132
189
1081
561
310
150
492
813
4304
Who is currently eligible
• Non-pregnant
• Stable
• Adult (or at least adult doses of ARVs)
Who could be eligible?
•
•
•
•
•
•
Pre-ART populations
Pregnant HIV-infected women
Children
Defaulters
TB infected patients
HIV/TB co-infected patients
Challenges
• Allowing for a flexible dynamic
• Phased implementation
• Perception of strategy as a panacea
• Staff ownership
• CD4 count monitoring
• Demand creation
• Urban settings
• Links with other adherence and retention strategies
• Patients with the most need may not have access
“The most important aspect of self-management is
the realization that people with a chronic condition
are those that have the most comprehensive
expertise in dealing with that condition.”
-Katarina Kober & Wim Van Damme
Obrigado!
Acknowledgements
HIV-infected and affected Mozambicans
Aleny Couto (MISAU)
Vania Macome (MISAU)
Armando Bucuane (MISAU)
Joe Lara (MISAU)
Tom Decroo (MSF-B)
Sergio Dizembro (MSF-B)
Inacio Malimane (CDC)
Paula Samo Gudo (CDC)
Lisa Nelson (CDC)

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