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Absorption, Retention and Empowerment Addressing the Root Causes of Attrition Through Scale-up of Community Adherence Support Groups.

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Presentation on theme: "Absorption, Retention and Empowerment Addressing the Root Causes of Attrition Through Scale-up of Community Adherence Support Groups."— Presentation transcript:

1 Absorption, Retention and Empowerment Addressing the Root Causes of Attrition Through Scale-up of Community Adherence Support Groups

2 Mozambique Population: 23.4 million (2011) Human Development Index (165/169) Life expectancy 48.4 years Mean years of schooling: % 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

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5 National and USG-supported ART coverage through 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 USG targets are as proposed in COP12.

6 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

7 Traditional Retention Strategies –Pre-ART/ART counseling –Care package –Peer educators –Support groups –Defaulter tracing –Community health workers –SMS messaging

8 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

9 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

10 Patient Level Characteristics Median CD4 count at ART initiation: 176 cells/mm 3 Median amount of time on ART prior to CAG: 22.3 months Median age: 36 years 70% female Median CD4 count gain: cells/mm 3

11 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

12 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

13 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

14 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

15 Scale-Up Government of Mozambique piloting the model in all 11 Provinces –3-6 health facilities per Province –3 tiers >1000 patients patients <500 patients 12-month pilot with national scale-up pending the results of retrospective evaluation

16 6 Months of Progress PROVINCE NUMBER OF GROUPS NUMBER OF PATIENTS Cabo Delgado51229 Gaza Inhambane Manica94318 Maputo Cidade87152 Maputo Provincia Nampula84310 Niassa41150 Sofala Zambezia Grand Total

17 Who is currently eligible Non-pregnant Stable Adult (or at least adult doses of ARVs)

18 Who could be eligible? Pre-ART populations Pregnant HIV-infected women Children Defaulters TB infected patients HIV/TB co-infected patients

19 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

20 “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

21 Obrigado!

22 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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