CQUIN Call to Action Peter Preko MB, ChB Project Director, CQUIN ICAP at Columbia University 21 July 2019

The CQUIN Learning Network Outline Differentiated Service Delivery The CQUIN network The ‘call to action’ The CQUIN Learning Network

The CQUIN Learning Network Differentiated Service Delivery is a client-centred approach that simplifies and adapts HIV services across the cascade to reflect the preferences and expectations of various groups of people living with HIV while reducing unnecessary burdens on the health system The CQUIN Learning Network

How can we improve outcomes? Change the package of care (the “what”) Change the way we deliver care (the “how”) The CQUIN Learning Network

Differentiated Service Delivery is about the “how” not the “what” Service Intensity Service Frequency Service Location Service Provider The CQUIN Learning Network

Optimizing Care To Achieve Impact The CQUIN Learning Network

DSD is not just for stable patients Countries are making great strides scaling up less-intensive DSD models for stable patients But DSD also includes more- intensive models for people who need specialized or frequent services The CQUIN Learning Network

The CQUIN Learning Network Outline Differentiated Service Delivery The CQUIN network The ‘call to action’ The CQUIN Learning Network

The CQUIN Learning Network The CQUIN Network The HIV Coverage, Quality, and Impact Network (CQUIN) is a south-to-south learning network designed to foster the scale up of differentiated service delivery as a means to HIV epidemic control Priority activities include: facilitating country-to-country knowledge exchange providing demand-driven technical assistance supporting catalytic projects and knowledge generation Funded by the Bill and Melinda Gates Foundation Convened by ICAP at Columbia University The CQUIN Learning Network

The CQUIN Learning Network CQUIN Network Member Countries The CQUIN Learning Network

CQUIN Communities of Practice Ad hoc technical working groups designed to co- create resources and tools in priority domains: Differentiated M&E DSD for people at high risk of disease progression TB/HIV and DSD Quality improvement and DSD Community engagement and DSD The CQUIN Learning Network

Newly Initiating ART or on ART for < 1 year What do we mean by P@HR? PLHIV Newly Initiating ART or on ART for < 1 year Early Disease Advanced Disease On ART for ≥ 1 year Stable Unstable The CQUIN Learning Network

The CQUIN Learning Network CQUIN: DSD for P@HR Many countries have guidelines and systems related to the package of care (the “what”) However, national guidelines and systems related to the way in which care is delivered (the “how”) are scarce The CQUIN Learning Network

Programmatic Challenges The CQUIN Learning Network

Illustrative Programmatic Challenges How can we swiftly identify patients at high risk of HIV disease progression and “flag” them for rapid and prioritized services? How can we provide services that are both intensified and patient-centered? The CQUIN Learning Network

Illustrative DSD models for P@HR SERVICE FREQUENCY SERVICE INTENSITY Weekly or Biweekly visits Monthly Visits Interim mHealth contacts Enhanced Prophylaxis Enhanced Counseling Baseline CD4 at ART initiation Reflex Lab Testing (e.g Crag for those with low CD4) SERVICE LOCATION SERVICE PROVIDERS Specialty Clinics Intermediate care facilities Housing near facility (like maternity waiting homes) mHealth enabled home-based care NIMART “plus” Super mentors (e.g. in Kenya) Telemedicine Oversight committees for 3rd line ART The CQUIN Learning Network

The SIPOC Model from Kenya (“Severely Immunosuppressed Package of Care”)

Kwazulu Natal’s Viral Load Priority Clinic What: Adherence Counseling Psychosocial support ART CD4 OI Screening and Diagnosis Management of OI Repeat VL When: Monthly Friday Where: Health Facility Who: Medical Officer Counselor Social Worker

Priority Research Questions To what extent can care for P@HR be decentralized and delivered outside of the hospital setting? Would community-based DSD models of care work for unstable patients? Can non-physician clinicians be trained to provide care for unstable patients? The CQUIN Learning Network

The CQUIN Learning Network Outline Differentiated Service Delivery The CQUIN network The ‘call to action’ The CQUIN Learning Network

The CQUIN Learning Network CQUIN’s Call to Action Developed by the CQUIN community of practice on P@HR Summarizes the published and grey literature on DSD Calls for programs and policy- makers to prioritize innovative service delivery models for P@HR https://cquin.icap.columbia.edu/resources/call-to-action/ The CQUIN Learning Network

The CQUIN Learning Network Summary An evidence-based package of services has been identified for P@HR, but coverage of these services is low We are not getting the right care to the right people at the right time Similarly, not much progress has been made in developing innovative differentiated service delivery models for P@HR Innovative program designs and implementation research are needed to improve the coverage, quality, and impact of services for P@HR as we strive to reduce HIV-associated mortality and achieve epidemic control The CQUIN Learning Network

The CQUIN Learning Network Acknowledgements Beckman Coulter Foundation The Bill & Melinda Gates Foundation ICAP colleagues CQUIN network participants The CQUIN Learning Network