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Absorption, Retention and Empowerment

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Presentation on theme: "Absorption, Retention and Empowerment"— 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: 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 Mozambique is one of PEPFAR’s 15 focus countries. Situated on the east coast of Africa, and with a coastline twice the length of California, it has a populaton of about 20 million people, 54% of whom live on less than a dollar a day, Population 23 million people 44% children <5 chronically malnourished Ranked 165th of 169 on UNDP’s Human Development Index 36% of the population lives within 30 minutes of a health facility 60% of the population lives on less than $1.25/day In 2004 reported as the world’s 7 the poorest country according to UNDP’s Human development index rating scale. It is also recovering from a 16 year civil war which ended in 1992, Apart from poverty, emerged from a 16 year civil war in 1992. Extreme poverty, and the after effects of war, make Mozambique one of the worlds 25 worst affected countries by the global Health worker shortage with 3 physicians per 100,000 population UNDP) human development index (HDI) listings, which arranges countries according to their overall level of human development, ranks Mozambique 168th out of a total of 174 nations. The HDI, a composite index (one that assesses more than one variable) that measures life expectancy at birth, adult literacy rate, school enrollment ratio, and GDP per capita, is indicative of a country's general social and economic wellbeing. As such, Mozambique's HDI ranking demonstrates that the country is one of the least developed in the entire world. The one used:



5 National and USG-supported ART coverage through 2013
Coverage estimates fell in 2009 and 2011 though absolute numbers on treatment increased throughout the last 10 years because of changing eligibility criteria (CD4<200 prior to 2009, CD4< , CD4< > for adults, children <12 months in 2009 and <24 months in 2011 (as well as various CD4 threshold changes)) * 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 Add some data here on the HSS impact of HIV on MZ public health sector Discuss the chronic care model in broad strokes here.

7 Traditional Retention Strategies
Pre-ART/ART counseling Care package Peer educators Support groups Defaulter tracing Community health workers SMS messaging The point here is that none of these strategies, with the exception of the care package, address the root causes of why patients are lost to follow-up. They are ex-post facto approaches that are simply not effective and likely far more costly than alternative approaches that do address the reasons why patients default

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 Between February 2008 and May 2010, 1384 members were enrolled into 291 groups. Median follow-up time within a group was 12.9 months (IQR 8.5–14.1). During this time, 83 (6%) were transferred out, and of the 1301 patients still in community groups, 1269 (97.5%) were remaining in care, 30 (2%) had died, and 2 (0.2%) were lost to follow-up. Data is available for 78% of patients 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/mm3 Median amount of time on ART prior to CAG: 22.3 months Median age: 36 years 70% female Median CD4 count gain: cells/mm3

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 Note: HAI article re: pharmacy overload and the impact that has upon clinical care and retention

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 Outline the criteria: ART > 6 months 3 tiers >1000 patients patients <500 patients Describe the process of making scale-up happen.

Cabo Delgado 51 229 Gaza 121 552 Inhambane 159 727 Manica 94 318 Maputo Cidade 87 152 Maputo Provincia 123 561 Nampula 84 310 Niassa 41 150 Sofala 132 492 Zambezia 189 813 Grand Total 1081 4304

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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