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 yearsMean years of schooling: 1.2- 33% adult men and 63% adult women illiterateLimited human resources and physical infrastructure> 830,000 births per year, ~65% in health facilities50-60% DO NOT have access to health careMany clinics and hospitals lack continuous access to water (63%), electricity (74%)Poor roads, seasonal flooding>70% ruralMozambique 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,Population23 million people44% children <5 chronically malnourishedRanked 165th of 169 on UNDP’s Human Development Index36% of the population lives within 30 minutes of a health facility60% of the population lives on less than $1.25/dayIn 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 populationUNDP) 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 CapacityThe public health system in Mozambique is currently straining to serve the needs of the population3 physicians/100,000 inhabitants21 clinical officers/100,000 inhabitants40 MCH nurses/100,000 inhabitants1.4 million infected603,375 eligible for treatment273,561 alive and on treatmentModel of HIV care must be adaptedAdd some data here on the HSS impact of HIV on MZ public health sectorDiscuss the chronic care model in broad strokes here.
7 Traditional Retention Strategies Pre-ART/ART counselingCare packagePeer educatorsSupport groupsDefaulter tracingCommunity health workersSMS messagingThe 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 membersOne representative from the group visits the health facility every month and does the following:Clinical assessment and CD4 countProvides feedback to the health facility about the five other members of the groupObtains lab results for other membersCollects 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 Province291 groups formed12-month retention: 97.5%Mortality: 0.2%LTFU: 2.3%Median follow-up time: 12.9 monthsBetween 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 patientsDecroo, 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/mm3Median amount of time on ART prior to CAG: 22.3 monthsMedian age: 36 years70% femaleMedian 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 arisePill countsBasic 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 resultsDistribute medicationsConvey any health messages received during the clinic visit
13 Impact at Health Facility Reduce number of stable ART patients accessing the health facilitiesIncrease capacity of a health facility to enroll new patientsIncrease amount of time staff can dedicate to sick or complex patientsDecrease congestion at the pharmacyDecrease acuity of consultations and admissions due to earlier access to health servicesImproved reporting on patient outcomesNote: 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 conditionsImproved psycho-social supportStigma reductionEarly warning system for illnessImproved monitoring and resources to address adherence problemsSocial safety netIncome generationFamily testingCommunity education
15 Scale-UpGovernment of Mozambique piloting the model in all 11 Provinces3-6 health facilities per Province3 tiers>1000 patientspatients<500 patients12-month pilot with national scale-up pending the results of retrospective evaluationOutline the criteria:ART > 6 months3 tiers>1000 patientspatients<500 patientsDescribe the process of making scale-up happen.
16 6 Months of Progress PROVINCE NUMBER OF GROUPS NUMBER OF PATIENTS Cabo Delgado51229Gaza121552Inhambane159727Manica94318Maputo Cidade87152Maputo Provincia123561Nampula84310Niassa41150Sofala132492Zambezia189813Grand Total10814304
17 Who is currently eligible Non-pregnantStableAdult (or at least adult doses of ARVs)
18 Who could be eligible? Pre-ART populations Pregnant HIV-infected women ChildrenDefaultersTB infected patientsHIV/TB co-infected patients
19 Challenges Allowing for a flexible dynamic Phased implementation Perception of strategy as a panaceaStaff ownershipCD4 count monitoringDemand creationUrban settingsLinks with other adherence and retention strategiesPatients 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
22 AcknowledgementsHIV-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)