Community Based Treatment Support Services: The Treatment Support Arm of the AIDSRelief Program

Community Based Treatment Support Services: The Treatment Support Arm of the AIDSRelief Program Martine Etienne, DrPH Director of The Community Based Treatment Support Services (CBTS) UMSOM-IHV/AIDSRelief April 29, 2010

Overview
History of CBTS
A critical part of the clinical program
Implementation and Evidence

Our Evolution
Adherence Programs
Community Adherence Programs
COMMUNITY BASED TREATMENT SERVICES
Community Health & Treatment Support

The AIDSRelief Philosophy
Maintain the 1 st line regimen
For as long as possible
Ensure durable viral suppression
Through adequate adherence
Patient follow up and engagement in care
Enhance the capacity of the community health treatment supporters to adequately support PLHIV
Establish the need and use of treatment supporters as a vital therapeutic intervention for community health

CBTS lays the framework for successful treatment outcomes
Initial and continuous highly intensive treatment support
Patient and family undergo structured treatment preparation and education
Engaging the patient’s community through C&T, addressing general community health issues that impact patient adherence

CBTS interfaces between the health facility, the patient and the community
Managing loss to follow up
Early identification and referral of OIs
Increased capacity of side effect identification and management in the home and community
Through increased engagement and capacity of the layworker

CBTS is the heartbeat of a successful HIV care and treatment program
Are patients getting their CD4 tests and other necessary labs?
Are patients missing appointments?
Are patients exhibiting non adherence?
Engaging in high risk behavior?
In need of psychosocial support? Networks?
Extensive use of treatment supporters and PLHIV

Comprehensive, integrated and sustainable
With the use of the treatment supporter structure (including supportive supervision)
LTFU decreases
Viral load suppression increases
Engagement in care increases
Implementation Sustainable, durable treatment outcomes

Tiered programs Retrospective review of patients enrolled in the AIDSRelief program treatment sites between Aug 2004-June 2005. Loss to follow up (ltfu) data was aggregated from the quarterly grant reports. Programs are tiered according to their particular components Tier II Adherence counseling plus a structured treatment preparation plan * Tier III Tier I plus Tier II plus home visits conducted by community treatment supporters * Tier IV Tier III plus Use of community health nurses to provide supportive supervision to the Tier III staff in the field Tier I Adherence Counseling only Prior to Starting ART * This is developed by the site with specific guidelines from AIDSRelief

(within first 12 months of AR- Guyana, Haiti, Kenya, Nigeria, Rwanda, Tanzania, Uganda, Zambia) Etienne, et al. 2010. Situational analysis of varying models of adherence support and loss to follow up rates; findings from 27 treatment facilities in eight resource limited countries

AIDSRelief Year 1
The use of trained community treatment supporters decreased ltfu from 10% to 5%
Addition of supportive supervision of the CHN further decreased ltfu to 1%

Five Year Follow up

Using evidence to effect care and treatment

Using scientific methods to complement and ensure treatment adherence
Adherence Red Flag Indicators (ARFI) as a possible proxy for detecting early treatment failure
Survey currently being piloted in country

ADHERENCE RED FLAG INDICATORS
What about adherence indicators as a predictive measure of failure?
Disclosure
Condom Use
Sexual Partners
Alcohol Use
Pregnancy
STIs
Missed doses
Missed appointments
Depression
These indicators are highly correlated with viral suppression

RWANDA

RWANDA
Reducing Lost-to-Follow-Up by Integrating Clinical Data Management in the Community Support System and use of benevoles (CHW)
Alain KOLOMOYI , Marik MOEN, John BUTONZI, Eva KARORERO, University of Maryland School of Medicine, Institute of Human Virology, AIDSRelief, Nyamasheke district, Rwanda; Ingabire SPECIOSE, Alphonse KAYIRANGA, Honoré MEDA, Parfait RABEZANAHRY: Catholic Relief Services, AIDSRelief, Kigali, Rwanda; Marie-Chantal UMUHOZA , Olivier BYICAZA : Futures Group International, AIDSRelief, Kigali, Rwanda. IAS 2009

RWANDA
Data teams at AR sites alerted clinical teams to the high number of missed ART appointments.
They generated a missing patient list for the community-based treatment support (CBTS) team (coordinator, social workers, and bénévoles or community volunteers assigned to each patient).
The CBTS team prepares patients for treatment, conducts home visits, screens for adherence, medical, or psychosocial complications.
Together, these teams located patients and determined the reasons underlying the missed appointments.

RWANDA
From May to November 2008, the number of patients with missed ART appointments declined from 650 to 11, at 10 health facilities--a 98% reduction.
Of 650 patients considered LTFU, 251 (38.6%) were actually current with their appointments but data entry errors indicated them as missing.
In one month, the number of missed appointments declined by 65% largely due to rectification of records.
The benevoles identified the status of the other 400 patients:
232 (58%) unofficially transferred to other sites- most to another site within the same district;
75 (18.7%) had died;
92 (23%) were identified as LTFU for preventable and remediable reasons. Of those, 81(88%) were retrieved and re-enrolled in care.

TANZANIA

TANZANIA
Overarching Goals
Increase access to therapy
Engage patients earlier in disease progression
Below Patient Targets (August 07)
Number of eligible patients ( estimated 3,000 )
Number on ART at that time: 8,431 ( target was 15,000 )
Retention 63%
Lessons from the ground:
Use of community treatment supporters to support patients were not in place
Patient monitoring was a major problem e.g. CD4 @ baseline and 6 months

TANZANIA
Engaged the Community Treatment Supporters
Emphasize Stigma reduction
Emphasize importance of disclosure
Education and re-education of the importance of CD4 cell counts
Provided health education talks in the clinic
Peer networks
Treatment buddies
Referral of patients to clinic

Know Your CD4 Campaign 114% increase based on the use of community treatment supporters and their continued reinforcement and follow up of patients reminding them of their CD4 cell count 3585 7698

Median CD4 at enrollment also increased overtime

TANZANIA
Increased implementation of the CBTS strategies reduced LTFU rates
18%-Feb 2007
9%-Feb 2009
7%-Sept 2009

NIGERIA

NIGERIA
Piloting the DAAS (depression, anxiety, and stress scale)
Addressing patient mental health issues
Highly correlated with viral load outcomes
Finalizing a collaboration with the Volunteer Service Organization (VSO)

GUYANA

Guyana Age appropriate Groups Pt Education Classes ADT Missed Appointments LTFU Reducing Mortality

Is our approach working?
Current AIDSRelief data:
LTFU <4%
Mortality <7%
Still Active 89%

More than just adherence…
Ensuring treatment preparation-making sure patients and their families understand HIV care and treatment and the consequences of nonadherence
Ensuring the community in which the patient lives is motivated, de-stigmatized and educated and seeks testing, treatment and care
Increasing continuity of treatment, care and prevention
Defines the level of “services” that can be provided in the community outside of the clinic, the patient level
its not a program it’s a cadre of community services that we have been able to master and deliver

THANK YOU!

Community Based Treatment Support Services: The Treatment Support Arm of the AIDSRelief Program

by jehill3 on May 04, 2010

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Community Based Treatment Support Services: The Treatment Support Arm of the AIDSRelief Program — Presentation Transcript