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

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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, UMSOM-IHV/AIDSRelief

HIV/AIDS Working Group Showcase

CORE Group Spring Meeting, April 29, 2010

Published in: Health & Medicine

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  • 1. Adherence programs- provided treatment preparation-making sure patients and their families understand HIV care and treatment and the consequences of nonadherence 2. Community Adherence Programs- focused on supporting patients and their families in the community (home visits) 3. Community Health & Treatment Support- expanding on the support we provide as this team to our patients in the community including prevention, and continuous care and treatment 4. Community Based Treatment Services- really defines the “services” that we provide 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
  • Campaign was started because our target for Sept 07 was about 15,000 and in July we had 9000 according to SI’ reports which would mean we would not even come close if we didn’t change something. When we looked to see WHY we were low we id’d CD4 as a major stumbling block plus NO ADHERENCE programs in any of these facilities before we started in November of 06.
  • VSO is important especially as we engage in transition strategies, training and collaborating with this group will support the continued emphasis of the AIDSRelief support model
  • Transcript

    • 1. 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
    • 2. Overview
      • History of CBTS
      • A critical part of the clinical program
      • Implementation and Evidence
    • 3. Our Evolution
      • Adherence Programs
      • Community Adherence Programs
      • COMMUNITY BASED TREATMENT SERVICES
      • Community Health & Treatment Support
    • 4. 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
    • 5. A critical part of the clinical program
      • 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
    • 6. A critical part of the clinical program
      • 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
    • 7. A critical part of the clinical program
      • 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
    • 8.
      • 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
    • 9. 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
    • 10. (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
    • 11. 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%
    • 12. Five Year Follow up
    • 13.
      • Using evidence to effect care and treatment
    • 14.
      • 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
    • 15. 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
    • 16. RWANDA
    • 17. 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
    • 18. 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.
    • 19. 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.
    • 20. TANZANIA
    • 21. 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
    • 22. 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
    • 23. 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
    • 24. Median CD4 at enrollment also increased overtime
    • 25.  
    • 26. TANZANIA
      • Increased implementation of the CBTS strategies reduced LTFU rates
        • 18%-Feb 2007
        • 9%-Feb 2009
        • 7%-Sept 2009
    • 27. NIGERIA
    • 28. 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)
    • 29. GUYANA
    • 30. Guyana Age appropriate Groups Pt Education Classes ADT Missed Appointments LTFU Reducing Mortality
    • 31. Is our approach working?
      • Current AIDSRelief data:
        • LTFU <4%
        • Mortality <7%
        • Still Active 89%
    • 32. 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
    • 33. THANK YOU!