3rd South African AIDS Conference, Durban 2007Plugging the leaky cascade , Rome IAS, July 2011

Plugging the Leaky Cascade:Programmatic adjustments for specific

target populations

Dr Eric Goemaere

Regional TB/HIV Advisor

MSF South Africa

3rd South African AIDS Conference, Durban 2007Plugging the leaky cascade , Rome IAS, July 2011

TestingTesting Staging/EligibilityStaging/Eligibility ARTART

Post –initiation

Post –initiation

Long Term survival

Long Term survival

The low hanging fruits

Increased coverage/Higher Cd4 threshold

Triage and fast track

PHC decentralised care, nurse based CHW supported

Patient friendly regimenPatient self

management

3

Specific targets, specific strategiesAdult males

43 % of male testing at site C are less than 25 yrs

4

Recruiting eligible males: have a look at TB clinic

Source : Fuchia bulletin (OCB)

N= 54.679

Source: Town II TB clinic,

Khayelitsha= 188

5

Median CD4 count

= 218

Baseline retention on pre-ART in SA ( CD4 monitoring within 12 months ):

31-45%

ART ineligible enrolled 1828

Recorded CD4/visit within 8m prior to end of study/starting ART

8m

Active in care % 61.9

Requested transfer out %

4

Deceased % 10.28

LTFU % 23.85

Factors Influencing Retention in Care after Starting Antiretroviral Therapy in a Rural South African Programme.

Boyles TH, Wilkinson LS, and all, 2011 PLoS

6

Weekly peer educator ledHIV Care Group (Pre-ART+ART)

group support and education

CD4 count monitoring weight + symptom

screening pregnancy referrals ART prep/ counselling Bactrim dispense CD4

<500 IPT refills pap smear monitoring nutrition defaulter tracing

referrals

Comprehensive care for pre-ART

Effective referral system btw HIV care group and clinic

Accessible CD4/VL results to peer educator

Provision of ART/Cotri/IPT refills to HIV care group

• M&E system at community level – simple mobile options?

7

8

Specific targets, specific strategiesAdolescents

• Denial• Stigma /parental judgment• Peer pressure

Outreach testing Reduce time/number prep sessions Mixing positive and negative ones

Not

Peer supporter <> counselor 1:1 guidance across all initial step Intensive emotional support

9

ART for youth and adolescents in Khayelitsha, IAS poster THPE 0170

Van Cutsem G 1, 2 , Knight L 1, Abrahams M 1, Kerschberger B 1, Malavazzi C 1, Ford N

1, Boulle A 2

0.0

00

.10

0.2

00

.30

0.4

0

0 6 12 18 24 30 36 42 48Months on ART

10-24 >=25

Kaplan-Meier: Virological failure by age group

Remaining in care at 24 mths:

Children 95.4 % <> Adolescents 81.6 % ( p=0.007)

Youth 78.7 % <> Adults : 83.3% ( p=0.008)

Virological suppres.@24mths

children 80.4 % Adolescents:87.0 %Youth : 74.5 % Adults : 88.2 % ( p <0.001)

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• Multivariate analysis -> AHR for LTFU in migrants at one year 6.69 ( 3.18-14.09)

Helen Bygrave1*, Katharina Kranzer2, Katherine Hilderbrand3,4, Jonathan Whittal3, Guillaume Jouquet1,Eric Goemaere3, Nathalie Vlahakis1, Laura Trivin˜o1, Lipontso Makakole5, Nathan Ford3,4, Plos One , October 2010 | Volume 5 | Issue 10 | e13198

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Mobile clinic one stop shop for the HIV/TB co-infected patient

• HCT, POC CD4 at mobile points• Each visit, patient asked about

travel plan and documented• Health passports + alternative

treatment points• Temporary Transfer Out (TTFO): =

plans to return (circular migration)• 3 months ARV supply + tail

protection • If not intention to return, self

addressed stamped envelope signed by receiving sites

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Acknowledgments

• MSF teams in South Africa, Lesotho and Zimbabwe

• South African Medical Unit & CAME• Gilles Van Cutsem , Guiseppe Demola,

Daniela Garone, Katherine Hilderbrand, Nathan Ford

• Staff and patients who are driving these new ideas

Dedicated to Babalwa