AIDS 2012 - Turning the Tide Together

IAS Satellite: Where the Tide Will Turn: How is Community Level Participation Most Effective in

Turning the Tide?

Ashraf Grimwood, G Fatti, M Malahlela, E Mothibi

Kheth’Impilo, South Africa

Context

• South Africa is a MIC with LIC health outcomes• Population of 50m, 5.6m HIV infected• Antenatal HIV prevalence 30%• Maternal mortality 310/100000 as @ 2009• Neonatal mortality rate 14/1000 live births• Infant mortality 40/1000; <5 mortality rate 56/1000 live births• Unemployment officially 24% (reality 60%)• 70% rural children nutritionally challenged• One of the most obese nations in the world with high levels of

violence/trauma• Largest HIV burden• Second highest TB incidence -948/1000 and 70% dually infected• Government launches the NSDA, re-PHC as well as NHI with an

essential component being community systems & services strengthening besides HSS

Intervention South African NGO - founded in 2009

Vision:

An AIDS Free Generation in our time

Objectives:

• To support the SAG achieve its goals for the scale up of quality services for the

management of HIV/TB in the Primary Health Care sector as outlined in the National

Strategic Plan, NHI & re-PHC.

• Work in close partnership with the Health departments to provide comprehensive services

for the management of HIV & TB in primary health care facilities.

• Partner with other government departments to support the psychosocial needs of infected

and affected families.

• Strengthen community adherence & psychosocial support for improved HIV treatment

outcomes through community health care workers or Patient Advocates- paid workers, on

contract with benefits like all staff

Patient Advocate Support Structure

AREA COORDINATOR

PAPA PAPA PAPA PAPA PAPA PAPA

PAPA

PAPA

PAPAPRIMARY HEALTH CARE

CENTRE (Clinics)PRIMARY HEALTH CARE

CENTRE (Clinics)PRIMARY HEALTH CARE

CENTRE (Clinics)PRIMARY HEALTH CARE

CENTRE (Clinics)

DISTRICT OFFICEDISTRICT OFFICE

NATIONAL OFFICENATIONAL OFFICE

COMMUNITY HEALTH CENTRE

COMMUNITY HEALTH CENTRE · Site Facilitator

· CSC District Coordinator· CSC Trainer· Doctor

· Nurse· Pharmacist

· PMTCQuality Mentor· Social Worker

· Data Quality Manager

Roving SWAT TEAM

· Site Facilitator· Site Facilitator

Objectives: • Estimate effect of Clinic & Community Based Adherence

Support on mortality, loss to follow up, & virological suppression in adults and children receiving ART.

• Multicentre cohort analysis using routinely collected data.• ART naïve patients starting ART between Jan 2004 and Sep

2010 at 57 government ART sites in 4 provinces.• Patients categorised as receiving or not receiving CBAS

from the start of ART.• Virological suppression (< 400 copies/ml) at six-monthly

intervals until 5 years of ART, by intention to treat analysis.XIX International AIDS Conference

www.aids2012.org

Methods

Results

• 66,953 adults included, 29.4% received community support.• Total observation time was 100,295 person-years • Deaths: 970 (4.9%) CBAS patients; 2,968 (6.3%) non-CBAS patients.

(P < 0.0001)• LTFU: 1,185 (6.0%) CBAS patients and 4,498 (9.5%) non-CBAS

patients. (P < 0.0001)• Virological suppression (at six months):

-CBAS patients: 76.6% (95% CI: 75.8%-77.5%)-Non CBAS patients: 72.0% (95% CI: 71.3%-72.5%)(P < 0.0001)

XIX International AIDS Conference

www.aids2012.org

Virological suppression by intention-to-treat on ART

XIX International AIDS Conference

www.aids2012.org

Pro

po

rtio

ns

wit

h v

iro

log

ical

su

pp

ress

ion

Months on ART

Mortality in adults with and without PAs

0.00

0.02

0.04

0.06

0.08

0.10

Cum

ula

tive in

cid

ence

of

mort

alit

y

0 12 24 36 48 60

Months on ART

without PAs

with PAs

logrank P < 0.0001

0.00

0.05

0.10

0.15

0.20

Cum

ula

tive in

cid

ence

of

loss

to

follo

w-u

p

0 12 24 36 48 60

Months since starting ART

Loss to follow up in adults with and without PAs

without PAs

with PAs

logrank P < 0.0001

Retention in care - children with and without PAs

0.7

0.8

0.9

1.0

Pro

babi

lity

of r

em

aini

ng in

car

e

0 12 24 36

Months since starting ART

with PAs

without PAs

Retention in care

logrank P = 0.027

Adjusted hazard of attrition of patients with PAs: 0.57 (CI: 0.35–0.94)

3563 children included, 323 (9%) received community support

Mortality in children with and without PAs

0.00

0.02

0.04

0.06

0.08

Pro

babi

lity

of d

eath

0 12 24 36

Months since starting ART

Adjusted hazard of mortality of patients with PAs: 0.40 (CI: 0.15–1.06)

Corrected mortality

without PAs

with PAs

logrank P = 0.060

Summary of effectiveness of community adherence support

AdultsMortality: 35% reduction, aHR 0.65 (95% CI: 0.59-0.72)Loss to follow up: 37% reduction, aHR 0.63 (95% CI: 0.59-0.68)Virological suppression:After 6 months: 22% improvement, aOR 1.22 (95% CI: 1.14-1.30)After 5 years: 2.6 fold improvement, aOR 2.6 (95% CI: 1.6-4.4)

Children:Mortality: 61% reduction, aHR 0.39 (95% CI: 0.15-1.04)Program attrition: 43% reduction, aHR 0.57 (95% CI: 0.35-0.94)Virological suppression: 60% overall improvement, aOR 1.60 (95% CI: 1.35-1.89)

Key considerations for Replication

• The large-scale implementation of clinic linked community based adherence support programs is shown to improve survival and retention in care for adults & children receiving ART

• Scale-up of these programs should be considered as a critical part of the clinical intervention & be linked & coordinated with the clinical program for greater community impact

• Quality of service depends on ongoing didactic training, supervision, mentoring & support/debriefing of community workers

• This intervention is community development in action through job creation & further career development

Acknowledgement

THANK YOU

This research was made possible by the President's Emergency Plan for AIDS Relief (PEPFAR) through the United States Agency for International Development (USAID) under the terms of grant no. P3121A0051 &

Global Fund. The contents of the presentation are the sole responsibility of “Kheth’Impilo” and do not necessarily

reflect the views of USAID or the United States Government.