Providing Treatment, Restoring Hope

Community Based Treatment Support Services: The Treatment Support Arm of

the AIDSRelief Program

Martine Etienne, DrPHDirector of The Community Based Treatment

Support Services (CBTS) UMSOM-IHV/AIDSRelief

April 29, 2010

Slide 2

Overview

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

Slide 3

Our Evolution

Adherence Programs

Community Adherence Programs

COMMUNITY BASED TREATMENT SERVICES

Community Health & Treatment Support

Slide 4

The AIDSRelief Philosophy

• Maintain the 1st 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

Slide 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

Slide 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

Slide 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

Slide 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

Slide 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 IIAdherence counselingplus a structured

treatment preparation

plan*

Tier IIITier I plus Tier II plus

home visits conducted by

community treatment

supporters*

Tier IVTier III plus

Use of community health nurses

to provide supportivesupervision

to the Tier III staff in the field

Tier IAdherence

Counseling onlyPrior to Starting

ART

*This is developed by the sitewith specific guidelines from AIDSRelief

Slide 10

14%

10%

5%

1%0%2%4%6%8%

10%12%14%16%18%20%

Percent loss to

follow up

Tier I

(n=8

)

Tier II

(n=3

)

Tier II

I (n=9

)

Tier IV

(n=7

)

(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 andloss to follow up rates; findings from 27 treatment facilities ineight resource limited countries

Slide 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%

Slide 12

4.3% 4.1%

2.2%

0%1%2%3%4%5%6%7%8%9%

10%

Percent loss to

follow up

Tier I

(n=0

)

Tier II

(n=2

0)

Tier II

I (n=3

1)

Tier IV

(n=9

2)

Five Year Follow up

Slide 13

Using evidence to effect care and treatment

Slide 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

Slide 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

Slide 16

RWANDA

Slide 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

Slide 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.

Slide 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.

Slide 20

TANZANIA

Slide 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

Slide 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

Slide 23

Know Your CD4 Campaign

114% increase based on the use of community treatment supporters and theircontinued reinforcement and follow up of patients reminding them of their CD4 cell count

3585

7698

Slide 24

Median CD4 at enrollment also increased overtime

Slide 25

Slide 26

TANZANIA

• Increased implementation of the CBTS strategies reduced LTFU rates

• 18%-Feb 2007• 9%-Feb 2009• 7%-Sept 2009

63%

76%

0

10

20

30

40

50

60

70

80

2007-08 2009

Retention

Slide 27

NIGERIA

Slide 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)

Slide 31

Is our approach working?

• Current AIDSRelief data:

• LTFU <4%• Mortality <7%• Still Active 89%

Slide 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

Slide 33

THANK YOU!