The CQUIN Learning Network

Patients at High Risk: Service Delivery for Unstable HIV Patients

Dr Daniel Mwamba, MD

Centre for Infectious Diseases Research in Zambia July 17-19, 2017

Harare, Zimbabwe

Background

•  CIDRZsupports233sitesin4provinces•  Implemen7ngdifferen7atedservice

delivery(DSD)modelssince2015–  Communityadherencegroups(CAGs)–  Urbanadherencegroups(UAGs)

•  AsofJune2017:–  763CAGsand16UAGsformed–  5,062pa7entsonregularfollowup

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CurrentEligibilityCriteriaforCIDRZDSDModels

•  Individuals>14yearsstableonART:– CD4≥200– Noac7veOI(noWHOstage3or4condi7on)– ReceivingARTfor≥6months– Viralload<1000copies/ml

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LessonsLearntfromDSDforStablePa7ents

•  Highyieldindextes7ngcomparedtodoor-to-door–  12.3%posi7vityand>90%linkagetocare

•  12monthreten7on:97%comparedto76%ofpa7entsreceivingstandardofcare.

•  Highlyacceptabletoallstakeholderspar7cularlypa7ents

•  Pa7entsareunhappytoleaveDSDcareserviceswhenup-referredtoclinicbasedcareforeitherOIordetectableVL

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Thelast90,Zambiastatus

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90:90:90inZambiaDatafromZAMPHIA

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DSDfor“Unstable”Pa7ents

•  Understandingbarrierstoengagementandreten7oniskeyinformula7ngstrategiestoimprovepa7entoutcomes

•  Barrierstopa7entengagementandul7matelyVLsuppressioninclude:–  LowHIVliteracy–  S7gma/denialofdiagnosis/tradi7onalbeliefs– Mentalhealthdisorders–  PrimaryHIVdrugresistance/drugtoxicity–  Incorrectdosing/impaireddrugabsorp7on

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Mostcommonpa1ent-reportedreasonsforstoppingcare(N=603).Be>erinfoStudy

363739404646515155555862

7190

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0 20 40 60 80 100 120 140

IcametobelieveIdonotactuallyhaveHIVIhadfamilyobliga1ons

Movedtoanewplace,nomen1onifARTavailableThestaffdidnottreatmewithrespect

ItwastakingtoolongtostartARTIlostmycardforARTCare

IwasafraidclinicwouldscoldmeformissingmyHadhighCD4anddidn'tseeareasontoa>end

IintendedtogobutwastoolazyImovedandtherewasnocareavailableinthis

Ispenttoomuch1meatclinicA>endingclinicriskeddisclosuretosomeoneI

IfeltwellandthoughtIdidn’tneedcareorTransporta1onwastoodifficultorexpensive

Workrequirementsinterferedwithpickingup

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0% 20% 40% 60% 80% 100%

Structural Psychosocial Clinic

StrategiesforImprovingOutcomes

Targe7nginterven7onsaddressing:1.  Clinic/Facilitybasedbarriers•  Lackofdedicatedcliniciantooverseecare•  Qualityofcare/respectfromproviders•  Longwait7mes

2.  Psychosocialbarriers•  S7gma•  Culturalbeliefs

3.  Structuralbarriers•  Distance/Access•  Workdemands

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ProposedInnova7on:Include“Unstable”ClientsinCAGModel

•  RevisedEligibility:– >14years– OnART>6months–  RegardlessofVLorWCS

•  Anynewlyiden7fiedunstableclientsinalreadyestablishedtradi7onalDSDmodelswillbeeligibletoreceivecareunderthismodelwhilebeinginaCAG

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Ra7onaleforInclusionof“Unstable”ClientsintheCAGmodel

•  ThehypothesesisthatDSDforsuchpa7entswillprovideanintegratedclinicalandcommunitycarepackagetoimproveadherenceandaddressassociatedbarriersthatmayhavecontributedtoadetectableviralloadwhilemanagingallcomorbidi7es.

•  Thisstrategyaimtoajainthelast90oftheUNAIDStargetsinabidtoendtheHIVepidemic

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Clinic-basedCareforClientsatHighRisk

•  Dedicatedmul7disciplinaryclinicalteamtrainedinmanagementofpa7entswithcomplicateddisease-doctor,nurse,pharmacist,laboratorytechnician

•  Dedicatedadvancedtreatmentdiseaseclinic(stakeholderstodecidewhichday/7mebestforall)

•  Reliablelaboratorysupportwith72hrVLresultturnaround7me

•  HIVgenotypeasrequiredwithrapidTAT(14-21days)•  Enhancedcounselingservices(HIVliteracy,mentalhealthscreening,sexualreproduc7vehealth)

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Community-basedCareforClientsatHighRisk

•  Treatmentsupporterled•  Psycho-socialsupport/counseling–bothathomeatingroupadherencemee7ngs

•  Homedrugdeliverywithsimplesymptomscreen(h/ofevers,nightsweats,weightloss,cough,headaches)–monthlyorperphysiciansrecommenda7on

•  DBSVLcollec7onevery3months•  Appointmentremindersperclinicianrecommenda7on•  Groupadherencemee7ngswithincommuni7esatagreedintervals(e.g.every4or8weeks)

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M&E

•  DevelopSOPstoguidefacility-basedandcommunity-basedac7vi7es

•  Adoptcurrentna7onaldatacollec7ontoolsforbothfacilityandcommunityac7vi7eswithsomerevisionsincommunitytoolstoincludehomedeliveryofART,symptomscreenandresultfeedback

•  TraincliniciansinmanagementofunstableHIVpa7ents

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Thankyou

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