providing treatment, restoring hope community health & treatment support programs aidsrelief...

Providing Treatment, Restoring Hope

Community Health & Treatment Support ProgramsAIDSRelief

Gabou Mendy, MD, MPHTMMartine Etienne, DrPH

AIDSRelief Service Areas

• Mostly rural and “para-urban”• Problematic access to care• Limited infrastructure • Significant logistical difficulties in

terms of both transport and procurement systems

Proposed Solution

Community based service model to ensure maximum access

Community Oriented Primary Care versus Traditional Primary Care

COPC TPC

Community as Patient Individual Patient

1. Subjective evaluation

Similarity Community's perceived need Chief complaints

Difference Provider selects the community and conducts an opinion survey to define the perceived health issues

Patient comes to provider for help

2. Objective evaluation

Epidemiologic data History, physical and laboratory data

3. Treatment Intervention program Specific treatment of identified problem

4. Subsequent care Ongoing evaluation and feedback, with appropriate modifications

Follow-up

HRSA, HAB SPNS Project, 2000

Community Oriented Primary Care (COPC)

• Dialogue in systemic planning and developmental process

• Difference in program and target population

• Changes exemplifying sound public health principles and practices

• Identify and eliminate existing and potential barriers

Continuum of Care

• Key Elements Clinical Care Adherence and Treatment Support Health Literacy, Promotion, and

Education

• Package of Services Entry Point For HIV Prevention and Care Clinical Care (PMTCT/VCT, ART, PC/OVC,

CATS) Community Involvement

Overview

• The AIDSRelief Model - Expansion Into the Community

• 38/7 Targeting Everyone Sooner

• Fighting HIV/AIDS - An Effective Public Health Approach

Overview

• Provided over 160,000 patients with HIV care and support; 74,000 on ART

• 152 non-faith based and faith based facilities

• Rapid scale up yet cautious in an effort to maintain the integrity and quality of the programs

Why the community health support program is so important

• Due to increased access to antiretroviral therapy

• Few community based structured strategies to support patients on treatment and continuity of care

• Various treatment models used to support patients on ART with sites developing innovative ways to ensure and support adherence

Why the community health support program is so important

• Due to limited viral load and lack of resistance testing

• As strategies used to support prevention with positives

• Critical for continued successful scale up in resource limited settings, where communication infrastructure is often deficient and poverty is prevalent

Expansion of the treatment support programs into the community

• Increase in community support groups

• Increase in use of PLHIVs for training and continuous support of other patients

• Increase in community mobilization activities that target religious leaders, traditional healers, community officials

Phases of the AIDSRelief Community Health & Treatment

Support Model

I. Thorough treatment preparation for patients and family

II. Intensive treatment support during initiation of therapy

III. Long-term treatment support and continuity of care within the community (including patient support groups)


Support Model

Treatment Preparation includes:• A thorough patient assessment and

individualized and/or group patient education • Assessment of social factors that influence

patient adherence (disclosure, geographical distance, risk behaviors, etc..)

• Inclusive of patient support network (i.e. preparation of patient family, support system, guardian)

• Extensive emphasis on prevention and reduction of risk behaviors


Support Model

Intensive Treatment Support during Initiation of Therapy• Make contact with the patient within the first 2 weeks of treatmentModified DOT or WOTHome Visits

• Early recognition of treatment complicationsEffective communication

between community health workers and community nurse

• Appropriate identification of social hindrances to optimal ART adherence


Support Model

Long-term Treatment Support & Continuity of Care

• Engaging patients in the program

• Linking patients to support groups

• Reduces the burden on the clinic and staff

• Continuous patient education and secondary prevention

• Continuous follow-up and support

• Home visits targeting other family members

Clinic

Regional Community Nurse

AdherenceOfficer

AdherenceOfficer

CHWCHW-Patient

CHW-Patient

CHW-Patient

CHW-Patient

CHW

SupportGroups

Patients and Families Patients and Families

Regional Community

Nurse

Regional Community

Nurse

Does the AIDSRelief Model Works?

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.

Loss to follow up data is cumulative over time for each programin each country, and 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

non medical staff

and/or volunteers*

Tier IVTier III plus

community health nursessupervising Tier III staff

& supporting patients

at home

Tier IAdherence

Counseling onlyPrior to Starting

ART

*This is developed by the sitewith specific guidelines from AIDSRelief

18%

13%

8%

3%

0%2%4%6%8%

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

Percent loss to

follow up

Tier I

(n=1

1)

Tier I

I (n=4

)

Tier I

II (n

=10)

Tier I

V (n=9

)

(within first 12 months of AR - Guyana, Haiti, Kenya, Nigeria, Rwanda,

Tanzania, Uganda, Zambia)

38/7- Targeting Everyone Through Community Mobilization

• Increase testing, reduce stigma

• PLHIV advocates for primary and secondary prevention

• Increase in support of men


• Increase the visibility of the PLHIVs in the community

• Collaborate with surrounding partners (CBOs, NGOs) in adherence and prevention training to effectively support our patients


Increased efforts in strategies for community mobilization:

• Facilitate change within the community altering social patterns in ways that will improve the quality of life within the community

• Change the everyday environment in communities in ways that will result in better outcomes for everyone living within a designated geographic area.

• This crucial difference in strategy poses a new and complex set of challenges and at the same time multiplies and complicates the issues that need to be addressed by those evaluating the initiatives.

How much does this all cost?

Cost per patient of selected sites & tiers (inclusive of staff salaries, excludes RVs)

0255075

100125150175200225

Cost per patient (in US

dollars)

Tier I I Tier I I I Tier IV

<2000 2001-4000 4001-7000

Total patient Capacity by Tier

5010

015

020

0C

ost

Per

Pa

tien

t

II III IV

(Inclusive of staff salaries, exclusive of ARVs)

Median Cost Per Patient of Selected Sites and Tiers

Public Health Implications - What have we learned?

• Consider AR model as priority for programs seeking optimal treatment success

• Integration of the community into the treatment program is crucial

• Prevention with positives can be achieved best by the use of other PLHIVs within the program and in the community

• Community mobilization strategies using people living with HIV/AIDS help decrease stigma within the community

• Support groups made up of patients and their families provide comprehensive & continuous support of the community

Public Health Implications - What have we learned?

Engaging Community: Capacity Utilisation vs Capacity Building

“The process of engaging community leaders happens when they use their social interpretations of reality, their way of communicating it to others and build on their social remedies. Capacity utilisation should not be viewed as an exclusively external process but as a process that builds on what keeps that community going, their social capital, to use the sustainable livelihood language.”

Chabu Kangale , International HIV/AIDS Alliance, Zambia Country Office

THREE SAMARITANS

'The sweetness of hunger, misery and despair is found when the eyes close in an eternal sleep.' Vidho Lorville

providing treatment, restoring hope community health & treatment support programs aidsrelief...

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