Ambassadors for Adherence: Provision of Highly

Effective Defaulter Tracing by Peer Educators in

Tanzania

Mihayo M Bupamba, R. Mbatia, M. Strachan, G. Nkobelerwa, S. Spendi,

A. Mkamballah, A E Cunningham

ICAP-Columbia University, Tanzania

Background• Worldwide, Columbia University’s International Center

for AIDS Care & Treatment Programs (ICAP) supports comprehensive HIV prevention, care, and treatment services at more than 1200 health facilities in 15 countries.

• In Tanzania, ICAP collaborates with the Ministry of Health and local government authorities to support 127 HIV care and treatment centers (CTC) in 3 mainland regions and Zanzibar.

• Current Ministry policy links home based care (HBC) programs into defaulter tracing of HIV clients. But coverage of HBC activities is not universal and many CTC clients are not enrolled in HBC programs.

PE Program Overview (1)• Since 2008, people living with HIV/AIDS (PLHIV)

have been engaged to assist clients attending CTCs and support retention and adherence in CTC and PMTCT settings.

• By June 2010, a total of 389 PLHIV work in 74 CTCs and PMTCT Clinics as peer educators (PE).

• One of the core tasks of ICAP PEs is to follow-up defaulting clients in their homes to document their vital status, and to encourage them to return to care.

PE Program Overview (2)

• PEs were selected using standardized criteria including: adherence to HIV care/treatment, physical capability, demonstrated interpersonal skills, willingness and commitment

• District/Community involvement and sensitization• PE trained on HIV basic education, behavioural risk

reduction, drug side effects, adherence & psychosocial support, conducting peer-support groups

• Provided with working tools, monthly stipend and ongoing supervision and support

Roles and Responsibilities of PEs

• Work at both CTCs and PMTCT sites • Provide group and individual counselling• Facilitate internal and external referrals • Support linkages to community services• Conduct defaulter tracing for ART clients who miss

appointments and/or are lost to follow-up (LTFU) (three consecutive missed appointments)

• Receive lists of clients from clinic staff and call or visit clients at home and provide feedback to facility

Methodology

• PEs effect on defaulter tracing was assessed over 18 months (Oct 08 - Mar 10) at 41 CTCs with nearly 10,000 active clients on ART from Kagera, Kigoma, Pwani and Zanzibar.

• An additional 34 new sites have just received training in the last quarter and are not included in this analysis.

• 84% of all CTCs with active defaulter tracing programs reported their findings.

Distribution of ICAP Sites and PE activities as of June 2010

Region # of CTCs

# of CTCs with peer educators

# of sites reporting on

defaulter tracing

Kagera 57 19 13Kigoma 27 27 15Pwani 35 22 10Zanzibar 8 6 3TOTAL 127 74 41

Results (1)• 3,949 clients were

reported to have either missed appointments or LTFU

• PEs either reached personally or confirmed vital status for 2,720 (69%) of listed clients

• Of the clients traced by PEs, 411 (10%) had died and 2,309 (59%) were still alive

Regional Variations in PE Defaulter Tracing Outcomes(Oct 08 - Mar 10)

Kagera Kigoma Pwani Zanzibar TOTAL 0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0

500

1000

1500

2000

2500

3000

3500

4000

4500

57%64%

46%

86%

59%

18%

4%12%

6%

31%25%

31%

43%

8% 10%

3949

% found alive % not found % died # missed appointment or LTFU

drug side effects9%

distance / transport44%

transfer / changed address

35%

alternative treatment

13%

Reasons for defaulting among clients who gave one or more reasons when

located by PEs (Oct 09 - Mar 10)

Conclusion

• Trained and supervised PEs in the 3 regions plus Zanzibar have demonstrated high effectiveness in tracing patients lost to follow-up.

• PEs are highly valued by the CTC and PMTCT clinic staff for their support to clients, retention and clinic operations.

• Next steps in defaulter tracing include focusing on pre-ART patients, PMTCT mothers, and linking PE tracing activities to patient records to accurately measure ‘return to clinical care’ outcomes.

Acknowledgements

Asante Sana!