Enhancing access to community clinical services

July 2014

LINKAGES - Overarching goal

Accelerate the ability of governments, KP organizations and private sector providers to collaboratively plan, deliver and optimize services that reduce HIV transmission among KP and extend life for those who are HIV-positive.

Implemented by core partners: FHI 360, IntraHealth, PACT and University of North Carolina (UNC)

Key focal areas

• Increased availability of comprehensive prevention, care and treatment services, increasing coverage across the Continuum of Care for key populations

• Demand for comprehensive prevention, care and treatment services among key populations enhanced and sustained

• Strengthened systems for planning, monitoring, evaluating and assuring the quality of programs for key populations

Strategic approach

Ultimately increasing…

• Access to better quality, more integrated HIV services closer to home in welcoming settings that protect their privacy

• Support from trained peers who can help them access HTC and other HIV services, as well as legal aid, psychosocial and nutrition support, and economic opportunities

• KP-friendly HCWs who understand and address their multi-faceted needs in a non-stigmatizing way

• Safer communities, with less gender-based and other violence and stronger crisis response systems

• Meaningful opportunities to have their voices heard in how services are delivered, improved and evaluated

• Relevant communication that empowers them to be savvy health care consumers and make decisions that lead to better health

• Protective environments and mitigating impact of discriminatory laws

The Cascade Framework

The Cascade framework is…

• Old, but new…building on the continuum of care• Improvement on older methods for presenting data &

illustrating program performance• Simple, easy to communicate with powerful impact• Easily adaptable to different programs, strategies and

populations • Promotes different interventions targeted to different

phases of - or gaps in - the cascade• Based on a set of available core indicators

The Cascade Framework: Patching a Leaky Pipe

The cascade

HIV cascade - MozambiqueSummary of flow in HIV Care system, Beira and Chimoio, July 2004 - June 2005

0

1000

2000

3000

4000

5000

6000

7000

8000

Step 2 Step 3 Step 4 Step 5

HIV+

Enroll ART clinic <30d(56%)

CD4 testing <30d(77%)

Eligible for ART(49%)

Started ART <90d(31%) On ART >180d

(81%)

Adherence >90% at 180d(83%)

Step 2:Drop-off 44%

3,049 lost

Step 4:Drop-off 69%

1,035 lost

Micek et al 2008

Cascade of HIV diagnosis, care and treatment in Vietnam among key populations, Sep-2013

Estimated PLHIV

Diagnosed PLHIV

Enroll in care

Sustain on ART

0

50000

100000

150000

200000

250000

300000

192966146128

52728 51563

65558

72299

28879 28256

Female Male

Pers

on

36.1%

39.9%

97.8%

97.8%

110%

75.7%

Source: Report on HIV and Drug for UB50, VAAC – Sep, 2013; D28 – Quarter 3, 2013; EPP, 2012

Community clinical services are the glue

• DICs – safe spaces at center of clinical services for KPs

• Clinical outreach led by non-stigmatizing health care workers and key populations leads

• A case management approach – training KP community workers to reach and support peers over time to keep them linked to clinical services, sustain retention and bolster ART adherence

Improved retention in care

Etienne et al 2007

Thank you!