msf adherence and retention strategies · potential to reduce pre-art attrition time to initiation...
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MSF Adherence and Retention Strategies
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linkage
ART initiation Monthly ART
supply at clinic
ART eligibility
and preparation
stable
unstable
ART adherence support
ART adherence support
HIV testing
ART Continuum of Care
Re-entry
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linkage
ART initiation Monthly ART
supply at clinic
ART eligibility
and preparation
stable
unstable
ART adherence support
ART adherence support
HIV testing
ART Continuum of Care
Re-entry
ART initiation counselling model
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• Fast tracking ART initiation without compromising adherence preparation
ART initiation counselling intervention
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Limit number of preparation
sessions
Strengthen post-initiation support (active learning on treatment)
Allows for fast tracking without compromising
content
4 sessions 1 pre initiation 1 at initiation 2 post initiation
14 standardized adherence steps
Limit repeated treatment literacy
Patient centred readiness to initiate
Focus on goal of undetectable VL!
ART initiation counselling intervention
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ART initiation counselling intervention
Limiting pre-initiation counseling
strengthening support after ART initiation
Potential to reduce pre-ART attritionTime to initiation had no impact on short term
retention (HR 1.11, 95% CI 0.95 – 1.30)
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linkage
ART initiation Monthly ART
supply at clinic
ART eligibility
and preparation
stable
unstable
ART adherence support
ART adherence support
HIV testing
ART Continuum of Care
Re-entry
Community models of care
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Lay worker led
Quick clinical assessment
Collection of 2m supply of ART
Quick optimized peer support session
Nurse supported
Immediate referral support
Blood investigations
Annual check up and re-scripting
ART adherence clubs
Quick service option groups of 30 stable ART patients
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ART adherence clubs
Pilot outcomes: 97% versus 85% RIC over 40 months
67% less virological rebound
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Best strategy:Reliable/flexible drug supply
Recognition of lay cadres
Open for debate:management by clinic of their community
model of careOptimal adherence monitoring
Monitoring and evaluationInteraction of models
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linkage
ART initiation Monthly ART
supply at clinic
ART eligibility
and preparation
stable
unstable
ART adherence support
ART adherence support
HIV testing
ART Continuum of Care
Re-entry
Risk of treatment
failure intervention or
EAC
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Risk of treatment failure intervention
Flag patients with high VL
Structured adherence focused support group
Integrated clinical and adherence consultations for patients with 2 high VLs with NIMART nurse
VL repeated per guidelines(4 adherence sessions)
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Risk of treatment failure intervention
Posters75-77
32%
78%
52%
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MSF KwaZulu Natal Enhanced Adherence Counselling
Posters75-77
• Strengthened routine VL monitoring
• 3 individual EAC sessions on first line ART
• 58% overall re-suppressed after EAC
Poster 67What we know:
Support groups (29%) non-inferior to individual counseling (25%) [OR 1.20. p=0.52)
Switch to 2nd line with adherence support achieves high rates of re-suppression
Minimal PI resistance but low re-suppression rates on 2nd line
What we don’t know:Optimal and feasible adherence intervention –
adaptable modelsDuration of adherence support with 2nd line failure
When to genotype
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linkage
ART initiation Monthly ART
supply at clinic
ART eligibility
and preparation
stable
unstable
ART adherence support
ART adherence support
HIV testing
ART Continuum of Care: children, youth, pregnant women
Re-entryRisk of
treatment failure
intervention
POC and ART initiation
counselling Youth clubs
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Youth specific retention model
POC CD4
ART initiation counselling model
Youth clubs: combine pre-ART/new ART/stable ART
Risk of treatment failure intervention
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Youth specific retention model
POC + fast tracked ART initiation counsellingmodel
= Reduced losses to care between HCT and
ART initiation
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Children specific adherence and retention
(Child ART initiation counselling model)
Child disclosure caregiver support intervention Throughout continuum
Family clubs Caregiver/child
Paediatric risk of treatment failure intervention
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Children specific adherence and retention
To ta l w i t h V L 1 : 7 4 ( 6 6 % )
# S u p p r e s s e d : 3 6 ( 4 9 % )
To ta l e n r o l l e d : 1 1 2
To ta l w i t h V L 2 : 4 6 ( 4 1 % )
# S u p p r e s s e d : 3 0 ( 6 5 % )
To ta l w i t h V L 3 : 1 2 ( 1 9 % )
# S u p p r e s s e d : 1 0 ( 8 3 % )
Evidence: Paediatric HIV treatment failure is a silent epidemic
Disclosure is essential Adolescents are less likely to re-suppress (74% vs 62%)
Half of children on PI regimen are resistantGap in paediatric care between nurses and tertiary care
Unknowns:Family clubs (for stable) and support groups (at risk of
failing) may enhance RICAdaptation of adult ART initiation approach
Feasible adjustment of paediatric failure approach
Posters 20 - 21
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Pregnant women – PMTCT B+
PMTCT B+ same day initiation counsellingintervention
Risk of treatment failure clinic
Adherence clubs post delivery
Survey:94% of women are willing to start ART at any CD4 for
PMTCT
Questions/Gaps: Short term retention in care
30% uncomfortable with same day initiationImplementation of standardized Option B+ counselling
Poster 98
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DR-TB patient support strategies
Counselling model: four initial sessions from initiation to end of intensive phase
Home visit
Additional sessions on treatment interruption, XDR-TB, and palliative care
Self administered continuation phase DR-TB treatment
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DR-TB patient support strategies
Results:• Urgent need to improve patient support for
patients with DR-TB• Treatment interruption support increases RIC
(100% RIC at 6 months)• Self administered continuation phase
treatment results in lower loss from treatment than DOT
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Acknowledgements:Lynne Wilkinson
Gilles van CutsemEric Goemaere
City of Cape Town Health DepartmentWestern Cape Government Health
MSF Khayelitsha team