Interventions that reduce the need for people to visit medical clinics all too often are proving highly successful in retaining people in care and support for ART in Southern Africa, as was heard in the 21st International AIDS Conference (AIDS 2016) during the past week.
Measures to reduce the burden of demand for health care are also crucial to improve the ability of health systems to manage an increasing number of patients, many presenters of the conference confirmed this practice.
The new wave of interventions - described as "special care" in guidelines - to reduce the waiting time at clinic visits, and monitoring requirements.
The benefits to patients include less waiting time in clinics and trips to the clinics, lower expenses out of pocket with travel costs and less time off work due to clinical presence and more support in the community for medication adherence.
The benefits to health services come in the form of an increased ability to cope with the growing number of patients, more time to focus on patients with complex needs and better retention of patients in treatment due to the use of community workers health and other mechanisms at EU level to support the treatment.
In new guidelines issued ahead of the century's International AIDS Conference, the World Health Organization urged national treatment programs to start thinking in terms of providing treatment to four different patient groups and personalization services for each group accordingly.
The four groups of patients are:
- People who are newly diagnosed when: new patients who have no need for membership and retention support starting treatment and follow-up during the first months of treatment.
- People with advanced disease: new patients who present with symptomatic HIV disease or CD4 counts below 200, or who develop TB, which need fast-track clinical care and more intensive follow-up.
- Stable patients: people in treatment for at least one year with an undetectable viral load, not pregnant or nursing.
- Unstable patients: people in treatment with a detectable viral load, which need support accession, possible second or third line monitoring switches for HIV Drug Resistance.
People can be expected to transition from one group to another; in most cases from the "Newly diagnosed" to the category of "stable".
A "one size fits all approach to care is no longer adequate, said Gottfried Hirnschall, director of HIV prevention / AIDS program that, with the guidance.
A new differentiated approach to care is needed, said Anna Grimsrud the International AIDS Society. "We're not doing the maintenance of the care we need, so something is wrong for patients. We have to treat everyone, so we need to treat more people, and in order to reach 90-90-90 goals, we need to speed up, "she told a pre-conference satellite meeting of special care.
special care involves not only change jobs to new frameworks for the health system, such as health workers from the community, but the assumption of responsibility for managing elements of their own care for groups of patients self organized. These mechanisms include the distribution of medicines by patient groups, which may require changes in the rules in many countries.
"One of the biggest obstacles to special care is rules - rules that say that this person can not do it," said Carlos del Rio of Emory University.
The conference heard conclusions on a number of different care models including six monthly appointments, membership clubs and community groups to resupply ART.
But Dr Eric Goemaere of MSF warned that community services and membership clubs are an extra charge. "Clinics are still needed for these practices," he said, noting that the membership clubs need to be understood as a mechanism for expanding the volume of treated patients and not as a cost-saving mechanism.
A review of a switch to six monthly appointments for clinically stable patients in Malawi found that switching to a six-month service system reduced friction care HIV and saved 30.000 medical appointments in a single neighborhood in 2014. Doctors Without Borders switched of from monthly or quarterly appointments to semi-annual appointments in the face of clinically stable patients in their treatment program in Chiradzulu district since 2008. obtained patients the drug charge for ARV treatment every three months. The program provides care to about 35.000 patients, 95% of which are now on ART.
The analysis focused on outcomes between patients treated 24,802 from 2008 who were eligible for semi-annual frequency, which 18% do not have the option of being less frequent to ambulatory appointments. Those who have not registered were significantly more likely to go to death or lose their segments the (adjusted odds ratio 3,09, 95% CI 2.47-3.87) possibly an indication that they were considered unsuitable for switching to less frequent clinic visits, although 250464clinicamente are stable. In general, only 3% of those enrolled in posteri25252525ormente biannual consultations lost their, compared to 35% of people never enrolled.
As for saved commitments, the analysis showed that a six-month schedule only started to have a substantial impact on the total number of medical visits in 2014, the first year in which the doctor visits decreased substantially. Presented the results, Alison Wringe School of Hygiene and Tropical Medicine in London said that a six-month deployment system was relatively slow, but it was expected to accelerate with the introduction of a viral load monitoring routine. (Wringe)
simplified clinic visits
The research study of community-based testing at joint and accelerated to care and treatment of all found that their simplified ambulatory care model resulted in substantially shorter patient visits - on average about one hour less and that both reduced waiting time and reduced clinical consultation time explained this difference.
"Nobody likes to wait, and these communities, patients can wait up to four to five hours to see a doctor for five minutes," said Starley B. Shadow of the University of California San Francisco, a member of the research study team. The anticipation of such long waiting periods can deter patients from going to the clinic, especially when it comes to the risk of a loss of income.
The SEARCH study used a simplified care system in its European operations in Uganda and Kenya where nurses perform triage of patients on arrival at the clinic, directing patients for collecting blood for tests, medical appointments and pharmacological resupply visits. The study included a moving element and in which the patients received a form to make during their clinic visit, what time was given the start and end each meeting with a doctor were recorded. The researchers compared the waiting times and every clinic visit for clinical intervention (353 patients) and government clinics (745 patients) providing standard level of care services for the control arm in the study. They found a mean business 1,08 hours duration for those with CD4 counts above 500 and 1,13 hours for those with CD4 counts below 500 intervention clinics, compared to an average of 2,35 hours governmental clinics, of which more than two hours were spent waiting, with the longest waiting time for clinical care service and receiving the medication. A quarter of patients in government clinics spent more than 3 hours in the clinic.
Rationalization of attention to clinical agents released to see patients who did not require clinical care model also reduced the total number of patient visits every day due to better planning of clinical commitments.
Community supply of ART
Swaziland is extremely high HIV prevalence (31%), but many people who need antiretroviral therapy are still without treatment. Expanding health system capacity to provide antiretroviral treatment in this country live in predominantly rural regions and will require a change to health care in community-based. MSF implemented a pilot program in Swaziland to assess the success of the move clinically stable patients on ART to community care models in 2015-2016. (Lukhele)
The patients in different types of installations have been given the option to move to different types of community care, all offered a reduced amount of clinic visits:
- membership-based installation in clubs (three months), where about thirty patients received assistance to get pre-packaged medication. Blood samples for viral load count and clinical analysis was made on the same day.
- The Community ARV groups had around 6 patients and were autoformados groups by patients in rural facilities that take turns to collect the medication and participate in the clinical group sessions; the next day involved the medication withdrawal, pill counts, adherence support and weight check.
- Service of long range to very remote areas where pre-packaged medication is delivered monthly.
By the end of the second quarter of 2016, 727 patients had been enrolled in community ARV treatment programs, 40% in nine clubs grip 46 60% in groups of Community and HAART 14% in three remote communities reach.
Patients in each group had a CD4 cell count above 500 and had been under antiretroviral therapy for more than five years. person visits each service model was very high: 96% adherence to these clubs and community outreach 100% for Community ARV groups. Forty-one patients returned to the main clinic; there was a greater retention of patients to such care, and was significantly more likely to hold membership in clubs than in Community HAART or local care groups.
The main reasons for the return to outpatient care were a lack of eligibility for community care first, results of viral load tests that required incisive clinical care and communication issues within the community ART group.
In the evaluation of MSF (Doctors Without Borders) concluded that community management of ART is feasible and that the community of health professionals and lay people have an important role to play in establishing and managing these services. Providing more than one template through a mechanism which improve the acceptance.
- The International AIDS Society has this site on differentiated carewhich provides a decisions window to implement these services and a repository of templates and features.
- MSF summarized the learning from a range of projects developed to support the delivery of community ART in a report approaching the home, Implementation experiences reports of various models in six countries in sub-Saharan Africa.
- MSF has produced a set of ARV distribution tools groupWhich offers advice and tools for creating community-ART groups.
- The SPS a group of grip and a set of tools to report membership, which offers advice and tools for the creation of membership clubs.
- Keith Alcorn
- Published: 26 2016 July
- Wringe A et al. Six-monthly appointments as a strategy for stable antiretroviral therapy pacientes: evidence of its effectiveness from seven years of experience in the Médecins Sans Frontières supported program in Chiradzulu district, Malawi.21st International AIDS Conference, Durban, South Africa, abstract FRAE020, 2016.
- View the abstract on the conference website.
- Shade S et al. SEARCH streamlined HIV care is associated with shorter wait times before and During patient visits in Ugandan and Kenyan HIV clinics.21st International AIDS Conference, Durban, South Africa, abstract FRAE0203, 2016.
- View the abstract on the conference website.
- Lukhele N et al.Implementation of combination ART refills models in rural Swaziland. 21st International AIDS Conference, Durban, South Africa, abstract FRAE0204, 2016.
- View the abstract on the conference website.