Involving the Community in HIV/AIDS Treatment Support Programmes: An Evidence-Based Approach.

Involving the Community in HIV/AIDS Involving the Community in HIV/AIDS Treatment Support Programmes:Treatment Support Programmes:

An Evidence-Based ApproachAn Evidence-Based Approach

Government Policies and Goals Government Policies and Goals (to be inserted by the user)(to be inserted by the user)

HIV prevention, treatment and care goalsHIV prevention, treatment and care goals

Community based HIV care and Community based HIV care and treatment goals treatment goals

Involvement of civil society organizations Involvement of civil society organizations in community based HIV prevention, in community based HIV prevention, treatment and caretreatment and care

Purpose of the Community Based Treatment Purpose of the Community Based Treatment Support Programme (CBTSP)Support Programme (CBTSP)

The CBTSP is designed to provide effective and comprehensive The CBTSP is designed to provide effective and comprehensive HIV/AIDS care, increase access to medicines and medical monitoring and HIV/AIDS care, increase access to medicines and medical monitoring and establish broad-based community support in resource-limited areas.establish broad-based community support in resource-limited areas.

The CBTSP model overlays community services that The CBTSP model overlays community services that support treatmentsupport treatment onto the clinical services provided.onto the clinical services provided.

The model emphasizes that people living with HIV and AIDS (PLWHA) The model emphasizes that people living with HIV and AIDS (PLWHA) in resource-limited settings need both clinical services and community in resource-limited settings need both clinical services and community services to effectively enhance their quality of life and achieve and sustain services to effectively enhance their quality of life and achieve and sustain health gains over the long-term. health gains over the long-term.

The model places equal emphasis on supporting the needs of patients The model places equal emphasis on supporting the needs of patients receiving antiretrovirals and of patients who are not receiving receiving antiretrovirals and of patients who are not receiving antiretrovirals because their disease has not yet progressed to treatment antiretrovirals because their disease has not yet progressed to treatment according to national treatment guidelines.according to national treatment guidelines.

The model is based on a five site*, three-year operational research and The model is based on a five site*, three-year operational research and demonstration project that investigated the 1) feasibility of providing ARV demonstration project that investigated the 1) feasibility of providing ARV treatment and HIV care in severely resource limited settings; and 2) the treatment and HIV care in severely resource limited settings; and 2) the added value of community services to clinical outcomes.added value of community services to clinical outcomes.* * Data from the site in Koulikoro, Mali are not included in the data presented here because the pilot study is still ongoing there.Data from the site in Koulikoro, Mali are not included in the data presented here because the pilot study is still ongoing there.

CBTSP: Models of Care and PartnershipCBTSP: Models of Care and Partnership

LadysmithLadysmith

BobonongBobonong

CapriviCaprivi

MbabaneMbabane

MaseruMaseru

KoulikoroKoulikoro

SOUTHSOUTHAFRICAAFRICASOUTHSOUTHAFRICAAFRICA

NAMIBIANAMIBIANAMIBIANAMIBIA

BOTSWANABOTSWANABOTSWANABOTSWANA

SWAZILANDSWAZILANDSWAZILANDSWAZILAND

LESOTHOLESOTHOLESOTHOLESOTHO

MALIMALIMALIMALI

Six Community-Based Treatment Sites

OutcomesOutcomes

OutcomesOutcomes

Increased efficacy. Increased efficacy. Overall efficacy of 64%, where efficacy was defined as Overall efficacy of 64%, where efficacy was defined as sustainable, greater-than-50 increase in CD4 count.sustainable, greater-than-50 increase in CD4 count. Rapid uptake of voluntary counselling and clinic services.Rapid uptake of voluntary counselling and clinic services. Increased more Increased more than 10 fold within three months of starting community mobilization. than 10 fold within three months of starting community mobilization.

Increased adherence. Increased adherence. 12 months after starting therapy, 84.5% of patients 12 months after starting therapy, 84.5% of patients were more than 95% adherent (equivalent to missing at most only one were more than 95% adherent (equivalent to missing at most only one dose per month). dose per month).

Increased CD4 counts.Increased CD4 counts. As demonstrated by an increase in CD4 counts As demonstrated by an increase in CD4 counts from 105 at baseline to 270 at 12 months. (Normal CD4 counts in adults from 105 at baseline to 270 at 12 months. (Normal CD4 counts in adults range from 500 to 1,500 cells per cubic millimeter of blood). range from 500 to 1,500 cells per cubic millimeter of blood).

Outcomes: Added Value of Community Outcomes: Added Value of Community SupportSupport

CD4 counts increased to significantly higher levels and at an accelerated rate in CD4 counts increased to significantly higher levels and at an accelerated rate in patients on ARVs who accessed community support than those who did not: 326 vs. patients on ARVs who accessed community support than those who did not: 326 vs. 268.268.

Patients satisfied with the level of community support they received also Patients satisfied with the level of community support they received also experienced better quality of life and adhered better to their ARV medication than experienced better quality of life and adhered better to their ARV medication than those who were not satisfied.those who were not satisfied.

Food security and home-based care were the two services statistically related to Food security and home-based care were the two services statistically related to better adherence.better adherence.

The lost-to-follow-up rate in Secure the Future CBTS programmes was only The lost-to-follow-up rate in Secure the Future CBTS programmes was only 5.1%. 5.1%. In Swaziland’s Prevention of Mother-to-Child Transmission programme, all In Swaziland’s Prevention of Mother-to-Child Transmission programme, all 224 women and their babies were accounted for up until 12 months of the child’s 224 women and their babies were accounted for up until 12 months of the child’s age, thanks to community workers who intensively tracked defaulters. age, thanks to community workers who intensively tracked defaulters.

Community services helped prepare patients for antiretroviral therapy and Community services helped prepare patients for antiretroviral therapy and “leveled the playing field” by dealing with psychosocial problems, inadequate “leveled the playing field” by dealing with psychosocial problems, inadequate nutrition and logistical issues such as transport to the clinic and disclosure of status nutrition and logistical issues such as transport to the clinic and disclosure of status to a significant other.to a significant other.

Research ConclusionsResearch Conclusions

Community and family support to patients Community and family support to patients on ART have a significant effect on on ART have a significant effect on reducing stigma and discrimination and reducing stigma and discrimination and HR-QoLHR-QoL

Community and family support to patients Community and family support to patients on ART have a significant effect on on ART have a significant effect on accelerating the improvement of CD4 accelerating the improvement of CD4 countscounts

Community and family support Community and family support impact stigma, QOL and CD4impact stigma, QOL and CD4

Patients* satisfied with the community support they receive have the Patients* satisfied with the community support they receive have the following better outcomes than those not satisfied; following better outcomes than those not satisfied;

a) Statistically significantly a) Statistically significantly greater reduction in perceived stigmagreater reduction in perceived stigma

b) Statistically significantly b) Statistically significantly greater improvement in QOLgreater improvement in QOL

Patients accessing community services Patients accessing community services

c) Statistically & clinically significantly c) Statistically & clinically significantly greater increase in CD4 greater increase in CD4 count than those not accessing such servicescount than those not accessing such services

(*587 patients by enhanced evaluation)(*587 patients by enhanced evaluation)

An Example of Impact on a An Example of Impact on a communitycommunity

CBTSP Site: Bobonong Primary HospitalCBTSP Site: Bobonong Primary Hospital

Hospital bed occupancy by HIV/AIDS Hospital bed occupancy by HIV/AIDS patients reduced from patients reduced from 93% to 52% 93% to 52% from from 2004 to 20062004 to 2006

Hospital mortality from HIV/AIDS Hospital mortality from HIV/AIDS reduced from reduced from 25% to 13% 25% to 13% over the same over the same periodperiod

Back-up slides with outcomes chartsBack-up slides with outcomes charts

Community mobilization leads to rapid Community mobilization leads to rapid VCT and HIV clinic uptakeVCT and HIV clinic uptake

Intensive community mobilization using door-to-door Intensive community mobilization using door-to-door campaigns and public events reach:campaigns and public events reach:

More than 150,000 peopleMore than 150,000 people

Complemented by radio and television broadcastsComplemented by radio and television broadcasts

0

1000

2000

3000

4000

5000

6000

7000

Q4'03 Q2'04 Q4'04 Q2'05 Q4'05 Q2'06

Total # of clients pre-test counselled Total # of clients undergone an HIV test

Total # of clients post-test counselled

Encouraging Results Encouraging Results Clinical DataClinical Data

Over 17,000 patients enrolledOver 17,000 patients enrolled

Over 8,000 patients on ARVs Over 8,000 patients on ARVs

Median CD4 count increased from 94-282 at Median CD4 count increased from 94-282 at 12 months of treatment12 months of treatment

Viral load undetectable; 92% at 12 monthsViral load undetectable; 92% at 12 months

Response by intent-to-treat; 64%Response by intent-to-treat; 64%

Only 1% of patients progressed to 2Only 1% of patients progressed to 2ndnd line line

84% of patients at 95% compliance 84% of patients at 95% compliance

Key Community IndicatorsKey Community IndicatorsARV clients on HBC; ARV clients on HBC; 1,4911,491

non-ARV clients on HBC; non-ARV clients on HBC; 1,3981,398

clients attached to buddies; clients attached to buddies; 790790

clients in support groups; clients in support groups; 3,8593,859

ARV clients getting food parcels; ARV clients getting food parcels; 866866

non-ARV clients getting food parcels; non-ARV clients getting food parcels; 1,4031,403

clients trained in food security; clients trained in food security; 2,9532,953

clients trained in IGA; clients trained in IGA; 587587

Number of door-sized gardens; Number of door-sized gardens; 2,5512,551

Community services prepare patients for Community services prepare patients for ARV therapyARV therapy

34633463 patients assisted to disclose status patients assisted to disclose status

40844084 patients provided with adequate food patients provided with adequate food security security

368368 patients assisted with transport to the clinic patients assisted with transport to the clinic

6969 patients receiving essential psychosocial patients receiving essential psychosocial supportsupport

5050 defaulting patients traced by community defaulting patients traced by community workersworkers

Enhanced Patient Evaluation Enhanced Patient Evaluation

Instruments for Data CollectionInstruments for Data Collection

Five types of instruments:Five types of instruments: BaselineBaseline Health Related Quality of LifeHealth Related Quality of Life AdherenceAdherence Stigma and discrimination Stigma and discrimination Exposure to interventionExposure to intervention

Percentages of patients accessing Percentages of patients accessing various community support servicesvarious community support services

Community support is crucial in the Community support is crucial in the reduction of actual stigmareduction of actual stigma

Changes in Actual stigma by levels of satisfaction with community support

9.02

9.29 9.27

9.14

9.67

10.10

8.40

8.60

8.80

9.00

9.20

9.40

9.60

9.80

10.00

10.20

Baseline 6 months 12 months

Period

Me

an

Not satisfied with overall community support at 12 months Very satisfied with overall community support at 12 months

P value at baseline & 12 months =0.010; 0.000P value at 12 months difference =0.061

Change in CD4 count in patients exposed and Change in CD4 count in patients exposed and not exposed to community services ; patients not exposed to community services ; patients with baseline CD4 < 50with baseline CD4 < 50

21

146

188

29.5

172

310

0

50

100

150

200

250

300

350

Baseline 6 months 12 months

Med

ian

CD

4 co

un

t

No BMS services recieved in the last 4 weeks Has received BMS services in the last 4 weeks

P-values between baseline and 12 months less than 0.000P-value between groups not significant

Change in CD4 count in patients exposed and not exposed Change in CD4 count in patients exposed and not exposed to community services ; all patients to community services ; all patients

133

226

269.5

124.5

236

319

0

50

100

150

200

250

300

350

Baseline 6 months 12 months

Me

dia

n C

D4

co

un

t

No BMS services recieved Has received BMS services

P value at baseline & 12 months = 0.00P value at 12 months difference = 0.02

Exposure to community service has a significant effect on accelerating Exposure to community service has a significant effect on accelerating the improvement of CD4 counts of patients on ART (results of the improvement of CD4 counts of patients on ART (results of multivariate analysis)multivariate analysis)

Results of Multiple Regression on CD4 Count At 12 Months

Has received BMS intervention services in the last 4 weeks 39.19 17.3 0.02

Control Factors

Baseline CD4 Count 0.56 0.10 0.00

HR QoL increased between baseline and 12 months 0.40 0.70 0.57

Age greater than 35 years -45.85 18.28 0.01

Female 32.31 19.19 0.09

Secondary schooling 34.72 18.31 0.06

Constant 207.28 28.23 0.001

P-valueFactor Coefficient

Standard

error