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3rd South African AIDS Conference, Durban 2007Plugging the leaky cascade , Rome IAS, July 2011
Plugging the Leaky Cascade:Programmatic adjustments for specific
target populations
Dr Eric Goemaere
Regional TB/HIV Advisor
MSF South Africa
3rd South African AIDS Conference, Durban 2007Plugging the leaky cascade , Rome IAS, July 2011
TestingTesting Staging/EligibilityStaging/Eligibility ARTART
Post –initiation
Post –initiation
Long Term survival
Long Term survival
The low hanging fruits
Increased coverage/Higher Cd4 threshold
Triage and fast track
PHC decentralised care, nurse based CHW supported
Patient friendly regimenPatient self
management
3
Specific targets, specific strategiesAdult males
43 % of male testing at site C are less than 25 yrs
4
Recruiting eligible males: have a look at TB clinic
Source : Fuchia bulletin (OCB)
N= 54.679
Source: Town II TB clinic,
Khayelitsha= 188
5
Median CD4 count
= 218
Baseline retention on pre-ART in SA ( CD4 monitoring within 12 months ):
31-45%
ART ineligible enrolled 1828
Recorded CD4/visit within 8m prior to end of study/starting ART
8m
Active in care % 61.9
Requested transfer out %
4
Deceased % 10.28
LTFU % 23.85
Factors Influencing Retention in Care after Starting Antiretroviral Therapy in a Rural South African Programme.
Boyles TH, Wilkinson LS, and all, 2011 PLoS
6
Weekly peer educator ledHIV Care Group (Pre-ART+ART)
group support and education
CD4 count monitoring weight + symptom
screening pregnancy referrals ART prep/ counselling Bactrim dispense CD4
<500 IPT refills pap smear monitoring nutrition defaulter tracing
referrals
Comprehensive care for pre-ART
Effective referral system btw HIV care group and clinic
Accessible CD4/VL results to peer educator
Provision of ART/Cotri/IPT refills to HIV care group
• M&E system at community level – simple mobile options?
7
8
Specific targets, specific strategiesAdolescents
• Denial• Stigma /parental judgment• Peer pressure
Outreach testing Reduce time/number prep sessions Mixing positive and negative ones
Not
Peer supporter <> counselor 1:1 guidance across all initial step Intensive emotional support
9
ART for youth and adolescents in Khayelitsha, IAS poster THPE 0170
Van Cutsem G 1, 2 , Knight L 1, Abrahams M 1, Kerschberger B 1, Malavazzi C 1, Ford N
1, Boulle A 2
0.0
00
.10
0.2
00
.30
0.4
0
0 6 12 18 24 30 36 42 48Months on ART
10-24 >=25
Kaplan-Meier: Virological failure by age group
Remaining in care at 24 mths:
Children 95.4 % <> Adolescents 81.6 % ( p=0.007)
Youth 78.7 % <> Adults : 83.3% ( p=0.008)
Virological suppres.@24mths
children 80.4 % Adolescents:87.0 %Youth : 74.5 % Adults : 88.2 % ( p <0.001)
10
• Multivariate analysis -> AHR for LTFU in migrants at one year 6.69 ( 3.18-14.09)
Helen Bygrave1*, Katharina Kranzer2, Katherine Hilderbrand3,4, Jonathan Whittal3, Guillaume Jouquet1,Eric Goemaere3, Nathalie Vlahakis1, Laura Trivin˜o1, Lipontso Makakole5, Nathan Ford3,4, Plos One , October 2010 | Volume 5 | Issue 10 | e13198
11
Mobile clinic one stop shop for the HIV/TB co-infected patient
• HCT, POC CD4 at mobile points• Each visit, patient asked about
travel plan and documented• Health passports + alternative
treatment points• Temporary Transfer Out (TTFO): =
plans to return (circular migration)• 3 months ARV supply + tail
protection • If not intention to return, self
addressed stamped envelope signed by receiving sites
12
Acknowledgments
• MSF teams in South Africa, Lesotho and Zimbabwe
• South African Medical Unit & CAME• Gilles Van Cutsem , Guiseppe Demola,
Daniela Garone, Katherine Hilderbrand, Nathan Ford
• Staff and patients who are driving these new ideas
Dedicated to Babalwa