Journal Article > ReviewFull Text
J Int AIDS Soc. 13 May 2016; Volume 19 (Issue 1); DOI:10.7448/IAS.19.1.20751
Bemelmans M, Baert S, Negussie E, Bygrave H, Biot M, et al.
J Int AIDS Soc. 13 May 2016; Volume 19 (Issue 1); DOI:10.7448/IAS.19.1.20751
Introduction: Counselling services are recommended by the World Health Organization and have been partially adopted by national HIV guidelines. In settings with a high HIV burden, patient education and counselling is often performed by lay workers, mainly supported with international funding. There are few examples where ministries of health have been able to absorb lay counsellors into their health systems or otherwise sustain their work. We document the role of lay cadres involved in HIV testing and counselling and adherence support and discuss approaches to sustainability. Methods: We focused on a purposive sample of eight sub-Saharan African countries where Médecins Sans Frontières supports HIV programmes: Guinea, Lesotho, Malawi, Mozambique, South Africa, Swaziland, Zambia and Zimbabwe. We reviewed both published and grey literature, including national policies and donor proposals, and interviewed key informants, including relevant government staff, donors and non-governmental organizations. Results and discussion: Lay counsellors play a critical role in scaling up HIV services and addressing gaps in the HIV testing and treatment cascade by providing HIV testing and counselling and adherence support at both the facility and community levels. Countries have taken various steps in recognizing lay counsellors, including harmonizing training, job descriptions and support structures. However, formal integration of this cadre into national health systems is limited, as lay counsellors are usually not included in national strategies or budgeting. Conclusions: The current trend of reduced donor support for lay counsellors, combined with lack of national prioritization, threatens the sustainability of this cadre and thereby quality HIV service delivery.
Journal Article > ResearchAbstract
Int J STD AIDS. 1 June 2012; Volume 23 (Issue 6); DOI:10.1258/ijsa.2009.009328
Chu KM, Manzi M, Zuniga I, Biot M, Ford NP, et al.
Int J STD AIDS. 1 June 2012; Volume 23 (Issue 6); DOI:10.1258/ijsa.2009.009328
To describe the frequency, risk factors, and clinical signs and symptoms associated with hepatotoxicity (HT) in patients on nevirapine- or efavirenz-based antiretroviral therapy (ART), we conducted a retrospective cohort analysis of patients attending the ART clinic in Kibera, Kenya, from April 2003 to December 2006 and in Mavalane, Mozambique, from December 2002 to March 2007. Data were collected on 5832 HIV-positive individuals who had initiated nevirapine- or efavirenz-based ART. Median baseline CD4+ count was 125 cells/μL (interquartile range [IQR] 55-196). Over a median follow-up time of 426 (IQR 147-693) days, 124 (2.4%) patients developed HT. Forty-one (54.7%) of 75 patients with grade 3 HT compared with 21 (80.8%) of 26 with grade 4 had associated clinical signs or symptoms (P = 0.018). Four (5.7%) of 124 patients with HT died in the first six months compared with 271 (5.3%) of 5159 patients who did not develop HT (P = 0.315). The proportion of patients developing HT was low and HT was not associated with increased mortality. Clinical signs and symptoms identified 50% of grade 3 HT and most cases of grade 4 HT. This suggests that in settings where alanine aminotransferase measurement is not feasible, nevirapine- and efavirenz-based ART may be given safely without laboratory monitoring.
Journal Article > CommentaryFull Text
Trop Med Int Health. 16 February 2015; Volume 20 (Issue 4); 430-447.; DOI:10.1111/tmi.12460
Duncombe C, Rosenblum S, Hellmann N, Holmes CB, Wilkinson LS, et al.
Trop Med Int Health. 16 February 2015; Volume 20 (Issue 4); 430-447.; DOI:10.1111/tmi.12460
The delivery of HIV care in the initial rapid scale-up of HIV care and treatment was based on existing clinic-based models, which are common in highly resourced settings and largely undifferentiated for individual needs. A new framework for treatment based on variable intensities of care tailored to the specific needs of different groups of individuals across the cascade of care is proposed here. Service intensity is characterized by four delivery components: (1) types of services delivered, (2) location of service delivery, (3) provider of health services, and (4) frequency of health services. How these components are developed into a service delivery framework will vary across countries and populations, with the intention being to improve acceptability and care outcomes. The goal of getting more people on treatment before they become ill will necessitate innovative models of delivering both testing and care. As HIV programs expand treatment eligibility, many people entering care will not be "patients" but healthy, active and productive members of society.(1) In order to take the framework to scale, it will be important to: (1) define which individuals can be served by an alternative delivery framework; (2) strengthen health systems that support decentralization, integration and task shifting; (3) make the supply chain more robust; and (4) invest in data systems for patient tracking and for program monitoring and evaluation.
Journal Article > ResearchFull Text
Trop Med Int Health. 10 March 2003; Volume 8 (Issue 3); 211-8.
Biot M, Chandramohan D, Porter JDH
Trop Med Int Health. 10 March 2003; Volume 8 (Issue 3); 211-8.
Tuberculosis (TB) is a major public health problem in complex emergencies. Humanitarian agencies usually postpone the decision to offer TB treatment and opportunities to treat TB patients are often missed. This paper looks at the problem of tuberculosis treatment in these emergencies and questions whether treatment guidelines could be more flexible than international recommendations. A mathematical model is used to calculate the risks and benefits of different treatment scenarios with increasing default rates. Model outcomes are compared to a situation without treatment. An economic analysis further discusses the findings in a trade-off between the extra costs of treating relapses and failures and the savings in future treatment costs. In complex emergencies, if a TB programme could offer 4-month treatment for 75% of its patients, it could still be considered beneficial in terms of public health. In addition, the proportion of patients following at least 4 months of treatment can be used as an indicator to help evaluate the public health harm and benefit of the TB programme.
Journal Article > ResearchFull Text
Int Health. 1 September 2009; Volume 1 (Issue 1); 97-101.; DOI:10.1016/j.inhe.2009.03.002
Caluwaerts C, Maendaenda R, Maldonado F, Biot M, Ford NP, et al.
Int Health. 1 September 2009; Volume 1 (Issue 1); 97-101.; DOI:10.1016/j.inhe.2009.03.002
Scale-up of antiretroviral therapy (ART) in sub-Saharan Africa is a major public health priority, but ensuring long-term adherence to treatment is a growing concern. The objectives of this retrospective study were to determine risk factors and true outcomes for individuals lost to follow-up in a routine HIV/AIDS care programme in Tete, Mozambique. Between May 2002 and August 2007, 2818 individuals were initiated on ART and 594 (21%) considered lost to follow-up were actively traced. Risk factors for being lost to follow-up were: age between 16 and 35 years [odds ratio (OR) = 1.4, P = 0.009]; CD4 count <50 cells/μl (OR = 1.7, P < 0.001); time on ART <3 months (OR = 3.6, P < 0.001); tuberculosis infection (OR = 2.5, P < 0.001); and Kaposi's sarcoma infection (OR = 5.9, P < 0.001). Sixty-four percent (380/594) of patients lost to follow-up could not be traced. Of the 214 (36%) that could be traced, 118 (55%) were dead, 43 (20%) were transferred out, 7 (3%) were misclassified and 46 (22%) were true defaulters. Active tracing should be conducted routinely to better understand the reasons for defaulting and to provide evidence for action. Early mortality may be reduced by enrolling patients in care as early as possible and providing optimal adherence counselling in the first months.
Journal Article > ResearchFull Text
Health Policy Plan. 5 November 2015; Volume 31 (Issue 5); 592-599.; DOI:10.1093/heapol/czv106
Bemelmans M, Goux D, Baert S, van Cutsem G, Motsamai M, et al.
Health Policy Plan. 5 November 2015; Volume 31 (Issue 5); 592-599.; DOI:10.1093/heapol/czv106
Between 2006 and 2011, when antiretroviral therapy (ART) was scaled up in a context of severe human resources shortages, transferring responsibility for elements in human immunodeficiency virus (HIV) care from conventional health workers to lay counsellors (LCs) contributed to increased uptake of HIV services in Lesotho. HIV tests rose from 79 394 in 2006 to 274 240 in 2011 and, in that same period, the number of people on ART increased from 17 352 to 83 624. However, since 2012, the jobs of LCs have been at risk because of financial and organizational challenges. We studied the role of LCs in HIV care in Lesotho between 2006 and 2013, and discuss potential consequences of losing this cadre. Methods included a case study of LCs in Lesotho based on: (1) review of LC-related health policy and planning documents, (2) HIV programme review and (3) workload analysis of LCs. LCs are trained to provide HIV testing and counselling (HTC) and ART adherence support. Funded by international donors, 487 LCs were deployed between 2006 and 2011. However, in 2012, the number of LCs decreased to 165 due to a decreasing donor funds, while administrative and fiscal barriers hampered absorption of LCs into the public health system. That same year, ART coverage decreased from 61% to 51% and facility-based HTC decreased by 15%, from 253 994 in 2011 to 215 042 tests in 2012. The workload analysis indicated that LCs work averagely 77 h per month, bringing considerable relief to the scarce professional health workforce. HIV statistics in Lesotho worsened dramatically in the recent era of reduced support to LCs. This suggests that in order to ensure access to HIV care in an under-resourced setting like Lesotho, a recognized and well-supported counsellor cadre is essential. The continued presence of LCs requires improved prioritization, with national and international support.
Journal Article > ResearchFull Text
Int STD Res Rev. 31 October 2013; Volume 1 (Issue 2); 49–59.; DOI:10.9734/ISRR/2013/5867
Decroo T, Lara J, Rasschaert F, Bermudez-Aza EH, Couto AM, et al.
Int STD Res Rev. 31 October 2013; Volume 1 (Issue 2); 49–59.; DOI:10.9734/ISRR/2013/5867
AIMS
To describe the stepwise implementation and roll out of Community ART Groups (CAG) in Mozambique.
STUDY DESIGN
Descriptive study
PLACE AND DURATION OF STUDY
Mozambique, between February 2008 and December 2011.
METHODOLOGY
Description of the stepwise implementation of a model for Anti-Retroviral Therapy (ART) delivery based on the principles of peer support and self-management. The program data on CAG were obtained through a chart review and routine datacollection.
RESULTS
To overcome patient reported barriers to monthly drug refills for ART the Tete Provincial Directorate of Health and Medecins Sans Frontieres developed a communitybased ART model or patient-centered model, through peer support groups named CAG. The first CAG commenced in 2008, in rural health facility catchment areas, where members of CAG shared transport costs to overcome distances to the ART clinics. In 2009, lessons learnt were exported in Tete province and CAG model was launched in semi-urban contexts to decrease time spent in the clinics. In 2011, retention rates as high as 97,5 % convinced a joint task force that included Ministry of Health and major partners Original Research Article Decroo et al.; ISRR, Article no. ISRR.2013.001 50 to pilot the CAG strategy on a national scale.
CONCLUSIONS
To respond to staggering attrition rates Ministry of Health in Mozambique and partners piloted an innovative patient-centered model for HIV care and exported good practices from local to provincial and national level. Success of scale up will depend on the collaboration and interaction between policymakers, donors, health-managers, caregivers, communities, and patients.
To describe the stepwise implementation and roll out of Community ART Groups (CAG) in Mozambique.
STUDY DESIGN
Descriptive study
PLACE AND DURATION OF STUDY
Mozambique, between February 2008 and December 2011.
METHODOLOGY
Description of the stepwise implementation of a model for Anti-Retroviral Therapy (ART) delivery based on the principles of peer support and self-management. The program data on CAG were obtained through a chart review and routine datacollection.
RESULTS
To overcome patient reported barriers to monthly drug refills for ART the Tete Provincial Directorate of Health and Medecins Sans Frontieres developed a communitybased ART model or patient-centered model, through peer support groups named CAG. The first CAG commenced in 2008, in rural health facility catchment areas, where members of CAG shared transport costs to overcome distances to the ART clinics. In 2009, lessons learnt were exported in Tete province and CAG model was launched in semi-urban contexts to decrease time spent in the clinics. In 2011, retention rates as high as 97,5 % convinced a joint task force that included Ministry of Health and major partners Original Research Article Decroo et al.; ISRR, Article no. ISRR.2013.001 50 to pilot the CAG strategy on a national scale.
CONCLUSIONS
To respond to staggering attrition rates Ministry of Health in Mozambique and partners piloted an innovative patient-centered model for HIV care and exported good practices from local to provincial and national level. Success of scale up will depend on the collaboration and interaction between policymakers, donors, health-managers, caregivers, communities, and patients.
Journal Article > ResearchFull Text
J Int AIDS Soc. 1 January 2014; Volume 17 (Issue 1); 18910.; DOI:10.7448/IAS.17.1.18910
Rasschaert F, Decroo T, Remartinez D, Telfer B, Lessitala F, et al.
J Int AIDS Soc. 1 January 2014; Volume 17 (Issue 1); 18910.; DOI:10.7448/IAS.17.1.18910
INTRODUCTION
To overcome patients' reported barriers to accessing anti-retroviral therapy (ART), a community-based delivery model was piloted in Tete, Mozambique. Community ART Groups (CAGs) of maximum six patients stable on ART offered cost- and time-saving benefits and mutual psychosocial support, which resulted in better adherence and retention outcomes. To date, Médecins Sans Frontières has coordinated and supported these community-driven activities.
METHODS
To better understand the sustainability of the CAG model, we developed a conceptual framework on sustainability of community-based programmes. This was used to explore the data retrieved from 16 focus group discussions and 24 in-depth interviews with different stakeholder groups involved in the CAG model and to identify factors influencing the sustainability of the CAG model.
RESULTS
We report the findings according to the framework's five components. (1) The CAG model was designed to overcome patients' barriers to ART and was built on a concept of self-management and patient empowerment to reach effective results. (2) Despite the progressive Ministry of Health (MoH) involvement, the daily management of the model is still strongly dependent on external resources, especially the need for a regulatory cadre to form and monitor the groups. These additional resources are in contrast to the limited MoH resources available. (3) The model is strongly embedded in the community, with patients taking a more active role in their own healthcare and that of their peers. They are considered as partners in healthcare, which implies a new healthcare approach. (4) There is a growing enabling environment with political will and general acceptance to support the CAG model. (5) However, contextual factors, such as poverty, illiteracy and the weak health system, influence the community-based model and need to be addressed.
CONCLUSIONS
The community embeddedness of the model, together with patient empowerment, high acceptability and progressive MoH involvement strongly favour the future sustainability of the CAG model. The high dependency on external resources for the model's daily management, however, can potentially jeopardize its sustainability. Further reflections are required on possible solutions to solve these challenges, especially in terms of human resources.
To overcome patients' reported barriers to accessing anti-retroviral therapy (ART), a community-based delivery model was piloted in Tete, Mozambique. Community ART Groups (CAGs) of maximum six patients stable on ART offered cost- and time-saving benefits and mutual psychosocial support, which resulted in better adherence and retention outcomes. To date, Médecins Sans Frontières has coordinated and supported these community-driven activities.
METHODS
To better understand the sustainability of the CAG model, we developed a conceptual framework on sustainability of community-based programmes. This was used to explore the data retrieved from 16 focus group discussions and 24 in-depth interviews with different stakeholder groups involved in the CAG model and to identify factors influencing the sustainability of the CAG model.
RESULTS
We report the findings according to the framework's five components. (1) The CAG model was designed to overcome patients' barriers to ART and was built on a concept of self-management and patient empowerment to reach effective results. (2) Despite the progressive Ministry of Health (MoH) involvement, the daily management of the model is still strongly dependent on external resources, especially the need for a regulatory cadre to form and monitor the groups. These additional resources are in contrast to the limited MoH resources available. (3) The model is strongly embedded in the community, with patients taking a more active role in their own healthcare and that of their peers. They are considered as partners in healthcare, which implies a new healthcare approach. (4) There is a growing enabling environment with political will and general acceptance to support the CAG model. (5) However, contextual factors, such as poverty, illiteracy and the weak health system, influence the community-based model and need to be addressed.
CONCLUSIONS
The community embeddedness of the model, together with patient empowerment, high acceptability and progressive MoH involvement strongly favour the future sustainability of the CAG model. The high dependency on external resources for the model's daily management, however, can potentially jeopardize its sustainability. Further reflections are required on possible solutions to solve these challenges, especially in terms of human resources.
Journal Article > ResearchFull Text
PLOS One. 20 March 2014; Volume 9 (Issue 3); e91544.; DOI:10.1371/journal.pone.0091544
Rasschaert F, Telfer B, Lessitala F, Decroo T, Remartinez D, et al.
PLOS One. 20 March 2014; Volume 9 (Issue 3); e91544.; DOI:10.1371/journal.pone.0091544
BACKGROUND
To improve retention on ART, Médecins Sans Frontières, the Ministry of Health and patients piloted a community-based antiretroviral distribution and adherence monitoring model through Community ART Groups (CAG) in Tete, Mozambique. By December 2012, almost 6000 patients on ART had formed groups of whom 95.7% were retained in care. We conducted a qualitative study to evaluate the relevance, dynamic and impact of the CAG model on patients, their communities and the healthcare system.
METHODS
Between October 2011 and May 2012, we conducted 16 focus group discussions and 24 in-depth interviews with the major stakeholders involved in the CAG model. Audio-recorded data were transcribed verbatim and analysed using a grounded theory approach.
RESULTS
Six key themes emerged from the data: 1) Barriers to access HIV care, 2) CAG functioning and actors involved, 3) Benefits for CAG members, 4) Impacts of CAG beyond the group members, 5) Setbacks, and 6) Acceptance and future expectations of the CAG model. The model provides cost and time savings, certainty of ART access and mutual peer support resulting in better adherence to treatment. Through the active role of patients, HIV information could be conveyed to the broader community, leading to an increased uptake of services and positive transformation of the identity of people living with HIV. Potential pitfalls included limited access to CAG for those most vulnerable to defaulting, some inequity to patients in individual ART care and a high dependency on counsellors.
CONCLUSION
The CAG model resulted in active patient involvement and empowerment, and the creation of a supportive environment improving the ART retention. It also sparked a reorientation of healthcare services towards the community and strengthened community actions. Successful implementation and scalability requires (a) the acceptance of patients as partners in health, (b) adequate resources, and (c) a well-functioning monitoring and management system.
To improve retention on ART, Médecins Sans Frontières, the Ministry of Health and patients piloted a community-based antiretroviral distribution and adherence monitoring model through Community ART Groups (CAG) in Tete, Mozambique. By December 2012, almost 6000 patients on ART had formed groups of whom 95.7% were retained in care. We conducted a qualitative study to evaluate the relevance, dynamic and impact of the CAG model on patients, their communities and the healthcare system.
METHODS
Between October 2011 and May 2012, we conducted 16 focus group discussions and 24 in-depth interviews with the major stakeholders involved in the CAG model. Audio-recorded data were transcribed verbatim and analysed using a grounded theory approach.
RESULTS
Six key themes emerged from the data: 1) Barriers to access HIV care, 2) CAG functioning and actors involved, 3) Benefits for CAG members, 4) Impacts of CAG beyond the group members, 5) Setbacks, and 6) Acceptance and future expectations of the CAG model. The model provides cost and time savings, certainty of ART access and mutual peer support resulting in better adherence to treatment. Through the active role of patients, HIV information could be conveyed to the broader community, leading to an increased uptake of services and positive transformation of the identity of people living with HIV. Potential pitfalls included limited access to CAG for those most vulnerable to defaulting, some inequity to patients in individual ART care and a high dependency on counsellors.
CONCLUSION
The CAG model resulted in active patient involvement and empowerment, and the creation of a supportive environment improving the ART retention. It also sparked a reorientation of healthcare services towards the community and strengthened community actions. Successful implementation and scalability requires (a) the acceptance of patients as partners in health, (b) adequate resources, and (c) a well-functioning monitoring and management system.
Journal Article > LetterFull Text
Int J Tuberc Lung Dis. 1 November 2012; Volume 16 (Issue 11); DOI:10.5588/ijtld.12.0466
Biot M, Saranchuk P, Ellman T, Bygrave H, Bemelmans M
Int J Tuberc Lung Dis. 1 November 2012; Volume 16 (Issue 11); DOI:10.5588/ijtld.12.0466