Transcript No Slide Title

Involving the Community in HIV/AIDS
Treatment Support Programmes:
An Evidence-Based Approach
Government Policies and Goals
(to be inserted by the user)
 HIV prevention, treatment and care
goals
 Community based HIV care and
treatment goals
 Involvement of civil society organizations
in community based HIV prevention,
treatment and care
Purpose of the Community Based Treatment
Support Programme (CBTSP)
 The CBTSP is designed to provide effective and comprehensive
HIV/AIDS care, increase access to medicines and medical monitoring and
establish broad-based community support in resource-limited areas.
 The CBTSP model overlays community services that support treatment
onto the clinical services provided.
 The model emphasizes that people living with HIV and AIDS (PLWHA)
in resource-limited settings need both clinical services and community
services to effectively enhance their quality of life and achieve and sustain
health gains over the long-term.
 The model places equal emphasis on supporting the needs of patients
receiving antiretrovirals and of patients who are not receiving
antiretrovirals because their disease has not yet progressed to treatment
according to national treatment guidelines.
 The model is based on a five site*, three-year operational research and
demonstration project that investigated the 1) feasibility of providing ARV
treatment and HIV care in severely resource limited settings; and 2) the
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.
CBTSP: Models of Care and Partnership
Six Community-Based Treatment
Sites
Caprivi
MALI
Koulikoro
NAMIBIA
Bobonong
BOTSWANA
SWAZILAND
Mbabane
Ladysmith
SOUTH
AFRICA
Maseru
LESOTHO
Outcomes
Outcomes
Increased efficacy. Overall efficacy of 64%, where efficacy was defined as
sustainable, greater-than-50 increase in CD4 count.
Rapid uptake of voluntary counselling and clinic services. Increased more
than 10 fold within three months of starting community mobilization.
Increased adherence. 12 months after starting therapy, 84.5% of patients
were more than 95% adherent (equivalent to missing at most only one dose
per month).
Increased CD4 counts. As demonstrated by an increase in CD4 counts
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).
Outcomes: Added Value of Community
Support
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.
268.
Patients satisfied with the level of community support they received also
experienced better quality of life and adhered better to their ARV medication than
those who were not satisfied.
Food security and home-based care were the two services statistically related to
better adherence.
The lost-to-follow-up rate in Secure the Future CBTS programmes was only
5.1%. 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
age, thanks to community workers who intensively tracked defaulters.
Community services helped prepare patients for antiretroviral therapy and
“leveled the playing field” by dealing with psychosocial problems, inadequate
nutrition and logistical issues such as transport to the clinic and disclosure of status
to a significant other.
Research Conclusions
Community and family support to patients
on ART have a significant effect on
reducing stigma and discrimination and
HR-QoL
Community and family support to patients
on ART have a significant effect on
accelerating the improvement of CD4
counts
Community and family support
impact stigma, QOL and CD4
Patients* satisfied with the community support they receive have the
following better outcomes than those not satisfied;
a) Statistically significantly greater reduction in perceived stigma
b) Statistically significantly greater improvement in QOL
Patients accessing community services
c) Statistically & clinically significantly greater increase in CD4
count than those not accessing such services
(*587 patients by enhanced evaluation)
An Example of Impact on a
community
CBTSP Site: Bobonong Primary Hospital
Hospital bed occupancy by HIV/AIDS
patients reduced from 93% to 52% from
2004 to 2006
Hospital mortality from HIV/AIDS
reduced from 25% to 13% over the same
period
Back-up slides with outcomes charts
Community mobilization leads to rapid
VCT and HIV clinic uptake
Intensive community mobilization using door-to-door
campaigns and public events reach:
More than 150,000 people
Complemented by radio and television broadcasts
7000
6000
5000
4000
3000
2000
1000
0
Q4'03
Q2'04
Q4'04
Total # of clients pre-test counselled
Total # of clients post-test counselled
Q2'05
Q4'05
Q2'06
Total # of clients undergone an HIV test
Encouraging Results
Clinical Data

Over 17,000 patients enrolled

Over 8,000 patients on ARVs

Median CD4 count increased from 94-282 at
12 months of treatment

Viral load undetectable; 92% at 12 months

Response by intent-to-treat; 64%

Only 1% of patients progressed to 2nd line

84% of patients at 95% compliance
Key Community Indicators
ARV clients on HBC;
1,491
non-ARV clients on HBC;
1,398
clients attached to buddies;
790
clients in support groups;
ARV clients getting food parcels;
3,859
866
non-ARV clients getting food parcels;
1,403
clients trained in food security;
2,953
clients trained in IGA;
Number of door-sized gardens;
587
2,551
Community services prepare patients for
ARV therapy
3463 patients assisted to disclose status
4084 patients provided with adequate food
security
368 patients assisted with transport to the clinic
69 patients receiving essential psychosocial
support
50 defaulting patients traced by community
workers
Enhanced Patient Evaluation
Instruments for Data Collection
Five types of instruments:

Baseline

Health Related Quality of Life

Adherence

Stigma and discrimination

Exposure to intervention
Percentages of patients accessing
various community support services
Community support is crucial in the
reduction of actual stigma
Changes in Actual stigma by levels of satisfaction with community support
10.20
P value at baseline & 12 months =0.010; 0.000
P value at 12 months difference =0.061
10.10
10.00
9.80
9.67
Mean
9.60
9.40
9.29
9.27
9.20
9.14
9.00
9.02
8.80
8.60
8.40
Baseline
6 months
12 months
Period
Not satisfied with overall community support at 12 months
Very satisfied with overall community support at 12 months
Change in CD4 count in patients exposed and
not exposed to community services ; patients
with baseline CD4 < 50
350
300
P-values between baseline and 12 months less than 0.000
P-value between groups not significant
310
Median CD4 count
250
200
188
172
150
146
100
50
29.5
21
0
Baseline
6 months
No BMS services recieved in the last 4 weeks
12 months
Has received BMS services in the last 4 weeks
Change in CD4 count in patients exposed and not exposed
to community services ; all patients
350
P value at baseline & 12 months = 0.00
P value at 12 months difference = 0.02
319
300
269.5
250
Median CD4 count
236
226
200
150
133
124.5
100
50
0
Baseline
6 months
No BMS services recieved
12 months
Has received BMS services
Exposure to community service has a significant effect on accelerating
the improvement of CD4 counts of patients on ART (results of
multivariate analysis)
Results of Multiple Regression on CD4 Count At 12 Months
Standard
Factor
Has received BMS intervention services in the last 4 weeks
Coefficient
39.19
error
17.3
P-value
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
-45.85
18.28
0.01
Female
32.31
19.19
0.09
Secondary schooling
34.72
18.31
0.06
207.28
28.23
0.001
Age greater than 35 years
Constant