Transcript Document

WHO 2013 ARV Consolidated Guidelines
Recommendations for
HIV Service Delivery
Key service delivery and programme issues
 Low testing coverage, and inadequate linkage
from testing to care
 Delayed diagnosis and treatment initiation,
inadequate retention in care
 Low treatment coverage among key populations
Key Operational Considerations
• Expanded testing scenarios
• Decentralization and service
integration
• Task shifting
• Adherence support
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Considerable operational challenges
Low testing
coverage, and
linkage to care
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Expanded testing and linkage to care
Type date
Suthar et al, Plos Medicine 2013 (in press)
WHO 2013 Recommendations:
• Generalized epidemics: communitybased HIV testing in addition to PITC
• Concentrated epidemics: communitybased HIV testing for key populations in
addition to PITC
• provider-initiated testing and
counselling (PITC)
• Adolescent testing and counselling
Experience in home based testing
• Multiple countries implemented
community based testing approaches:
• supplementing PITC in health
facilities
• provides opportunity to reach
individuals tested for the first time
• provided opportunity for multi
disease interventions
Sweat M et al. Community-based intervention to increase HIV
testing and case detection in people aged 16—32 years in
Tanzania, Zimbabwe, and Thailand (NIMH Project Accept, HPTN
043): a randomised study. The Lancet Infectious Diseases,
Volume 11, Issue 7, Pages 525 - 532, July 2011
• 4 RCTS + 8 observational studies
(community vs facility based testing
in generalised epidemics)
•
Increased rate of first testers
and diagnoses CD4 >350 cells
• 3 studies in key populations
• Increased uptake, but rate of
first testers comparable
Considerable operational challenges
Inadequate retention in care
Delayed initiation of ART
ARV stock outs
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Losses along the Continuum of Care
15-30% drop out of
care at each step
from testing to ART
50% lost to care
After 5 years
Mugglin et al, Trop Med Int Health, 2013
Western Cape Provincial Dept. of Health,
South Africa, 2013
Recommendations: Decentralization
of HIV Care And Treatment To Primary Care And Community Settings
Central/Regional Hospitals
Clinical teams led by
nurse or clinical officer
District hospital
Option 1:
Option 2:
Community-based care
Option 3:
RECOMMENDATION
STRENGTH & QUALITY OF EVIDENCE
ART initiation at hospital and maintenance at
peripheral health facility.
Strong recommendation, Low quality of
evidence
ART initiation and maintenance at peripheral
health facility.
Strong recommendation, Low quality of
evidence
ART initiation at peripheral health facility with
maintenance at community level.
Strong recommendation and Moderate
quality of evidence
• Moving to more integrated and linked and primary care models of service delivery
• Impact of decentralization will improve programme outcomes
• Consider drugs and diagnostics supply, training/supervision of health workers;task-shifting
Decentralization: Bringing ART closer to
communities
WHO 2013 Recommendations:
• Initiation and maintenance of ART in
peripheral primary facilities
• maintenance of treatment at community
level between clinic visits.
• 2 observational studies
(initiating and maintaining at
peripheral sites)
Attrition declined at 12 months
• 2 cluster RCTs (community
maintenance)
Attrition comparable at 12 months
Recommendations: Service Integration
of ART with ANC/MCH Care, TB Care, OST Settings
RECOMMENDATION
STRENGTH & QUALITY OF
EVIDENCE
ART initiation and maintenance in pregnant/BF women
and their infants in MNCH settings, with link to ongoing
HIV care and ART.
Strong recommendation, and
Very low quality of evidence
ART initiation in TB care settings in high TB and HIV
burden settings, with linkage to ongoing HIV care and
ART.
Strong recommendation, Very
low quality of evidence
TB treatment and diagnosis in HIV care settings in high
burden of HIV and TB.
Strong recommendation and
Very Low quality of evidence
ART initiation and maintenance in OST settings.
Strong recommendation and
Very Low quality of evidence
Implementation considerations
o Mobilizing and allocating resources
o Training, mentoring and supervising health workers
o Procuring and managing drugs and other medical supplies
o Monitoring and evaluation
TB/HIVService integration: Responding to
co-morbidities and multiple needs
• 19 observational studies – ART
delivery in TB settings
• increased ART uptake and
timeliness of ART initiation
• 5 observational studies – TB
treatment in HIV care
• Decreased mortality
Examples of integration:
South Africa
 60% co-infection rate (HIV and TB)
 50% of deaths in pregnant women and children
associated with HIV
 Need for integration is obvious
 Since 2010 all PHC facilities that provide TB,
sexual & reproductive, ANC and child health
services, including school health services, also
targeted for HIV services
 Currently most public health facilities and over 3500
of 4200 public health facilities offer ART
 Many challenges to integration still exist,
including infection control!
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Delivery of ART in settings providing opioid
substitution therapy
• Existing WHO guidance on HIV testing
•
•
in all drug dependency treatment
services
Low OST and ART coverage
1 RCT and 3 observational studies
• Small sample size and variable results
• Trends for improved viral suppression
and reduced mortality
Recommendations: Task Shifting
RECOMMENDATION
Trained non-physician clinicians, nurses,
midwives on 1st line ART initiation.
Trained non-physician clinicians, nurses,
midwives on ART maintenance.
STRENGTH & QUALITY OF EVIDENCE
Strong recommendation, Moderate
quality of evidence
Strong recommendation, Moderate
quality of evidence
Strong recommendation and Moderate
Trained community health workers dispense ARV quality of evidence
between clinical visits.
Implementation considerations
o
o
o
Enabling policy/regulatory framework
Quality assurance, health workers ongoing professional education,
mentoring, supportive supervision,
Sustainability
Task shifting
WHO 2013 Recommendations:
• Trained non-physician clinicians,
midwives and nurses can initiate
first-line ART and maintain
treatment
• Trained and supervised community
health workers can dispense ART
between clinic visits
3 RCTs and 6 observational studies
Sanne et al, Lancet 2010;
Fairall et al, Lancet 2012
• No difference in mortality of LFU at
12 months (non-physicians initiate
and maintain on community
workers maintain)
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Essential for effective task
shifting
 Enabling policy/regulatory framework
 Quality assurance, ongoing
professional education, mentoring,
supportive supervision,
 Sustainability
– Broader strengthening of health systems agenda
– Country overall strategy for health workforce planning and
management
– Political and financial commitment
– Need to engage stakeholders, including public service, local
government, private sectors and donors
2013
Interventions to support ART adherence:
Start before ART initiation and continue throughout
treatment
Programme
Patient and service delivery
• Avoid out of pocket
•
•
•
•
payment
FDC regimens
Prevent ARV stock out
Task shifting
Linkage with community
level interventions
ADHERENCE
Monitoring
•
•
•
•
Viral load monitoring
Pharmacy drug refill records
Self-reporting
Pill counts
•
•
•
•
•
•
•
Patient education & counselling
Peer & community support
Co-management of substance
use disorder
Co-management of mental
health disorders
Nutritional support in food
insecure settings
Financial support
Mobile phone text message
• Mobile phone text messages could be considered as a reminder tool
for promoting adherence to ART as part of a package of adherence
interventions (strong recommendation, moderate-quality evidence).
Adherence support:
combinations of interventions
WHO 2013 Recommendations:
Combination of interventions
• Minimizing out of pocket payments
• Use of fixed-dose combinations
• Strengthening drug supply system
• Patient counselling and education
• Peer support
• Nutritional support in food insecure
settings
• Mobile phone text messages
Structural factors
Psycho-social factors
Related to knowledge,
beliefs and motivations
within a given social
context (herbal medicine,
lack of disclosure, stigma)
Underlying economic conditions of daily life
(accessibility of care, transportation, work
responsibilities, food insecurity)
Health care delivery factors
Quality of care at the point of contact with the patients (waiting
time, conflict with staff, coordination of care, stigma); service
inaccessibility (distance from home)
Retention in care: Potential
interventions
No specific recommendations: multiple interventions
necessary to retain patients in care
o No single or package of interventions support
o
o
o
o
o
retention in all context
Service decentralization
Improved patient –provider interaction
Social and peer support
Training of health workers
Programme monitoring and focused evaluation of
retention
Summary: operations and service delivery
Recommendation
Strength
Quality of
Evidence
Strong
Very Low
ART initiation in TB care settings in high TB and HIV burden
settings, with linkage to ongoing HIV care and ART
Strong
Very Low
TB treatment and diagnosis in HIV care settings in high burden of
HIV and TB
Strong
Very Low
ART initiation and maintenance in OST settings
Strong
Very Low
ART initiation at hospital and maintenance at peripheral health
facility
Strong
Low
ART initiation and maintenance at peripheral health facility
Strong
Low
ART initiation at peripheral health facility with maintenance at
community level
Strong
Moderate
Trained non-physician clinicians, nurses, midwives on 1st line ART
initiation
Strong
Moderate
Trained non-physician clinicians, nurses, midwives on ART
maintenance
Strong
Moderate
Trained community health workers dispense ARV between
clinical visits
Strong
Moderate
Operational Recommendations
Specific Recommendation
ART initiation and maintenance in pregnant/BF women and their
infants in MNCH settings, with link to ongoing HIV care and ART
Service integration
Decentralization of
treatment and care
Options of
decentralization
Task shifting