Facilitating Adherence through Community-based

Facilitating Adherence through Community-based
Delivery of Antiretroviral Therapy in Rural Rwanda
Michael L. Rich, MD, MPH
Partners In Health (PIH) – RWANDA
Brigham and Women’s Hospital –BOSTON, USA
3rd International Conference on HIV Treatment Adherence
March 17-18, 2008
Jersey City, New Jersey U.S.A.
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RWANDA
Catchment area of community-based program
Southern
Kayonza
(Rwinkwavu)
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Kirehe
Core philosophy of the community-based care model
• Comprehensive health care, available to all
• Relentless focus on the patient and quality of care,
regardless of the challenges of the environment
• Community-based model, decentralized where
possible from hospital to health center and from
health center to patients’ homes (including
incentives and training for community health
workers)
• Holistic care for the community beyond the purely
clinical that address basic social and economic needs
Milestones
•During two years, 2,236 patients initiated ART,
including 206 children <15 years-old.
•A total of 207 medical providers and 825 community
health workers (accompagnateurs) have been hired
and trained to provide care.
•All HIV care is provided free of charge.
Accompagnateur Program
•All patients initiating ART select an
accompagnateur.
•Accompagnateurs provide social support and
once-daily home-based directly observed therapy.
•Accompagnateurs attend regular trainings in
HIV prevention, treatment, adherence, and
recognition of opportunistic infections and
adverse effects.
•Supervisors routinely monitor accompagnateurs
by conducting unannounced pill counts and home
visits.
Accompagnateur Program
The PIH/Rwanda MoH CHW model is based on:
•Adequate number of CHWs: One for every 6 households with a patient
on ART.
•Community involvement and CHW integration into the health system:
Elected by the community, CHWs participate in meetings and advocacy,
build solidarity and establish a community link to the healthcare system.
•Standardization of training: CHWs receive standardized training
(including modules on TB, HIV/AIDS, chronic diseases, IMCI, nutrition,
sanitation, reproductive health, and family planning) with consistent
supervision from health center personnel.
•Adequate compensation: For CHWs to be held fully accountable and be
a sustainable part of the system, they need to be compensated adequately.
Performance based financing can be used.
Role of the Accompagnateur
1. Support patient(s) in taking medications each day (directly
observed therapy).
2. Converse with patients to identify difficulties:
• Health problems
• Difficulty taking medications
• Housing concerns
• Food insecurity
• Family or social problems
3. Act as a general liaison between the clinic and the patient;
refer patients with complications to the health center.
4. Accompany sick patients to clinic visits as needed.
5. Pick-up monthly ART refills.
Organizational structure
Health center
Community health
nurse
Principal trainer
and supervisor
Chronic care nurse
ID clinic nurses
Health center
nurses
Community health workers are the cornerstone of the
Healthcommunity-based
promoters model.
Health promoter
Health center-based
Community health program
Household
Household
Daily
Accompaniment
Goes at least
twice monthly to
the Health center
for training and
medicine pick up
Seeks help if
necessary
Household
Health promoter
Average 3- 6 households
Unannounced
spot checks
Accompagnateur Leader
Average 20 accompagnateurs/health promoters
Co-lateral Benefits
• Neighbors helping neighbors, in a country riven
by political divisions,
• Job creation, economic growth
• Kids in school
• Prenatal care
• Family planning uptake
• Less late presentations of illness
• Advocacy and decreased stigma
• Adherence and solidarity
Adherence
Default was rare. As of January 2008, only 21 of the
2236 patients defaulted or became lost to follow up.
Adherence
Adherence
HIV patient on food
supplements for fist
10 months and
ART with daily
accompaniment
for 18 months
Adherence
Adherence
Treatment outcomes
Rwanda
Community-based
program (N=2,236)
Died
90 (4.0%)
Lost to follow up 21 (<1%)
Transfer-out
78 (3.5%)
Treatment outcomes
• We conducted plasma viral load testing for 116 children
completing at least one year of antiretroviral therapy and for
150 adults completing at least two years of therapy.
•Informed consent was obtained for viral load testing.
•89.5% of children and 98.0% of adults receiving ART had a
viral load < 400 copies/mL after one and two years of ART,
respectively.
Plasma Viral Load Levels for:
Children (N=116) Receiving ART for at least one year
Adults (N=150) on ART at least two years
100%
87%
90%
80%
73%
70%
Percent
60%
Children
50%
Adults
40%
30%
17%
20%
11%
10%
10%
2%
0%
< 40
40 - 400
copies / mL
> 400
Lessons Learned
•Community health workers can serve as the cornerstone
of ART delivery in regions where medical professionals
are scarce and frequent visits to health centers are difficult
due to illness or distance.
Lessons Learned
Free community-based care, in combination with
nutritional and socioeconomic support, fosters good
adherence by providing social stabilization and facilitating
access to care.
TB/HIV
8 Months
After
MOST IMPORTANT
Our patients need food, shelter, and jobs in
addition to good health care.
We call this “accompaniment.”
Basic care
housing
Principle 10: : Comprehensive rural health
must go beyond the purely clinical
by providing socio-economic support as well
Access to education
Job
creation
Access to water &
improving food security
Sanitation
Visits each house
monthly
Visits each house
daily
THANK YOU
The Collaborators
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Ministère de la Santé du Rwanda
Partners In Health (PIH)
Clinton Foundation
Global Fund
UNICEF
CNLS
WFP
Gates Foundation
Local HIV Associations