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Decentralizing ARV Therapy through FaithBased Health Care Networks Anthony Amoroso, MD Assistant Pro


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Title: Decentralizing ARV Therapy through FaithBased Health Care Networks Anthony Amoroso, MD Assistant Pro

Decentralizing ARV Therapy through
Faith-Based Health Care NetworksAnthony
Amoroso, MDAssistant Professor of
MedicineUniversity of Maryland School of
MedicineInstitute of Human VirologyDirector
HIV Services, VA Maryland Health Care
SystemMedical Advisor, AIDSRelief-PEPFAR
Presented at Faith-Based Organizations as
Pioneers and Partners in Health Systems
Development, May 31, 2005, Omni Shoreham Hotel,
Washington DC
AIDSRelief Consortium
  • Catholic Relief Services
  • Catholic Medical Missions Board
  • Interchurch Medical Assistance
  • Institute of Human Virology/University of
    Maryland School of Medicine
  • Futures Group

In Dec 2000 only 50,000 pts estimated to be on
ART in all of sub Saharan Africa.
  • The Global AIDS fund, WHOs 3 by 5 Program and
    the PEPFAR each are poised to accelerate access
    to antiretroviral therapy particularly in
    resource constrained countries confronting

Total USG global expenditure in HIV/AIDS in 2004
was 2.217 billion
  • 317 million spent on research
  • 547 million to global aids fund
  • 845 million to PEPFAR countries

Magnitude of the Challenge
  • Providing durable ART therapy in terms of
  • Providing treatment that is scalable in terms of
    100,000s of patients
  • The urgent need to begin expanding treatment
    programs in the setting of few local experienced
    ART providers and few continuity clinics
  • Limited evidence based data, in the different
    targeted populations, to guide clinical decision
    making process

45 of Eligible US Patients Not On HAART
Teshale E, et al. Abstract 167.
Decentralizing HIV Care to the Community Clinic
Level Will Be Essential to Meet Treatment Needs
and Goals (WHO Public Health Approach)
Mission Hospitals haves long been respected in
the community but until recently access to ART
was limited.   As a Faith-based organization, we
have been able to tap into existing FBO/CBO in
the community to help identify, refer, and
follow-up patients.
2004 WHO 3 by 5 reportEstimated 700,000
patients on ARV worldwide
  • 67,000 directly supported by 300 USG supported
    health facilities
  • Only 40,000 new patients directly supported
  • MSF 12,058 patients on ARV
  • AIDSRelief supports a reported
  • 15,500 patients directly supported
  • over 12,000 new patients
  • 54 sites

AIDSRelief Contribution to PEPFAR 2004
  • Country AIDS AIDSRelief
  • Total ART Releif of ART PTs
  • Guyana  400     49      12.25 Haiti  
    2800    156     5.57  Kenya   8000   
    4403    55.04 Nigeria 5700   
    831     14.58 Rwanda  4200    0      
    0.00  So.Africa  4900    2537   51.78 Tanz
    ania   1500    756     50.40 Uganda  26400
    5847    22.15 Zambia  3400    977    
    28.74 Total 57,300 15,556 27
  • From PEPFAR Annual Report to Congress From
    AIDSRelief Dec 04-Feb 05 Quarterly Reports to CDC

The Challenge of Decentralization
  • Decentralized faith based healthcare
  • very few tertiary referral hospitals
  • working with mostly small rural mission
  • rural dispensaries run by nursing staff,
  • home based care projects with community nurse
    support only
  • Different treatment populations
  • from pregnant women,
  • infants, children,
  • very advanced AIDS,
  • previous treatment experienced patients,
    significant SD NVP exposure,
  • to asymptomatic ambulatory patients
  • Markedly different socioeconomic factors
  • from working urban residents, to displaced
    refugees with enormous food insecurities.

  • Ensuring equal access to quality care in a
    decentralized health care infrastructure
  • The need to not forfeit quality clinical care in
    the process

  • The reason for high mortality rates at some
    sites is simple but depressing  Patients become
    ill because of TB or some other OI they think
    they may have HIV they attend VCT they present
    to an ART program faced with targets and bereft
    of basic diagnostic capabilities they are placed
    on ART they die of the OI or of immune
    reconstitution syndrome.
  • J. Fielder, Kijabe Hospital Kenya

Only 12 million spent directly on the purchase
of ARV drugs within PEPFAR
  • ARV drug related costs are estimated to be less
    than 30 of total care package to support ART.
  • Drug costs are no longer the fundamental
    obstacle for treatment PEPFAR congressional

Lack of human resources without a doubt are the
critical limiting element for scale up
  • Little experience exists in the treatment of HIV
    outside of developed world
  • This is particularly severe for treatment of
  • building clinical capacity/ experience in
    medical, lab, and basic sciences was not
    adequately addressed prior to availability for
    ARV drugs
  • Real mentored medical education of MD, RN, lab,
    other health care professional
  • Lab diagnostic systems, evaluation systems,
    information systems, drug procurement/distribution
    , logistic systems, are costly and were non
    existent in many cases
  • simple medical records do not exist at many
    treatment facilities

  • Efforts to date are using the experienced
    providers to maximal degree and utilized the
    best sites to have treated the current patients
  • Ability to reach beyond established programs,
    beyond tertiary govt. referral hospitals and into
    rural settings, small mission hospitals, small
    govt. hospitals will take an enormous amount of
    experienced human resources, concerted and
    reasoned planning and monetary resources.

Keys to Efficient Scale-UP
  • Rapid and lasting improvement in clinical
  • Breaking paradigm that physicians have to
    complete initial patient encounter and prescribe
  • Strong emphasis on patient preparation and family
    directed care

Improving Clinical CapacityFour major working
  • Improving what we have
  • Initiate process to foster existing provider
  • 2. Building new sustainable capacity
  • Increase treatment expertise throughout the
    decentralized network
  • 3. Increase utilization of all medical personnel
  • 4. Support after training
  • Maintaining continuous communication and QA/QI

Developing Clinical Centers of Excellence
  • Already there exists outstanding HIV care
    programs and experienced providers within
  • Some sites have different strengths, being large
    volume management, adherence treatment support
    programs, clinically strong medical director,
    well organized nurse based home based care
  • Developing these sites into centers of
    excellence to support scale up of new sites in
    the surrounding area.
  • Allows for a modeling approach for development of
    a treatment plan for initiating AVR and provides
    a training center for new/novice providers to
    gain clinical experience in a supportive setting

Optimizing non-physician staff to support HIV
care and treatment
  • Equip existing community nursing /community
    health workers with
  • Clear identification/ establishment of
    expectations of what different levels of
    providers should be accomplishing.
  • Integrate staff to improve overall efficiency of
    continuity of care
  • Build fund of knowledge and improve clinical
  • What is critical, what should be addressed
    immediately, what should be referred, etc.

Treatment preparation
  • Acceptance of HIV status
  • Spousal and guardian disclosure/notification
  • Willing to be visited at home
  • Referral by community health worker/patients
  • Compliance with multiple clinic visits
  • Septrin pill counts
  • Pill box
  • Attendance at treatment preparation seminar

Utilization of current health care
strengthsCommunity Nursing and Health Workers
  • Prior to ARVs,
  • Counseling is done
  • Home visits performed
  • Pill counts are performed
  • Family support assessed
  • Frequent home visits emphasized for first few
    weeks following ARV initiation
  • DOT for 2-4 weeks
  • Home visits 3X week until improvement

Treatment preparation
  • Most patients well-prepared to start ARVs
  • Better acceptance of HIV status
  • Higher compliance compared with previously
    treated patients
  • Patient and family understanding of HIV and ART
    greatly increased after treatment preparation
  • Follow-up is facilitated through home visits and
    support groups

FBO Keys to Success
  • Strong community referral networks with trained
    community health workers
  • Pre-existing Home visits by nurse and adherence
    staff, now including HIV-positive persons
  • A network of support groups
  • Standardized treatment preparation
  • Team cohesion with frequent meetings (community
    and clinical)
  • Emphasis on diagnosis and treatment of
    opportunistic infections, particularly CNS
    infections and TB
  • Pre-existing hospital infrastructure has been
    vital in this regard
  • Clinicians dedicated to providing comprehensive

  • Tuesday we reviewed the files of 34 patients
    from a rural and impoverished area who are
    currently on ARVs.  There had not been one missed
    appointment among this cohort (we did have one
    default and one death from this region).  We just
    started our first mobile clinic to this region
    the project vehicle is key to reaching patients
    and providing access to care.

Negatives to current approach
  • Slower enrollment
  • Process sometimes must be compromised to reach
    patient targets
  • A few patients feel stigmatized
  • More expensive initially (staffing)
  • In the long run, will be less expensive by
    preventing resistance, need for second line
    regimens, and hospitalizations

Comprehensive delivery of care
  • Kijabe Hospital-Kenya
  • Individual counseling is done by the nurse,
    social worker, or clinician
  • Guardian required
  • Disclosure required
  • Treatment preparation seminar is mandatory
  • Barriers to adherence questionnaire and treatment
    contract emphasize important points prior to
  • Home visits, especially early in the course of
    therapy, and support groups are crucial
  • Post-pharmacy counseling done for all patients
    until stable
  • Pill box and medication chart filled
  • Pills counted prior to departure from hospital
  • Regimen explained
  • Nutrition assistance (now under private funding)
    distributed to needy patients

  • I should state that not all patientsdo well. 
  • Some just never understand, or are never able to
    understand, because of cognitive dysfunction
    induced by HIV and/or an OI.  Others have such
    weak social supports that the burden of the
    disease and ART is just too great. But these are
    the uncommon exceptions in our program. 
  • Community efforts can have a tremendous
    transformative effect when it comes to stigma and
    compliance.  Fielder

Future directions
  • Devolving care of stable patients to sites closer
    to patients homes through mobile clinics,
    dispensaries, and community health workers
  •  Besides stigma, the biggest obstacle we face is
  • Utilization of best available antiretroviral
  • over emphasis on immediate cost to access ARVs
    driving unfavorable regimen selection
  • Identifying HIV and beginning treatment earlier
    in the disease process
  • Guidelines for ARV initiation for only
    symptomatic patients severely complicating and
    increasing costs of medical care

  • The pathway to achieve long term durable benefits
    of antiretroviral therapy in different settings
    remains to be defined
  • Durability of ARV induced viral control in the
    end will determine ultimate access, scalability
    and sustainability of current and future ARV