Reaching 90 90 90
- Call for comprehensive plan for immediate implementation of quality HIV care in neglected communities [Press Release]
- Reaching 90 90 90 - what will it take? [Briefing Document]
- Drug supply & counsellors as essential parts of getting to 90 90 90
- Bending the Curves, Eshowe, Kwazulu Natal
- Introducing the Viral Load reports, findings
- Community models of care
Reaching 90 90 90: What will it take?
In 2014 UN member states endorsed a Political Declaration on HIV/AIDS to reach 30 million people with HIV treatment by 2020. The ambitious ’90 90 90’ targets are evidence of this political commitment while science has provided the tools and evidence base to achieve it. However, while critical progress has been achieved, a number of key interventions must be implemented to reach these goals. This includes community-based treatment; solidifying the role of HIV/TB lay counsellors; early treatment for all people living with HIV and routine viral load monitoring, to facilitate rapid treatment scale-up and help people remain in care. This is particularly critical in West and Central Africa, where 3 out of 4 people in need don’t have treatment.
Drug supply & counsellors as essential parts of getting to 90 90 90
No HIV response is possible without a reliable supply ARVs that is properly managed. MSF and its partners in Southern Africa have developed means to monitor drug stock outs, while empowering patients and bringing practical recommendations.
The lay workers in communities and facilities are the glue holds together important elements in the HIV response — improving both quality of care and access. Governments need to ensure that a workforce of lay people is employed, maintained and expanded throughout the region, to provide testing, treatment initiation and adherence support for all who need it.
Bending the Curves, Eshowe, Kwazulu Natal
To reduce the rate of HIV infection in a community is to bend the curves of the epidemic and save lives.
Bending the curves requires that at least over 80% of people with HIV should be virally suppressed to dramatically lower the risk of HIV transmission at community level.
In April 2011, MSF together with the KwaZulu-Natal Provincial Department of Health started the ‘Bending the Curves’ project in the Eshowe and Mbongolwane areas in the uThungulu District.
This rural area is home to 114,000 people and has one of the highest rates of HIV and TB in South Africa: 1 in 4 people aged 15 – 59 years old is HIV positive.
Working with local NGOs and communities MSF pilots new and innovative community driven ‘models of care’ to significantly reduce the rate of HIV and TB infection through:
- Prevention: Condom distribution and Male Medical Circumcision
- Testing: Mobile HIV testing at outlying schools, colleges and local community events, Fixed Testing Sites in centrally locate places, Community Health Agents delivering HIV counselling & testing door-to-door in remote areas
- Treatment: Facility-based Adherence Clubs and Community ART Groups
- Enhanced adherence counselling: delivered by lay counsellors regularly testing patients’ viral loads.
Community Health Agents Programme – CHAPS
Babongile Luhlongwane, one of over 80 Community Health Agents in the Entumeni and Mbongolwane districts near Eshowe, wakes up every weekday morning to travel long distances, often by foot, to deliver HIV Counselling and Testing to people who seldom make it to distant public health facilities for medical checkups.
MSF’s Dr Vivian Cox explains the value of the CHAPS programme, and Babongile explains how people value the service she’s providing.
Male Medical Circumcision – MMC
Medical circumcision has been shown to decrease the chances of HIV infection by up to 60% for life. This video follows a group of young boys in the Mbongalwane District as they undertake this simple procedure in the safe and supportive environment provided by local partners.
MSF’s Deputy Field Co-ordinator Musa Ndlovu and Dr Vivian Cox explain why this service is an essential tool in stopping the spread of HIV in Southern Africa. Strong support from local traditional leaders has also been essential for promoting MMC among males between the ages of 15 and 34.
In the last five years, the number of people in South African health facilities receiving life-saving antiretroviral treatment (ART) in the last five years has grown from 382,000 to more than 1.79 million. However, South Africa’s National Strategic Plan aims to put more than 3 million people on ART by 2016. As numbers nearly double, the health service will struggle to retain and manage such a high number of patients in care. In this video, we see how MSF’s Adherence Club model of care is helping stable patients in Eshowe to remain adherent.
In late 2011, MSF launched the Mobile 1 Stop Shop (M1SS). These are mobile testing units (tents or a van) that provide information, HIV Counselling & Testing, screening for tuberculosis and sexually transmitted infections, pregnancy testing, condom distribution, health promotion and mobilisation for Medical Male Circumcision. Practice may change with the implementation of Test & Start, but people currently testing positive are provided with a CD4 count point of care test (PIMA), and referred to the nearest health facility if necessary.
Depending on the location and expected number of beneficiaries, each team consists of one or more HIV counsellors and site mobilisers.
Mobile outreach testing occurs at farms, schools, taxi ranks, churches, local businesses and during community events.
In August 2012 MSF established three Fixed Sites providing the same services as the M1SS sites, and staffed by lay counsellors and mobilisers.
Two sites are located along the main street in Eshowe, a third at the TVET college in Eshowe and a fourth recently opened in Mamba, in rural Mbongolwane.
Some mobile and stand-alone sites have added a nurse to the team to treat minor ailments and distribute chronic medications, including ARV drugs.
Community ART Groups - CAGS
MSF and the KwaZulu-Natal Department of Health offer several ART delivery strategies in Eshowe & Mbongolwane for patients who are stable on treatment:
- Standard Care: Clinical consultation and ART collection at the facility every two months.
- Facility Clubs and community clubs: lay counsellor-led groups of up to 30 patients meeting every second month in locations near the facility or based in the community, for ART collection and yearly for clinical consultation.
- Community ART groups (CAG): patient-led groups of three to eight HIV-positive patients. Patients rotate visiting the facility for three-monthly ART collection for all members and an annual clinical consultation.
- Central Chronic Medicine Dispensing and Distribution: patients receive their medicines on a monthly basis at a DOH-approved “pick-up point” in the community.
By the end of 2015 over 21% of eligible patients were receiving ART refills and adherence support through either a club or CAG in the project catchment area. There was a steady increase in adherence club enrolment over the course of 2015, from 64 clubs in the first quarter to 83 clubs in the last quarter. CAG enrolment remained constant over 2015.
In this video, MSF Eshowe Deputy Field Co-ordinator Musa Ndlovu and Project Medical Referent Dr Vivian Cox explain how CAGs work, we follow Community Caregiver Nonhlanhla Ngema as she provides support to a newly formed CAG, and we hear from patients themselves how this model of care is working for them.
Throughout sub-Saharan Africa, lay counsellors have played a crucial role in providing testing and counselling services in health facilities, yet no national policy exists in South Africa to guide employment practices. At the end of 2014, the KwaZulu-Natal Department of Health announced the phasing out of lay counsellors, with the stated aim of retraining and identifying new careers for these individuals.
In the uMlalazi municipality, lay counsellors have been withdrawn from nine clinics in the project area in two waves: January 5th, 2015 and June 15th, 2015.
Following the withdrawal of counsellors from facilities in KZN:
- the monthly average of HIV tests conducted in facilities in Eshowe/Mbongolwane decreased 25% after the first withdrawal phase, and a further 13% after the second withdrawal.
- ART initiation at health facilities in the Eshowe/Mbongolwane area has dropped in pace with the decline in HIV testing.
- 842 patients were initiated on ART in project-area health facilities in the first three months of 2015, while only 504 were initiated on ART in the same period in 2016.
If these findings are representative of the experience across the province or in other parts of the country, they imply that lay counsellor withdrawal may have a negative influence on the health of the population and jeopardise efforts to deliver on the globally agreed 90-90-90 strategy.
Click on the image below to view the Slideshow: Bending the Curves
Introducing the Viral Load reports, findings
Routine viral load monitoring is essential to improving people’s HIV treatment outcomes. Annual viral load tests check if a person’s treatment is working, and can identify those who are either failing treatment, and must be switched to different drugs –or need extra adherence support to get back on track.
Because viral load testing more accurately detects problems it can also prevent people from being unnecessarily switched to more expensive "second-line" medicines.
Despite being the gold standard for treatment monitoring, it’s largely unavailable in developing countries because cost is a major factor.” From 2013-2016 the UNITAID-funded MSF viral load initiative has supported the scale-up of viral load testing capacity in six countries (Lesotho, Malawi, Mozambique, Swaziland, Uganda and Zimbabwe). Despite challenges, scale-up of viral load was feasible in these resource-poor settings: almost 320,000 tests were performed in MSF supported laboratory services since 2013, and over 150,000 in 2015.
After three years of implementation MSF shares the successes and challenges encountered by our teams and the Ministry of Health teams and a new report ‘Making Viral Load Routine’.
Community models of care
Despite the rapid scale up of antiretroviral therapy patients still encounter barriers accessing treatment. Health systems struggle to provide care to their ever-increasing cohorts and address barriers to care.
By involving an entire community in the HIV response at different levels – from testing people where they live and work, and ensuring those testing positive are initiated on treatment, and supported to stay adherent to lifelong treatment – far better outcomes are possible. Here are just some of tool kits MSF developed to adapt HIV care to the needs of patients closer to where they live.