Are Expert Patients an Untapped Resource for ART Provision in Sub-Saharan Africa?

Since the introduction of antiretroviral treatment, HIV/AIDS can be framed as a chronic lifelong condition, requiring lifelong adherence to medication. Reinforcement of self-management through information, acquisition of problem solving skills, motivation, and peer support is expected to allow PLWHA to become involved as expert patients in the care management and to decrease the dependency on scarce skilled medical staff. We developed a conceptual framework to analyse how PLWHA can become expert patients and performed a literature review on involvement of PLWHA as expert patients in ART provision in Sub-Saharan Africa. This paper revealed two published examples: one on trained PLWHA in Kenya and another on self-formed peer groups in Mozambique. Both programs fit the concept of the expert patient and describe how community-embedded ART programs can be effective and improve the accessibility and affordability of ART. Using their day-to-day experience of living with HIV, expert patients are able to provide better fitting solutions to practical and psychosocial barriers to adherence. There is a need for careful design of models in which expert patients are involved in essential care functions, capacitated, and empowered to manage their condition and support fellow peers, as an untapped resource to control HIV/AIDS

Adapting a community-based ART delivery model to the patients’ needs: a mixed methods research in Tete, Mozambique

BACKGROUND: To improve retention in antiretroviral therapy (ART), lessons learned from chronic disease care were applied to HIV care, providing more responsibilities to patients in the care of their chronic disease. In Tete - Mozambique, patients stable on ART participate in the ART provision and peer support through Community ART Groups (CAG). This article analyses the evolution of the CAG-model during its implementation process. METHODS: A mixed method approach was used, triangulating qualitative and quantitative findings. The qualitative data were collected through semi-structured focus groups discussions and in-depth interviews. An inductive qualitative content analysis was applied to condense and categorise the data in broader themes. Health outcomes, patients’ and groups’ characteristics were calculated using routine collected data. We applied an ‘input – process – output’ pathway to compare the initial planned activities with the current findings. RESULTS: Input wise, the counsellors were considered key to form and monitor the groups. In the process, the main modifications found were the progressive adaptations of the daily CAG functioning and the eligibility criteria according to the patients’ needs. Beside the anticipated outputs, i.e. cost and time saving benefits and improved treatment outcomes, the model offered a mutual adherence support and protective environment to the members. The active patient involvement in several health activities in the clinics and the community resulted in a better HIV awareness, decreased stigma, improved health seeking behaviour and better quality of care. CONCLUSIONS: Over the past four years, the modifications in the CAG-model contributed to a patient empowerment and better treatment outcomes. One of the main outstanding questions is how this model will evolve in the future. Close monitoring is essential to ensure quality of care and to maintain the core objective of the CAG-model ‘facilitating access to ART care’ in a cost and time saving manner

Paralisis aislada del serrato mayor : a propósito de dos casos

The authors report two cases of Isolated Paralysis of the Serratus Anterior Muscle. The first case, traurnatic ethiology long thoracic nene. The second case neuralgic arnyarrophy

Four-year retention and risk factors for attrition among members of community ART groups in Tete, Mozambique.

OBJECTIVE: Community ART groups (CAG), peer support groups involved in community ART distribution and mutual psychosocial support, were piloted to respond to staggering antiretroviral treatment (ART) attrition in Mozambique. To understand the impact of CAG on long-term retention, we estimated mortality and lost-to-follow-up (LTFU) rates and assessed predictors for attrition. METHODS: Retrospective cohort study. Kaplan-Meier techniques were used to estimate mortality and LTFU in CAG. Individual- and CAG-level predictors of attrition were assessed using a multivariable Cox proportional hazards model, adjusted for site-level clustering. RESULTS: Mortality and LTFU rates among 5729 CAG members were, respectively, 2.1 and 0.1 per 100 person-years. Retention was 97.7% at 12 months, 96.0% at 24 months, 93.4% at 36 months and 91.8% at 48 months. At individual level, attrition in CAG was significantly associated with immunosuppression when joining a CAG, and being male. At CAG level, attrition was associated with lack of rotational representation at the clinic, lack of a regular CD4 count among fellow members and linkage to a rural or district clinic compared with linkage to a peri-urban clinic. CONCLUSIONS: Long-term retention in this community-based ART model compares favourably with published data on stable ART patients. Nevertheless, to reduce attrition, further efforts need to be made to enroll patients earlier on ART, promote health-seeking behaviour, especially for men, promote a strong peer dynamic to assure rotational representation at the clinic and regular CD4 follow-up and reinforce referral of sick patients

Participants of the focus group discussions and in depth interviews.

<p>CAG – Community ART groups; IDI – In depth interviews; FGD – Focus group discussions.</p>§<p>Patients in CAG were divided in three groups according to their geographical residence and the distance to the clinics: (1) remote areas – patients who have to travel long distances to access care with major transport problems, (2) rural areas –patients who can reach healthcare services by foot or bicycle and (3) semi-urban areas – patients who live close to main road with access to public transport.</p><p><b>*</b> To ensure a fluent implementation of the CAG model and monitoring of the groups, MSF appointed counsellors to the large health facilities, taking a major role in the daily management of the CAG activities. Whereas in smaller health facilities, MoH nurses are responsible for all these activities. For the interviews nurses have been divided into two groups: (1) nurses working with counsellors and (2) nurses working without counsellors.</p

Role and perceived impact of CAG members at the different levels of ART care.

<p>Role and perceived impact of CAG members at the different levels of ART care.</p

Quotes of key informants illustrating the major findings.

<p>Quotes of key informants illustrating the major findings.</p

Summary of the six themes identified based on the content of the interviews.

<p>CAG – Community ART Groups.</p

The Community ART Groups model.

<p>The Community ART Groups model.</p