Dr Daniel Mwamba, MD - Columbia...
Transcript of Dr Daniel Mwamba, MD - Columbia...
![Page 1: Dr Daniel Mwamba, MD - Columbia Universitycquin.icap.columbia.edu/.../7.-Mwamba_CIDRZ-Zambia_FINAL.pdfThe CQUIN Learning Network Patients at High Risk: Service Delivery for Unstable](https://reader034.fdocuments.in/reader034/viewer/2022051801/5adf683e7f8b9a6e5c8c1c7e/html5/thumbnails/1.jpg)
The CQUIN Learning Network
Patients at High Risk: Service Delivery for Unstable HIV Patients
Dr Daniel Mwamba, MD
Centre for Infectious Diseases Research in Zambia July 17-19, 2017
Harare, Zimbabwe
![Page 2: Dr Daniel Mwamba, MD - Columbia Universitycquin.icap.columbia.edu/.../7.-Mwamba_CIDRZ-Zambia_FINAL.pdfThe CQUIN Learning Network Patients at High Risk: Service Delivery for Unstable](https://reader034.fdocuments.in/reader034/viewer/2022051801/5adf683e7f8b9a6e5c8c1c7e/html5/thumbnails/2.jpg)
Background
• CIDRZsupports233sitesin4provinces• Implemen7ngdifferen7atedservice
delivery(DSD)modelssince2015– Communityadherencegroups(CAGs)– Urbanadherencegroups(UAGs)
• AsofJune2017:– 763CAGsand16UAGsformed– 5,062pa7entsonregularfollowup
2
![Page 3: Dr Daniel Mwamba, MD - Columbia Universitycquin.icap.columbia.edu/.../7.-Mwamba_CIDRZ-Zambia_FINAL.pdfThe CQUIN Learning Network Patients at High Risk: Service Delivery for Unstable](https://reader034.fdocuments.in/reader034/viewer/2022051801/5adf683e7f8b9a6e5c8c1c7e/html5/thumbnails/3.jpg)
CurrentEligibilityCriteriaforCIDRZDSDModels
• Individuals>14yearsstableonART:– CD4≥200– Noac7veOI(noWHOstage3or4condi7on)– ReceivingARTfor≥6months– Viralload<1000copies/ml
3
![Page 4: Dr Daniel Mwamba, MD - Columbia Universitycquin.icap.columbia.edu/.../7.-Mwamba_CIDRZ-Zambia_FINAL.pdfThe CQUIN Learning Network Patients at High Risk: Service Delivery for Unstable](https://reader034.fdocuments.in/reader034/viewer/2022051801/5adf683e7f8b9a6e5c8c1c7e/html5/thumbnails/4.jpg)
LessonsLearntfromDSDforStablePa7ents
• Highyieldindextes7ngcomparedtodoor-to-door– 12.3%posi7vityand>90%linkagetocare
• 12monthreten7on:97%comparedto76%ofpa7entsreceivingstandardofcare.
• Highlyacceptabletoallstakeholderspar7cularlypa7ents
• Pa7entsareunhappytoleaveDSDcareserviceswhenup-referredtoclinicbasedcareforeitherOIordetectableVL
4
![Page 5: Dr Daniel Mwamba, MD - Columbia Universitycquin.icap.columbia.edu/.../7.-Mwamba_CIDRZ-Zambia_FINAL.pdfThe CQUIN Learning Network Patients at High Risk: Service Delivery for Unstable](https://reader034.fdocuments.in/reader034/viewer/2022051801/5adf683e7f8b9a6e5c8c1c7e/html5/thumbnails/5.jpg)
Thelast90,Zambiastatus
5
![Page 6: Dr Daniel Mwamba, MD - Columbia Universitycquin.icap.columbia.edu/.../7.-Mwamba_CIDRZ-Zambia_FINAL.pdfThe CQUIN Learning Network Patients at High Risk: Service Delivery for Unstable](https://reader034.fdocuments.in/reader034/viewer/2022051801/5adf683e7f8b9a6e5c8c1c7e/html5/thumbnails/6.jpg)
90:90:90inZambiaDatafromZAMPHIA
6
![Page 7: Dr Daniel Mwamba, MD - Columbia Universitycquin.icap.columbia.edu/.../7.-Mwamba_CIDRZ-Zambia_FINAL.pdfThe CQUIN Learning Network Patients at High Risk: Service Delivery for Unstable](https://reader034.fdocuments.in/reader034/viewer/2022051801/5adf683e7f8b9a6e5c8c1c7e/html5/thumbnails/7.jpg)
DSDfor“Unstable”Pa7ents
• Understandingbarrierstoengagementandreten7oniskeyinformula7ngstrategiestoimprovepa7entoutcomes
• Barrierstopa7entengagementandul7matelyVLsuppressioninclude:– LowHIVliteracy– S7gma/denialofdiagnosis/tradi7onalbeliefs– Mentalhealthdisorders– PrimaryHIVdrugresistance/drugtoxicity– Incorrectdosing/impaireddrugabsorp7on
7
![Page 8: Dr Daniel Mwamba, MD - Columbia Universitycquin.icap.columbia.edu/.../7.-Mwamba_CIDRZ-Zambia_FINAL.pdfThe CQUIN Learning Network Patients at High Risk: Service Delivery for Unstable](https://reader034.fdocuments.in/reader034/viewer/2022051801/5adf683e7f8b9a6e5c8c1c7e/html5/thumbnails/8.jpg)
Mostcommonpa1ent-reportedreasonsforstoppingcare(N=603).Be>erinfoStudy
363739404646515155555862
7190
121
0 20 40 60 80 100 120 140
IcametobelieveIdonotactuallyhaveHIVIhadfamilyobliga1ons
Movedtoanewplace,nomen1onifARTavailableThestaffdidnottreatmewithrespect
ItwastakingtoolongtostartARTIlostmycardforARTCare
IwasafraidclinicwouldscoldmeformissingmyHadhighCD4anddidn'tseeareasontoa>end
IintendedtogobutwastoolazyImovedandtherewasnocareavailableinthis
Ispenttoomuch1meatclinicA>endingclinicriskeddisclosuretosomeoneI
IfeltwellandthoughtIdidn’tneedcareorTransporta1onwastoodifficultorexpensive
Workrequirementsinterferedwithpickingup
8
0% 20% 40% 60% 80% 100%
Structural Psychosocial Clinic
![Page 9: Dr Daniel Mwamba, MD - Columbia Universitycquin.icap.columbia.edu/.../7.-Mwamba_CIDRZ-Zambia_FINAL.pdfThe CQUIN Learning Network Patients at High Risk: Service Delivery for Unstable](https://reader034.fdocuments.in/reader034/viewer/2022051801/5adf683e7f8b9a6e5c8c1c7e/html5/thumbnails/9.jpg)
StrategiesforImprovingOutcomes
Targe7nginterven7onsaddressing:1. Clinic/Facilitybasedbarriers• Lackofdedicatedcliniciantooverseecare• Qualityofcare/respectfromproviders• Longwait7mes
2. Psychosocialbarriers• S7gma• Culturalbeliefs
3. Structuralbarriers• Distance/Access• Workdemands
9
![Page 10: Dr Daniel Mwamba, MD - Columbia Universitycquin.icap.columbia.edu/.../7.-Mwamba_CIDRZ-Zambia_FINAL.pdfThe CQUIN Learning Network Patients at High Risk: Service Delivery for Unstable](https://reader034.fdocuments.in/reader034/viewer/2022051801/5adf683e7f8b9a6e5c8c1c7e/html5/thumbnails/10.jpg)
ProposedInnova7on:Include“Unstable”ClientsinCAGModel
• RevisedEligibility:– >14years– OnART>6months– RegardlessofVLorWCS
• Anynewlyiden7fiedunstableclientsinalreadyestablishedtradi7onalDSDmodelswillbeeligibletoreceivecareunderthismodelwhilebeinginaCAG
10
![Page 11: Dr Daniel Mwamba, MD - Columbia Universitycquin.icap.columbia.edu/.../7.-Mwamba_CIDRZ-Zambia_FINAL.pdfThe CQUIN Learning Network Patients at High Risk: Service Delivery for Unstable](https://reader034.fdocuments.in/reader034/viewer/2022051801/5adf683e7f8b9a6e5c8c1c7e/html5/thumbnails/11.jpg)
Ra7onaleforInclusionof“Unstable”ClientsintheCAGmodel
• ThehypothesesisthatDSDforsuchpa7entswillprovideanintegratedclinicalandcommunitycarepackagetoimproveadherenceandaddressassociatedbarriersthatmayhavecontributedtoadetectableviralloadwhilemanagingallcomorbidi7es.
• Thisstrategyaimtoajainthelast90oftheUNAIDStargetsinabidtoendtheHIVepidemic
11
![Page 12: Dr Daniel Mwamba, MD - Columbia Universitycquin.icap.columbia.edu/.../7.-Mwamba_CIDRZ-Zambia_FINAL.pdfThe CQUIN Learning Network Patients at High Risk: Service Delivery for Unstable](https://reader034.fdocuments.in/reader034/viewer/2022051801/5adf683e7f8b9a6e5c8c1c7e/html5/thumbnails/12.jpg)
Clinic-basedCareforClientsatHighRisk
• Dedicatedmul7disciplinaryclinicalteamtrainedinmanagementofpa7entswithcomplicateddisease-doctor,nurse,pharmacist,laboratorytechnician
• Dedicatedadvancedtreatmentdiseaseclinic(stakeholderstodecidewhichday/7mebestforall)
• Reliablelaboratorysupportwith72hrVLresultturnaround7me
• HIVgenotypeasrequiredwithrapidTAT(14-21days)• Enhancedcounselingservices(HIVliteracy,mentalhealthscreening,sexualreproduc7vehealth)
12
![Page 13: Dr Daniel Mwamba, MD - Columbia Universitycquin.icap.columbia.edu/.../7.-Mwamba_CIDRZ-Zambia_FINAL.pdfThe CQUIN Learning Network Patients at High Risk: Service Delivery for Unstable](https://reader034.fdocuments.in/reader034/viewer/2022051801/5adf683e7f8b9a6e5c8c1c7e/html5/thumbnails/13.jpg)
Community-basedCareforClientsatHighRisk
• Treatmentsupporterled• Psycho-socialsupport/counseling–bothathomeatingroupadherencemee7ngs
• Homedrugdeliverywithsimplesymptomscreen(h/ofevers,nightsweats,weightloss,cough,headaches)–monthlyorperphysiciansrecommenda7on
• DBSVLcollec7onevery3months• Appointmentremindersperclinicianrecommenda7on• Groupadherencemee7ngswithincommuni7esatagreedintervals(e.g.every4or8weeks)
13
![Page 14: Dr Daniel Mwamba, MD - Columbia Universitycquin.icap.columbia.edu/.../7.-Mwamba_CIDRZ-Zambia_FINAL.pdfThe CQUIN Learning Network Patients at High Risk: Service Delivery for Unstable](https://reader034.fdocuments.in/reader034/viewer/2022051801/5adf683e7f8b9a6e5c8c1c7e/html5/thumbnails/14.jpg)
M&E
• DevelopSOPstoguidefacility-basedandcommunity-basedac7vi7es
• Adoptcurrentna7onaldatacollec7ontoolsforbothfacilityandcommunityac7vi7eswithsomerevisionsincommunitytoolstoincludehomedeliveryofART,symptomscreenandresultfeedback
• TraincliniciansinmanagementofunstableHIVpa7ents
14
![Page 15: Dr Daniel Mwamba, MD - Columbia Universitycquin.icap.columbia.edu/.../7.-Mwamba_CIDRZ-Zambia_FINAL.pdfThe CQUIN Learning Network Patients at High Risk: Service Delivery for Unstable](https://reader034.fdocuments.in/reader034/viewer/2022051801/5adf683e7f8b9a6e5c8c1c7e/html5/thumbnails/15.jpg)
Thankyou
15