Ryan White @ AIDS 2012: The World Links
African nations and American agencies, particularly Ryan White programs, are using some of the same techniques to engage people in care, like follow-up with clients, peer advocates, technology. All are seemingly good ideas. The trick is to determine what works, in what combination, and with what individuals and populations. Here are some findings from Starting and Staying on Course: HIV Linkage and Retention in Care (WEAE02) and observations on similar work in the U.S. under Ryan White.
- Peer Support: The first HIV drug regimens in the 1990s were handfuls of pills, some taken with food, some without. With combination drug pills, things are much simpler now. But adherence still matters and is still tough going for some people, whether it’s managing high cholesterol or HIV disease. South Africa uses community-based adherence-support (CBAS) workers to conduct home visits and deal with adherence challenges (Community-Based Adherence Support Associated with Improved Virological Suppression in Adults Receiving Antiretroviral Treatment, WEAE0204). Their results show that the cohort receiving added support achieved better rates of viral suppression, statistically-significant, as compared to non-supported patients. Similar projects exist in the U.S. and are typically called peer educators and treatment advocates.
- Tracking and Follow-Up: Malawi’s Back to Care project uses an electronic data system (with unique identifiers) and patient tracing (via phone calls and home visits) to engage and re-engage children in care through their caregivers. After tracing, the project reduced loss to follow-up by 62% (Risk Factors and True Outcomes of Children Lost to Follow-Up from Antiretroviral Therapy in Lilongwe, Malawi, WEAE0203). Equally important: the data system is helping Malawi learn what factors are causing loss to care so that changes can be made in response. The same can be said for the client level data system (RSR or Ryan White Services Report) of the Ryan White program, which is providing grantees with new tools to monitor and improve their work.
- Improving Lab Services: While the U.S. and Africa are using similar techniques to engage people in care, African nations have an added set of unique system challenges, like laboratory services. In Nigeria, people were being lost to follow-up because of inefficiencies and long wait times for processing of CD4 results by laboratory services. Data clerks now fill out lab request forms instead of very busy and scarce doctors. Lab technicians underwent extensive training on use of automated equipment to record CD4 results. CD4 results can now be turned around in 24 hours instead of 7 days. And more. Their results are impressive. For example, the percent of clients lost to follow up went from 58.7% to 10.7% (A Laboratory-based Approach to Reduce Loss to Follow-Up of HIV-Positive Clients, WEAE0202). On the Ryan White side, integration of laboratory data tracking in part of the CAREWare software system that is used to manage and monitor clinical and supportive care.