Download Initiation of Antiretroviral Therapy in HIV-Infected Adults

Task shifting and sharing for distributing antiretroviral
medications to patients living with HIV:
Systematic review and meta-analysis
Wiysonge, Charles Shey1,2, Mbeye, Nyanyiwe1,2, Adetokunboh, Olatunji1,2, Meg Doherty 3,
Negussie, Eyerusalem3, Kredo, Tamara2
1Stellenbosch
University, Centre for Evidence-based Health Care, Cape Town, South Africa,
2South African Medical Research Council, Cochrane South Africa, Cape Town, South Africa,
3HIV/AIDS department, World Health Organization, Geneva, Switzerland
Outline
 Progress and challenges – HIV treatment
– Pharmacy health workforce and medication pickup
 Systematic review
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–
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Objective
Search strategy, study selection, prisma flow,
Findings
Conclusion
Policy and programme implications
 Acknowledgements
2|
Results
Policies adopted in 144 LMIC
6% - treat all
53% - CD4 < 500
3|
ICASA 2015
WHO Consolidated guidelines on the use of
ARV drugs for treating and preventing HIV
4|
ICASA 2015
Pharmacy health workforce in high HIV burden settings:
Long waiting time to pick ARV and
 Improving efficiency of services and people-centred
care are important aspects of chronic HIV care.
 Several high HIV burden countries experience
shortage of health workforce, including for
providing essential pharmacy services.
 Long facility waiting time often discourages patients
to return back, due to direct or indirect costs of
care for patients.
 Some high burden countries already implementing
alternative models of community ARV distribution
by lay providers
5|
Frequency of ARV pickups common practice in
selected countries in Southern Africa:
3 monthly
1 - 3 monthly
Monthly
1 - 2 monthly
6|
Adapted from Eric G presentation. WHO GDG
meeting, July 2015.
The Guy Who Delivers HIV Medicine On His Bicycle:
Sizwe Nzima, right, and one of his six employees deliver
medicines to patients in a Cape Town neighborhood.
Anders Kelto for NPR
Systematic Review
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Objectives of systematic review
 Earlier evidence review on task sharing and shifting for HIV care and
ART focused clinical services where nurses and non-clinician
physicians provide care in several countries.
 The objective of this review is to evaluate the efficacy of sharing
and shifting tasks of distributing ART to lay providers in community
settings.
 This move could support in reducing facility patient load in high
burden settings where there is also health workforce shortage.
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Method and Searches
 1996- 2015 March
 Any language eligible
DATABASES
 Cochrane Central Register, PsycINFO,
PubMed, Web of Science, WHO Global
Health Library
 Bibliographies of included studies;
other systematic reviews
 Consultation of experts in the field
CONFERENCES
 International AIDS Conferences, IAS
pathogenesis, CROI
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Searc
h
Core PubMed strategy
(modified and adapted as needed for use in the other databases)
#4 #1 AND #2 AND #3
#3 ((HIV Infections[MeSH] OR HIV[MeSH] OR hiv[tiab] OR hiv-1[tiab] OR hiv-2*[tiab] OR
hiv1[tiab] OR hiv2[tiab] OR hiv infect*[tiab] OR human immunodeficiency virus[tiab]OR
human immune deficiency virus[tiab] OR human immuno-deficiency virus[tiab] OR
human immune-deficiency virus[tiab] OR ((human immun*) AND(deficiency virus[tiab]))
OR acquired immunodeficiency syndromes[tiab] OR acquired immune deficiency
syndrome[tiab] OR acquired immuno-deficiency syndrome[ tiab] OR acquired immunedeficiency syndrome[ tiab] OR ((acquired immun*) AND (deficiency syndrome[tiab])) or
“sexually transmitted diseases, viral”[mh]) OR HIV[tiab] OR HIV/AIDS[tiab] OR HIVinfected[tiab] OR HIV[title] OR HIV/AIDS[title] OR HIV-infected[title]) AND ((HAART[tiab]
OR ART[tiab] OR cART[tiab] OR antiretroviral[tiab] OR anti-retroviral[tiab] OR antiviral[tiab] OR antiviral[tiab] OR "Antiretroviral Therapy, Highly Active"[Mesh]))
#2 randomized controlled trial[pt] OR controlled clinical trial[pt] OR randomized controlled
trials[MeSH] OR random allocation[MeSH] OR double-blind method[MeSH] OR singleblind method[MeSH] OR clinical trial[pt] OR clinical trials[MeSH] OR ("clinical trial"[tw])
OR ((singl*[tw] OR doubl*[tw] OR trebl*[tw] OR tripl*[tw]) AND (mask*[tw] OR blind*[tw]))
OR random*[tw] OR research design[mh:noexp] OR prospective studies[MeSH] OR
control*[tw] OR volunteer*[tw]) OR observational[tw] OR non-random*[tw] OR
nonrandom*[tw] OR before after study[tw] OR time series[tw] OR cohort*[tw] OR crosssection*[tw] OR prospective*[tw] OR retrospective*[tw] OR research design[mh:noexp]
OR follow-up studies[MeSH] OR longitud*[tw] OR evaluat*[tiab] OR pre-post[tw] OR
(pre-test[tw] AND post-test[tw]) NOT (animals[MeSH] NOT human[MeSH])
#1 (task*[tiab] OR task-shifting[tiab] OR referr*[tiab] OR referral and consultation[mh] OR
role*[tiab]) AND (health personnel[mh] OR doctor[tiab] OR doctors[tiab] OR
clinician[tiab] OR clinicians[tiab] OR physician[tiab] OR physicians[tiab] OR "healthcare
provider"[tiab] OR "healthcare providers"[tiab] OR "health care provider"[tiab] OR "health
care providers"[tiab] OR pharmac*[tiab] OR apothecar*[tiab] OR chemist*[tiab] OR
dispensar*[tiab])
Study selection
• References from all databases
combined in EndNote X6 and
duplicates removed
• One author reviewing titles excluded
clearly irrelevant records
• Two authors working independently
applied inclusion criteria in reviewing
titles, abstracts and keywords of all
records
• Full texts examined by two authors
independently if any doubt
• TWO studies met inclusion criteria
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Systematic review findings
 Two studies with cluster randomized trials met
inclusion criteria.
 Both studies are from sub-Saharan Africa – Kenya and
Uganda.
 Both studies enrolled non-pregnant adults living with
HIV.
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Evidence Summary: Risk of death, lost to follow
up or virologic supression
Moderate quality evidence
reveals no risk of death with
task shifting as compared to
those receiving care in facility (2
cluster randomized studies)
Moderate quality evidence
reveals no for risk of lost to
follow up with task shifting
as compared to compared to
those receiving care in facility
(2 cluster randomized
studies)
12 |
Mortality
Loss to follow up
CI confidence interval; df, degrees of freedom;
Evidence Summary: Risk of death, lost to follow
up or virologic supression
Virologic supression
Moderate quality evidence
reveals no risk of
decreased virologic
supression with task
shifing as compared to
those receiving care in
facility (2 cluster
randomized studies)
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CI confidence interval; df, degrees of freedom;
Trained lay providers can distribute ARVs in
community settings
• Trained and supervised lay
providers can distribute ARV in
community settings (strong, low)
• Less frequent clinic visits (3-6 months)
(strong, moderate) and
• Less frequent medication pick up visits (36 months) (strong, low) for patients stable
on ART can contribute in reducing long
queues in facilities and reduce cost of care
for patients.
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ICASA 2015
Service Delivery Approaches to Treat All
 The HOW: Differentiated care interventions:
Early
Advanced
Stable
Unstable
• Adherence & retention support
• Minimal clinical package to reduce M&M
• Simplified ART delivery- Differentiated Care
Models
• Adherence vs switch
The Package of Care for stable
• Less frequent (3-6 months)
clinical visits
• Less frequent (3-6 months) ART
refills
• Community based differentiated
care
• CD4 monitoring stopped where
viral load available
The Package of Care for advanced
disease :
• Rapid Initiation of ART
• Cryptococcus antigen screening
• TB screening following by IPT
• Screening for toxoplasmosis and
cotrimoxazole prophylaxis
• Intensive follow-up
Conclusions
 There is no significant difference in mortality, viral suppression, and
loss to follow up between facility and community-based ARV
distribution by lay providers in both studies.
 In both studies, interventions were implemented as part of broader
community and home based HIV treatment programme.
 In both trials trained lay providers (i.e. non-health professionals)
distributed pre-packaged ARV to patients and were supported,
including for back referral of patients when required.
 The study population included only non-pregnant adults, who were
on ART.
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Policy and programmes implications
 Spaced clinic and pharmacy pickup visits
with community ARV distribution models,
linked with health facilities can safely be
delivered in similar settings;
 Training, supervision and recognition of lay
providers is essential for success;
 Strengthening patient monitoring and
referral systems, including at community
level is critical;
 Dependable drug supply system to prevent
ARV stock outs is essential.
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Acknowledgement
 World Health Organization
 PAPFAR through USAID and the BMGF for
funding the systematic review.
 The 2015 WHO ARV guidelines development
group.
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