The CQUIN Learning Network
Patients at High Risk: Innovations and Experience
Lucas Molfino
Medecins Sans Frontieres – MSF Mozambique July 17-19, 2017
Harare, Zimbabwe
ChamanculoProjectBackgroundCRAM-IntermediaryReferralCenter-
ü MaputoPop:1.240.000Pop.ü HIVprevalence:16,9%ü ARTCoverage:94%ü 3formerHealthAreas(newadministraOveprocesson-going)EachareahaveHospital+Primaryhealthcenters.ü MSFsupporOngChamanculoHealthareainHIV/TBcaresince2001.2003-ScaleupofHIVcaretroughverOcalapproach2006-DecentralizaOonofHIVcaretoPHC2009-CreaOonofReferralcenterofAltoMae(CRAM)duetolackofHospitalinChamanculoarea.2010-CreaOonofKaposiUnitinCRAM
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CRAMAimCRAM:
1. toprovideasafetynetfortheHCforclinicalmanagementofcomplicatedHIVpaOentsthatdonotrequirehospitalizaOon
2. toreducetheworkloadofMaputo’sreferralhospitalsCharacterisOcsofCRAM:- 6outpaOentconsultaOonrooms- 1HospitalizaOonroom(3bed-dayCareUnit)- KaposiUnit(PreparaOonroom&chemotherapyadministraOonroom)- Labpla_orm(Samedayresult)-PoC’s,RDT,biochemistry,RouOneVL-- Technicalpla_orm(ProceduresLP,pleural/peritonealtap,fibroscan)- QualifiedstaffMoH&MSF(IDMD’s,Psy,CO’s,counselors).- SOP’sforCRAMacOviOes.- Referral’sandcontra-referral'scriteriabetweenPHC–CRAM–Hospital- Pla_ormtoimplementOR/PiloOngnewstrategies/training.
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Admission&DischargeCriteriav Admission-CD4<50Cells/mlwithsignsofOI(WHOIII/IV)- SuspicionsofARTtreatmentfailureorneededof2nd/3rdARTline.- KSeligibleforChemotherapy(T1)- Pediatricscomplexcases(treatmentfailures,comorbidiOes)- SevereARTsideeffects- HIV&comorbidiOes(PWID/HCV,HBV,MHdiseases)- PaOentsincriOcalhealthcondiOon,lackingcomplementaryexaminaOons,
andinneedofmorespecializedcareorinvasivemedicalprocedures.v Discharge- ART1stline>6M- CD4>200cells/ml- UndetectableHIVVL- FuturedecentralizaOonofstable2ndlineARTpaOentstoPHC
v LinkagetoHospital
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PackageofcareatCRAM(I)v CommonpackageforallHIVpa:ents- Screening&treatmentofTB(orIPTifindicated)- ScreeningforHBV/HCVandcervicalcancer(VIA)- IntegraOonofNCD&HIV(mainlyMentalHeathdiseases)- NutriOonalassessment&support.- PaOentsupportholisOcapproach(EducaOon,EAC&psychologicalcare)- Homebasecare&palliaOvecare(medicalprogram)- TracingsystemforthoseLTFUthroughphonecalls- LinkedwithcommunityCSO’s(hospice,orfanate,PWIDnetwork)- Adherenceclub’s(2ndlinecohort)&familyapproach.- MulOdisciplinaryteamdiscussionsforcomplicatedpaOents.
v PackageforKaposiSarcomapa:ents.- Chemotherapy(MoHstandardofcare–Bleo/vincrisOne/doxorrubicine)(IntroducOonofPLD–Doxoliposomal-Greatsuccess!!)- EducaOon,counsellingandpsychologicalsupport.- LinkedwithMaputocentralhospitalfor2ndlinechemotherapy.
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PackageofcareofCRAM(II)
v AdvanceHIVdiseases-DeepclinicalexaminaOon&comprehensivenursingcare.-ScreeningforCryptoAnOgen(pre-empOvetherapy&CCMtreatment-selectedcasesfordayhospital-)-Screening&treatmentofTB–MolecularMethods,TBLAM--RapidiniOaOonofART&Intensivefollowup-CTX&OIprophylaxis
v SuspicionofARTtreatmentfailure-EACcounselling&Switchto2ndART/ARTcommioee-Fasttrackswitchto2ndLine.(LowCD4orOI)-AccesstoHIVgenotype&switchto3rdARTLine/ARTcommioee-AdvanceARTmanagementwithDrugsresistancedonebyIDMD
v KeyPop(PWID-HIV/HCVprevalence-)- Specialcare&CRAMfocalpointforthistargetpopulaOon.- Care&treatmentforHCV(newDAA’s)- StronglinkwithCSO’sworkingwithPWID.
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CRAMataglancev CRAMacOvecohort:2513paOents(8%children)-1°ART-1089/2°ART1380/3°ART44-Averageof900admissions/year&2000consultaOons/month.-68CD4cells/mlmedianatadmission.-64%male&60%receivingART.v HIVadvancediseasesub-group-Averageof270admission/year-31CD4cells/mlmedianatadmission-50%male&50%receivingART.
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Reasonofadmission 2016 2015 2014
HIVAdvancedisease 239(25%) 308(34%) 269(35%)KaposiSarcoma 254(27%) 234(26%) 290(37%)ARTTreatmentFailure 350(37%) 315(35%) 62(8%)Other 108(11%) 46(5%) 138(18%)
GrandTotal 951 903 775
CRAM–2ndlineARTcohort
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• GoodRetenOonincareinrecentyears(Includingchildren-10%cohort-)• 22%ofcohort>1000cop/mlaser6monthonARTormore.• 45Adherenceclubs(60%cohort)• DecentralizaOonprocessplanfornearfuturetoPHC.
CRAM-Kaposicohort
- PoorretenOonincare-AcOvecohortof608paOents/183onchemoox.- 1803paOentstreated(ABV)since2010/40%complete-parOalremission- IdealsetngtointroducePLD(feasibilitystudyongoing)
At6months,63%ofparOcipantshadcomplete/parOalremission,andanother16%hadstabledisease
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AdvanceHIVdiseasecohort
-PoorRetenOoninCare(Mortality>LTFU)- SystemaOcscreeningforOI(TBLAM&cripto)- AmbulatorytreatmentofCCMforselectedpaOents.- TB,CCM,wasOngsyndrome,anemiamainreasontohospital
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HIV/HCVPWID
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I.
II.
III.
HEPATITISCdiagnosis,enrolmentandtreatment
71VHCRDTsPositive 5HIVneg
61CVresult3waitingtocollect5waitingresults
1LFU1dead
51CVdetected(85%)88%GNT1a
38patientsenrolled
10CVnotdetected4HIVneg1dead
Among35HIV+enrolled,14wereinitiatedontreatmentsince
Dec2016(12patientsJan-June2017)
Among 14 patients initiated on treatment 2 SVR12 (cured)
2 finished treatment 10 are still on treatment
Ø12male,2female-MedianAge:32yearsØ12ex-drugusers;1activedruguser;1non-druguser(druguserpartner)Ø3patientsF3-F4byFibroscanØMedianCD4:211cel/mm3(range169-1034)
Patientnoteligiblefortreatment*3willstartinJuly*3onTBtreatment;*2withKS*1patientwithcomorbidities*5onTARV<6months*3workingoutofarea*3activeDUnonadherent*1inprison
Challenges&limitaOons- Latearrivals&highmortality- LackofawarenessofdangersignsofpaOents- HighaoriOonrateinspecificgroupsKS,advancedisease- HighVLdetectabilityrates(adherence/resistance?)- ScreeningofothersOI(Toxo,CMV)- ManagementofpaOentwithpreviousexposuretoART- ImplementaOonofOIProphylaxis(IPT,Extendedprophylaxis)- DecentralizaOonof2ndlineARTcohort(stablepaOents)- IntegraOngHIV&NCDservices(CVD,DBT)- PaOentswithacuteclinicalcondiOonsthatneedshorttermobservaOon.àNotcapacityfor24/7funcOoningforobservaOon.- LinkagetomainHospitalàReferralbetweenCRAM&Hospitals.àLinkagetoCRAMaserhospitaldischarge.-Lackofsupportofdonors/partnersinvolvedinHIVadvancecare.
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CRAMasamodelofcareforAdvanceHIV
disease?AddedvalueofCRAM–intermediaryfacility-inaurbansetngwith
highHIVprevalence?
OngoingDebate…Sustainability
cost-effecOvenessproporOonofpaOentsthatneedshortperiodofhospitalizaOon
geographicallocaOonofthisfacilityspectrumofacOviOesbeyondHIV.
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