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[e-med] Espacer les visites et des dispensations dans le cadre de la prise en charge du VIH

Chers lecteurs de emed

Je vous partage un article qui pourrait intéresser certains d'entre vous
car il pose plusieurs questions sur la simplification des circuits de
soins dans la prise en charge des maladies chroniques et pourrait donc
servir à certains.

La revue JAIDS (J Acquir Immune DeÞc Syndr) a publié dans son numéro de
juin un article sur un travail initialement présenté à la conférence
africaine sur le VIH SIDA et les IST à l'ICASA de 2013 (Anna Grimsrud et
al. Extending Dispensing Intervals for Stable Patients on ART J Acquir
Immune Defic Syndr Volume 66, Number 2, June 1, 2014, pages e58-59;
l'article ci-dessous). Il s'agit d'un travail mené en Afrique du Sud dans
la région du Cap dans des structures de santé appuyées par MSF et la
fondation Desmond Tutu sur le VIH.

Cette étude a été menée en 2012/2013 avec pour objectif de comparer les
résultats virologiques et en termes de rétention chez des membres de club
d'observance entre des dispensations d'ARV espacées de 2 mois ou de 4 mois.
Notons que le travail de ces clubs d'observance est assez spécifique à ce
contexte.

Il est détaillé dans un récent rapport de MSF
http://www.msf.fr/sites/www.msf.fr/files/plus_pres_des_patients_avril_2014_
web.pdf, dont est extrait le paragraphe suivant :
Le modèle des clubs d¹observance s¹articule autour de trois principes clés
:
? Distribution en groupe des médicaments fournis au niveau du centre de
santé ou à l¹échelon
communautaire pour les patients stables sous ARV
? Les conseillers communautaires distribuent les médicaments, pèsent les
patients et évaluent
leur état de santé général sur base des symptômes
? Soutien par les pairs assuré par le conseiller et le groupe au moment de
la distribution des
médicaments

Les patients sont éligibles pour rentrer dans les clubs d'observance s'ils
ont le même traitement depuis un an et s'ils ont eu 2 charges virales
indétectables.

Cette étude s'est faite avec 1860 patients répartis sur 2 sites de prises
en charge.

Les résultats de ce travail ne montre pas de différences significatives
entre les 2 modèles dispensation 2 ou 4 mois.

Même si ce travail nécessite des recherches complémentaires il soulève
clairement la question de l'espacement des visites et des dispensations
dans le cadre de la prise en charge du VIH.

Dans une majorité de pays d'Afrique de l'Ouest, les dispensations se font
encore mensuellement. (en France aussi d'ailleurs pour des raisons
administratives liées à la Sécurité sociale) Un tel travail montre ainsi
qu'espacer les dispensations est possible (l'Afrique du Sud ayant déjà
pour standard 2 mois d'espacement) et cet espacement n'est pas péjoratif
pour les patients s'ils sont bien préparés et adhérents.

Outre l'avantage que ça peut avoir pour les patients (pas uniquement VIH
mais vivant avec une maladie chronique), l'espacement des visites peut
également alléger le travail des équipes de prise en charge et des
pharmaciens/dispensateurs notamment. En allégeant la charge de travail, on
peut faire l'hypothèse que l'on permet au pharmacien / dispensateur d'être
plus disponible, moins saturé et de mieux faire son travail de bonnes
pratiques de dispensation (bien que ça reste à montrer) Cet article peut
donc être utile à certains d'entre vous pour porter ces messages dans les
équipes de prise en charge pour simplifier les circuits de prise en charge)
Par ailleurs ce travail (et le rapport de MSF mentionné plus haut) montre
que des modèles innovants d'accompagnement des patients sont possibles.

Bien à vous  

Etienne

Etienne GUILLARD
PharmD - MSc | Directeur du Département Pharmacie | Pharmacy Department
Director
SOLTHIS | www.solthis.org

Tél : +33 (0)1 53 61 53 64 | Mob : +33 (0)6 82 85 26 00 | e-mail :
etienne.guillard@solthis.org | Skype : etienneguillardsolthis
________________________________________

Extending dispensing intervals for stable patients on ART
J Acquir Immune DeÞc Syndr  Volume 66, Number 2, June 1, 2014

Anna Grimsrud1, Gabriela Patten2, Joseph Sharp3, Landon Myer1, Lynne
Wilkinson2, Linda-Gail Bekker3,4
1Division of Epidemiology & Biostatistics, School of Public Health & Family
Medicine, University of Cape Town, 2Médecins Sans Frontières South Africa,
3Desmond Tutu HIV Foundation, 4Department of Medicine, University of Cape
Town.

Extending dispensing intervals for stable patients on ART
Over the past decade, antiretroviral therapy (ART) programs have been
rapidly
expanded in resource-limited settings. South Africa has the largest ART
program
in the world with nearly 2 million people accessing treatment1. ART
Adherence
Clubs (ACs) have been implemented in the Western Cape of South Africa to
improve long-term retention in care for stable ART patients by providing
quick
and patient friendly access to treatment and care whilst decreasing the
burden
on overstretched healthcare facilities.

ACs are facilitated by a lay club facilitator and consist of approximately
30 stable
patients who meet every 2-months either at the health facility or in a
community
venue. Patients are eligible to join an AC if they have been on the same
ART
regimen for 12 months or more, have had two consecutive undetectable viral
loads and do not have any other medical condition requiring more frequent
follow-up. Each visit consists of a quick clinical assessment and on-site
dispensation of pre-packed ART with a nurse available for referral as
necessary2.
Early evidence suggests ACs are effective in retaining stable patients in
care with
high levels of virologic suppression3.

Migration is common in sub-Saharan Africa where patients move away from
home for economic reasons. This movement results in circular migration
patterns that impact adherence and retention in antiretroviral care. In the
Western Cape many patients return to their province of origin over the
holiday
period of December/January and do not seek care while away. This migration
puts patients at risk of ART interruptions and defaulting care especially
when
time away from the Western Cape is extended beyond the period initially
intended due to unforeseen circumstances 4. The extent of this seasonal
migration has not been quantified, but experience at the clinics suggests
that the
majority of patients are affected.

Current ART pharmacy guidelines in South Africa require ART scripts to be
written every 6-months despite national adult ART guidelines only
requiring an
annual clinical assessment for stable ART patients. While national policy
allows
3-month dispensing, there is great variation between provinces and
individual
facilities. Accordingly, stable patients in the Western Cape receive a
maximum of
2-months of ART per visit. To support ART patients who most commonly
migrate over the holiday period, ACs that were scheduled to meet between
mid-
December 2012 and mid-January 2013 were given 4-months ART in their
October/November 2012 AC visit. Four-months of ART were dispensed as two
2-monthly supplies to align with national policy. Data are limited on how
long
ART dispensing intervals should be to optimise retention in care. The
objective
was to compare outcomes among AC members who received 2-months ART
(normal standard of care) to 4-months ART.

The Hannan Crusaid Treatment Centre in Gugulethu and Ubuntu Site B Clinic
in
Khayelitsha are large treatment facilities in peri-urban, high-prevalence
areas of
Cape Town South Africa. Both services have been described in detail
previously
and are or have previously been supported by the non-governmental
organizations Desmond Tutu HIV Foundation and Médecins Sans Frontières
South Africa, respectively5-11.
All adult ACs at the Hannan Crusaid Treatment Centre and Ubuntu Site B
Clinic in
Khayelitsha who were enrolled in an AC before the end of 2012 were
included in
the analysis. Adult ACs includes stable patients ? 18 years of age. AC
procedures
at the two sites are similar.

Data presented includes the number and proportion of patients receiving
each
interval of ARVs overall and by site. ACs were assigned to receive either
4-
months or 2-months of treatment based on when their December/January visit
was scheduled. ACs with a scheduled visit between the 17 December and 18
January were assigned to the 4-month group. Outcomes of patients who
received two 2-month prescriptions simultaneously (i.e. 4-months) of ART
(group A) are compared to those who received the standard 2-months of ART
(group B). Outcomes include the proportion of patients defaulting from ACs
4
months after their last 2012 visit and for those with blood results in
2013, the
proportion of patients who were not virally suppressed (viral load above
400
copies/mL). Associations by group were assessed with chi-squared tests.
A total of 1866 patients in one of 76 ACs were eligible for the analysis
(Table 1).
Over the holiday period, 42 ACs were given 4-months of ART and 34 ACs were
given 2-months ART. Four months after the final AC visit in 2012, 4.0% had
defaulted care overall [Group A: 41 of 1054 (3.9%), Group B: 33 of 806
(4.1%)].

There was no difference in the risk of defaulting from an AC in Group A who
received 4-months of ART compared with Group B who received 2-months of
ART (Risk Ratio: 0.95, 95% CI 0.61-1.49, p-value=0.82). Of the 1507 of
patients
with a blood draw at their first or second 2013 visit, 3.6% were not
virally
suppressed [Group A: 31 of 842 (3.7%), Group B: 23 of 665 (3.5%)]. No
significant associations were observed between viral suppression and group
(Risk Ratio: 1.06, 95% CI 0.63-1.81, p-value=0.82). Between the last visit
of 2012
and the first schedule visit of 2013, none of the club patients died.

This analysis was limited to two sites where 4-months of ART was provided
to
those clubs whose 2 month return date would have fallen in December or the
first part of January. We only compared the short-term outcomes of the two
groups. There was some variability in the proportion of patients
defaulting in the
two arms between sites. The small sample size restricted our ability to
determine if these differences were meaningful. While both sites were
utilizing
the standardized Adherence Club model, there is potential for some factors
to
differ at the site level. Clubs in the two arms may have been operational
for
different amounts of time. A limitation of our data is that we only looked
at
extending one refill interval and therefore further research is needed to
ascertain the impact of regular longer supply intervals.

Short-term outcomes among all AC patients were good with no difference in
defaulting or viral suppression between groups. Longer ART supply refill
intervals over holiday periods can support the extensive circular migration
amongst patient populations without having a negative impact on patient
outcomes. These findings also suggest that less frequent visits for stable
ART
patients should be evaluated as regular practice in order to alleviate an
unnecessary burden on patients and clinic resources.

References
1. Johnson L. Access to antiretroviral treatment in South Africa, 2004 -
2011.
Southern African Journal of HIV Medicine. 2012;13(1):22-27.
2. Wilkinson LS. ART adherence clubs: A long-term retention strategy for
clinically stable patients receiving antiretroviral therapy. South African
Journal of HIV Medicine. 2013;14(2):48-50.
3. Luque-Fernandez MA, Van Cutsem G, Goemaere E, et al. Effectiveness of
patient adherence groups as a model of care for stable patients on
antiretroviral therapy in Khayelitsha, Cape Town, South Africa. PLoS One.
2013;8(2):e56088.
4. Orrell C, Dipenaar R, Killa N, Tassie JM, Harries AD, Wood R.
Simplifying
HIV Cohort Monitoring - pharmacy stock records minimise resources
necessary to determine retention in care. J Acquir Immune Defic Syndr.
Nov 26 2012.
5. Bekker LG, Orrell C, Reader L, et al. Antiretroviral therapy in a
community
clinic--early lessons from a pilot project. S Afr Med J. 2003;93:458-462.
6. Kaplan R, Orrell C, Zwane E, Bekker L-G, Wood R. Loss to follow-up and
mortality among pregnant women referred to a community clinic for
antiretroviral treatment. AIDS (London, England). 2008;22:1679-1681.
7. Lawn SD, Myer L, Harling G, Orrell C, Bekker LG. Determinants of
mortality and nondeath losses from an antiretroviral treatment service in
South Africa: implications for program evaluation. Clinical Infectious
Diseases. 2006;43:770-776.
8. Nglazi MD, Lawn SD, Kaplan R, et al. Changes in programmatic outcomes
during 7 years of scale-up at a community-based antiretroviral treatment
service in South Africa. J Acquir Immune Defic Syndr. Jan 2011;56(1):e1-8.
9. Boulle A, Van Cutsem G, Hilderbrand K, et al. Seven-year experience of a
primary care antiretroviral treatment programme in Khayelitsha, South
Africa. Aids. 2010;24:563-572.
10. Van Cutsem G, Ford N, Hildebrand K, et al. Correcting for Mortality
Among
Patients Lost to Follow Up on Antiretroviral Therapy in South Africa: A
Cohort Analysis. PLoS One. 2011;6(2):e14684.
11. Coetzee D, Hildebrand K, Boulle A, et al. Outcomes after two years of
providing antiretroviral treatment in Khayelitsha, South Africa. Aids.
2004;18:887-895.




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