Welcome to I-TECH India

National Distance Learning Seminar Series

Date : 21-08-2018
Time : 2 PM - 3 PM
Title: Multi Month Dispensation (MMD)
Speaker:
Dr R S Gupta, DDG (CST)
Dr Manish Bamrotiya, NPO (CST)
Current Status: India’s 90-90-90 targets
Beyond Target of 90-90-90 To be Achieved by 2020 Achieved as on Mar-2018

0.20

0.50

2.1
1.7
1.50
(80%) 1.2
(58%)

Estimated HIV positive people Estimated Diagnosed On ART Viral suppression

 Patient flow dynamics impacting Second 90
Pre-ART

F-ICTC ICTC ARTC ART Initiation

Linkage loss

Pre-ART Defaulter
LFU Tracking
Second 9 (81% of total estimated)

Current Second 90 (58%)

LFU Pool ART LFU Deaths

Biggest Challenge

• Even though we keep on

adding new client to service
pool

• Significant loss at various

stages

• Biggest loss in Retaining and

Maintaining Adherence
 National cascade - India
Diagnosed at ICTC : 1,90,387 100

Registered at ART center : 1,72,418 ( 91%) 91

Initiated on ART : 1,50,222 ( 87%) 79

Retention will be calculated once cohort completes 12 month.

Retention rate for Cohort of Jan-Dec 2016 is 72 % as per IMS 57
Data.
Experience so Far ..
 Increasing patient load – decreasing time per patient – impacts
quality of care
 HR issues – Vacancy and Trainings
 Certain population are more vulnerable to be Lost / died
 Certain periods have more vulnerability of becoming LFU
 Every one – Same Package –
Need to Differentiate
Differentiated Care
Differentiated care is a client - centered approach that simplifies
and adapts HIV services across the cascade to reflect the preferences
and expectations of various groups of people living with HIV
(PLHIV) while reducing unnecessary burdens on the health system.
“It’s not about everybody getting the same thing. It’s about everybody getting what they need in
order to improve the quality of their situation.”
Cynthia Silvia Parker, Interaction Institute for Social Change

Image : “Interaction Institute for Social Change | Artist: Angus Maguire.”

 Diversity of Needs
Presenting well
Presenting with First 12 months of Stable clients Unstable clients
at time advanced
of disease: ART: • Constitutes app
registration: • Proper and 67% of OPD • Proper and
specialized • Active follow up • Needs care sos specialized care
• Proper medical care • Counselling • Thorough • Advanced
counselling• OI Management • Side effect examination disease
• ART • ART Initiation management once in six management
Initiation • Constitutes app • Constitutes app months • OI Management
• Constitutes 2-3 % of total 14 % of total • Constitutes app
app 2-3 % of OPD OPD 15 % of total
total OPD OPD
Comprehensive Care Package
ART Preparedness
Phase
• Advanced Disease
Package
• Early ART Initiation
On-ART Intensive Phase
• Focused counselling and
intensive follow-up
• Side Effect Management
• Adherence Monitoring
Long Term Retention Phase
Stable Patients
• Multi-month dispensation
• Patient Fact-tracking
• Dispensation at CSC, TI,
LAC

HIV ART 12 Healthy

Diagnosis Initiation month Patient

Unstable Patient
• Medical Support (ADP)
• Psycho-social Support
Multi Month Dispensation
 Dispensation of more then one month drugs / therapy
 Generally for maintenance therapy in “chronic manageable disease”
 For clients who are doing well on treatment
 NACO has approved, 2 months dispensation in past
Multi Month Dispensation
◦ Reduction in travelling and waiting time of patients

◦ Efficient patient management at ART centers

◦ Increasing retention of PLHIV under program

◦ Enhancing adherence to treatment amongst PLHIV and

◦ Improving overall quality of ART services

MMD - Overview
The patient has to come under eligibility criteria before prescribing
ARV under MMD
The patients should be willing and have consented for getting
enrolled under MMD
This revised guideline currently implies only for TLE regimen, ARV
drugs stock availability should be confirmed by the ARTC with
SACS before starting MMD.
MMD does not imply during unavailability of adequate stock of ARV.
“Stable On ART”
On ART for at least 1 year
No major opportunistic infections (Clinical stage I / II)
No ARV side effects / co-morbidities requiring regular evaluations (eg:
chronic liver or renal disease, DM, severe hypertension etc.)
Good adherence to the treatment (adherence of more than or equal to 95 %
consequently over the last 3 months)
Good understanding of life long therapy
No evidence of immunological suppression (CD4 rising trend and recent CD4
above 350, recent CD4 shall be considered as CD4 done within last three
months)
Eligible for MMD
“Stable on ART” as per criteria
On TLE regimen
Not on any prophylaxis (IPT/CPT/Fluconazole)
Willing to get three-month dispensation
Have verified phone numbers and valid proof of address submitted as
per NACO ART guidelines
Standard Operating Procedure (SOP)
The flow of patients, 4S screening, Clinical monitoring, all laboratory
investigations, CD4 tests, viral load test shall be continued for all
PLHIV as per current guidelines and no deviation shall be done.
Patients during his/her visit at ART center shall follows the routine
patient flow as per operational guidelines.
The following steps are complimentary to existing operational
guidelines
SOP
When patient visit counselor, he/she will assess the patient on following criteria
◦ Patient has completed at least one year on ART
◦ Has adherence of >95% for last three consecutive months
◦ Good understanding of life long therapy
◦ On TLE regimen
◦ No major OI / No side effect
◦ Recent CD4 above 350 (done within last three months) with rising trend
◦ Willingness for getting three-month dispensation
Patient meeting all these criteria may be labelled as eligible for MMD in green
book along with detailed counselling notes
 
SOP
When patient visit counselor, he/she will assess the patient on following criteria

◦ Patient has completed at least one year on ART

◦ Has adherence of >95% for last three consecutive months
◦ Good understanding of life long therapy
◦ On TLE regimen
◦ No major OI / No side effect
◦ Recent CD4 above 350 (done within last three months) with rising trend
◦ Willingness for getting three-month dispensation
 
SOP
Patient meeting all these criteria may be labelled as eligible for MMD
in green book along with detailed counselling notes
 
Those who are “not stable” should be counseled accordingly to
address the issues.
 
Counsellor fills the registers as per existing guidelines.
SOP
When patient visits Medical Officer, Medical Officer ensures following:
◦ WHO clinical stage I /II
◦ No major OIs
◦ No side effects / co morbidities
◦ Latest CD4 above 350 (within last three months) with rising trend
◦ Verify that adherence is more then 95% for last three consecutive
months.
◦ Patients understand concept of life long therapy
◦ Reconfirm willingness.
SOP
If all these are fulfilled, Medical officer prescribes TLE for three
months (90 days) and suggests next due date after 88 days. Medical
Officer to mention this specifically in white card in Section 13,
column number 10 (Anti retro viral drugs) as TLE – 3MD.
 
Those who are not “stable on ART” due to medical reasons should be
managed accordingly
SOP
Pharmacist dispense TLE for three months and records this in
dispensing register and IMS.

White card of these clients to be entered in Master Line List by Data

Managers. The column of date of visit, next visit and Regimen shall
be properly filled and regularly updated.

The proper due date shall be noted in routine due list of the center.
SOP - Monitoring / Follow up visits
Patient prescribed MMD should be proactively followed up and monitored
for adherence and on-time visits.
 
ART center CCC / counselor, may remind them regarding their scheduled
visit.
 
Patient will follow the routine patient flow and all other steps like 4S
screening / clinical examination / lab testing / etc shall be done as per
existing guidelines
SOP - Monitoring / Follow up visits
During visit to counselor, adherence will be assessed properly for three
months along with all other criteria mentioned above.
Counselor shall complete the documentation in register. Under column
20 (OT/A), MMD can be mentioned for the months when visit was not
scheduled.
Patient visits Medical officer and MO ensures that all the above-
mentioned criteria are being fulfilled. MMD may be continued as per
final assessment by MO.
SOP - Monitoring / Follow up visits
In case patient does not meet the criteria / have adherence issues / OI,
MMD may be discontinued and patient may be prescribed one-month
drugs as per routine guidelines.
If patients on MMD does not turn up for drug pick up, same existing
guidelines of tracking shall be followed up, like:
◦ Call shall be made with in 48 hours of missed appointment
◦ Name shall be shared with CSC for home visits
Labelling of Miss /LFU shall be same as per existing guidelines.
Frequently Asked Question
Stocks:
If done properly in a planned way, MMD does not increase consumption
significantly.
There might be some increase in first three months, however consumption
trends tend to stabilize later on.
All SACS / ART centers need to ensure that at least 3 months buffer stock is
available before starting MMD.

 
 Ineligible
Group-1 Group-2 Group-3
Number of months Patients
Total ARV
of ARVs given in
Dispensed
particular month 31% 23% 23% 23%

Month 1 1 3 1 1 1.46
Month 2 1 0 3 1 1.23
Month 3 1 0 0 3 1
Month 4 1 3 0 0 1
Month 5 1 0 3 0 1
Month 6 1 0 0 3 1
Month 7 1 3 0 0 1
Month 8 1 0 3 0 1
Month 9 1 0 0 3 1
Month 10 1 3 0 0 1
Month 11 1 0 3 0 1
Month 12 1 0 0 3 1
Total ARVs dispensed in 12 months 12.69
Frequently Asked Question
MMD for regimens other than TLE: Since the concept is being
rolled out recently, NACO plans to implement it in phased manner.
Currently it is applicable for eligible patients on TLE regimen only, for
another regimens guidance will be shared subsequently.
Family: If people of same family are on different regimen and wants
to get MMD then first it shall be ensured that all members are “stable
on ART”. If all are “stable on ART” but are on regimens other then
TLE, in such cases, MO can take decision on case to case basis after
discussion with concerned JD / RC.
Frequently Asked Question
ANC / Breast Feeding women:
Pregnant women / breastfeeding women may not be required to
physically travel to ART centers for refilling of ART, particularly in
third trimester and first three-month post-partum (irrespective of
eligibility criteria and regimen).
ART centers may provide three-month refill to women / relative of
women during this period.
ART centers shall share the details of above clients with CSC and
ORW shall do home visit for adherence support.
Frequently Asked Question
Adherence Calculation: Adherence shall be calculated as per existing
practice for three months. The formula used for this is
( No of Pill actually have taken / No of pill should have taken)X 100
 
Definition of Miss / LFU for PLHIV under MMD: The definition
remains the same as per current guidelines. If patient misses his visits for
three consecutive visits, he/she shall be mentioned as Miss for fourth
month onward he/she shall be termed as LFU.
 
Frequently Asked Question
 
Link ART Centers: Currently the concept of MMD is only for ART. It
will be scaled up based on learnings and experience to LAC
subsequently.
 
Proxy: Patient who does not comes to ART for his refills personally
and sends someone else shall not be considered for MMD. However,
MO may take final decision on case to case basis after due
consideration of all aspects.
For Feedback or any assistance, you may contact
Dr Manish Bamrotiya – bamrotiya.manish@gmail