 Our next speaker is Emily Vinat. Emily has been working for MSF since 2012. She's currently working as a qualitative research MIO. Emily, please. All right, good morning, everyone. We're now going to move over to Kenya, where I'm going to talk to you about a model that we call Medication Adherence Clubs, or MAX. And this is in Kibera, the informal settlement in Nairobi. So just to give you a bit of background, we know that there are 13 million people around the world on lifelong ART. And over time, we've seen the ways of delivering ART adapted, and they've become more innovative. MSF has done this very, very well and helped provide treatment to large numbers of stable patients. We've introduced things such as longer drug refills, so patients don't have to come in so often. Patients can collect drugs in clinic-based clubs or in the community in some settings in Southern Africa. And what we saw in Kibera, in Kenya, is this growing burden of NCDs, particularly diabetes type 2 and hypertension. So the idea was to take this model, to take the club model that's been used in other settings and apply the lessons from that to NCD cohorts as well as HIV ones. So the research that I'm talking about today actually comes from two different studies that were conducted in Kibera South Clinic. Both of them were really looking at implementation. So I was focused more on the qualitative side, looking at the acceptability of this model. And one of my colleagues collected data from the first 12 months of implementation, from August 2013 to 2014. I was in Kibera at the beginning of this year to do the qualitative part of the study, which involved in-depth interviews, focus groups and participant observation, both with healthcare workers and with patients. And we took patients who were in the max, who were in the medication adherence clubs, as well as those who weren't in the max to get both perspectives. And you can just see a breakdown there of who actually took part in the different bits of the research. So what exactly is this max model of care? The max were introduced in 2013, and some of you might be familiar with clubs. Basically, in Kibera, up to 30 people with HIV, diabetes, hypertension, or both in some cases, come together and they meet every three months to collect their medication. These sessions last 30 minutes to an hour, which is very, very different from sitting in a clinic queue for most of the day, which was happening for a lot of patients previously. And the sessions take place in the clinic, in a specific room, either in the afternoons or on Saturdays, because this is more convenient for the patients to come. At the same time as collecting their medication, they also get health talks and peer support from the other people in their group. And in addition to this, all of the patients have an annual clinical consultation with monitoring blood tests. There is an alternative to the max, and I'm going to talk about this throughout the presentation, which is a fast-track drug refill. So patients can come, they have their script already, they can go directly to the pharmacy without seeing a clinician and then go home with their medication. For those of you who are interested in the more medical side, this is the eligibility criteria that were first used, and these are adapting and being discussed as we go along. So there are slightly different eligibility criteria to join a Mac for HIV or NCD-stable patients. And this is what we used for stable. Okay. The first results are from the study that my colleague did. There were over 5,000 HIV and NCD patients in the cohort in Kibera. And of these, we can see that almost half were eligible to join the Macs. From those that were eligible, because they were considered stable, as we saw in the previous slide, 28% of that total cohort were then enrolled into Macs. The breakdown, the demographics of the patients are pretty much what you'd expect. Almost three-quarters of them are HIV positive. There was a much bigger HIV cohort compared to NCDs. And two-thirds of them are female. And that's a pattern that we see in most of our cohorts. And you just have to look around the clinic waiting room to see that most of the patients there are often female. Over this first 12 months of implementation, 109 group sessions were held, which equals 2,208 individual consultations. So you can already see from the figures the amount of time that's been saved. And of those, there were 2% referred back to clinical care because they needed extra clinical support. One of the big questions was about, are Macs acceptable? Do people actually like these? Do healthcare workers like them? Are the patients like them? And the main message that I was always told was, they save us time. It's a great way to pick up drugs, whether I am HIV positive or I'm diabetic or I'm hypertensive. There were challenges along the way with implementation and recruitment. And it became clear that not everybody in a Mac actually understood why they were there. Once they were there, they liked the model. But they didn't really know what was written in their card and they just turned up when they were told to. They really, really enjoyed the health talks. And as a qualitative researcher, I had to put my own bias to one side there. And they kept telling me, we really like them. They're not boring, they're interesting and we get to learn about other conditions that aren't our own. And non-Mac patients were very enthusiastic about the idea of Macs, but they didn't have much knowledge of them. So in a way, the research study kind of became a bit of advertising for Macs and pharmacy pickup at the same time. And you can just see a couple of quotes there from participants. People always ask me about stigma. And it's quite a complex thing to try and explain in probably the next minute. But Macs were believed to both reduce stigma and increase stigma. And I just want to point out that nobody had to disclose their HIV status. It wasn't like they were sitting in a group and everyone had to say why they were there. So the model treats HIV as any chronic disease. And I think that's the key point. And patients would say to me, it's great because I'm coming to this club and rather than people going, oh, you're going to the HIV club, you're just going to the medication club. They don't know what medication people are picking up. But at the same time, HIV positive patients were more likely to fear being stigmatized by the other patients in the group. They felt that everyone was kind of looking at each other, working out whose bag was bigger, who had which pills. But I do want to point out that these fears were more amongst people who had less knowledge and experience of Macs than those who did. So I think over time, there was a sense that the stigma did decrease. Healthcare workers recognized the benefits and the uniqueness of this model of care. They were really proud to be a part of it. As much as some of the patients weren't always aware, the healthcare workers were. Combining HIV and NCD cohorts together is logistically simpler. It also allows for comorbidities. You're not having to separate and have a group of HIV patients, a group of diabetic, a group of comorbid patients. As I've mentioned, not everyone who is HIV positive did feel comfortable disclosing. So to some extent, this affected the capacity for peer support and open discussions. But on the other hand, the health talks and the benefits of learning about different diseases made up for this. The qualitative data showed that the decision to join a Mac was very much driven by the clinicians. And the non-Mac patients, as I've said, were actually really keen to explore the other options available to them. Whether that's going straight to the pharmacy or being part of a Mac. And the key message here is it's important to offer people a choice. There's not one model that suits everybody. And I think the more somebody can see themselves fitting into a model, the more likely they are to be a part of that, to collect their drugs and ultimately adhere to their treatment. So just to finalize, it's a very innovative approach, this joining together of HIV and NCD patients, that both patients and healthcare workers have liked being a part of in its first year of implementation. Large numbers of stable patients have been provided with their drug refills. And the next step is to assess the retention data once we've got more, a longer period of time. And as much as disclosure is a challenge, Macs do provide peer support. And we also have to remember this is only 12 months of implementation. If these people have only met three times for half an hour, that's not long enough to really build a group dynamic. So I think over time, peer support will strengthen. And my final message is that increasing the promotion of these different strategies is required to empower patients, to improve their choice in accessing chronic medication, whether that's for HIV or for NCDs. And I'd just like to thank everybody who assisted with the research. Thank you. Thank you very much for being in time and sorry, I apologize for just mentioning all that time. I know that's very stressful, but again, any other technical questions? Please, sir. Petri Am from MSF Sweden. Thanks a lot. I was wondering, in terms of analysing the group dynamics for around the Mac, to what extent could the particular social fabric of the Kibera slum be a factor in the stability of a Mac compared to the Matar Islam in East Nairobi, which is much looser in terms of social cohesion, much more communal tensions? Thanks. I mean, I only worked in Kibera, but thinking about cohesion, something that patients did mention is they didn't always live very close to the other people in the Mac. So I was asking them, you know, what about walking to the Mac together or getting transport together? And there wasn't so much of that, because although people were in the same community, it was very spread out. Please. Hello, my name is Kirily. I'm from the Institute of Tropical Medicine and Antwerp. My question, I suppose, is not so relevant to the hypertension and diabetes, but in terms of the HIV, what's the rationale for the above 25-year criteria? And then have you also considered doing this for teenagers and young people the same sort of Mac setup? Yeah, I was actually discussing this with a colleague last night, because the 25 years was brought in at the beginning, but now I think we're thinking about reducing that. And there have been questions about youth Macs and youth groups, so it's definitely something that's been looked at, as well as whether or not to take the Macs out of the clinic and into the community to make them more accessible to a wider range of people. Any other question? Hi, my name is Emma, MSFUK. I was just interested to see, thank you, it was a lovely presentation, your data about the breakdown, there were two-thirds women that were involved in these clubs, and did you address that issue, or did you look at strategies of trying to improve the optic from men? So having the clubs in the afternoons and on Saturdays, I think if we broke down the data even more, we'd probably see the Saturday ones were male, more male-orientated. And I think the issue of the lower percentage of men is something that's across the clinic in general. So yeah, I think the Saturdays may be looking at even an additional Saturday clinic would help. I think we'll keep the other question to the open discussion. Thank you very much, Emily. Thanks a lot.