 I'm just going to take a quick minute before the next speech just to say hello to our online audience. Of course it's fantastic to have all of you here, but we also very much wanted to be able to have a broader audience from far-fung places, including people who are working on NCDs in different places of the world. So we had around 500 people sign up to watch online, and so far we've had some comments from Belarus, Kenya, Lebanon, Swaziland, Canada, and as far away as Greece, Sweden and Italy. So thanks to all of you. And if we haven't mentioned your country and you're watching, please send us a comment or a question so we can include you in the discussion. So for the next discussion, you know, in our first session we heard a little bit about how our traditional approach in humanitarian settings is not necessarily adapted for NCDs, but of course we have some good examples and evidence from another chronic conditions, which is HIV and TB. And so our next speaker, Helen, is going to discuss for us some of the lessons learned from HIV and TB programs. So Helen Bygrave is a primary care physician from the UK who describes herself as having been bitten by the HIV and MSF bug many years ago. So I'd describe her as a bit of a guru on HIV programs and MSF. So she's a good person to tell us about the lessons to learn. OK, good morning, everybody. I feel very honored to be invited to this event from the HIV department. So thanks for having me. But secretly, as Philippe said, I am a North London GP. So NCDs are kind of quite close to my heart as well. So I've been asked to come and talk about some of the strategies that we've been using over the last decade to help support the scale up of antiretroviral therapy and how some of these ideas and strategies might be transferable to the NCD context. So where are we now? Globally, 17 million people on ART. It's been hailed to be one of the greatest kind of public health responses and successes. And in terms of this concept of what can we learn and how can we leverage the experience of the HIV response in terms of NCDs? In contrast to the evidence, there's quite a lot of stuff that's been written about how we can link up and learn from each other. A nice piece here from the ICAP team. Another piece from Botswana, which is one of the most successful antiretroviral therapy programs and a meta-analysis looking at the elements, both at the multi-sectorial response that can be compared between HIV and NCDs down to programmatic strategies in the clinic. So quite a lot out there in the literature about how we can potentially learn from each other. But if I kind of come back to a little anecdote from one of my last field trips in terms of how this is really relating to what we're seeing on the ground, this is one of our community ART groups in Zimbabwe. They go once a year to the clinic for their clinical review and they take it in turns to pick up drugs for each other every three months. I'm going to talk a little bit more about that later. But when we're just chatting with them, I discover two of them have hypertension. They go every month to pick up their hypertension drugs. Quite often they're out of stock and they have to buy them out of pocket. Another one of them has diabetes and she has a four hour round trip once a month to collect her diabetes medication. So to quote one of my kind of clinical colleagues, I think there is a tension between how HIV services are being offered compared with NCD services. He describes when I'm doing HIV care, I'm driving my Rolls Royce. When I'm doing NCD care, I'm back in my old banger. So there is a tension around the systems that are being developed for HIV care versus noncommunicable disease. Three points I want to kind of frame my discussion around. The first one says the value of targets. Now we've had several targets over the over the years. Five by five, 15 million by 2015. And it's great to see now for NCDs. NCDs has been picked out in the sustainable development goals with I think it's to reduce by one third premature mortality due to NCDs. But do these targets speak to the people on the ground? Do they speak to the health care workers doing the job? In 2014, UNAIDS came with what are now the famous 1990 90 targets. A lot of us were quite skeptical of these and some of us are still skeptical of these. But I think what they've done is they talk to people at different levels. They talk to the national program managers, to district program managers and they talk to the clinicians and the patients on the ground. If I go to pretty much any clinic in the east and southern Africa, the staff know this. They are working towards the 1990 90 targets. It's clear. The other thing that these targets have done is in the first, I'd say, decade of the response, we very much have focused on putting people on to treatment. And I think quite rightly so. But I think what these targets have again have kind of pushed governments towards is to look at across the spectrum of the continuum of the HIV cascade, looking at testing, identification, so looking at that, how many people are actually being diagnosed. And what we know is that only about half people with HIV know their status. So it's a massive testing gap. But also looking at quality. It's no good just keeping putting people on treatment unless we know they're retained and unless we know they're responding to their treatment. So we're now having targets across that continuum of care from screening on treatment to quality outcomes. A lot has been said. It seems to be a bit of a bone of contention, the issue of guidelines. And I just want to say I have a huge amount of respect for the HIV department in WHO. They work tirelessly. And we have been really lucky to have over the years developed very evidence-based, pragmatic guidelines, initially very much focused on the when to start and the what to start. But what's come new in the first time in 2013 was a new chapter in the guidelines on the how to do it. So looking at the evidence, as Pablo has touched on, on kind of the service delivery guidance. How do we deliver services? And some of it is a question of how much evidence do we need for this? What do we need a randomized controlled trial for? What can we look at programmatic data? And what, quite frankly, is common sense. Do I need a randomized controlled trial to say it's okay to give my patient three months of drugs versus one month of drugs? Or can we sit together as a collective group of experts and make that recommendation? And I love the WHO recommendations that say strong recommendation, low quality of evidence. The other thing is we do need this research and we do need these recommendations because I'm sorry, if you want donors to put money into your programs, they want evidence. And they want to be shown that these interventions are cost effective. So if you want the Gates Foundation and Global Fund, et cetera, et cetera, to wake up to the burden and needs of NCDs, we do need to work together with the research community to generate the evidence to support these recommendations. The third point for me is we keep it very simple. Yeah, we recognize within stable resource constraints and setting, but even more if we're talking about delivering HIV care in Eastern DRC, in CHAD, in CAR, where we are providing HIV care and Ministers of Health are providing HIV care, we have to keep things simple. So the things we've really looked at simplifying over the decade or 15 years now really of scaling up is looking at the drug therapies we're using. So if we look back at the guidelines, in 2006, WHO gave Ministers of Health eight first line choices that they could choose to put on the shelf. It was completely confusing, yeah? In 2013, on review of the evidence I'm going to say in terms of looking at toxicity and looking at a regimen that we could use across populations, so adults, patients with TB, pregnant and breastfeeding women, we've come with one regimen that's clearly recommended to governments by this for everybody. So we have one adult regimen on the shelf. We've really looked a lot and lobbied drug companies a lot around fixed dose combinations. There's evidence and WHO has come in the 2016 guidelines with a clear recommendation on this, evidence that they support adherence, but not only do they support adherence, just from a very practical point of view, they simplify procurement, they simplify getting those drugs to primary healthcare settings. And if you want to scale up and decentralize, storage of this stuff is an issue. And by having fixed dose combinations, you almost halve your storage capacity, which is an important logistical point. Whether this is feasible in NCDs, I question, I think potentially that is an area for further research. There's a lot of conversation about polypill for prevention, but where are some potential gains in terms of treatment? I don't know. The other thing that we've looked at and demanded from the drug companies is heat stable formulations, yeah? I remember the days of the Lepinavir, Pantanavir capsules, had to go in the fridge. And unfortunately for pediatrics, we're still pushing the drug companies for improved formulations. But I think the example from MSF Switzerland, who worked together with some researchers in Switzerland, looking at the heat stability of insulin, has been really, really useful to say, it's okay to have insulin in a cool clay pot. And that's made a big difference for patients not having to come daily to get their injections. So what can we do in terms of evidence around current formulations that need cold shame? We've simplified the monitoring. And again, I think this is a very pragmatic response. We're very lucky now. We are moving towards viral load monitoring, but we've accepted by looking at the evidence that we're only going to do it once a year. We don't need to do this once every three months. We accepted with the regimen we're using, minimal toxicity monitoring. In all the projects I support, we don't do anything. We don't monitor carotidine for tonopovir. And we accept that small risk from a public health perspective. So again, if we're talking about using ACE inhibitors, what are we prepared to accept from a public health perspective? But we've also, and I say I've been involved in some interesting work over the last three years on viral load, worked very closely with the tech companies to say to them, this is not feasible. We're never going to scale up viral load if we rely on plasma. We cannot do it. The sample transport is too difficult. So in the space of three years, we've gone from one company that's approved to this. This is a dry blood spot for viral load. We've gone from one company being able to have a technology that we can do that to three companies having a technology that we can now do viral load on dry blood spots. In our project in Yambio in South Sudan, so quite unstable setting, intermittent periods of conflict, they have an HIV project which is a mobile clinic. They go out once a week to different assigned settings doing tests and treat, initiating people on antiretroviral therapy and they get a viral load. They do the DBS, they put it in an envelope, send it by DHL to a lab in South Africa and they get the results in two weeks. The other thing is the potential role of point of care and again, you have to know what you want and you have to go to the companies and tell them what you want. We're now looking at using a gene expert in settings such as CAR and Eastern DRC to do viral load and early infant diagnosis as well as TB diagnosis. And the third thing we've simplified, so we simplified the drugs, the monitoring, but also the way the models of care for delivering ART. The buzzword in the HIV, or buzz, I don't know, or buzzword, let me leave it at that in HIV at the minute, is differentiated care and differentiated ART delivery is part of that. The idea is that when we're designing a model of ART delivery, that we look first of all at these three elements. So what are the clinical needs of the patient? Do they just have HIV or do they also have HIV and diabetes? What sub-population do they fall into? Are they pregnant? Are they a child? Are they a part of a key population? And then what's the contextual factors? Is it stable? Is it a conflict setting? Is it urban-rural? Once we've defined those elements, we then use these building blocks to develop our model of service delivery. So the when, the where, the who, and the what. And these are the questions that have been addressed by WHO in these new service delivery chapter, the new service delivery chapter of the 2016 guidelines with very clear PICO questions addressing these building blocks of how we provide care. So for example, if we look at the when, there's a new recommendation to say it's okay. The outcomes are as good if you reduce the frequency of clinical and refill visits to three to six months new. WHO has made a recommendation that the outcomes are, in fact, often improved if we take treatment closer to the patient's home. So to decentralize primary care and in a new recommendation to further decentralize ART delivery to the community. Who's doing the job? And somebody raised this issue of human resources, which has been a massive challenge. There's no way we could have got where we are today without tar shifting. But there have been a number of studies because of this involves policy change within countries. And to change policy, it's very difficult to do that with a number of ministers of health if you don't have the evidence. So evidence to show that tar shifting to non-physicians has resulted in equivalent and in some cases again, better outcomes for patients. And a new recommendation that, to suggest that having the refills of drugs to stable patients can be done by lay carders. So just to give a couple more examples of these models of care that MSF has been working on over the last six, seven years. These are the community ART groups I mentioned at the start. They're being taken to scale at national level in Mozambique and Zimbabwe and pilot programs in a number of other countries. They're self-forming groups of people who live near each other between four and 12 in a group, stable adults on ART. And basically they take it in turns to collect drugs for each other. So they meet every three months, usually in one of their houses or another defined, another chosen community spot. And the group leader leads that group. They've had a bit of training and they complete a checklist of questions about health, so symptoms of TB, diarrhea, et cetera, yeah. And then every three months they nominate one person to go and collect the drugs for each other. And once a year they'll go together as a group for their clinical review and their viral load. Again, what we've worked on quite hard the last week is documenting the outcomes of these models, yeah, okay? And so what we're seeing now is uptake between 20 to 45% of our ART cohorts where this is being offered are going into the CAGs. It's resulting in decreased clinic visits. Retention appears to be good, particularly once you get looked past, they actually, we've got retention at 48 months which is much improved compared with conventional care. And the benefits of peer support in these groups have started income generating activities. And also we're working with these groups to mobilize for screening and testing, yeah. And I think what's interesting in Zimbabwe, the NCD patients have seen these groups meeting and doing their thing, yeah. And they've said, hang on a minute, what about us? So in our new project in Zimbabwe, what the team is about to do is to try from the start to set up these groups for both HIV and NCD care. And that's come from the patient's demand by seeing what's going on. The other thing we've seen in the countries where we've got these groups, or this model of care, is that in the event of a natural disaster, actually it's enabled us to continue care. In Mozambique, where we had periods of really severe flooding, we worked with the community health workers to take ART out to the group where they would meet the group leader in a defined place and they then distributed the drugs to the rest of the group. So again, it helped that contingency plan to continue care. And also we're starting to use these models in conflict settings. So we've got some examples just starting up in DRC and CAR. I'm sorry we don't have the outcome data from those settings yet, but I hope it will come. Because again, there is some anecdotal evidence that it's supporting continuity of care. Just a second example, adherence clubs. These are groups of 20 to 30 stable patients who are meeting these patients, these groups are meeting primarily in the facility. They're led by usually a lay worker and they receive, instead of queuing up one by one to see the nurse to get their drug, their drugs are pre-packed, there's a general group chat and discussion and then they just pick up the pre-packed drugs from the lay worker. Again, if we look at outcomes in the Western Cape in South Africa, there are now over 34,000 patients receiving their care in these clubs and 97% of club patients remained in care compared to a comparable group where 85% remained in care. Also there's benefit in terms of biological outcomes. The other important thing they did in the study in Western Cape is they've looked at cost showing that this model is more cost efficient, which the donors like. So building on the model that was developed in Kailitsha, what we've now done in Kibera in Kenya, and I'm sorry this wasn't picked up in your systematic review, I don't know, maybe it was. It was, alright. We've now tried to develop these medication adherence clubs. So again, 20 to 30 clients, they meet every three months, but we're grouping together patients with both HIV, diabetes and hypertension. Some of them obviously have comorbidities but some with individual diseases as well. They meet in the facility usually in the afternoon so they don't have to miss work or on a Saturday morning. And we've done some qualitative and we're starting more quantitative analysis of the outcomes, but from the qualitative work, it's really quite interesting because there was a lot of fear about doing this, bringing the HIV and the NCD patients together. But the initial experience is actually quite positive. There's a lot of sharing that goes on. There's a lot of cross-fertilization in terms of healthy lifestyle, the challenges of taking medication for life with the hypertension patients saying, oh, I've got a lot more pills to take than you. There's a lot of useful cross-fertilization. I think maybe we shouldn't be so afraid to look at how we can do this going forward in terms of an integrated approach. The other thing in Kibera is that it is a primary healthcare setting. All the services are integrated so a nurse can see somebody coming for acute diarrhea, one consultation, the next one is the HIV consultation and the next one is an HIV patient with diabetes. And that's been a real challenge and has taken a lot of investment in terms of training and human resources to enable the healthcare workers in that clinic to take that integrated approach to care. So I really feel NCDs and HIV are coming together. We're seeing more and more integrated screening strategies if we're seeing money available for door-to-door testing, outreach testing, more and more people are going out and doing both HIV screening, TB screening and taking the blood pressure. We've got clear guidance from WHO that all HIV positive patients should have their blood pressure taken and be screened for depression and more and more hopefully documented examples of these integrated chronic care clinics. But I think the issue of setting the right targets, having evidence-based guidelines but guidelines that then can be used in the clinic. A nurse in the clinic in Zimbabwe is not going to read the 600-page WHO guideline. Let's forget it, yeah? So we need simplified one-page field guides, whatever you want to call it, that clinicians can use on a daily basis to do the job. And it is possible, because I've done it for HIV, to put the 50-page chapter of PMTCT onto one page. It is possible. And I think if we want to make this a reality in these very challenging conflict, humanitarian settings, this is what we need to do and keep it simple. I just want to leave that slide up, because for me, the combination of those two things is actually what's made it work. Patient activism, yeah? And sustained donor funding. I'm really pleased somebody from the NCD Alliance is here. I'm gonna hear from them later on, yeah? But and I think one of the biggest lessons we could learn is why don't we get the diabetic patient activists, whoever they are, together with the HIV activists, because we've got 15 years of very good experience of how the HIV community has held healthcare workers and ministers of health accountable for delivering a quality service. So let's learn those grassroots lessons in terms of how we can work together to improve the quality of NCD care. Thank you. Thanks very much, Helen. Any questions of clarification for Helen? To Mum. Thank you. Helen, that's a very, very good point. Thank you very much about the activism and people coming up. And I just want to say that it has happened. The Diabetes Federation came and presented. I was on the Interagency Emergency Health Kit in 2008 and 2009, and they came and presented and requested that insulin, for example, sits on it, and it was rejected. It was rejected on basis that we didn't know it would survive without cold chain. We didn't know whether it would be accepted in country. But it's interesting, because this is a very good point. In HIV, at least as an outsider to HIV, it's easier because you have a single disease, incredibly high burden, and clear villains. And you don't have almost any of those in NCDs. You have a heterogeneous group of diseases, no villains, and no single solution. You could gather people around, give me a single dose, don't be greedy as a pharmaceutical company. We don't really have that, and it's very difficult to gather people around a vague cause that affects people variably, and you don't have a concentration, which is frustrating. I think this is one of your biggest problems, I'm going to be honest. I saw some dialogue, I can't remember whether it was the NCD Alliance website or the WHO website around this issue of what you're calling it. I mean, I think it is a problem to lump. How can you talk about diabetes and breast cancer in the same breath? I think it's a real challenge when the dialogue is NCDs. So yeah, I think that's an issue that needs to be fleshed out as we take the challenges of these diseases going forward. Any other clarification questions? Okay, so we need the, thanks, Helen.