ART distribution and adherence support by community groups in Mozambique
Polly Clayden, HIV i-Base
An article in the 1 February edition of JAIDS by Tom Decroo and colleagues, describes a patient-initiated community ART group formed to assist with access, adherence and retention in care and to reduce the workload of a saturated health service. This community programme shows excellent preliminary outcomes.
The programme is conducted in the Tete Province in Mozambique where Medicins Sans Frontieres (MSF) has been involved in HIV care and treatment since 2002. About one in five patients are loss to follow up (LTFU) in this province and at least half of these losses are estimated to be deaths.
In order to improve this situation, consultations took place between patients and counsellors at provincial health facilities. The patients identified the main barriers to ART access as:
- Transport costs
- Perceived stigma from being seen attending clinics
- Long waiting time at clinics (often just for refills)
In Mozambique, ART guidelines only recommend 6-monthly monitoring for stable patients, but supply means drugs must be collected monthly. A Community ART Group (CAG) model was proposed in order to use existing social networks to pool resources so that each person did not have to travel and queue every month for their medicines. CAGs could also provide mutual adherence support.
The groups were established at 12 health facilities in Tete Province. As of May 2010, 11,052 people were on ART of which 5772 were attending facilities with CAGs. CAGs had four key functions: to collect and distribute ART every months to group members; to provide adherence support and treatment monitoring; to establish community-based treatment social support; and to make sure each group member attends a clinic every six months.
The CAGs were publicised in waiting rooms, at clinical appointments and counselling sessions and through information distributed in the community. People were eligible to join a CAG if they were stable on ART for a minimum of six months and had a CD4 count > 200 cells/mm3. Counsellors trained and monitored new groups.
Group members visit the clinic on rotation so that each patient has contact with the health system every six months. Prior to the clinic visit, the groups meet to check adherence and any signs or symptoms or intention to move location. The representative takes all the appointment cards to the facility where each group member is discussed and a clinician prescribes ART and other medicines for each of them. The representative also attends a clinic appointment. They then return to the community and distribute the medicines and cards to the group members and inform anyone who needs to visit the clinic for a follow up.
All CAG members associated with the same health facility are invited to a six-monthly group session providing health education and all attendees have a sample taken for CD4 monitoring.
Between February 2008 and May 31 2010, 1384 patients had joined 291 CAGs. When they enrolled in the CAGs, group members had been receiving ART for a median of 22.3 months. The majority (70%) were women and their median age was 36 years. The median follow up time within a CAG was 12.9 months.
All doses of ART had been collected by representatives and delivered to members and adherence monitoring was high: 1173/1269 (92%) of members had their last two pill counts recorded correctly.
Only 83/1384 (6%) of patients had been transferred back to more conventional care or moved treatment centre. Of the remaining CAG members, 1269/1301 (97.5%) had remained in care, 30 (2%) had died and only 2 (0.2%) were LTFU.
In addition the health workers reported that having CAGs associated with the facility resulted in a reduction in consultations by approximately 4-fold.
This is a fantastic and innovative model! It could be duplicated among many similar (particularly rural) populations. For people facing long journeys and long waits to get ART this could make a huge difference.
Reducing the burden on already saturated health systems is an ever increasing challenge in resource limited settings. Stable patients, will need to have limited interaction with their health facilities if these are to continue with new ART initiations. So monitoring and adherence support in the community is critical.
Sharonann Lynch from MSF wrote: It relies upon the simplest component: mutual self interest. And while there is of course self-selection at work here (it is based on a self-formed group model after all), it is still the best adherence rates that Ive seen within MSF and in all the cascade literature.
Decroo T et al. Distribution of antiretroviral treatment through self forming groups of patients in Tete Province, Mozambique. J Acquir Immune Defic Syndr. Vol 56. Number 2. February 1, 2011.