groups of patients which distribute antiretroviral drugs to those on treatment
have proved highly successful in retaining patients in care in Mozambique, and
drastically reduced the need for patients to travel to health facilities, according
to Tom Decroo and colleagues in a study reported in the advance online edition
of the Journal of Acquired Immune
to patient-identified barriers to care Médecins
sans Frontières (MSF) together with
patients created a community antiretroviral group (CAG) model. For patients,
stable on antiretroviral treatment (ART), this model reduced transport costs and provided an incentive for
patients to take greater responsibility for their own health and be active
partners in healthcare delivery. It helped build and strengthen social networks
and peer support; important factors in ensuring adherence to treatment.
four-fold decrease in consultations among patients in CAGs was reported by
staff at healthcare facilities.
authors note the initial findings suggest a viable approach to supporting
long-term ART management.
the numbers of people on treatment and awaiting treatment in low-income
countries continues to increase, there is growing concern about how to get and keep
people on treatment and in care. Reports show that as many as a third are lost
to follow-up within two years of starting ART.
In Mozambique, as
in other high-prevalence countries, the needs outstrip available resources, and
an estimated seven-fold increase in health personnel is needed to meet the
health needs of the population, note the authors.
authors highlight that the long-term success of ART delivery requires models of
care that separate those functions needing trained healthcare workers from
those that do not (giving out medicines). New models also need to address
barriers to access and retention in care. HIV, as a chronic disease and not an acute
one, must focus on self-management of the disease outside of the clinic setting,
authors cite the example of many Western countries where self-management is the
norm for a range of chronic diseases and has been shown to improve patient outcomes
and reduce the burden on healthcare systems.
is in central Mozambique
where approximately 85% of the population live in rural areas. Adult HIV
prevalence is estimated to be 13%. Since 2002 MSF has been supporting
the health authorities in Tete. In spite of progress in increasing access to
ART services through decentralisation and task-shifting approximately one in
five on ART are lost to follow-up, note the authors.
discussions between patients and counsellors at MSF-supported facilities
identified transport costs and perceived stigmatisation at health facilities
and time lost waiting in long queues as the main barriers to retention and care.
The Ministry of Health guidelines recommend patients stable on ART need a
clinical consultation every six months but ART can only be given out on a
community ART group was developed so that patients using existing social
networks and the pooling of resources would reduce their individual need to
travel and queue as well as provide mutual support for adherence and social
ART groups (CAGs) were established in twelve health facilities in six districts
of Tete Province. Those patients stable on ART
for at least six months were told about the model and invited to form groups. The
key functions of the group members included:
- Facilitate monthly ART
distribution to other group members in the community
- Provide adherence and social
- Monitor outcomes and
- Ensure each group member
has a clinical consultation at least once every six months.
members visit the health centre on a rotational basis so that each member has
contact with the health service every six months.
the 1384 members enrolled in 291 groups from February 2008 to May 31 2010, 83
(6%) transferred to another conventional care or another treatment centre,
because of a change in residence. Of the remaining 1301 patients in community
groups 1269 (97.5%) were still in care, 30 (3%) had died and 2 (0.2%) were lost
to follow-up. The latter two was due to change of residence or social reasons
and not related to CAGs or their care.
challenges for this model, according to the authors, include supporting health
services across the treatment spectrum and amongst vulnerable sub-groups
(children, adolescents, pregnant women, sex workers and HIV/TB co-infected
authors conclude that these initial findings support the establishment of community-based
out-of-clinic solutions, notably for patients stable on ART, as key in the
long-term management of ART in resource-poor settings.