People with HIV who were receiving their HIV treatment outside of health facilities in community-based adherence clubs close to or in their homes demonstrated extremely high rates of retention in care and adherence to treatment, according to a study presented at the 7th South African AIDS Conference last month in Durban. The study was presented by Suhair Solomon from Médicins Sans Frontières (MSF/Doctors Without Borders) and conducted in Khayelitsha, a large informal settlement of 500,000 people, situated 40km outside of Cape Town in South Africa.
Of 203 people who were enrolled in the community clubs, 196 (97%) were retained in HIV care. Loss to follow-up was defined as no recorded clinic or club visit for more than three months.
The community-based antiretroviral therapy (ART) adherence clubs are based on the same model as the out-of-clinic adherence club for delivery of care instituted at Khayelitsha’s Ubuntu clinic, which has shown better retention of care than standardised health facility based care. To date, the Cape Town Metro has more than 400 of these clubs as part of a partnership between MSF, the Western Cape Department of Health, Cape Town’s City Health and the Institute for Healthcare Improvement.
However, instead of holding club meetings near the health facility, the club members choose a venue close to their homes, or host the club within their own homes. In this way, group members are from the same geographical area and do not need to pay for transport costs.
Of the 196 people retained in ART care, 172 (88%) remained in club care, while 22 (11%) received their ART at the clinic and 2 (1%) were transferred. Ninety-five per cent of community club care members (145 of 153 due for viral load testing) were virally suppressed.
Of those with 12 months of follow-up in community clubs (n = 101), 99% (n = 100) remained in ART care. Of the 98 due for viral load testing, 96% (n = 89) had at least one viral load test done, of which all were virally suppressed.
The median time on ART was 3.6 years (IQR: 2.2 to 5.5 years) and the median time in community clubs was 336 days (IQR: 224 to 728). Seventy-eight per cent (158) of those enrolled in community clubs are female. The median age at enrolment was 36.7 years (IQR: 32.7 to 42.8).
In the adherence club model, groups of 15 to 30 people are formed and convene every two months in meetings facilitated by non-clinical staff. However, the community club size ranged from 10 to 38 members, due to club members wanting to belong to a club that is closest to their homes.
All club members are people who are clinically stable and have been on ART for more than 12 months, with two consecutive suppressed viral load tests, and who have no health conditions that require frequent clinic consultation. A clear clinical referral pathway for clinical support is mapped out at the establishment of the club.
Essential tasks, such as weight measurement and symptom-based general health assessment, are conducted by a trained lay health worker counsellor (the club facilitator). Medicines are pre-packaged for each participant and brought to the group by the facilitator. Anyone reporting symptoms suggestive of illness, adverse drug effects or weight loss is referred back to the clinic to be assessed by a nurse.
People enrolled in the club also have the option of using a ‘treatment buddy’ to collect their medication when they are unable to. Sixty-one per cent (n = 124) had used a buddy for pick up at least once, while 25% (n = 50) had used a buddy more than once.
The aim of the programme is to relieve the burden on formal health services, promote adherence through peer support, reduce waiting times for patients and to identify defaulters early.
“Homes and community venues close to a patient’s home are feasible options for the delivery of ART, with high retention rates. It empowers patients through self-management and reduces community stigma. This model should be considered for roll-out in other settings,” said Solomon.
It is however cautioned that this requires resource management and planning, including a reliable drug supply, suitable monitoring systems, trained and supported lay healthcare workers, effective referral systems and adequate funding.
Family ART clubs
MSF also supports the implementation of family ART adherence clubs which are a long-term retention model of care catering for children stable on ART and their caregivers, which follows a similar lay counsellor run model as the community-based clubs. The family clubs are supported by nurses, who write pharmacy prescriptions for children under 40kg, based on a quick weight assessment.
Between March 2011 and September 2013, 146 children on ART and their caregivers enrolled in family clubs. Overall 136 children (93%) were retained in care, 96 (66%) in family club care, 33 (23%) in clinic care, 7 (5%) transferred out and 10 (7%) were lost to follow up. Of those retained in family club care, 91 (95%) had suppressed viral loads in the last 12 months.
Of the children retained in family club care, all of those between 7 and 10 years of age achieved partial disclosure. This is when a child is told some information about their health and why they take medication, but the word HIV is not used. Fifty-seven children (79%) over the age of 10 years achieved full disclosure.
Solomon S et al. Community based ART adherence clubs: A community model of care for ART delivery. 7th South African AIDS Conference, June 2015, Durban, South Africa.
MSF Family ART Adherence Clubs: An overview. Available at: http://samumsf.org/documents/2015/06/family-art-clubs.pdf
MSF How to keep ART patients in long-term care: ART Adherence Club report and toolkit. Available at: https://www.msf.org.za/msf-publications/how-to-keep-art-patients-long-term-care-art-adherence-club-report-and-toolkit