Self-forming 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 Deficiency Syndromes.
Responding 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.
A four-fold decrease in consultations among patients in CAGs was reported by staff at healthcare facilities.
The authors note the initial findings suggest a viable approach to supporting long-term ART management.
As 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.
The 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, they add.
The 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.
Tete Province 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.
Group 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 monthly basis.
The 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 needs.
Community 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 support
- Monitor outcomes and
- Ensure each group member has a clinical consultation at least once every six months.
Group members visit the health centre on a rotational basis so that each member has contact with the health service every six months.
Of 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.
Future 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 patients).
The 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.
Decroo T et al. Distribution of antiretroviral treatment through self-forming groups of patients in Tete province, Mozambique. Advance online edition J Acquir Immune Defic Syndr January 2011 doi:10.1097/QAI.0b013e3182055138