Implementation of community‐based adherence clubs for stable antiretroviral therapy patients in Cape Town, South Africa

• Published in: Journal of the International AIDS Society Vol. 18; no. 1; pp. 19984 - n/a
• Main Authors: Grimsrud, Anna, Sharp, Joseph, Kalombo, Cathy, Bekker, Linda‐Gail, Myer, Landon
• Format: Journal Article
• Language: English
• Published: Switzerland International AIDS Society 01-01-2015; John Wiley & Sons, Inc
• Subjects: Acquired immune deficiency syndrome; Adult; AIDS; AIDS/HIV; Analysis; Anti-HIV Agents - therapeutic use; Antiretroviral agents; Antiretroviral drugs; Antiviral agents; ART delivery; Care and treatment; Chronic illnesses; Clubs; Community health aides; community‐based; Complications and side effects; Counseling; Decentralization; Dosage and administration; Drug therapy; Evaluation; Female; Global health; Health aspects; Health facilities; Health Resources; Highly active antiretroviral therapy; HIV; HIV infection; HIV infections; HIV Infections - drug therapy; Human immunodeficiency virus; Humans; loss to follow‐up; Male; Medical referrals; Medication Adherence; Middle Aged; models of care; Patient compliance; Patients; Pharmacy; Phlebotomy; Politics; Prevention; Primary care; Primary Health Care; Public health; Referral and Consultation; Retention; Risk factors; Services; South Africa; Systematic review; task shifting; South Africa; Sub-Saharan Africa; Cape Town South Africa; Uganda; Africa; community-based; task shifting; ART delivery; decentralization; models of care; loss to follow-up
• ISSN: 1758-2652; 1758-2652
• DOI: 10.7448/IAS.18.1.19984

Introduction
Community‐based models of antiretroviral therapy (ART) delivery have been recommended to support ART expansion and retention in resource‐limited settings. However, the evidence base for community‐based models of care is limited. We describe the implementation of community‐based adherence clubs (CACs) at a large, public‐sector facility in peri‐urban Cape Town, South Africa.
Methods
Starting in May 2012, stable ART patients were down‐referred from the primary care community health centre (CHC) to CACs. Eligibility was based on self‐reported adherence, >12 months on ART and viral suppression. CACs were facilitated by four community health workers and met every eight weeks for group counselling, a brief symptom screen and distribution of pre‐packed ART. The CACs met in community venues for all visits including annual blood collection and clinical consultations. CAC patients could send a patient‐nominated treatment supporter (“buddy”) to collect their ART at alternate CAC visits. Patient outcomes [mortality, loss to follow‐up and viral rebound (>1000 copies/ml)] during the first 18 months of the programme are described using Kaplan–Meier methods.
Results and Discussion
From June 2012 to December 2013, 74 CACs were established, each with 25–30 patients, providing ART to 2133 patients. CAC patients were predominantly female (71%) and lived within 3 km of the facility (70%). During the analysis period, 9 patients in a CAC died (<0.1%), 53 were up‐referred for clinical complications (0.3%) and 573 CAC patients sent a buddy to at least one CAC visit (27%). After 12 months in a CAC, 6% of patients were lost to follow‐up and fewer than 2% of patients retained experienced viral rebound.
Conclusions
Over a period of 18 months, a community‐based model of care was rapidly implemented decentralizing more than 2000 patients in a high‐prevalence, resource‐limited setting. The fundamental challenge for this out of facility model was ensuring that patients receiving ART within a CAC were viewed as an extension of the facility and part of the responsibility of CHC staff. Further research is needed to support down‐referral sooner after ART initiation and to describe patient experiences of community‐based ART delivery.