A team led by researchers from University of California San Francisco, Organic Health Response, and Microclinic International is reporting results of a study that showed significant benefits of microclinics – an innovative intervention that mobilised rural Kenyan HIV patients’ informal social networks to support their staying in care.
The results showed that microclinics cut in half the normal rate of disengagement from care, which was defined as missing a clinic appointment by 90 days or more, when compared to the control group, and reduced the perceived stigma of HIV by 25% within the larger community.
“When HIV patients fall out of care, they lose access to their medications, and untreated HIV patients will eventually develop Aids. Keeping patients in care is not only a challenge in resource limited settings, but even in the US where the CDC estimates that only 40% of HIV patients are regularly engaged in care,” said the study’s lead author, Matthew D Hickey, a graduating UCSF medical student. “Microclinics are a novel approach in solving this problem,” he said, “in large part because they directly and innovatively address the issue of stigma.”
The intervention took place on Mfangano Island in Lake Victoria, which is surrounded by the countries of Uganda, Kenya and Tanzania. The island has a population of about 21,000 living in small villages of 500 to 1,500 people. Almost 30% of the population is HIV infected. FACES (Family AIDS Care and Education Services), a joint programme of UCSF and the Kenya Medical Research Institute, has been supporting HIV care, treatment and prevention in western Kenya, including the island, in collaboration with the Kenya Ministry of Health since 2004.
FACES researchers and clinicians partnered with Microclinic International and the Organic Health Response to assess whether its social network model would help retain HIV patients in care. The Microclinic Social Network Model works with individuals and communities to identify existing social networks and use those to address wide spread and deadly diseases in communities. The Organic Health Response coordinates a solar-powered community centre on Mfangano Island that served as the headquarters for this intervention.
“The rural communities on Mfangano Island where we are working have tremendous stores of social capital. People help each other when an individual or family is in need. If someone gets sick or injured, needs help farming or getting together the money for school fees, friends and family pitch in to help. But, that often was not true when the need was due to HIV. For example, a breadwinner became sick with Aids and everyone knew what was going on, but no one talked about it. He fell through the cracks of his social network, and without support, he was lost to care and did not manage to take his medications faithfully. Eventually, he died of Aids,” said study co-lead author, Dr Charles R Salmen, the founding director of Organic Health Response.
The intervention was introduced into one set of communities served by the Sena Health Centre; other similar neighbouring communities in the clinic’s catchment area served as controls. Patients on antiretroviral medications were invited to form microclinic groups. These groups included five to 15 family members, close friends or other members of the patients’ social network, regardless of HIV status. Pre-existing social groups such as churches, soccer teams and money lending clubs were also invited to form microclinic groups and participate. Each microclinic group was assigned a community health worker and a facilitator. All participants received confidential HIV testing and counselling.
“Microclinics are not a traditional support group composed of people confronting a similar challenge, many of whom may not know each other. Instead, microclinics use organic networks to drive positive behaviour. And since patients receive support from existing networks, support is sustained,” said study co-author Dr Daniel Zoughbie, CEO of Microclinic International.
The participants attended 10 group-discussion sessions over five months. The sessions educated participants about HIV prevention and treatment, promoted group support through discussions about confidentiality and HIV status disclosure, encouraged group support to assist in taking anti-HIV medications faithfully and making clinic appointments, and encouraged participants to outreach to the community to promote HIV testing and clinic enrolment. At the end of the intervention, participants were invited to take part in voluntary group HIV testing.
“Previously, stigma blocked access to social support because patients didn’t disclose. Microclinics opened up discussion and became the catalyst for destigmatising HIV. This led to access to support within social networks. Friends and family supported patients in getting to clinic appointments and, in turn, expected appointments to be kept. They supported patients’ taking medications as directed and expected patients to take them. Silence was replaced by active support,” said Hickey.
“UNAIDS has set a goals aiming to have 90% of people with HIV in the world successfully treated and retained in care by 2020. The microclinic intervention, which redefines the unit of care from an individual to an individual and his/her social network, is a cost effective, scalable initiative that could help governments meet their targets,” said study co-author, Dr Craig Cohen, UCSF professor of obstetrics, gynaecology and reproductive sciences.
Piloted by Médecins Sans Frontières/Doctors Without Borders (MSF) in Khayelitsha, the award-winning ART Adherence Club model focuses on patient participation and peer support, for improved treatment adherence. This simple model allows patient groups to collect pre-packed, two-month supplies of treatment from lay health workers either at the clinic or outside of the clinic – whether at a local library or at a fellow patient’s home.
ART Adherence Clubs give stable adherent HIV patients easier access to their treatment, while unclogging clinics and freeing up scarce nurses and doctors to manage new or at-risk HIV patients.
Today, the Cape Town Metro is home to 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.