Tx close to home more effective

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People with HIV who were receiving their HIV treatment outside of health facilities in community-based ART adherence clubs close to or in a patient’s home demonstrated extremely high rates of retention in care and adherence to treatment, according to a study presented at the 7th South African AIDS Conference by Suhair Solomon from Médicins Sans Frontières (MSF/Doctors Without Borders) in Khayelitsha. 196 of 203 people (97%) who were enrolled in the community clubs were retained in ART care. Loss to follow-up was defined as no recorded clinic or club visit for more than three months.

The community-based 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. 95% of community club care members (145 of 153 due for viral load testing) were virally suppressed. Of those with 12 months 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 – 5.5 years) and the median time in community clubs was 336 days (IQR: 224 – 728). 158 (78%) of those enrolled in community clubs are female. The median age at enrolment was 36.7 years (IQR: 32.7 – 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 stable patients who have been on ART for more than 12 months, with two consecutive suppressed viral load tests, 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. 61% (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.

Aidsmap material
SAAIDS 2015 presentation


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