A Qualitative Assessment of a Community Antiretroviral Therapy Group Model in Tete, Mozambique

Abstract

BackgroundTo improve retention on ART, Médecins Sans Frontières, the Ministry of Health and patients piloted a community-based antiretroviral distribution and adherence monitoring model through Community ART Groups (CAG) in Tete, Mozambique. By December 2012, almost 6000 patients on ART had formed groups of whom 95.7% were retained in care. We conducted a qualitative study to evaluate the relevance, dynamic and impact of the CAG model on patients, their communities and the healthcare system.MethodsBetween October 2011 and May 2012, we conducted 16 focus group discussions and 24 in-depth interviews with the major stakeholders involved in the CAG model. Audio-recorded data were transcribed verbatim and analysed using a grounded theory approach.ResultsSix key themes emerged from the data: 1) Barriers to access HIV care, 2) CAG functioning and actors involved, 3) Benefits for CAG members, 4) Impacts of CAG beyond the group members, 5) Setbacks, and 6) Acceptance and future expectations of the CAG model. The model provides cost and time savings, certainty of ART access and mutual peer support resulting in better adherence to treatment. Through the active role of patients, HIV information could be conveyed to the broader community, leading to an increased uptake of services and positive transformation of the identity of people living with HIV. Potential pitfalls included limited access to CAG for those most vulnerable to defaulting, some inequity to patients in individual ART care and a high dependency on counsellors.ConclusionThe CAG model resulted in active patient involvement and empowerment, and the creation of a supportive environment improving the ART retention. It also sparked a reorientation of healthcare services towards the community and strengthened community actions. Successful implementation and scalability requires (a) the acceptance of patients as partners in health, (b) adequate resources, and (c) a well-functioning monitoring and management system.

Barriers and facilitators of interventions for improving antiretroviral therapy adherence: a systematic review of global qualitative evidence

“…All studies were conducted in a single country. Twelve studies were conducted in high-income countries (HICs: Canada and United States) [33,34,40,44–46,48–52,56], 13 in middle-income countries (MICs: Brazil, China, India, Nigeria, Peru, Romania, South Africa, Swaziland, Thailand and Zambia) [15,17,30–32,36,38,41–43,47,53,54] and six in low-income countries (LICs: Mozambique, Rwanda, Tanzania, Uganda and Zimbabwe) [16,29,35,37,55]. The overall studies focused on children living with HIV (two studies) [30,54], adolescents (four studies) [43,45,48,53], adults (21 studies) [15,16–37,39–41,44,46,49–52,54,56] and pregnant women (one study) [55].…”

Understanding Sustained Retention in HIV/AIDS Care and Treatment: a Synthetic Review

“…If a patient had no money, he would not go to the clinic, that is why there were many deaths. Now the number of deaths decreased because with the groups, we are helping each other [65].^Furthermore, observational analyses of CAG cohorts (n = 5729) demonstrated 4-year retention rates of greater than 90 % in Mozambique [63]. Thus, CAGs represent a promising intervention that can address multiple barriers (structural, clinical, and psychosocial) at the same time.…”

Sustaining the future of HIV counselling to reach 90‐90‐90: a regional country analysis

“…NGOs are supporting the implementation of these in various countries in sub-Saharan Africa [15,19,51]. In order to support these activities, there is an increased need for lay counsellors to perform some of their activities at the community level [15,19,22]. There are reports of pilot projects that conduct ART initiation and other HIV-related counselling in the community instead of at the health facility [52].…”

“…Lay counsellors can play an important role in the functioning of these models, for example in the formation and facilitation of community ART groups in Mozambique [22]. Reducing the workload for professional health staff allows them to better focus on patients with complex needs that require clinical expertise [18,23,24].…”

“…In some settings, such lay counsellors perform a wider range of tasks such as home-based care and additional support to the wider health system, in the form of screening, patient referral, drug refills and administrative tasks [18]. The WHO and others have recognized the potential for lay counsellors to improve clinical and public health outcomes in the HIV response, in particular by supporting HIV testing services (HTS), improving adherence and enhancing community-based ART delivery [16,19–22]. Documented benefits of these cadres include shorter waiting times for patients, improved adherence and retention in care and a reduction of the burden on the health system by decreasing the workload of professional staff [18,23–31].…”