Community ART Support Groups in Mozambique: The Potential of Patients as Partners in Care

Abstract

BackgroundHigh rates of attrition are stymying Mozambique’s national HIV Program’s efforts to achieve 80% treatment coverage. In response, Mozambique implemented a national pilot of Community Adherence and Support Groups (CASG). CASG is a model in which antiretroviral therapy (ART) patients form groups of up to six patients. On a rotating basis one CASG group member collects ART medications at the health facility for all group members, and distributes those medications to the other members in the community. Patients also visit their health facility bi-annually to receive clinical services.MethodsA matched retrospective cohort study was implemented using routinely collected patient-level data in 68 health facilities with electronic data systems and CASG programs. A total of 129,938 adult ART patients were registered in those facilities. Of the 129,938 patients on ART, 6,760 were CASG members. A propensity score matched analysis was performed to assess differences in mortality and loss to follow-up (LTFU) between matched CASG and non-CASG members. Propensity scores were estimated using a random-effects logistic regression model. The following covariates where included in the model: sex, educational status, WHO stage, year of ART initiation, age, CASG eligibility, CD4 cell count category, weight, and employment status.ResultsNon-CASG participants had higher LTFU rates (HR 2.356; p = 0.04) than matched CASG participants; however, there were no significant mortality differences between CASG and non-CASG participants. Compared with the full cohort of non-CASG members, CASG members were more likely to be female (74% vs. 68%), tended to have a lower median CD4 counts at ART initiation (183 cells/m3 vs. 200cells/m3) and be less likely to have a secondary school education (15% vs. 23%).ConclusionART patients enrolled in CASG were significantly less likely to be LTFU compared to matched patients who did not join CASG. CASG appears to be an effective strategy to decrease LTFU in Mozambique’s national ART program.

Retention in care and factors critical for effectively implementing antiretroviral adherence clubs in a rural district in South Africa

“…Overall, LTFU in this cohort was high (20.9%), similar to that reported for other clinics in the sub‐district during the same period . In line with some previous publications . LTFU was much lower among clients referred to adherence clubs, when compared to those who stayed in clinic care.…”

“…A large study conducted in the Cape Metropole, South Africa, included 3216 clients and showed overall retention in ART care of 95% and 89% at 12 and 24 months respectively, after adherence club referral [10]. Another study from Khayelitsha, Cape Town, showed higher rates of ART client retention over 18 months of follow-up among 502 clients attending adherence clubs compared with 2327 clients not attending clubs (97% vs. 85%) [11][12][13]. In contrast, a recent pragmatic trial conducted in Johannesburg, showed higher LTFU among ART clients in community-based adherence clubs compared with clinic-based adherence clubs.…”

Retention on ART and predictors of disengagement from care in several alternative community‐centred ART refill models in rural Swaziland

“…Second, 50% of CAG members who returned to clinical care did so because of personal reasons or because the group dissolved due to conflicts within the group members. Similar challenges were reported from another setting in Mozambique where eligibility criteria were not always respected [7,10] and in Malawi where some CAGs collapsed due to tensions and interpersonal conflicts within the groups [4]. Reportedly there was need of active involvement of health workers to manage CAGs.…”

“…Implementation of patient-centred ART care has been reported from several settings in sub-Saharan Africa [6][7][8][9][10][11][12][13][14][15][16][17][18][19]. Community ART Groups (CAGs) have been piloted in Malawi, Lesotho and Mozambique as a way to reduce patient time and costs spent travelling and queuing for ART refills [7,10,11,18]. In Mozambique the CAG model retained 97.7% and 91.8% of patients at 12, and 48 months [12].…”

Community-Based ART Programs: Sustaining Adherence and Follow-up

“…Grimsrud and colleagues recently published two analyses of community-based adherence clubs in South Africa and showed their positive effects on both decentralization and retention in care (measured as loss to follow-up, which they defined as “having no visit in the first 12 weeks of 2014”); of 2133 patients with HIV who participated in community-based adherence clubs, only 6 % of participants were lost to follow-up after a period of 12 months [24, 25]. Similarly, a matched retrospective cohort study in 10 provinces of Mozambique demonstrated lower lost-to-follow-up rates among patients in Community Adherence and Support Groups than among those in individual care (11 versus 26 %) and lower overall attrition (12 versus 28 %), but similar mortality (1 % in both cohorts) [26]. Other studies have shown similar improvement in retention associated with community-based support but without clear mortality benefit [27, 28].…”