Effect of Community ART Groups on retention-in-care among patients on ART in Tete Province, Mozambique: a cohort study

Decroo, Tom; Telfer, Barbara; Dores, Carla das; White, Richard A.; Santos, Natacha dos; Mkwamba, Alec; Dezembro, Sergio; Joffrisse, Mariano; Ellman, Tom; Metcalf, Carol

doi:10.1136/bmjopen-2017-016800

Cited by 55 publications

(74 citation statements)

References 29 publications

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“…Both clients and HCWs consistently self-reported that CARGs improved adherence and reduced client loss to followup. This is consistent with quantitative evaluations of pilot programmes, which found that clients in CAGs had lower rates of loss to follow-up [11,[22][23][24]. Once sufficient person-time in CARGs has accrued, quantitative analyses should be done to evaluate the impact of CARG membership on retention and viral suppression.…”

Section: Discussionsupporting

confidence: 70%

The rollout of Community ART Refill Groups in Zimbabwe: a qualitative evaluation

Bochner

Meacham

Mhungu³

et al. 2019

J Intern AIDS Soc

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Introduction Community ART Refill Groups (CARGs) are an antiretroviral therapy (ART) delivery model where clients voluntarily form into groups, and a group member visits the clinic to collect ART for all group members. In late 2016, Zimbabwe began a nationwide rollout of the CARG model. We conducted a qualitative evaluation to assess the perceived effects of this new national service delivery model. Methods In March‐June 2018, we visited ten clinics implementing the CARG model across five provinces of Zimbabwe and conducted a focus group discussion with healthcare workers and in‐depth interviews with three ART clients per clinic. Clinics had implemented the CARG model for approximately one year. All discussions were audio recorded, transcribed, and translated into English, and thematic coding was performed by two independent analysts. Results In focus groups, healthcare workers described that CARGs made ART distribution faster and facilitated client tracking in the community. They explained that their reduced workload allowed them to provide better care to those clients who did visit the clinic, and they felt that the CARG model should be sustained in the future. CARG members reported that by decreasing the frequency of clinic visits, CARGs saved them time and money, reducing previous barriers to collecting ART and improving adherence. CARG members also valued the emotional and informational support that they received from other members of their CARG, further improving adherence. Multiple healthcare workers did express concern that CARG members with diseases that begin with minor symptoms, such as tuberculosis, may not seek treatment at the clinic until the disease has progressed. Conclusions We found that healthcare workers and clients overwhelmingly perceive CARGs as beneficial. This evaluation demonstrates that the CARG model can be successfully implemented on a national scale. These early results suggest that CARGs may be able to simultaneously improve clinical outcomes and reduce the workload of healthcare workers distributing ART.

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Section: Discussionsupporting

confidence: 70%

The rollout of Community ART Refill Groups in Zimbabwe: a qualitative evaluation

Bochner

Meacham

Mhungu³

et al. 2019

J Intern AIDS Soc

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“…The practical benefits of sharing the logistical constraints for ART collection and facilitating patients retention in care is mirrored in a quantitative analysis of this model in Malawi [10] and Mozambique [14], and was also observed in a study of a similar model of ART refill distribution, conducted in South Africa [15]. …”

Section: Discussionmentioning

confidence: 93%

“We are part of a family”. Benefits and limitations of community ART groups (CAGs) in Thyolo, Malawi: a qualitative study

Pellecchia

Baert

Nundwe

et al. 2017

Journal of the International AIDS Society

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Introduction: In 2012 Community ART Groups (CAGs), a community-based model of antiretroviral therapy (ART) delivery were piloted in Thyolo District, Malawi as a way to overcome patient barriers to accessing treatment, and to decrease healthcare workers’ workload. CAGs are self-formed groups of patients on ART taking turns to collect ART refills for all group members from the health facility. We conducted a qualitative study to assess the benefits and challenges of CAGs from patients’ and healthcare workers’ (HCWs) perspectives. Methods: Data were collected by means of 15 focus group discussions, 15 individual in-depth interviews, and participant observation in 2 health centres. The 94 study participants included CAG members, ART patients eligible for CAGs who remained in conventional care, former CAG members who returned to conventional care and HCWs responsible for providing HIV care. Patient participants were purposively selected from ART registers, taking into account age and gender. Narratives were audio-recorded, transcribed, and translated from Chichewa to English. Data were analyzed through a thematic analysis. Results: Patients and HCWs spoke favourably about the practical benefits of CAGs. Patient benefits included a reduced frequency of clinic visits, resulting in reduced transportation costs and time savings. HCW benefits included a reduced workload. Additionally peer support was perceived as an added value of the groups allowing not only sharing of the logistical constraints of drugs refills, but also enhanced emotional support. Identified barriers to joining a CAG included a lack of information on CAGs, unwillingness to disclose one’s HIV status, change of residence and conflicts among CAG members. Participants reported that HIV-related stigma persists and CAGs were seen as an effective strategy to reduce exposure to discriminatory labelling by community members. Conclusions: In this setting, patients and HCWs perceived CAGs to be an acceptable model of ART delivery. Despite addressing important practical barriers to accessing ART, and providing peer support, CAGs were not well known by patients and had a limited impact on reducing HIV-related stigma. The CAG model of ART delivery should be considered in similar settings. Further measures need to be devised and implemented to address HIV-related stigma.

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“…Differentiated models of ART delivery can be broadly classified into individual models (facility or out‐of‐facility) and group models (health worker or client‐managed) . Several group and out‐of‐facility individual models have demonstrated promising results, including health worker‐led ART refill groups in South Africa , patient‐led community ART groups in Mozambique and community ART distributions points in the Democratic Republic of Congo . However, health worker‐managed or patient‐managed group strategies may require additional resources in order to scale‐up implementation, and concerns have been raised about their sustainability .…”

Section: Introductionmentioning

confidence: 99%

Retention in care among clinically stable antiretroviral therapy patients following a six‐monthly clinical consultation schedule: findings from a cohort study in rural Malawi

Wringe

Cawley²,

Szumilin

et al. 2018

J Intern AIDS Soc

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IntroductionLonger intervals between clinic consultations for clinically stable antiretroviral therapy (ART) patients may improve retention in care and reduce facility workload. We assessed long‐term retention among clinically stable ART patients attending six‐monthly clinical consultations (SMCC) with three‐monthly fast‐track drug refills, and estimated the number of consultations “saved” by this model of ART delivery in rural Malawi.MethodsStable patients (aged ≥18 years, on first‐line ART ≥12 months, CD4 count ≥300 cells/mL 3, without opportunistic infections, not pregnant/breastfeeding) were eligible for SMCC, with three‐monthly drug refills from community health workers. Early enrollees were those starting SMCC within six months of eligibility, while late enrollees started at least 6 months after first eligibility. Kaplan–Meier methods were used to calculate cumulative probabilities of retention, stratified by timing of their enrolment and from first six‐monthly clinical consultation. Cox regression was used to measure attrition hazards from the first six‐monthly clinical consultation and risk factors for attrition, accounting for the time‐varying nature of their eligibility and enrolment in this model of care.ResultsFrom 2008 to 2015, 22,633 clinically stable patients from 11 facilities were eligible for SMCC for at least three months, contributing 74,264 person‐years of observation, and 18,363 persons (81%) initiated this model of care. The median time from eligibility to enrolment was 12 months and the median cumulative time on SMCC was 14.5 months. Five years after first SMCC eligibility, cumulative probabilities of retention were 85.5% (95% CI: 84.0% to 86.9%) among early enrollees and 93% (95% CI: 92.8% to 94.0%) among late enrollees. The cumulative probability of retention from first SMCC was 97.0% (95% CI: 96.7% to 97.3%) and 86% (95% CI: 85% to 87%) at one and five years respectively. Among eligible patients initiating SMCC, the adjusted hazards of attrition were 2.4 (95% CI: 2.0 to 2.8) times higher during periods of SMCC discontinuation compared to periods on SMCC. Male sex, younger age, more recent SMCC eligibility and WHO Stage 3/4 conditions in the past year were also independently associated with attrition from SMCC. Approximately 26,000 consultations were “saved” during 2014.ConclusionAfter five years, retention among patients attending SMCC was high, especially among women and older patients, and its scale‐up could facilitate universal access to ART.

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Effect of Community ART Groups on retention-in-care among patients on ART in Tete Province, Mozambique: a cohort study

Cited by 55 publications

References 29 publications

The rollout of Community ART Refill Groups in Zimbabwe: a qualitative evaluation

The rollout of Community ART Refill Groups in Zimbabwe: a qualitative evaluation

“We are part of a family”. Benefits and limitations of community ART groups (CAGs) in Thyolo, Malawi: a qualitative study

Retention in care among clinically stable antiretroviral therapy patients following a six‐monthly clinical consultation schedule: findings from a cohort study in rural Malawi

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