Four‐year retention and risk factors for attrition among members of community ART groups in Tete, Mozambique

Abstract

Abstractobjective Community ART groups (CAG), peer support groups involved in community ART distribution and mutual psychosocial support, were piloted to respond to staggering antiretroviral treatment (ART) attrition in Mozambique. To understand the impact of CAG on long-term retention, we estimated mortality and lost-to-follow-up (LTFU) rates and assessed predictors for attrition.methods Retrospective cohort study. Kaplan-Meier techniques were used to estimate mortality and LTFU in CAG. Individual-and CAG-level predictors of attrition were assessed using a multivariable Cox proportional hazards model, adjusted for site-level clustering.results Mortality and LTFU rates among 5729 CAG members were, respectively, 2.1 and 0.1 per 100 person-years. Retention was 97.7% at 12 months, 96.0% at 24 months, 93.4% at 36 months and 91.8% at 48 months. At individual level, attrition in CAG was significantly associated with immunosuppression when joining a CAG, and being male. At CAG level, attrition was associated with lack of rotational representation at the clinic, lack of a regular CD4 count among fellow members and linkage to a rural or district clinic compared with linkage to a peri-urban clinic.conclusions Long-term retention in this community-based ART model compares favourably with published data on stable ART patients. Nevertheless, to reduce attrition, further efforts need to be made to enrol patients earlier on ART, promote health-seeking behaviour, especially for men, promote a strong peer dynamic to assure rotational representation at the clinic and regular CD4 follow-up and reinforce referral of sick patients.

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.…”

“…In CAGs, groups of six stable HIV patients meet in the community and take a greater role in managing their own illness by taking turns obtaining medications from the clinic for the entire group, self-monitoring medication adherence, and providing support to each other [62][63][64]. By working together, a group of patients transfers the ownership of the treatment process into the community thereby enhancing patient activation, social normalization, and routinization simultaneously.…”

Community-Based ART Resulted in Excellent Retention and Can Leverage Community Empowerment in Rural Lesotho, A Mixed Method Study

“…9 In the same project a qualitative study showed that peer support resulted in a better understanding of treatment, improved adherence and retention on ART. Moreover, the group dynamic created a protective environment where patients discuss problems, exchange experiences and support each other.…”

“…6 Scale-up of ART has been hampered by chronic understaffing and inadequate infrastructure in the healthcare system. 7 In 2009, drawing on a care model rolled out in Mozambique, 8,9 the Lesotho Ministry of Health decided to pilot Community ART Groups (CAG). CAG are self-formed peer groups, in which PLWHA engage to assure community ART distribution.…”

Critical considerations for adopting the HIV ‘treat all’ approach in Zimbabwe: is the nation poised?

“…CAGs have been shown to decongest busy clinics by reducing the number of individual patient visits and improving long-term retention in Mozambique. 23 How these differentiated care strategies improve the quality of the service for the patient (shorter waiting times, less money spent on travel, peer support) and encourage self-management is also worth evaluating.…”