What was the problem?
The majority of PEFPAR-supported ART services are provided in resource-limited settings in standardized, though often inefficient ways. This makes long term ART adherence and retention difficult. Antiretroviral drugs (ARVs) are usually delivered at facilities and distribution is frequently associated with long waiting times for patients. Additionally, where multi-month scripting or other differentiated-care models have not been implemented, clinic congestion impacts patients and providers, and is a barrier to patient adherence and retention.
What is the solution?
The Western Cape Government Department of Health adopted the adherence club (AC) model for the Cape Metro district in January 2011[i]. The ART-AC model provides patient-friendly access to ART for clinically stable patients, ART distribution, and care and support to groups of stable patients. ACs can reduce the burden that stable patients place on healthcare facilities, freeing healthcare workers to treat new and unstable patients. This innovative solution addresses congestion in health facilities due to large volume of patients and provides more flexible and convenient services for stable patients [ii].
ACs meet either at a health care facility or at a community-based venue for symptom screening, group discussions, ART distribution, and care and support to groups of stable patients[iii]. Each AC is composed of approximately 25 to 30 patients who meet for 30 to 60 minutes, five times per year to receive their pre-packed ART supply. This is a two-month supply, over year-end when they received a four-month supply. Annually, blood is drawn for viral-load (VL) monitoring at month four and a clinical consultation occurs at month six. ACs are facilitated by lay health care workers (LHCWs) and usually supported by nurses, particularly for blood draws and clinical consults. Thus, the ACs are initiated by and connected with specific health facilities. A number of non-governmental organizations (NGOs) provided limited technical assistance support.
What was the impact?
An epidemiological study of AC implementation scaled up across an entire district in a high-burden setting, assessed retention in care, and VL suppression (indicating adherence). The study sample size was 3,216 adults in 100 ACs linked to 15 health care facilities in the Western Cape. Retention was 95.2% (95% CI, 94.0-96.4) at 12 months and 89.3% (95% CI, 87.1- 91.4) at 24 months after AC enrollment. In the 13 months prior to analysis closure, 88.1% of patients had VL assessments; of those, 97.2% (95% CI, 96.5-97.8) were virally suppressed. Significantly, risk of loss to follow up from ACs was higher in younger patients and patients accessing ART from facilities with larger ART cohorts. These results provided substantial reassurance that stable patients on long-term ART can safely be offered differentiated care, particularly ACsiii. By March 2015, 55 of 70 health facilities providing ART services in Cape Town had ACs[iv]. From 2011 through March 2016, ACs has been further scaled up to reach approximately 32% of 142,000 patients on ART patientsii.
How does it work?
Most ACs studied were facilitated by lay healthcare workers (LHCWs), such as lay facility counsellors or community health workers, with management support, blood draws, and clinical consultation from nurses and/or clinicians. The AC model gives patients the flexibility to ask a third-party ‘buddy’ to attend the AC meeting for ART pick up at every alternate standard AC meeting.
Participation in ACs is voluntary. Eligible patients have to be “stable” (i.e. have been on ART more than 12 months), have two consecutive suppressed VLs (<400 copies/ml), and have been on ART for 6 months or longeriii. Additionally, patients had to be referred by a physician and they are eligible if they did not have other chronic conditions requiring more frequent clinical consultationsiv.
Scaling Up ACs
From 2011 to 2015 the cohort in ACs almost doubled in size, growing from 5,683 patients (7.3% of PLHIV attending facilities) to 32,425 (25%). In March 2015, 55 of 70 health facilities providing ART services in Cape Town had ACs, which increased from 16 facilities in 2011. From 2011 to March 2015 ACs had been scaled up to reach 25.2% of the 128, 697 HIV patients accessing health services in Cape Town public health facilities. By March 2016 ACs has been further scaled up to reach approximately 32%of 142,000 patients on ART patients. The number of patients in each AC remained between 24 and 27 since scale up started in 2011. The overall ART program in Cape Town also grew from 2001 to 2015 from 53 facilities providing ART to 66,626 patients (in 2011) to 70 facilities and 128,697 patients (in March 2015). The ART cohorts in these 70 facilities ranged from 26 to 8,884 patients[iv].
The AC model was scaled up in three waves of implementation. “The first wave identified 15 willing ART facilities struggling with congestion, with ART cohorts of more than 1,000 patients. The majority of these facilities’ ART cohorts exceeded 2,000 patients. The second wave dropped the clinic size criteria, and the last wave allowed all remaining willing facilities to implement the AC model. A collaborative quality improvement approach was taken to support implementation. The approach included setting up a provincial steering committee, nominating and training AC model mentors who supported a number of facilities during implementation and met bi-monthly to assess issues and determine resolutions arising from implementation, and providing two or three learning sessions six months apart for facility teams in each implementation wave. An important lesson learned from the scale up is that constant monitoring and adaptation are needed to meet new and emerging challenges in AC implementationv. NGO support was limited to providing technical support in the provincial steering committee and learning sessions with scale up driven by the Western Cape and city health departments. No additional funding was provided to the Western Cape Health Department to support scale-up of ACs. LHCWs were already employed as adherence counsellors or community health workers by various health department-funded NGOs. AC implementation was driven by the provincial steering committee members and AC model mentors, mostly sub-district HIV managers and clinic doctors, with an additional one to three part-time mentors from NGOsiv.
Challenges to scale up have primarily been associated with the complexity of managing a large program and dwindling political support at the later stages of scale up[v]. Since scale up started in 2011 the AC model of care has adapted to ensure meeting new challenges and increasing demands on the health care system. For example, the model was initially clinic based but in 2012 it became clinic and community based and a variety of group specific clubs have been formed (e.g. male clubs, female clubs, youth clubs, family clubs, etc)ii.
Specifically, when scaling up ACs to large areas (like Cape Town) the following factors need to be considered:
- If eligibility to be in a club changes over time, then ensure member recruitment is strengthened to meet new criteria.
- It is important to maintain linkages between ACs and clinics so patients from the clubs can easily access medical care when needed.
- Ensure continuous monitoring of various clubs structures that emerge to ensure high-quality services across the whole spectrum of care options for HIV positive patientsii.
In terms of the workforce, it is important to have a management group dedicated to the ACs. Specifically, a management team should ensure that:
- There are clear roles and responsibilities for all involved workers and that the workload is reasonable, to ensure quality.
- Implement activities to motivate the teamv.
The following information management and communications components are necessary to ensure successful scale up:
- Utilizing tools to schedule AC sessions and activities.
- Systems for filing documents.
- Appropriate systems to communicate challenges.
- Appropriate system to monitor and track those who defaultii.
Government & NGO Support
The ACs were successful because received the full support of the Western Cape Government Department of Health. Additionally, there were champions from Médecins Sans Frontières –who initially implemented the AC model--and the government who provided strong leadership to ensure that program was scaled up. Support from LCHWs, with whom club members feel trust and accountability for their health, was another key factor to success. Trust and solidarity among club members is essential to the long-term sustainability of ACs.
A collaborative quality improvement (CQI) approach was used throughout implementation. The CQI process included: establishing a provincial steering committee; selecting and training AC model mentors to support the facilities during implementation by providing guidance and helping to troubleshoot challenges; and offering facility teams two to three learning sessions six months apart. NGOs provided technical support in the provincial steering committee and learning sessions. Also, these HIV care programs report into routine HIV program monitoring and reporting systems in the Western Cape. It is recommended that differentiated-care models like ACs maintain monitoring systems that are disaggregated, and can compare patient output and outcomes to those in standard care models.
[i] Cape, South Africa: A study of the institutionalisation of a pilot innovation. Global Health Systems, Under review
[ii] MacGregor, H. M., Andrew; Jacobs, Tanya; Ullauri, Angelica. (2016). Analysis of Factors affecting the scale up and roll out of Adherence Clubs in the Cape Town Metro. Cape Town, South Africa.
[iii] Tsondai, P. R., Wilkinson, L. S., Grimsrud, A., Mdlalo, P. T., Ullauri, A., & Boulle, A. (2017). High rates of retention and viral suppression in the scale-up of antiretroviral therapy adherence clubs in Cape Town, South Africa. Journal of the International AIDS Society, 20, 21649-n/a. doi: 10.7448/IAS.20.5.21649
[iv] Wilkinson, L., Harley, B., Sharp, J., Solomon, S., Jacobs, S., Cragg, C., . . . Grimsrud, A. (2016). Expansion of the Adherence Club model for stable antiretroviral therapy patients in the Cape Metro, South Africa 2011–2015. Tropical Medicine & International Health, 21(6), 743-749. doi: 10.1111/tmi.12699
[v] MacGregor, H. M., Andrew; Jacobs, Tanya; Ullauri, Angelica. (2017). Scaling up ART adherence clubs in the public sector health system in the Western Cape.