What was the problem?
Because the majority of antiretroviral therapy (ART) services provided in resource-limited settings are done so in standardized yet inefficient ways, long-term ART adherence and retention is difficult. In Uganda, stable clients needed ways to access medications closer to their home, which would reduce the cost and disruption of remaining adherent to ART.
What is the solution?
The AIDS Support Organization (TASO), a Ugandan non-governmental organization (NGO), developed a community-based ART delivery program beginning in 2006. ART care and treatment is delivered to consenting, stable patients at a pre-identified, community-based site, called a “community drug distribution point (CDDP)." Eligible clients receive a 2-month supply of ART and a follow-up appointment at the CDDP for continued care. Core services provided at the CDDP by TASO staff in collaboration with expert patients include:
- refills every two to three months,
- assessment of clinical status by the clinical team every 6 months,
- psychosocial support by expert clients, and
- clinical services, such as TB screening, weight measurement, and lab testing.
What was the impact?
CDDPs have been introduced in all 20 districts supported by TASO in Uganda. ART outcomes show CDDP is an effective alternative service delivery model. As of September 2017, approximately 80,000 patients on ART, which is about two-thirds of the ART patients supported by TASO, receive their medications through the CDDP model. Here are some of the noted impacts:
- Shorter wait times for ART refills at pharmacies linked to CDDPs – from 2-3 hours to 30-45 minutes.
- Reduced travel time and costs for patients by providing ART refills closer to their homes.
- 98% ART retention for patients at CDDPs. While this is a higher rate than among patients at TASO-supported sites overall (71%), it is important to note that CDDPs only enroll stable, adherent patients.
- An estimated 5-10% of patients are re-referred to their health facility at some point.
- Viral suppression testing is being introduced nationwide, though it has not yet achieved sufficient scale for analysis.
Approximately 65% of patients enrolled in CDDPs are women. While some children and adolescents are engaged in CDDPs, their parents are usually already enrolled as well. While CDDPs are not offered to pregnant women at antenatal clinics (ANC), women may become pregnant while enrolled in CDDPs. They continue to receive treatment through the CDDP, while attending ANC. Two sites have begun CDDPs targeting key populations, with approximately 200 female sex workers enrolled.
Community ART distribution through CDDPs has led to decongestion at ART sites across the health system. This allows health care workers at health facilities to focus on new and more complicated patients, and has improved both health worker and patient satisfaction in ART service delivery. While there are added fuel and staffing costs associated with the CDDP model, CDDPs may be more cost-effective over time if they result in higher rates of patient retention and viral suppression.
How does it work?
Improved access to treatment
Patients are eligible to receive antiretroviral drugs (ARVs) through a CDDP once they have been on treatment for 10 weeks, have no evidence of opportunistic infections, have stable weight, are adherent to treatment, and voluntarily consent to participate in a CDDP. While viral load testing has not been required, it can be used as another criterion to enroll a patient in community ART delivery.
Both men and women who meet the eligibility criteria are enrolled into CDDP, as well as some HIV+ children who are stable and whose caregivers are also receiving ARVs through the CDDP. For clients living with HIV, CDDPs address the following challenges:
- Congestion and long wait times at health facilities.
- Long travel distances to health facilities.
- Time away from work for patients in formal employment.
- Cost to attend clinics, such as transportation.
Maximized resources in the healthcare system
When setting up a new CDDP, TASO identifies high-volume facilities before approaching district health leadership, usually in collaboration with community leaders or people living with HIV (PLHIV) support groups. Together they identify an appropriate location for the CDDP. The District Health Management team is involved early to assist with oversight and approvals. Community adherence support agents (CASAs), typically expert clients from the local community, support setup and implementation of the CDDP model.
Source: The AIDS Support Organization (TASO). (2015). The TASO Community Drug Distribution Points (CDDP) Model.
CDDPs are more appropriate and efficient at high-volume sites and underserved communities where the distance to ART clinics is far. The model is most efficient for large ART sites (>500 clients on ART), where the decongestion effect allows those sites to perform better, and justifies the resource inputs required to set up a CDDP. The site should be at least 5 km from the nearest ART-accredited health facility, and may be a school, place of worship, a residence, or a local government building.
Originally designed to offer more options where there are not many ART-accredited sites, CDDPs continue to be a popular choice for clients. This could be attributed to the community nature of the approach, shorter wait times, ease of access, and/or reduced stigma.
The community drug distribution point (CDDP) model
Each CDDP is a linked to a health facility and is coordinated and supported by a health care worker from that facility. Patients are recruited voluntarily from health facilities and are seen every 6 months. Patients in need of medical attention are referred back to the health facility through self-referral, peer referral, or by a health care worker.
Clinical teams visit each CDDP twice per year to provide a clinical assessments and lab testing (e.g. viral load). Between visits, a team of one to two social workers visit the CDDP every two to three months to distribute pre-packaged ARVs, ask basic screening questions for potential problems, and update basic attendance/monitoring registers.
A group size of 30 to 40 clients, with no more than 15 to 20 clients per community adherence support agent (CASA), is recommended for each CDDP, in order to balance the cost of transporting ARVs with CASA and social worker caseloads.
Attendance registers document drug pickup at the CDDP and flag patients who do not attend. The information collected is then entered into the health facility’s health management information system (HMIS) when the visiting team returns. For the biannual clinical visits, facility-based health cards are also brought to the CDDP for completion as the clinical team assesses each patient. Data from these visits is brought back to the health facility and entered into the HMIS. The facility-level HMIS can identify who is receiving ART through CDDPs, and is able to analyze outcomes for clients enrolled in CDDPs.
Objectives of the CDDP model include:
- to reduce the cost of delivering ARVs to clients, while increasing access;
- to maximize use of the human resources available, including community ART clients and volunteers;
- to continuously work towards a sustainable community-based option in ensuring ART adherence; and
- to enhance monitoring of ART adherence and promote HIV prevention following the national goals of accelerated HIV prevention through the index client as an entry point to the community at grassroots level.
Management and operational factors that have allowed the CDDP model to scale effectively include:
- Participatory planning with meaningful client involvement.
- Involvement and engagement of local community leadership to support the initiative, including offering space within the community to allow clients to meet.
- Engagement of the Community Adherence Support Agents (CASAs)in model implementation.
- Investment in client literacy and empowerment to allow for greater self-management.
- Support from TASO senior management and funders (PEPFAR, GFATM).
- Addressing stigma through community dialogues, drama groups, and mass media campaigns.
To ensure the fidelity of the scale-up, TASO staff is involved in the initial setup of CDDPs and the training of new CASAs. Periodic assessments can be made to look at the effectiveness of the CDDP model by evaluating outcome data for patients receiving drugs at the CDDP versus outcomes for those who receive their drugs at the facility.
Client exit interviews are conducted on a quarterly basis to collect and document feedback from the clients. This feedback is shared at performance reviews, used to inform quality improvement initiatives, and directs changes to the models.
Each TASO center has a Client Relations Officer who helps link clients and management, and provides an avenue for feedback that has helped in communicating issues regarding the CDDP model. They are supported by Community Adherence Support Agents, who regularly interact with clients and then report to the staff and vice versa. The Client Relations Officer also works with a Client Team, an elected team from the client body that spearheads coordination and mobilization of clients.
What does it cost?
CDDP start-up costs include outreach to community leaders and district health officers, and the identification of and training for CASAs. Cost drivers include transportation, health care worker visits to CDDPs, and printing materials. A retrospective cost analysis was performed for three task-sharing models (including TASO’s CDDPs) in 2014, which showed an equal distribution of costs across different categories (i.e. personnel, drugs, etc.) and reductions to cost at scale. A modeling of the differentiated service delivery’s (DSD) effect estimated a 15% reduction in the unit cost per person on ART from the scale-up of DSD in Uganda. An ongoing true-cost analysis of multiple differentiated service delivery models, including the CDDP, is occurring in 2018.
To enhance the efficiency of community ART models, TASO has taken the following measures:
- TASO has formed Community Client Led ART Delivery (CCLAD), a variation of the CDDP model. In this model, clients, in groups of 10, select a group leader who picks up ARV drugs on behalf of the other members. This CCLAD model saves on the cost of fuel and travel time for health workers, while increasing the meaningful involvement of clients in their care.
- TASO began implementing ART refills at 3 month intervals to minimize travel costs and time spent in the field, while also minimizing costs incurred by clients.
- Encouraging utilization of motorcycles for most trips to the CDDP.
- Minimizing transport and time costs by more efficiently routing CDDP refill trips.
- Merging CDDPs in close proximity for biannual clinical reviews, including laboratory testing and monitoring.
- Dividing large groups (>50 clients) into smaller groups, with nearby locations, to reduce the time required by patients to attend clinic and allow them to lead more productive lives.