What was the problem?
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. 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 caused by large volumes of patients, and provides more flexible and convenient services for stable patients (MacGregor et al., 2017).
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 (Tsondai et al., 2017). 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, until year-end when they receive a four-month supply. Annually, both 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 ACs (Tsondai et al., 2017). By March 2015, 55 of 70 health facilities providing ART services in Cape Town had ACs (Wilkinson et al., 2016). From 2011 through March 2016, ACs have been further scaled up to reach approximately 32% of 142,000 patients on ART (MacGregor et al., 2017).
How does it work?
Most ACs studied were facilitated by LHCWs (such as lay facility counselors 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,” have two consecutive suppressed VLs (<400 copies/ml), and have been on ART for 6 months or longer (Tsondai et al., 2017). Additionally, patients had to be referred by a physician, and they are only eligible if they did not have other chronic conditions requiring more frequent clinical consultations (Wilkinson et al., 2016).
Scaling Up ACs
From 2011 to 2015 the cohort in ACs almost doubled in size, growing from 5,683 patients (7.3% of people living with HIV [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 have been further scaled up to reach approximately 32% of 142,000 patients on ART. 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 2011 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 (Wilkinson et al., 2016).
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 implementation (MacGregor et al., 2017) 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 counselors 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 NGOs (Wilkinson et al., 2016).
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 (MacGregor et al., 2017). Since scale up started in 2011, the AC model of care has adapted to ensure that it meets 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).
Specifically, when scaling up ACs in large areas (like Cape Town) the following factors need to be considered:
If eligibility to join a club changes over time, it is necessary to ensure that member recruitment strategy is changed to meet new criteria.
It is important to maintain linkages between ACs and clinics so that patients from the ACs can easily access medical care, when needed.
Ensure continuous monitoring of alternative club structures to ensure high-quality services across the whole spectrum of care options for HIV positive patients.
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 team
The following information management and communications components are necessary to ensure successful scale-up:
Utilize tools to schedule AC sessions and activities.
Systems for filing documents.
Appropriate systems to document and communicate challenges.
Appropriate system to monitor and track patients who default from ART (MacGregor et al., 2017).
Government & NGO Support
The support of the Western Cape Government Department of Health contributed to the success of ACs. Additionally, there were advocates of ACsfrom Médecins Sans Frontières (MSF) who initially implemented the AC model, and from the government, who provided strong leadership to ensure that the program was scaled up. Support from LCHWs, with whom club members trust and feel are accountable 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 outcomes to those in standard care models.
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
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
MacGregor, H. M., Andrew; Jacobs, Tanya; Ullauri, Angelica. (2017). “Scaling up ART adherence clubs in the public sector health system in the Western Cape.” Globalization and Health, 14(40). doi: 10.1186/s12992-018-0351-z
Revised by the PEPFAR Solutions Team, May 2018