Improving Retention, Viral Suppression, and Facility Congestion through Postes de Distribution Communautaire in the Democratic Republic of the Congo

what was the problem?

Standard care health clinics and pharmacies are highly congested due to required monthly patient visits, and in-person prescription refills and medication distribution. This places undue burden on both the patients, and the monitoring and evaluation (M&E) systems, and is particularly prominent at large health care facilities. Comparatively, larger clinics tend to have longer wait times, and fewer resources to offer patients for whom clinic and transport costs, as well as lost work time, may have a significant negative impact. The additional burden of cost, time, and effort on patients can contribute to poor adherence and retention, leading to lower viral suppression rates and ongoing HIV transmission.

In the Democratic Republic of the Congo (DRC), overall retention rates at the end of fiscal year 2016 (FY16/COP15) were documented to be 69.5%. As the country began transitioning to a Treat All model, many facility staff members were concerned they would be able to keep up with demand, given the ongoing long wait times for stable patients seen monthly in clinics. 

what is the solution?

The Postes de Distribution Communautaire (PODI) plus model is a community-based, individual drug distribution and psychosocial support model. PODI provides a point from which clients can pick-up their medication and receive additional services outside of the standard health care facility. The PODI plus model is intended for adults on antiretroviral therapy (ART) who are stable and meet certain criteria. Patients come every 3 months to the PODI to collect their antiretrovirals (ARVs), monitor their weight, screen for TB symptoms, and receive – if necessary—adherence support from other people living with HIV (PLHIV) who are trained for this purpose. All services are free of charge. The patient attends a health facility annually for a viral load (VL) test and clinical consultation. The PODI can also provide testing services (particularly testing contacts of index clients enrolled at the PODI, as well as VL testing), counselling and therapeutic education services (to improve treatment literacy and adherence), and organize support groups and social support.

PODIs reduce the workload of overburdened health care workers by decreasing the number of patients individually attending the clinic, whilst maintaining good health outcomes for patients. The PODI plus model also empowers PLHIV-driven Civil Society Organizations (CSOs) to become advocates and service providers in their own communities. This helps to create a sustainable, patient-centered (rather than facility-driven) system for supporting clients in maintaining adherence, and psychosocial health and wellbeing. Currently, 4 PODI locations have been established in two regions of DRC, Kinshasa and Lubumbashi, with plans for expansion in FY18.

what is the impact?

Recent data (March 2018) from two sites in Haut Katanga/Lualaba, Masina and Kingasini, demonstrate the following:

  Data provided by the implementing partner

Data provided by the implementing partner

  Graph created by the PEPFAR Solutions Team, based on data from the implementing partner.

Graph created by the PEPFAR Solutions Team, based on data from the implementing partner.

An evaluation at one of the referring sites noted an almost 45% reduction in workload for service providers at that facility. This was because 597 out of their total cohort of 1,330 patients on treatment transferred to the PODI plus site to receive services, and did therefore not need to be seen by providers on a monthly or even three-monthly basis. Thus allowing providers to spend more time with newly diagnosed PLHIV, as well as clients with health issues, including detectable VL.

How does it work?

Individual level

The creation of the original PODI by Médecins Sans Frontières (MSF) was in response to patient needs and requests. Engagement of empowered CSO groups made up of PLHIV, like RENOAC, has been critical in advocacy efforts with the Ministry of Health (MoH) and providers. Additionally, the data on retention and patient satisfaction has helped to convince even reluctant providers and MoH staff to allow additional pilot projects.

Service delivery level

PODI staff track relevant data on retention, medication pickup, and clinical status. Data is then shared with the facility through Excel spreadsheets or Tier.Net, with assistance from EQUIP/DRC. The patient returns to the facility once a year for VL testing, which PODI staff can do in advance of the clinical visit. These results are also tracked by the PODI to confirm that the patient continues to meet criteria for PODI membership. Any PODI client presenting with symptoms of OIs or adverse events, or other indications for clinical evaluation, is referred and often accompanied back to the facility for evaluation and treatment as necessary. Additionally, PODI clients can bring their family members to the PODI for testing of their contacts. Regardless of the location of testing (at the PODI or facility) the PODI actively tracks the testing of these contacts.

Currently PEPFAR/DRC programs are enrolling eligible PLHIV into PODIs in Kinshasa and Lubumbashi at a rate of 30-50 clients per month at each PODI. Many clients have stated that they prefer the PODI over other differentiated models of care that have been offered (monthly clubs, fast track pharmacy refills at the facility, etc.) since pick-up times are flexible and they can access services in a less stigmatizing environment.  Any client noted to have retention issues is tracked by PODI staff within 1 week (and often within 1-2 days) after missing their scheduled ART pick-up date.

Local Environment

Not only was the creation of the PODI model a response to PLHIV’s needs, the actual PODI sites are staffed and managed by CSO groups. This allows the community to be directly engaged in advocating for, planning, and providing care.

Provider engagement with the PODIs has been essential to ensuring that providers feel comfortable with seeing individual patients less frequently. Providers who have visited PODI sites and interacted with the staff and clients there have become strong advocates for referring stable patients to these non-facility-based services.

National Environment       

The director of the PNLS’s (National HIV Program) support in allowing and encouraging the piloting of differentiated models of service delivery, including PODIs, has been critical. The director maintains close attention on the progress and impacts of the models. He is leading the effort, with the support of many national and international stakeholders, to develop national guidelines on differentiated models of care using sufficient data from the different pilots.

Scalability

At the end of COP16, 4 PODI locations had been established in two regions of DRC (Kinshasa and Lubumbashi), in addition to the original MSF-established PODI, which is now supported through a U.S. Centers for Disease Control and Prevention (CDC) IP. These new PODIs provide services to over 1000 clients at present, with the largest PODI serving over 500 PLHIV. New clients continue to be recruited to the PODIs at a rate of 30-50 per month, and none of the PODI locations has yet reached capacity. During COP17, 4 other high volume facilities will add PODIs to extend the benefits of this patient-centered and facility-decongesting model.