What was the problem?
Frequent clinic visits and high volumes of patients in large facilities create challenges for patients, which can reduce long-term antiretroviral therapy (ART) adherence and retention. In Mozambique, with over 70% of the population living in rural areas, patients travel long distances and often wait hours to receive services. Patient access to treatment and over-burdened health facilities were major challenges to HIV service delivery, and contribute to a loss to follow-up (LTFU).
What was the solution?
Community Adherence and Support Groups (CASGs) are groups of stable patients on ART who take turns attending the facility for a clinical assessment and tests, whilst collecting drugs for themselves and the other members of the group. The CASG provides a means of accessing ART for the group members and a source of social support, both of which are intended to reduce LTFU. The CASG model also fosters patient self-management and independence.
What was the impact?
A retrospective analysis of 5,729 adults who joined CASGs between February 2008 and December 2012 in Tete, during a pilot of CASGs by Médecins Sans Frontières (MSF), showed rates of retention on ART of 98% at 12 months, 96% at 24 months, and 93% at 36 months, and 92% at 48 months (Decroo, 2014). This is substantially higher than national retention, which was around 70% at 12 months in 2012 (in sites with electronic patient tracking systems).
A national pilot of CASGs began in 2011. Of 288 ART facilities in CDC-supported provinces, 170 had EPTS and 68 were implementing CASGs in early 2014. Retention was significantly higher in the 6,760 patients who had participated in CASGs at these sites from 2011-2014 as compared to a matched cohort; with 12-month retention of 91% compared to 83% in non-CASG participants. This was almost entirely due to decreased LTFU among CASG participants (there was no significant difference in mortality) (Jobarteh, 2016).
How does it work?
Patients on ART learn about the CASG system through messages in health facility waiting areas, during clinical consultations or through support groups or lay counselors. Health providers assess patients for eligibility. Eligible patients are enrolled in a CASG only if they agree to participate. Every month one member of the CASG goes for a clinical visit to represent the group. During the visit, the representing CASG member receives a clinical evaluation and any lab testing necessary; they also pick up the medications for all other members of the CASG, and bring back any relevant counseling messages for the other group members. On a monthly basis, members of the CASG gather to provide support to each other, receive medications from the member who visited the health facility, and discuss any additional messages from the clinic.
The Ministry of Health (MoH) National Strategy on CASGs was developed in 2013 and approved in 2015. The CASG model has also been included in national ART guidelines and is being included in a current document under development summarizing differentiated service delivery in Mozambique.
Tools for monitoring and evaluation that had been developed as part of the national pilot were updated and incorporated into the approved national M&E system. This includes a CASG register and routine reporting indicators related to CASGs. Uptake of CASGs is reported monthly to the MoH.
The CASG initiative, which began as a local pilot in 2008, was subsequently piloted nationally in 2011 and then scaled nationally beginning in 2014. High-volume sites were the focus of the initial scale-up and scale-up to additional smaller facilities is on-going. As of September 2017, 717 (61%) of the 1,172 facilities supported by PEPFAR offered CASGs and a total of 97,255 patients were enrolled in CASGs, representing approximately 10% of patients nationally. Demand creation tools were developed in 2016 and approved in early 2017 to improve CASG uptake.
Cost of Innovative Solution: While one of the core objectives of the CASG model is to reduce the cost of providing ART services by improving efficiency at ART clinics, formal costing data is still limited; anecdotal reports from similar models in the Democratic Republic of the Congo suggest that the time saved on paperwork completion was not substantial. The model in Mozambique does require additional staffing costs as many of the CASGs are supported by lay counselors. Funding is also used to support training for CASG implementation, supportive supervision and M&E, community support, and demand creation.