How community groups drive uptake of antiretroviral treatment
It was a sunny morning when we visited the Comprehensive Care Centre (CCC) at Madiany Sub County Hospital, Siaya County. Here, people living with HIV/Aids receive holistic care and management.
We expected to find patients seated patiently outside the centre, waiting to honour their appointments. However, things were completely different. Empty seats welcomed us, with only a handful of patients waiting.
“If you had visited this centre three years ago, things were totally different. Back then, patients used to seat patiently outside the centre waiting their turn. The numbers used to be so high such that patients used to wait for hours before they were attended to,”says George Nyakora, an adherence counselor at the centre.
But since introduction of SHINDA Project in 2017 by Centre for Health Solutions (CHS), a non-governmental organisation in that hospital, things have changed. The centre no longer registers such huge numbers of people at any given day, and consequently, it has been able to provide quality care to the few who visit.
And why have the numbers reduced? Nyakora says CHS has introduced a new approach known as Community ART Group (CAG). This is a client centred approach for antiretroviral treatment (ART) distribution that ensures that People Living with HIV (PLHIV), who are stable, need not visit the facility every month to receive the services. Instead the services are taken closer to them.
Stable patients are individuals 20 years and above who have been on ART for at least 12 months, are adherent to their medication and have recorded good health outcomes thus do not require frequent clinical consultation or follow up.
“CHS has been working with the Siaya County Department of Health, to provide high-quality HIV services to its population. The aim of this intervention is to address existing treatment access barriers, improve quality of care, ensure increased retention in care and encourage sustained adherence to ART, thereby improving sustained viral suppression,”he says.
Reduced defaulters
Dr Momanyi Ogeto, HIV Treatment Advisor at CHS, says the organisation introduced the intervention in 2017 after realising PLHIV visit the center often to receive their ART, yet continue to encounter challenges accessing the drugs. After its introducing, this model has supported decongestion of health facilities and reinforced peer support for PLHIV at the community level. Defaulter and death rates have also reduced among PLHIV in CAGs mainly due to social support.
“We realised despite the rapid scale-up of ART, patients still encounter barriers accessing treatment. At the same time health systems struggle to provide care to the growing number of patients on ART. This is why we introduced this community-based service delivery model that aims to expand HIV prevention and treatment as well as decongest our health facilities,” says Ogeto.
He says groups are formed by about six to 12 stable patients. Members are segregated per village based on geographic proximity and individual preference. Members voluntarily choose whom they want to be with in the same group. The groups are managed by a peer educator from the health facility where the members of the group are enrolled in care.
Jenipher Atieno from Akuom village in Siaya County is a member of Nyakongo CAGs. Atieno, who runs a hotel in the area, says that enrolling to one of the groups has helped her not only save money but also time. Because of that, she is able to invest in and dedicate herself to the business. She also doesn’t worry about wasting time and money going to the health facility every month.
“I used to use about Sh200 every month for transportation. I would also waste between one and two hours at the facility every month. But since I joined the group, I use less than 10 minutes to get those services at my home since that is where the group meet. The number of facility visits have also reduced from monthly to after every six months,” says Jenipher.
Martin Odongo from the same village is another beneficiary. He says bringing the services closer to him has helped him to adhere to his medication. The nature of his job made him miss his refill dates frequently, leading to dire consequences. “As a plumber, I used to travel far and wide for work. The good thing about this intervention is that, even when you are not around to pick the drugs from the educator yoursel, they are delivered to your home, thus minimising the risk of not adhering to the medication,” says Odongo.
The groups works in such a way that members only meet during their refill day. Instead of going to the facility, they meet at a central area where a peer educator from the facility comes, conducts a health talk and a group adherence counseling session. During this time, members are given a chance to ask questions and discuss possible solutions to concerns raised as guided by the CAG representative.
Afterwards, each member hand in their patient card for registration in the CAG group membership register to receive their medication. They also receive clinical assessment and monitoring tests similar to what they would have received at the health facility. If a member of the group is particularly unwell and needs a clinical consultation they are referred to the hospital by the educator.
“In order to ensure the correct medicine are delivered to the correct CAG member, bottles are labelled at the health facility. At the hospital, we have a diary that informs us which group need a refill. With that information,we prepare the drugs well in advance then we deliver them or we call their peer leader and tell them the date they will be taking drugs to their community,” says Millicent Kanyala ,a peer educator at Madiany sub-county Hospital.
And what are some of the achievements since the introduction of this intervention?
Nyakora says the intervention has helped to retain thousands of PLHIV on ART, ministry of health has incorporate the CAG model into the national guidelines, delivery models have become increasingly patient-centred, allowing patients to combine lifelong ART refills with a normal social and economic life, stigma associated to HIV has reduced since CAGs encourage peer support at community level, thereby facilitating a social fabric among patients and reducing perceived stigma.
CAGs have also reduced the workload of overburdened healthcare workers by decreasing the number of patients individually attending the clinics whilst achieving good health outcomes for the patients. At Madiany Hospital, for example, there are about 90 community groups with a total of 822 members who are receiving their ARTs at home instead of going to the hospital. The model has also fostered patient self-management and independence from the health-service.
“This solution was piloted from 2017. After the pilot was proven extremely successful with excellent adherence and retention rates and minimal defaulter rates as compared to the conventional ART programme outcomes, in 2019, it was enrolled actively. We can say the solution has been a success because when we introduced the solution, viral load suppression rates at this facility were at 84 per cent but now we are at 96 per cent,” says Nyakora.
Stable patients
To ensure all stable patients on ART are in groups, patients are given the option of joining either a CAG or facility-based group. One can also move between the two models of care, according to their preference. A CAG member can even opt to go back to regular (conventional) ART care within the health facility at any moment.
Ogeto says though this model has been a success, it faced a lot of resistance initially but after awareness creation, PLHIV have started to embrace it because the more people are aware, the easier it becomes for groups to form spontaneously and present at the clinic.
“ It was hard at first to sell this model here because people didn’t know such a system exists. However, as we kept spreading the message in the health facility waiting area and through community channels patients started to embrace it. Today the model is well known since through this project over 820 CAGs have been formed with over 8,000 clients enrolled across the CHS supported health facilities in Siaya county,” he adds.
