Background
Alternative antiretroviral treatment models of care
Key objective | ART adherence clubs | CADP | CAG | CHBC | ||
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Facility-based club | Community-based club | |||||
Patient perspective | Reduce cost (time + transport) | • Reduction of clinical visit • Less time spent at clinic for drug refill | • Reduction of clinical visit • Less time spent a clinic for drug refill | • Reduction of clinical visit • Less time spent at clinic for drug refill | • Reduction of clinical visit • Less time spent at clinic for drug refill | • Reduction of clinical visit • Less time spent at clinic for drug refill |
Increase peer support | At club in health facility and potentially beyond into community | At club in community and beyond | At distribution points by expert patients | At CAG meetings in community and beyond | At HBC meetings by the CHWs | |
Enhance community participation | No | Potentially | Potentially | Potentially | Potentially | |
Healthcare service perspective | Reduce workload | |||||
• Nurse | Yes | Yes | Yes | Yes | Yes | |
• Pharmacist | No | No | Yes | Yes | Yes | |
• Counsellor/CHW expert patient | No (facilitation by club) | No (facilitation by club) | No (Distribution and monitoring) | No (formation, training and supervision of CAGs) | No (formation, training and supervision of HBC) | |
Maintain/improve health outcomes | ||||||
• Adherence | Yes | Yes | Unknown | Unknown | Unknown | |
• Retention | Yes | Yes | Yes | Yes | Yes | |
Improve self-management of patient | Adherence support | Adherence support and tracing | Organisation of service for drug refill, adherence support, tracing and testing | Drug refill, adherence support, tracing and testing | Adherence support and tracing | |
Decongest facility | No | Yes | Yes | Yes | Yes |
Review questions
Realist evaluation and generative mechanisms
Methods
Study design
Identification and selection of studies
Inclusion criteria
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Sample: Stable adult (18+ years) patients on ART
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Phenomenon of Interest: Retention in care and adherence to antiretroviral medication
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Design: Quantitative, qualitative and mixed-methods studies
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Exposure: Facility-based and community-based group-ART models in SSA
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Research type: Primary research articles on group-based ART models
Exclusion criteria
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All articles that did not deal with a group-based ART model of treatment and care such as home-based care models.
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Non-English papers
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Papers reporting non-primary research
Ethical considerations
Data analysis—analysing the papers for the narrative synthesis
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Developing a theory of how the intervention works, why and for whom
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Developing a preliminary synthesis of findings of included studies
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Exploring relationships in the data
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Assessing the robustness of the synthesis
Step 1. Developing a theory of how the intervention works, why and for whom
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Task-shifting of services to the lowest level of care provider, from nurses offering ART services to community health workers and in some instances to PLWHA (expert patients).
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Adherence is improved by decreasing the burden placed on patients (time, cost, pills) and by increasing the user-friendliness of care and treatment services.
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Having patients receive their care together to increase peer support among the patients and creating an enabling treatment and care environment.
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By separating the drug-delivery and clinical care and reducing the intensity of the services, the care process is simplified for the providers and made much user-friendly.
Data analysis/synthesis
Step 2. Developing a preliminary synthesis—extracting data from the included studies
Study | Intervention type: country | Description of sample sample size | Study design | Detailed description of outcomes |
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Decroo et al. (2011) [53] | Community ART group—alternative ART collection by a group member in Tete Mozambique. | Stable patients on ART (February 2008–May 2010)
N = 1384 | Cohort study | 1269 (97.5%) were retained in care, 83 (6%) were transferred out, 30 (2%) had died, and 2 (0.2%) were lost to follow-up. |
Decroo et al. (2014) [52] | Community ART group—alternative ART collection by a group member in Tete Mozambique. | Stable patients on ART (February 2008–December 2012)
N = 5729 | Retrospective cohort | Mortality and LTFU rates among 5729 CAG members were, respectively, 2.1 and 0.1 per 100 person-years. Retention was 97.7% at 12 months, 96.0% at 24 months, 93.4% at 36 months and 91.8% at 48 months. |
Dudhai & Kagee (2015)[58] | Facility-based adherence clubs—Cape Town, South Africa | Adult ‘stable’ patients are forming groups of 15–30.
N = 13 6 patients, 7 Health care workers | Descriptive qualitative design | 1) The adherence club reduces the time ART users spent at the clinic. 2) Logistical problems associated with the timely and correct delivery of drugs. 3) Sense of belonging and cohesion among club patients 4) Patients become active participants in care rather than passive receivers of health care The adherence club helps to decongest the facility |
Grimsrud et al. (2015) [30] | Community-based adherence clubs—Cape Town, South Africa | Stable patients are forming groups of 25–30. Down referred to an adherence club from May 2012–December 2013.
N = 2133 | Observational cohort | Over an 18-month period, 2113 patients were decentralised to one of 74 CACs (decongestion). LTFU among CAC patients was 2.6%, 3.9% and 6.2% at months 6, 9 and 12, respectively. Kaplan-Meier estimates of viral rebound were 1.4% at 6 months and1.7% at 12 months. Overall retention on ART was 97.2% at 6 months and 93.5% at 12 months. |
Khabala et al. (2015) [60] | Medication Adherence Club—Nairobi, Kenya | Mixed groups of 25–35 stable hypertension, diabetes mellitus and HIV patients. August 2013–August 2014.
N = 1432 | Retrospective descriptive study | From a total of 2208 consultations, for both HIV and hypertension/diabetes patients, adherence appears to be high with blood pressure checked in 99%, weight checked by 98% and blood tests ordered correctly in 98–99% of patients. 2208 consultations, 43 (2%) were referred to the regular clinic. The overall loss to follow-up was 3.5% (30). |
Luque-Fernandez et al. (2013) [29] | Facility-based adherence clubs—Cape Town, South Africa | Adult ‘stable’ patients are forming groups of 15–30. November 2007–February 2011.
N = 502 | Retrospective observational cohort | 97% of Club patients remained in care compared with 85% of other patients. Club participation reduced loss-to-care by 57% and a viral rebound in patients who were initially suppressed by 67%. |
Rasschaert et al. 2014 [27] | Community ART group—alternative ART collection by a group member in Tete Mozambique. | October 2011–May 2012 CAG patients and Stakeholders. 16 FGDs and 24 IDIs | Grounded theory | The CAG model provides cost and time savings for the patients, the certainty of ART access and mutual peer support resulting in better adherence to treatment. Patients also take more active role in their health care (self-management). Group members combine, share and develop their knowledge, experience and personal skills. At the community level, it has strengthened community action, empowered patients. |
Rasschaert et al. (2014) [27] | Community ART group—alternative ART collection by a group member in Tete, Mozambique. | October 2011–May 2012 CAG patients and Stakeholders. 16 FGDs and 24 IDIs | Exploratory qualitative | (1) The CAG model was designed to overcome patients’ barriers to ART and was built on a concept of self-management and patient empowerment to reach effective results. (2) The daily management of the model is still strongly dependent on external resources, especially the need for a regulatory cadre to form and monitor the groups. (3) The model is strongly embedded in the community, with patients taking a more active role in their healthcare and that of their peers. (4) There is a growing enabling environment with political will and general acceptance to support the CAG model. (5) Contextual factors, such as poverty, illiteracy and the weak health system, influence the community-based model and need to be addressed. |
Rasschaert et al. (2014) [27] | Community ART group (CAG)—alternative ART collection by a group member in Tete, Mozambique. | October 2011–May 2012 CAG Stakeholders. Quant data: February 2008–December 2012 Qualitative data: 16 FGDs and 24 IDIs
N = 105 | Mixed-methods design | The counsellors were considered key to form and monitor the groups. The main modifications found were the progressive adaptations of the daily CAG functioning and the eligibility criteria according to the patients’ needs. The CAG leads to cost and time-saving benefits and improved treatment outcomes. The model offered a mutual adherence support and protective environment to the members. The active patient involvement in several health activities in the clinics and the community resulted in a better HIV awareness, decreased stigma, improved health seeking behaviour and better quality of care. |
Rich et al. (2012) [57] | Community-based ART treatment. Group enrolment and patient support group in Rwanda. | HIV-positive adults starting community-based ART treatment between June 2005–April 2006
N = 1041 | Retrospective medical record review. | Among 1041 patients who initiated community-based ART, 961 (92.3%) were retained in care, 52 (5%) died and 28 (2.7%) were lost to follow-up. Median CD4 T-cell count increase was 336 cells/mL from median190 cells/mL at initiation. |
Vandendyck et al. (2015) [56] | Community ART group (CAG)—alternative ART collection by a group member in Lesotho | Six- Eight Stable patients on ART January 2007 December 2010 Qualitative Sample: 8 FGDs and 40 IDIs
N = 67 Quantitative Sample:
N = 199 | Mixed-methods design | One-year retention of among patients in CAG 98.7% and those not in CAG, 90.2%. The CAG members commented that their CAG membership 1) Reduced time, effort, and money spent to get a monthly ART refill. 2) Induce peer support, which enhanced adherence, socio-economic support and empowered members to deal with stigma; and 3) Resulted in the feeling of relief and comfort. 4) Village health workers confirmed increase openness about HIV in their community 5) Clinicians reported a workload reduction 6) Community-led indicated that CAG members promoted health seeking behaviour to the community members. |
Venables et al. (2016) [56] | Medication Adherence Club—Nairobi, Kenya |
N = 106 10 FGDs 19 IDIs with HIV-positive patients and patients with NCDs 15 sessions of observations | Qualitative design | 1) MACs reduce stigma for HIV-positive patients 2) MACs reduce waiting times and prevented unnecessary queues |
Results
Step 3. Exploring relationships in the data and between studies: a realist perspective
Study | Intervention modalities | Actors | Context | Mechanism | Outcome |
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Decroo et al. (2011) [53] | - A group representative visits the nearest health facility to collect medicines for the group. - Group members could still visit the health centre at any other time - A group meeting is held in the community before each clinic visit, and the designated group leader counts each members’ pills - The group representative meets with a clinician who prescribes ART and prophylactic drugs for each group member. | - Stable patients on ART - Adherence counsellor or clinician | - Poverty among ART patients - Perceived stigmatisation of patients when theyattend clinics - Treatments guidelines allow for one clinical consultation every 6 months and monthly supplies of medication. | - Building and reinforcing social networks and peer support - Encouraging greater patient responsibility | - Decrease the financial and economic/social costs of their treatment - Greater responsibility for the management of their own health |
Decroo et al. (2014) [52] | - Community ART groups (CAG) - Peer support groups involved in community ART distribution - Mutual psychosocial support | - Stable patients on ART - Group of CAG members | - Difference psycho-social and biomedical characteristics than patients - Difference in adherence profile of patients in the CAG model | None identifieda
| - Mortality and loss to follow-up rates were better for patients in the CAG group than the clinic cohort - Retention in care rates with time was also improved. |
Dudhai & Kagee [50] | - Facility-based antiretroviral adherence club | - Stable patients on ART | - Consistent and timely delivery of medication (failure) - Management of logistics by the host facility - Communication challenges between the host facility and the Chronic Dispensing Unit Staffing dynamics - need for more staff to run more clubs | - Cohesion among club members - ART users view themselves as active rather than passive participants in their care. | - Decongest the clinics so we have more time to spend with the sick patients or the new patients. - Shorter waiting time - Avoids financial loss on the part of the patient |
Grimsrud et al. (2015) [30] | - Community-based antiretroviral adherence club intervention - Support ART maintenance for groups of stable patients in a community health worker-facilitated model with peer-support and increased patient self-management - Shifting the service away from health facilities to be community-based - Most CACs met five times per year | - Stable ART patients - Groups of 25–30 - Community health worker - A professional nurse was assigned as the CAC nurse rotating on a monthly basis. | - Limited resources within the community venue and distance to CHC for supplies - Policies regarding dispensing and distribution - Ensuring access to a clean and appropriate community-based facility - Limited resources within the community venue and distance to CHC for supplies | None identifieda
| - Better retention in care - Fewer people lost to follow-up and less attrition from the care programme |
Khabala et al. (2015) [60] | - Medication Adherence Clubs - MACs are nurse-facilitated groups of 25–35 stable hypertension, diabetes mellitus and HIV patients who meet quarterly to (i) confirm their clinical stability, (ii) have a short health talk and (iii) receive pre-packed medications. - Routine patient follow-up with clinical officers occurs yearly when a patient develops complications or no longer meets the inclusion criteria. | - HIV and non-communicable disease patients - Professional nurse | None identifieda
| - Patient satisfaction | - An efficacious method of reducing clinicians’ workload - It also demonstrates a low loss to follow-up |
Luque-Fernandez et al. (2013) [29] | Facility-based antiretroviral adherence club - Facilitated by non-clinical staff (counsellors) - Groups of 15 to 30 patients are formed and convene at the clinic during quiet times - Medicines are pre-packaged for each participant and brought to the group by a counsellor who weighs the patients and administers a symptom-based general health assessment. - Any patients reporting symptoms suggestive of illness, adverse drug effects or who have weight loss are referred to the clinic to be assessed by a nurse. - The counsellor or experienced patients lead short group discussions on health issues - A draw blood for viral load and CD4 count testing. | - Stable patients on ART - Non-clinical staff (counsellors) - Professional nurse | None identifieda
| - Group dynamic itself may be an important contributor as was historically motivated | - Administrative efficiency and decongestion of services are key aspects of the model - Improved retention in care might result due to the removal of these and other structural barriers to care - Virologic rebound was lower in the club model |
Rasschaert et al. (2014a) [27] | - Community ART groups (CAG) - Based on the principles of self-management. - Patients rotate to pick up medication supplies for the rest of the group on a monthly basis - Each group elects a group leader, who functions as a spokesperson for the group. - The group members meet regularly in the community, perform monthly pill counts and offer mutual adherence support. - Lay counsellors, assist in forming and monitoring the groups in health facilities and the community | - Stable patients on ART - Group of CAG members - Involvement of other organisations likes MSF - Involvement of the Ministry of Health - Lay counsellors | - Progressive ministry of health involvement and integration of activities in existing health services - Flexibility to adapt to changing patients’ needs over time - Community participation - CAG model is well accepted by all stakeholders - Changed mindset of all stakeholders concerning the new health care approach - Continuous supervision, training and coaching sessions for patients and health staff - Low educational levels of most patients - Chronic shortage of staff | - Self-management and patient empowerment - Mutual adherence support - Increased assurance of timely access to ART - Motivation of care staff - Strong social links and networks between members | - Decreased workload and better monitoring of patients - Better general well-being - Less loss to follow-up and deaths - Improved adherence to treatment - Increased HIV awareness - Increased uptake of HIV testing, and a reduction of stigma |
Rasschaert et al. (2014b) [54] | - Counsellor key role in forming and monitoring groups - GAC members participate in HIV-related activities in clinics and community - Group established CAG entry requirements - Flexible application of medical CAG eligibility criteria | - MSF employed counsellors - Stable patients on ART - Group of CAG members | - Permanent presence of counsellors in clinics - Resources for training and meetings - Consistent drug supply - Buy-in from the Ministry of Health - Problems with group formation, rotation system and relationships in groups | - Empowerment of patients - Mutual adherence support - Social control through ‘Code of Conduct.’ - Bonding between CAG members - Trust relationship - Patients are actively involved in their health decision-making - Problem-solving skills | - Better HIV awareness - Improved quality of care provided as supervision is in place - Decreased stigma - Improvement in the quality of health for patients - Better access to drug refills contributed to improved retention on ART. |
Rasschaert et al. (2014c) [55] | - Groups comprise up to six stable patients on ART - Monthly, a group member is appointed to collect the drugs on behalf of the group and reports on and receives medical consultations for the group members. - Counsellors, sensitise patients to join groups and monitor the group activities. | - Stable patients on ART - Group of CAG members - MSF employed counsellors | - Weak healthcare system - Shortage in health staff - Lack of infrastructure - Discrimination and social exclusion when monthly attending the clinic. - Cultural beliefs that HIV is caused by spiritual spells and can only be managed by traditional healers - CAG intervention widely accepted among stakeholders | - Patients’ active role in health care - Social control and group rules - Psycho-social support - Understand the importance of taking medication - Very strong bond and network between the members. | - Reduced workload and improved quality of care in clinics - Better health outcomes - New identity of CAG members in group, clinic and community - The less frequent clinic visits per individual patient reduce the time and cost investment significantly - Better adherence to medication |
Rich et al. (2012) [57] | - Patients qualifying for ART were given the option of entering a group of 12–24 persons for ongoing patient education and support. - Group enrollment consisted of a 3-h educational session and four individual visits before the initiation of ART. - After ART initiation, groups would attend routinely scheduled visits on the same day and meet for ongoing patient education and social support. - Routine visits occurred monthly for the first 10 months and then bi-monthly afterwards | - Patients qualifying for ART - Trained community health workers, also known as an “accompagnateurs,” | - Targeted support provided to health centres to ensure adequate staffing and retention of trained nurses, plus weekly physician supervision visits. - Trained CHWs, also known as an “accompagnateurs,” performed daily home visits. - Each patient received a monthly food package valued at the US $30 - Housing assistance, employment training and school fee support for patients and families in grave socioeconomic circumstances. | None identifieda
| - Good retention in care rates is retaining people in care at 2 years with very low rates of loss to follow-up and death. |
Vandendyck et al. (2015) [56] | Community adherence group - PLWHA stable on ART was invited to constitute a CAG - CAG members meet monthly in the community. - During the meeting, they verify each other’s pill count (adherence) and choose a representative to go to the health facility. - At the health facility, the group representative has a consultation on behalf of the rest of the group members. - Then the representative returns to the community to distribute ART to the fellow group members | - PLWHA stable on ART - Community health workers | - Support from the village head - Separation of monthly ART refills from clinical assessments - Need for a reliable drug supply system to ensure access to ART - Availability of appropriate number of community health workers and lay counsellors to support the formation, training and monitoring of CAGs - Need for clear mechanisms to trigger support or referral back to clinic care to ensure patients and groups in need receive appropriate care - Availability of a simplified monitoring system to avoid increased administrative workload | - Being together, living in the same situation, bring the CAG to form a network of peers - Patients were empowered to take responsibility and to support each other. - Induced peer support, which enhanced adherence - Socio-economic support and empowered members to deal with stigma - Feeling of relief and comfort - Empowerment resulted from a new role for patients | - Village health workers confirmed increased openness about HIV in their community - Community leaders added that CAG members promoted health-seeking behaviour to community members - Clinicians reported a workload reduction. - Better retention in care within the first year of CAG membership. - Reduced time, effort and money spent to get a monthly ART refill |
Venables et al. (2016) [59] | - Medication Adherence Clubs provide a medication refill system for stable HIV, diabetes and hypertensive patients. - Medications are pre-packed and labelled by the pharmacy - MACs are made of 10–30 stable hypertension, diabetes mellitus and HIV patients who meet quarterly to (i) confirm their clinical stability, (ii) have a short health talk and (iii) receive pre-packed medications. - Fast-track appointments - Routine patient follow-up with clinical officers occurs yearly when a patient develops complications or no longer meets the inclusion criteria. | - Stable HIV, diabetes and hypertensive patients - Non-medical health educators | - High prevalence of HIV, diabetes and hypertension - Support from a non-government organisation - Population living in informal settlements | - Patient satisfaction - Social support (mutual adherence support) - Acceptability related to advantages, - Empowerment | - MACs reduce waiting times and prevented unnecessary queues - MACs reduce stigma for HIV-positive patients |