Ingrid Hein

October 18, 2016

New models for the delivery of antiretroviral therapy to patients with HIV in Sub-Saharan Africa are reducing the burden of care for both patients and healthcare workers.

One model presented at the Controlling the HIV Epidemic With Antiretrovirals Summit 2016 in Geneva changed the delivery of treatment by creating clubs that were not only treatment distribution points, but also community support centers.

The idea caught on quickly. "Today, there are about 10,000 community-based ART clubs in South Africa," said Eric Goemaere, MD, PhD, from the Southern African MSF Medical Unit at Cape Town University.

With the previous delivery system in South Africa, clinics were overwhelmed by the number of patients with HIV. For instance, a clinic in the township of Khayelitsha, near Cape Town, initiated treatment for 13,000 patients with HIV, 9000 of whom are receiving ongoing antiretroviral therapy.

To get treatment out to that many patients in one clinic, a new model of delivery was required, he explained.

In the "spirit of ubuntu" — a South African term meaning "humanity to others" or "I am because you are" — the clubs share the burden of picking up treatment supplies from clinics for multiple patients, Dr Goemaere said.

The Spirit of Ubuntu

In rural areas in particular, this eases the burden of travel, lost work days, and workloads at clinics. In addition, the clubs create an instant support network by providing a place for patients to exchange information, get support, and even identify newly infected patients.

"It's much easier when patients can share their concerns and objectives," he said. "They know each other. It's a peer-support system."

"They may not even speak about the disease," he added. "Teenagers sometimes go to the clubs and put on music and start dancing."

"They get the minimal clinical monitoring," Dr Goemaere said, and "they tell each other tricks, like what to tell a new boyfriend about HIV. They do it much better than I can."

Patients who belong to treatment clubs are still required to visit the clinic for check-ups, but can do so much less frequently. In many cases, once a year is considered sufficient.

Different situations call for different models, and different patients have different requirements, Dr Goemaere pointed out. "Initially, people living with HIV were considered to be one homogenous package, but we've realized there are different categories and needs."

He identified four categories of need during his presentation: patients doing well; patients with advanced HIV infection; patients stable on antiretroviral therapy; and patients on antiretroviral therapy with complex problems.

Some patients do well from the time they are diagnosed and can go straight into chronic care treatment with antiretroviral therapy, he explained. Others, however, develop adverse events or infections or drop out.

Then there are the so-called "late presenters," who have been diagnosed but need a different model of care.

"If you have 50 or 60 people to see in a day, you have no time to investigate new cases properly," said Dr Goemaere. The community-based model "saves time and energy for the patients who really need more attention."

Although the models vary from one facility to another, they all have one thing in common, he explained. "They all delink clinical consultation from ART."

In Zimbabwe, for example, one community club gets a 3-month supply of antiretroviral therapy and cotrimoxazole at a time. Patients who have a "regular" viral load visit the clinic once a year, and those with a viral load that is not routine visit every 6 months.

Community Clubs Improve Retention Rates

Researchers say they are seeing better adherence with community clubs and better retention in care support. The encouragement of the community and social networks allows patients to become more autonomous, "which in turn appears to result in better outcomes," Dr Goemaere said.

In a recent review of community-based care programs for patients with HIV, the decentralization of the delivery of medicines was shown to strengthen health systems and improve social support, education, and retention (Curr HIV/AIDS Rep. Published online October 13, 2016).

Community-based care could work in rich countries, too, especially in places with active LGBTQ groups. The more stigma there is, the more difficult it is, he said, but it is important to remember that stigma can be overcome.

"People wouldn't even dare talk about the disease when I started out in HIV in the early 90s," said Dr Goemaere. "Today, it's common."

 
We need to be smart if we're going to end this epidemic. Getting that last 10% is very important.
 

But to reach 90-90-90 targets, the HIV community needs to stop claiming that we have the tools and that we simply need to integrate them, said Dr Goemaere.

"There is no silver bullet," said Mark Dybul, MD, executive director of the Global Fund, during his presentation on stigma and discrimination.

It is important to fund projects in places where vulnerable patients are being left behind and to always look at who may be left out of treatment, he said. "We need to see who we're missing."

Funding organizations are realizing that they need to focus on marginalized groups. The Global Fund works to promote human rights and gender equality, and other organizations are doing the same, Dr Dybul reported. He applauded the President's Emergency Plan for AIDS Relief in the United States for focusing on women and LGBTQ groups.

"We need to be smart if we're going to end this epidemic," Dr Dybul said. "Getting that last 10% is very important."

Dr Goemaere and Dr Dybul have disclosed no relevant financial relationships.

Controlling the HIV Epidemic with Antiretrovirals Summit 2016. Presented October 13, 2016.

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