Medecins Sans Frontieres (MSF), known for its ability to find novel solutions to pressing health systems problems, this week launched an ART adherence club toolkit that can be rolled out to most public sector clinics, hospitals and communities where almost two million South Africans are being treated.
In a nutshell, the ART adherence clubs are a long-term retention model of care for stable patients on ARVs. Between 20 and 30 patients meet and are facilitated by a non-clinical staff member (often a Treatment Action Campaign counselor) who provides a quick clinical assessment, a referral where necessary and peer support in the form of a short group meeting. Pre-packed ARVs are distributed, enough to last for two months until the next meeting. MSF is keen to extend it to three months.
Once a year, the patient is referred for blood tests and is seen by a doctor.
This means that for one year the patient does not need to be seen by a professional health worker, essentially freeing them up to treat more complex cases and creating space in waiting rooms.
“The critical question we faced was how we place a further two million people in need of drugs on treatment and how we retain the two million already receiving ARVs,” explained Lynne Wilkinson, head of the MSF’s Khayelitsha programme and project co-ordinator for the adherence clubs. Wilkinson was also one of the key partners who managed to successfully establish a similar programme in the deep rural Eastern Cape a few years ago.
Wilkinson believes that if they continued with business as usual, with an increasing number of patients relying solely on healthcare facilities, there is a very real danger that many patients will be at risk of failing their treatment.
“There is no need to waste our scarce resources on patients who are doing well or forcing patients to make different decisions (when faced with spending a day in a clinic waiting for their pills or paying lots of money to travel far),” said Wilkinson.
A pilot study conducted by MSF with the support of project partners - the Western Cape health department, the Institute for Health Improvement and the Treatment Action Campaign (TAC) - showed that after almost four years 97 percent of club patients remained in care.
Club members were also 67 percent less likely to have virological rebound, a marker that indicates good adherence to treatment.
Almost 20 percent of the more than 23 000 patients receiving treatment from nine facilities in Khayelitsha, access it via clubs.
“This programme can be scaled up quickly,” said a confident Wilkinson, who would like to see it rolled out throughout South Africa and sub-Saharan Africa.
The next step for MSF has been to start evening clubs for those patients working during the day – they are able to attend after 6pm. Caregiver and child clubs will allow children requiring treatment to attend with their parents or caregivers. Youth clubs are also being tried for those adolescents in the pre-ART stage or newly initiated onto treatment.
A novel development has been the hosting of the adherence clubs in people’s homes and community venues.
Not surprising, the model has caught the eye of the Western Cape health department which has become a partner in rolling it out to several high burden urban centres in Cape Town and soon to more rural areas.
Dr Jannie Mouton of the provincial health department is unequivocal that “it is the way to go – we need to roll it out into communities and people’s homes”.
Mouton said the province was also looking at integrating the clubs into a chronic care model, which means that patients with for example diabetes or high blood pressure could benefit.
By August this year 149 new clubs had been established in Khayelitsha at nine health facilities. In total 5 195 patients had been enrolled.
Wilkinson says that fixed drug combination (one pill as opposed to three) drugs would allow for the clubs to be expanded even further. This could see the counselor collecting the drugs from a central point and carrying it to the meeting venue in a backpack as opposed to having to drive.
A slightly tweaked model is also being tried in KwaZulu-Natal where community members meet at a health facility for a couple of months. Once patients are able to establish which members live in the same village, they are able to establish clubs close to home. It is envisaged that this version could work in rural areas.
Other than the needs for fixed dose combination drugs, Wilkinson identified the lightening of the load on pharmacists as a critical priority that had to be addressed.
In the Western Cape they were hoping to sidestep this challenge by making use of the Central Dispensing Unit which is able to courier drugs.
The initiative has already won a 2012 platinum award from the Impumelelo Social Innovations Centre and is a finalist in the United Nations Public Service Awards, a prestigious international recognition of excellence in public service.
The Adherence Club model, which won an Impumulelo social innovation award earlier this year(http://www.ihi.org/about/news/Documents/IHIPressRelease_SouthAfricaImpumeleloAward_Sept12.pdf)), is also up for a UN award.
For more information about the toolkit, click here: http://www.msf.org.za/publication/art-club-toolkit