Model mechanics

ART refills

Clinical consultations

Individual/group approach

Group – individual from group collects on behalf of the group and distributes

Individual – clients from the group either rotate or all come on the same day

Who attends?

Representative client

Client

Client recruitment

Where

At facility and in community

By whom

Lay community health model education and promotion in facility waiting rooms
Community village health workers model education and promotion at community events and home visits
Existing community HIV support groups
Clinician suggesting enrolment

Eligibility assessment

By clinician during consultation; at individual clinical consultation; or screening group members once group has formed and conveyed intention to start group to facility

Group formation

Clients (self-forming), or through a counsellor/nurse introducing possible group members to each other

HIV disclosure

Does it happen?

Yes

If yes, where?

Within the group

Annual health care visit schedule for client

1-month supply:

  1. ART refill (in community)
  2. ART refill (in community)
  3. ART refill (in community)
  4. ART refill (in community)
  5. ART refill (in community)
  6. ART refill collection for group + blood draw + clinical review + rescript (at facility) + ART refill (in community)
  7. ART refill (in community)
  8. ART refill (in community)
  9. ART refill (in community)
  10. ART refill (in community)
  11. ART refill (in community)
  12. ART refill collection for group + blood draw + clinical review + rescript (at facility) + ART refill (in community)

3-month supply:

  1. ART refill (in community)
  2. ART refill (in community)
  3. ART refill (in community)
  4. ART refill collection for group + blood draw + clinical review + rescript (at facility) + ART refill (in community)

Please note: Visit schedules are presented here for 1- and 3-month ART refills. This model has also been used for 2-monthly refills and could be extended for 4- or 6-month refills. 

Alignment of ART refill and blood draw visit

Does it happen?

Yes. ART refill, blood draw and clinical visit on the same day

Aligment of ART refill and clinical visits

Does it happen?

Yes. ART refill, blood draw and clinical visit on the same day

Strategy and timing for actioning high VL/other red-flag results

Strategy

Immediate recall of client and/or group member informed of recall who then informs the red flag group member during ART refill distribution within the community

Minimum period for action/action failure risk

Immediately after result received at facility/high risk

Maximum period for action/action failure risk

1-3 months/medium risk

Clinical outreach from facility potential

By whom

No.

ART refill preparation

Is ART pre-packed?

No

ART refill collection date

All group members have the same scheduled appointment return date at the health facility

ART refill provision to group meeting location

How

One group representative goes to facility to collect ART refill for all group members and distributes upon return at group meeting venue in community

By

Rotating group member

Clinical referral mechanism

Criteria

Client complaining of being unwell / client reporting symptoms at symptom screen

By

Group members

To

Facility nurse

When

Same day as group ART refill return date at facility (attend with rotating group member collecting group ART refill)

Up referral (return to standard of care)

Criteria

Facility nurse assesses client to be clinically unstable requiring regular clinical follow up, including:

  • Develops TB
  • Serious OI
  • Other co-morbidity

Facility nurse identifies client with:

  • High VL (>1,000 copies/ml)
  • In absence of VL – evidence of clinical or immunological failure

Women during pregnancy and subsequent follow up of the “HIV-exposed” baby
Where repeated CAG problems observed – failure of member to collect refills or attend facility for clinical review

Communicated by

Facility nurse

Client records

Facility clinical folder

Completed at each ART refill collection at the facility

Client ART card

Brought by rotating group member to the facility for ART refill collection

Monitoring system

At group meeting venue

Group monitoring form managed by rotating group member

At health care facility

Group register, group monitoring form recorded in client ART card and facility clinical folder. Client visits captured from individual records into facility monitoring system

Staffing

In these models, every client no longer interacts with a health care worker at each health care visit. These group interactions are managed by clients themselves, reducing individual time spent with a professionally trained health care worker. This may require additional staffing to train, set up and support the client-managed model. All other staff resource needs are based on those needed to service a growing cohort of ART client despite optimization of such resources.

Lay health care worker

Promotion of group model at facility/in community

Nurse

Assesses eligibility for group model
Follow up with group representative collecting group refills on health and adherence of each member
Blood taking for each group member once/twice a year
Clinical review for each group member once/twice a year
*Script all group members
Provide clinical oversight of group visit
Provide oversight of groups – identifying groups where refills not collected or member fails to attend clinical review and meet with group members to remedy problem

Facility manager

Manages group system within facility, including:
Ensuring model implementation at facility
Quality control and training new staff
Reporting to health authorities on model outcomes

 

Pharmacist/pharmacy assistant/dispenser

Dispenses ART supply for all group members to collecting member
(where no pharmacist/pharmacy assistant/dispenser, activity is taken on by nurse)

Data clerk

Captures group members attendances from client ART cards/folder into electronic monitoring records (where available)

Training

Client training

Intensive initially for each group
Refresher training may be necessary

These groups are set up and run by clients. Each group requires training to understand how to set up and run their group – the detailed model mechanics, including roles, responsibilities, medical referral, forms

Facility staff training

Limited
Refresher training recommended to train new staff and maintain quality

Facility teams have to be trained to set up the model at their facility – limited to:

•    Model promotion
•    Health/adherence check, record completion and ART refill provision for each group member not present
•    Quality control

Considerations

Client considerations

Self-formation of groups

Groups self-form relying on client direct relationship network

Risks

HIV-related stigma and non-disclosure may result in clients having a limited network of other people stable on ART in their community to recruit into a group (especially in informal settlement environments with less community cohesion/trusted networks) reducing accessibility of the model

Opportunities

Self-formation protects clients’ confidentiality; not requiring disclosure to external networks

Responsibility/accountability for health care of others

Members are responsible for other members’ understanding of the model, ART refill collection and good functioning of group

Risks

Stronger members may carry responsibility for group duties to ensure individual access to model benefits
Certain members may not pull their weight in the group, not taking a rotational turn and possibly failing to collect ART refill from the group, putting other members/group existence at risk

Opportunities

Can support the development of strong group identity and trust among members
Supports weaker group members

Health system considerations

Identification of clinical deterioration

 Model relies on rapid self-referral if unwell

Risks

Group system allows certain members to avoid their clinical reviews, therefore reducing HCW clinical oversight of each member. In addition, health system remains reactive. This can result in clinical deterioration of members without action

Opportunities

Minimal clinical oversight and effective recall system can overcome risks

Requires model implementation team/counsellor cadre

Group formation, training and oversight requires additional resources

Risks

Where funding/resources not available, model may be limited in its growth and risk poor quality of care (missing clients not collecting ART refills or attending clinical reviews)

Opportunities

Limited investment for growth potential of model leveraging client self-management

Resources

Published evidence