Model mechanics

ART refills

Clinical consultations

Individual/group approach

Individual

Individual

Who attends?

Client or client-appointed representative

Client

Client recruitment

Where

At facility

By whom

Lay community health worker providing model education and promotion in facility waiting rooms
Clinician at eligibility assessment for model participation

Eligibility assessment

By clinician during consultation

HIV disclosure

Does it happen?

No. However, indirectly yes if ART clients in a group are given the same appointment date and time to meet at outreach point

Annual health care visit schedule for client

1-month community ART refill, bi-annual clinical consultations:

  1. ART refill (community/home)
  2. ART refill (community/home)
  3. ART refill (community/home)
  4. ART refill (community/home)
  5. ART refill (community/home)
  6. ART refill + blood draw + clinical review + rescript (facility)
  7. ART refill (community/home)
  8. ART refill (community/home)
  9. ART refill (community/home)
  10. ART refill (community/home)
  11. ART refill (community/home)
  12. ART refill + blood draw + clinical review + rescript (facility)

3-month community ART refill, annual clinical consultations:

  1. ART refill (community/home)
  2. ART refill (community/home)
  3. ART refill (community/home)
  4. ART refill + blood draw + clinical review + rescript (facility)

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

Alignment of ART refill and blood draw visit

Does it happen?

Variable; model dependent. Usually ART refill, blood and clinical visit are aligned on same day at the facility. However where ART refill and clinical visit are disconnected, ART refill visits continue to take place in community/home with blood/clinical visit at the facility on a different day

Alignment of ART refill and clinic visits

Does it happen?

Variable; model dependent

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

Strategy

Immediate recall of client and/or red flagged for referral to facility at next outreach/home ART refill visit or immediate review at mobile service point

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 where referral at next outreach/home ART refill or low risk if clinical services at mobile service point

Clinical outreach from facility potential

By whom

Yes. In some variations, health facility staff go into communities to provide clinical review at mobile/fixed community locations where ART refills are provided

ART refill preparation

Is ART pre-packed?

Variable

ART refill provision to group meeting location

How

Box with ART/individual pre-packs are either collected from facility pharmacy and taken to community distribution point/home or delivered directly to community distribution point/home

By

Outreach team, lay healthcare worker cadre running out-of facility individual model or courier service

Clinical referral mechanism

Criteria

Client complaining of being unwell, client reporting symptoms, pre-determined red flags

By

Lay health care worker/peer

To

Mobile clinical outreach or facility clinician

When

Immediately at mobile outreach / To attend facility as soon as possible

Up referral (return to standard of care)

Criteria

Client missed appointment date (variation with degree of flexibility), or clinically unstable requiring more frequent or intense clinical follow up

Client records

Facility clinical folder

Completed only at clinical consultations

Client ART card

Brought to every ART refill visit and updated with return date

Monitoring system

At community distribution point

Paper register/list/mobile application 

At health care facility

Client visits captured from paper register/list/mobile application export into facility ART register and/or into facility electronic monitoring system (where available).

Staffing

In these models, every client remains managed as an individual on arrival at the designated community point or at home. Staffing needs depend on the extent of the outreach service provided (including clinical services or not), whether grouped (central collection point in community) or not (home), the frequency of ART refill and clinical reviews conducted by the outreach service, and whether ART refills have been task shifted to lay health care workers 

Training

Client training

Limited
Only required for individual client understanding of model participation

Training is limited to client education on model offered and how participation works. This can be done briefly by lay health care workers or clinicians offering participation and in more detail during the first ART refill collection at the community distribution point or provision at home by a lay health care worker.

Facility staff training

Variable
Depends on whether clinical services are provided outside of the facility in the model variation. Limited training for facility-only staff.

Lay health care workers require training on preparing for and managing ART refill visits at the community distribution points/home, including referral and M&E systems. Possibly nurse ART management is needed if nurses are part of the out-of-facility team.
Facility teams require training on how to set up and run this model, including model promotion and enrolment, ART refill preparation, model referral and exit mechanisms and M&E.

Considerations

Client considerations

Community HIV disclosure

Community distribution points may be community venues located in public spaces near homes of clients

Risks

Reduced participation due to confidentiality concerns
Involuntary community disclosure

Opportunities

Reduction in community stigma or client-perceived stigma
Increasing client relationship network for peer support and empowerment to demand health system accountability

Requires strict appointment keeping

Community mobile/fixed distribution points are only available on scheduled day with no grace period and may not have community-based staff to guide those who have missed appointments

Risks

Missed appointment may lead to treatment interruption

Health system considerations

Requires management structures

These models are health system led, requiring forward planning and management of staffing or community platform that provides the staffing, logistics, ART refill pre-packing and interface between health system and community component.

Risks

Reactive health systems may not have the capacity to adapt to forward planning required.

Opportunities

A well-managed community healthworker platform with an effective interface with the health system can significantly improve patient outcomes and optimize facility resources for other patients
Could potentially leverage public-private partnerships
Clinical care (blood draws and clinical review) can be carried out off site 

Mobile outreach models: Requires reliable mobile outreach service

This model must be staffed and attend to its route without fail to ensure timeous ART refill access

Risks

Poorly organized/understaffed outreach services may be unable to adhere to fixed timetable

Opportunities

A well-managed mobile outreach service, with an effective interface with health facility, can significantly improve client outcomes, especially in remote areas

Requires additional and dedicated lay healthcare workers

Where ART refill is task shifted to lay health care workers, additional lay health care workers would be needed

Risks

Insufficient, sustainable funding
Poor-quality lay health care worker may reduce benefits of model if unprepared or unmotivated
Insufficient, sustainable funding

Opportunities

Task shifting ART refill can optimize both mobile and facility professional health care workers resources for other clients

Resources

Published evidence