Evidence for reducing the frequency of clinical visits and extending the duration of antiretroviral therapy (ART) refills for clients who are stable on ART is increasing. The World Health Organization (WHO) recommends both clinical visits and ART refills to be delivered every 3-6 months and is currently reviewing this guidance .
A recent systematic review to assess the impact of reduced frequency of clinic visits and drug dispensing on client outcomes reported that less frequent clinic visits led to high rates of retention (odds ratio, OR,: 1.90; 95% confidence interval, CI: 1.21-2.99). Although no differences were found in virological failure, morbidity or mortality, most estimates favoured reduced clinical visits. Reduced frequency of antiretroviral (ARV) pick-ups also supported improved retention (OR: 1.93; 95% CI: 0.62-6.04) . Client-managed groups are one example of a differentiated ART delivery model that utilizes the principle of differentiating between the need for a clinical versus an ART refill visit and reducing the frequency of clinic attendances.
The most common example of a client-managed group is where self-forming groups of people living with HIV meet at an agreed community location and nominate a member to collect ART for the group from the facility. That member then distributes ART to the group at the agreed community location. Data from client-managed group models has shown improved client outcomes with qualitative evidence supporting reduced costs and increased time savings.
The earliest evidence for client-managed groups came from the large cohort of clients enrolled in community ART groups (CAGs) in Tete, Mozambique. In a 2014 descriptive cohort study , retention outcomes at 12, 24, 36 and 48 months were 97.7%, 96.0%, 93.4% and 91.8%, with a mortality rate of 2.1 and loss to follow up (LTFU) rate of 0.1/100 per client year. Data from two qualitative studies found cost and time savings for clients and improved certainty of ART access and mutual peer support, which facilitated better adherence [4,5]. A descriptive editorial explains the step-wise scale-up approach that was taken from the pilot site, to the district, and eventually nationally in Mozambique .
Scaled CAG model outcomes were published in late 2016 in an evaluation of trends observed after a decade of ART scale up in Mozambique . From 2004 to 2013, 455,600 people over 15 years of age had initiated ART, with 6,766 enrolling in a CAG from 2011 to 2013 at 69 facilities. CAG participation was associated with 35% lower LTFU but similar mortality. Incidence of LTFU and mortality after ART initiation for CAG and non-CAG participants was 2.9% and 0.3% at two years and 10.1% and 1.4% at four years. In a further study  reporting outcomes for the same cohort of CAG clients matched with eligible non-CAG clients (37% of cohort) at facilities offering the CAG model, eligible non-CAG clients had a significantly higher LTFU rate (hazard ratio, HR: 2.36; 95% CI: 1.54-3.17) but also similar mortality. Interestingly, the study also compared outcomes of clients in CAGS who were eligible for CAGS with those in CAGs who were ineligible (19% of cohort). One-year retention was 92.5% and 86.4%, respectively (LTFU: 6.7% and 9.6%; mortality: 0.8% and 4%).
A recent retrospective study undertaken in northern Mozambique assessed all ART clients over 15 years of age who were eligible to join a CAG (n=1,306) from 2010 to 2015 for associations between baseline characteristics and total days late for appointments in the first six months on ART (prior to CAG eligibility) and CAG participation. It found no associations other than female sex. Only 13.8% joined a CAG, with CAG participation reducing mortality by 55.1% (adjusted hazard ratio, aHR: 0.449; 95% CI: 0.264-0.762) and reducing the risk of LTFU by 84.3% (aHR: 0.157; 95% CI: 0.086-0.288) .
In Uganda, The AIDS Support Organization (TASO), a non-governmental organization supporting more than 100,000 people living with HIV, has also reported encouraging adherence outcomes of 89% from their community client-led ART delivery model (CCLAD). Interventions that enabled the model included: i) a simple data collection tool that facilitated peers to collect information, which is then transcribed to national monitoring and evaluation tools; ii) pre-packing of drugs with clear labelling, which facilitated accurate distribution of ART; and iii) by jointly contributing to the costs for the member collecting the medication, patients were empowered to provide the transport costs .
Data from three smaller cohorts in Lesotho, Swaziland and Haiti also report positive outcomes. In Lesotho, a mixed-method comparison cohort study found 12-month retention of 98.7% (95% CI: 94.9-99.7) of stable clients who joined a CAG (n=199 with median time on ART of 54 months) versus 90.2% (95% CI: 86.6-92.9) among those who did not join the CAG (n=397 with median time on ART of 21 months) . In Swaziland, health facilities were offered a choice of three ART delivery models for implementation. Twelve clinics implemented CAGS, one health centre implemented ART adherence clubs (ACs), and one health centre and one clinic implemented an outreach service to support remote communities. Twelve-month retention was 81% in CAGs (n=336), 96% in ACs (n=289) and 77% for the outreach service model (n=102) . In Haiti, cross-sectional retention for a cohort of 80 CAG clients was 88.4% .
Recent qualitative work has also demonstrated positive outcomes for both healthcare workers and clients. In Zimbabwe, CAGs have been endorsed in the national operational and service delivery manual and collect ART refills three monthly; members attend once a year as a group for clinical review and viral load. Facility staff welcomed the formation of CAGs to decongest their facilities and give more time for unstable clients. Healthcare workers appreciated the group viral load testing and felt that it improved uptake for monitoring. New CAG members anticipated that savings in transport costs and reduced clinic visits would allow increased focus on productive activities. Group support through livelihood projects, adherence and defaulter tracing was highlighted to improve retention. Stigma and fear of disclosure were, however, still cited as reasons for not joining the CAGs, and young people and males preferred sending relatives to collect their medication than joining a CAG .
In Malawi, similar positive experiences regarding peer support were reported, but CAG uptake was hindered by limited awareness of the existence of CAGs or how they functioned .
Further qualitative work in Zambia demonstrated that both healthcare workers and clients favoured CAGs due to their ability to decongest the clinics and reduce workload. Several health system issues were, however, cited as problematic. Challenges included inadequate supplies of ARVs and inability to have monitoring tests performed according to the CAG schedule due to stock-outs of specimen bottles. It was also reported that some CAG members primarily wanted to participate in order to collect drugs and did not want to be included in the group health discussions. The additional monitoring tools also required additional space at the clinic .
In conflict settings, client-managed groups have also been implemented to support continuity of ART. In the Central African Republic and the Democratic Republic of the Congo, CAGs, combined with extended refills, enabled continuity of care throughout several outbreaks of violence .
Client-led groups have also been implemented for key populations. In Uganda, the community client-led groups (CCLAD) described above were introduced for female sex workers. The model was a response to the challenges faced by sex workers in conventional care facing long waiting times, inconvenient clinic times and discrimination when attending the clinic. Female sex workers (defined as stable according to specific criteria) chose to become part of a CCLAD group. The group selected a leader who was assigned responsibilities for the group, such as recording weight, filling the CCLAD documentation and delivery of condoms and ART. To date, two CCLADs of seven members each have been formed. Retention rates of 100% in each group were achieved and all female sex workers in the group remained virologically suppressed. ART adherence improved from 75% to 95% . Promotion of the model through peers caused other female sex workers in the same hotspots to ask to join the CCLAD groups.