Summary of published evidence

The most common example of a client-managed group is a self-forming group of people living with HIV who meet at an agreed community location and nominate a member to collect ART for the group from the facility on a rotational basis. That member then distributes ART to the group at the agreed community location. Data from client-managed group models have shown improved client outcomes with qualitative evidence supporting reduced costs and increased time savings.

The earliest evidence for client-managed groups came from a large cohort of clients enrolled in community ART groups (CAGs) in Tete, Mozambique. In a 2014 descriptive cohort study [1], retention outcomes at 12, 24, 36 and 48 months were 97.7%, 96.0%, 93.4% and 91.8%, respectively, with a mortality rate of 2.1 and loss-to-follow-up (LTFU) rate of 0.1/100 per client year. Data from three qualitative studies found cost and time savings for clients and improved certainty of ART access and mutual peer support, including health educational benefits, which facilitated better adherence [2,3]. The most recent of these qualitative studies across 10 health facilities also showed that CAG participation preserved social capital for members by providing a supportive extended family, access to mutual savings and financial assistance from other group members [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 [4]

Scaled-up CAG model outcomes were published in late 2016 in an evaluation of trends observed after a decade of ART scale up in Mozambique [5]. From 2004 to 2013, 455,600 people over 15 years of age had initiated ART, with 6,766 enrolling in a CAG at 69 facilities from 2011 to 2013. CAG participation was associated with a 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 [6] 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) [7]. A 2019 conference abstract compared viral suppression rates after the introduction of routine VL monitoring among persons receiving ART for more than 6 months at 83 health facilities, including those in CAGs (12% of the sample, n=1,823).  The overall viral suppression rate was 76% with significantly higher suppression rates among people in CAGs compared to those not in CAGs (OR 1.16; 95% CI: 1.03-1.30) [8].

In Lesotho, a small mixed-method comparison cohort study found 12-month retention of 98.7% (95% CI: 94.9-99.7) among stable clients who joined a CAG (n=199, median time on ART 54 months) versus 90.2% (95% CI: 86.6-92.9) for those who did not join the CAG (n=397, median time on ART 21 months) [9]. More recently, a cluster randomized trial in thirty facilities in Lesotho compared three-monthly clinical consultations and ART refill collection from a health facility (n=1,898), three-monthly ART refills from CAGs as per the national CAG model (n=1,558) and six-monthly individual ART refill collection from community pick-up points (n=1,880). Both latter community DSD models required annual clinical consultations at the health facility. 12-month retention was similar across arms (94.9% vs. 95.4 vs. 93.3%) and achieved the pre-specified non-inferiority limit (-3.25%) with viral suppression above 98% across arms [10]. The associated costing study found that the two community DSD models reduced provider costs per patient by approximately 7% and importantly client costs by approximately 60% [11]. 

In Zimbabwe, community ART refill groups (CARGs) have been endorsed in Zimbabwe’s National Operational and Service Delivery Manual. Clients collect ART refills every three months; members attend once a year as a group for clinical review and viral load. Qualitative work has explored patient and provider perspectives of CARGs [12], male engagement in CARGs [13], client and provider preferences for TB preventative treatment integration into the CARG model [14] and combined with a discrete choice experiment found clients in urban areas preferred facility-based individual models to community-based group models [15]. A three-arm, cluster randomized non-inferiority trial across thirty health facilities compared three-monthly clinical consultations and ART refill collections from the facility, three-monthly ART refills from CARGS as per the national CARG model and six-monthly ART refills from CARGs. 12-month retention was similar across arms (clinic-based: 91%; three-monthly CARG: 93.3%; six-monthly CARG: 93.6%) and met the pre-specified noninferiority limit (-3.25%, risk difference [RD]). VL completion at 12 months was poor across all arms (below 50%) but particularly in the six-monthly CARG arm (8%). Intention- to-treat VL suppression was above 99% for clinic-based and 3-monthly CARGs and marginally reduced in six-monthly CARGs mostly driven by poor VL completion (92.9%) [16].

In Uganda The AIDS Support Organization (TASO), a non-governmental organization supporting more than 100,000 people living with HIV, has reported encouraging adherence outcomes (89%) among a sample of clients (n=2,799 ) in its community client-led ART delivery model (CCLAD) [17]. In Eswatini, health facilities offered three different models (CAGs, mobile outreach and facility ACs). Among those enrolled, 12-month retention was high at 93.7% but retention by model varied substantially (CAG: 70.4%; mobile outreach 86.3%; facility AC 90.4% (p < 0.001)) [18]. In a small study in Haiti, cross-sectional retention for a cohort of 80 CAG clients was 88.4% [19].

Qualitative studies in Malawi and Zambia also explore client and provider perceptions of CAGs.  In Malawi, positive experiences regarding peer support were reported, but CAG uptake was hindered by limited awareness of the existence of CAGs or how they functioned [20]. In Zambia, qualitative work 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 the inability to have monitoring tests performed according to the CAG schedule due to stock-outs of specimen bottles [21].

Three studies reported outcomes for specific populations and contexts. A small study, which offered clients with elevated viral loads (VLs) enrolment in a CAG alongside attendance at a dedicated VL clinic, reported high CAG uptake (89.6%), but limited re-suppression (27.8%) among those with a documented follow-up VL [22].  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 [23]. In Uganda, CCLADs were introduced for clinically stable female sex workers. Two CCLADs of seven members each were formed. Retention rates of 100% were achieved in each group and all female sex workers remained virologically suppressed. ART adherence improved from 75% to 95% [24].

References

  1. Decroo T, Koole O, Remartinez D, dos Santos N, Dezembro S, Jofrisse M, et al. Four‐year retention and risk factors for attrition among members of community ART groups in Tete, Mozambique. Tropical Medicine & International Health. 2014;19(5):514-21.
  2. Rasschaert F, Telfer B, Lessitala F, Decroo T, Remartinez D, Biot M, et al. A qualitative assessment of a community antiretroviral therapy group model in Tete, Mozambique. PloS ONE. 2014 March ;9(3):e91544.
  3. Rasschaert F, Decroo T, Remartinez D, Telfer B, Lessitala F, Biot M, et al. Adapting a community-based ART delivery model to the patients’ needs: a mixed methods research in Tete, Mozambique. BMC Public Health. 2014;14(1):364.
  4. Decroo T, Lara J, Rasschaert F, Bermudez-Aza E, Couto A, Candrinho B, et al. Scaling up community ART groups in Mozambique. Int STD Res Rev. 2013;1(2):49Á59.
  5. Auld AF, Shiraishi RW, Couto A, Mbofana F, Colborn K, Alfredo C, et al. A Decade of Antiretroviral Therapy Scale-up in Mozambique: Evaluation of Outcome Trends and New Models of Service Delivery Among More Than 300,000 Patients Enrolled During 2004—2013. JAIDS Journal of Acquired Immune Deficiency Syndromes. 2016 Oct;73(2):e11-e22.
  6. Jobarteh K, Shiraishi RW, Malimane I, Gudo PS, Decroo T, Auld AF, et al. Community ART Support Groups in Mozambique: The Potential of Patients as Partners in Care. PloS one. 2016 Dec 1;11(12):e0166444
  7. Jefferys L, Hector J, Hobbins M, Ehmer J, Anderegg N. Improved survival and retention in HIV treatment and care: the value of community ART groups for HIV patients on ART in rural northern Mozambique.  Presented at AIDS 2016; 2016 Jul 18-22; Durban, South Africa.
  8. Van Rompaey S, Melo M, Bilhete F, Tancredo I, Wester C, De Schacht C. Improved viral suppression rates among HIV-positive adults receiving antiretroviral therapy (ART) via community adherence group (CAG) support in Zambézia province, Mozambique. In: INTEREST. Abstract Book from International Workshop on HIV Treatment, Pathogenesis and Prevention in Resource-Limited Settings INTEREST 14-17 May, Accra Ghana.  The Netherlands: INTEREST; 2019. P. 164
  9. Vandendyck M, Motsamai M, Mubanga M. Community-based ART resulted in excellent retention and can leverage community empowerment in rural Lesotho, a mixed method study. HIV/AIDS Res Treat Open J. 2015 May;2(2):44-50.
  10. Tukei BB, Fatti G, Tiam A, Ngorima-Mabhena N, Tukei VJ, Tshabalala I et al; EQUIP Health.Twelve-month outcomes of community-based differentiated models of multi-month dispensing of antiretroviral treatment among stable HIV-infected adults in Lesotho: a cluster randomized non-inferiority trial. J Acquir Immune Defic Syndr. 2020 Jul 7; Epub 2020 Jul 7
  11. Nicols B, Fatti G, Cele R, Leodeba N, Maotoe T, Sejana MV et al. Economic evaluation of differentiated service delivery models for ART service delivery from a cluster-randomized trial in Lesotho: cost to provider and cost to patient. Poster presented at AIDS2020: Virtual; 2020 July 6-10; https://programme.aids2020.org/Search/Search?search=PEE1626
  12. Bochner AF, Meacham E, Nhungu , Manyanga P, Petracca F, Muserere C et al The rollout of Community ART Refill Groups in Zimbabwe: a qualitative evaluation. J Int AIDS Soc. 2019;22:e25393.
  13. Mantell JE, Masvawure TS, Mapingure M, Apollo T, Cwanzura C, Block L et al. Engaging men in HIV programmes: a qualitative study of male engagement in community‐based antiretroviral refill groups in Zimbabwe. J Int AIDS Soc. 2019 Oct;22(10): e25403.
  14. Msukwa M, Apollo T, Mapingure M, Boccanera R, Chingombe I, Gwanzura C et al. Leveraging Zimbabwe’s Community Adherence Groups (CARGs) to deliver TB preventive treatment is feasible and acceptable: Findings from a mixed methods study.  Poster presented at AIDS2020: Virtual; 2020 July 6-10; http://programme.aids2020.org/Abstract/Abstract/2897
  15. Strauss M, George G, Mantell JE, Mapungure M, Masvawure TB, Lamb MR et al. Optimizing differentiated HIV treatment models in urban Zimbabwe: Assessing patient preferences using a discrete choice experiment. AIDS and Behavior. 2020 August. https://doi.org/10.1007/s10461-020-02994-z
  16. Fatti G, Ngorima-Mabhena N, Mothibi E,Muzenda T, Choto R, Kasu T et al. Outcomes of Three- Versus Six-Monthly Dispensing of Antiretroviral Treatment (ART) for Stable HIV Patients in Community ART Refill Groups: A Cluster-Randomized Trial in Zimbabwe. J Acquir Immune Defic Syndr. 2020;84(2):162-172.
  17. Okiror A. ART adherence among patients cared in the community client-led ART delivery (CCLAD) - TASO, Uganda experience.  Presented at AIDS 2018; 2018 Jun 23-27; Amsterdam, the Netherlands.
  18. Pasipamire L, Nesbitt RC, Ndlovu S, Sibanda G, Mamba S, Lukhele N et al. Retention on ART and predictors of disengagement from care in several alternative community‐centred ART refill models in rural Swaziland. J Int AIDS Soc. 2018 Sep;21(9):e25183.
  19. Naslund JA, Dionne-Odom J, Junior Destiné C, Jogerst KM, Renold Sénécharles R, Jean Louis M, et al. Adapting and Implementing a Community Program to Improve Retention in Care among Patients with HIV in Southern Haiti: “Group of 6”. AIDS Research and Treatment. 2014;2014.
  20. Pellecchia U, Baert S, Nundwe S, Bwanali A, Zamadenga B, Metcalf CA, et al. " We are part of a family". Benefits and limitations of community ART groups (CAGs) in Thyolo, Malawi: a qualitative study. J Int AIDS Soc. 2017;20:21374.
  21. Nkwemu S, Mwamba C, Bolton-Moore C, Topp S, Jere, LMukumbwa-Mwenechanya M, et al. Challenges in providing patients centred care through community adherence groups in three provinces of Zambia. Presented at AIDS 2018; 2018 June 23-27; Amsterdam, the Netherlands.
  22. Mwamba D, Herce M, Wa Mwanza M, Thulani R. Community Adherence Group (CAG) for HIV viremic patients: Early lessons learnt from Lusaka, Zambia.  Presented at IAS 2019; 2019 Jul 21-24; Mexico City, Mexico.
  23. Ssonko C, Gonzalez L, Mesic A, da Fonseca MS, Achar J, Safar N, et al. Delivering HIV care in challenging operating environments: the MSF experience towards differentiated models of care for settings with multiple basic health care needs. J IntAIDS Soc. 2017 Jul;20:21654.
  24. Kagimu D, Egessa J, Oucul L, Senyonga E. Overcoming barriers to access of HIV/AIDS services among female sex workers through differentiated service delivery models, TASO Entebbe experience. Presented at AIDS 2018; 2018 Jun 23-27; Amsterdam, the Netherlands.