Evidence on health care worker-managed groups highlights improved client outcomes, both at individual sites and at scale, and suggests benefits to specific client populations, including children, their caregivers and adolescents. The majority of evidence for health care worker-managed group models comes from implementation of the ART adherence club (AC) model in Cape Town, South Africa. Details of the model expansion highlight that from January 2011 to March 2015, 32,425 clients were in an AC (25.2% of the total ART cohort). Fifty-five facilities were offering a total of 1,308 ACs (1). In a cluster random sample of 10% of the Cape Town ACs (3,216 adults) from non-research supported ART sites, retention was 95.2% (CI 94-96.4) at 12 months and 89.3% (CI 87.1-91.4) at 24 months. In the 13 months prior to database closure, 88.1% of clients had viral loads (VL) taken with VL ≤400 copies/ml in 97.2% (CI 96.5-97.8) (2). An evaluation of disengagement from care in Khayelitsha, Western Cape reported AC participation as highly protective against disengagement (hazard ratio: 0.27 (0.24-0.30) (3). A 2019 evaluation of long term virologic outcomes of 10 869 Khayelitsha AC clients showed high annual VL completion over 40 months (82-85%) with 6% experiencing an elevated VL at a median of 350 days from AC enrolment (IQR 168-728) (4).
With ACs recognised since 2015 as one of three endorsed differentiated ART delivery models in South Africa, national retention and viral load suppression outcomes were evaluated in a 2019 study comparing 24 randomly allocated intervention and control facilities. AC patients had higher 12-month retention (89.5% versus 81.6%, aRD: 8.3%; CI: 1.1% to 15.6%) and comparable sustained viral suppression (<400 copies/mL any time ≤ 18 months) (80.0% versus 79.6%, aRD: 3.8%; CI: −6.9% to 14.4%). Retention associations were stronger for men than women (men RD: 13.1%, CI: 0.3% to 23.5%; women RD: 6.0%, CI:−0.9% to 12.9%) (5).
Three comparison cohort studies report client outcomes from ACs (6, 7). In the pilot study in Khayelitsha, Cape Town, retention at study end was 97% for those stable clients who enrolled in an AC versus 85% for those who did not. LTFU was reduced by 57% (hazard ratio, HR, 0.43, 95% CI 0.21-0.91) and viral rebound by 67% (HR 0.33, 95% CI 0.16-0.67) (6). In Gugulethu, Cape Town, 94% were retained at 12 months post AC enrolment, with 3% experiencing viral rebound by study end (7). After adjustment, AC participation was associated with a 67% reduction in the risk of LTFU (aHR: 0.33, 95% CI: 0.27-0.40) compared with clients in the standard of care. In rural Cape Winelands, a 2019 retrospective cohort study of all adult clients starting ART in 2014-2015, found lower loss to follow-up in those attending an AC (aHR =0.25, CI: 0.11 to 0.56). This finding was confirmed on analysis restricted to those eligible for adherence club referral (aHR =0.28, CI: 0.12 to 0.65) (8). A costing study found the Khayelitsha piloted AC model cost effective with a cost per patient year of $300 versus $374 for standard of care (9).
Four studies have described various aspects of the AC model. The first describes the AC model and the strategy used by local health authorities to scale out the model (10). The second describes the quality improvement approach embedded in the scale-out strategy (11). The third describes the adjusted AC model implemented in Gugulethu, where ACs were run at a community venue instead of the clinic (12). The Western Cape AC model changed from providing 2-monthly ART refills (6 times a year) to providing a 4-monthly ART refill at year end (5 total visits per year) to accommodate year-end holiday migration. A comparison study found no difference in short-term retention or viral rebound risk comparing clients who receive 2 months versus 4 months of ART over the holiday period (13). A non-inferiority cluster randomized trial comparing retention and VL suppression outcomes of experienced AC clients receiving 6-monthly ART refill in their ACs compared with those in the aforementioned Western Cape AC model found similar retention (SOC 98% (CI 97.2-98.8); Intervention arm 97% (CI 96.1-98.2), higher VL completion (98% vs 94.4%) and similar VL suppression (97.8% vs 96.5%) (14).
Three qualitative studies looked at healthcare worker and/or client perceptions around ACs. The first explored the acceptability of community-based ACs from a health worker perspective including enablers and barriers to roll out (15). The second explored the perceptions of AC members and non-members at two sites in Khayelitsha and Gugulethu, Cape Town (16). The third explored the perceptions of clients who were enrolled in either community or facility-based ACs in Witkoppen, Johannesburg (17).
Two studies compared retention outcomes after providing clients with a choice of differentiated ART delivery model. Within the PopART study in Lusaka Zambia, clients in two study arms were offered a choice for collecting a three-month ART refill i) clinic-based care or home delivery ii) clinic-based care or community-based AC. 18-month retention for those selecting ACs was 93.6% compared with 84.9% for home delivery (18). Research from Swaziland reported outcomes where health facilities were offered a choice of three ART delivery models for implementation. One health centre chose to implement ACs, 12 clinics implemented community ART groups (CAGs) and one health centre and one clinic implemented an outreach service to support remote communities. Twelve-month retention was 96% in ACs (n=289), 81% in CAGs (n=336) and 77% for the outreach service model (n=102) (19).
Four small studies from Cape Town, South Africa, reported outcomes for specific populations: youth, children and their caregivers and post-natal women receiving their care from youth-specific ACs, family ACs or adults ACs respectively and one study reported outcomes for clients enrolled in adult ACs who had recently re-suppressed after a viral rebound episode. For youth ACs, ART client outcomes were good. Retention at 12 months for youth stable on ART was 94.3% (CI 85.4-96.8); for youth newly initiated on ART, it was 86.4% (CI 78.7-91.4); and for youth ineligible for ART, it was 52.9% (CI 40.0-64.2) (20). For family ACs, child and caregiver retention was 93.7% (CI 88.7 – 96.6) and 93.9% (CI 85.9 – 97.4) at 12 months and 86.1 (CI 79.5 – 90.8) and 89.7 (CI 80.4 – 94.8) at 36 months (21). For women initiated on ART during pregnancy, who chose to join an existing community-based adult AC immediately post-delivery (84/129; 65%), 15% did not attend the AC and 11% only attended their first AC visit. AC participants had similar VL suppression outcomes 6 months post-partum as those women who chose to receive their care at the ART clinic had similar retention and VL suppression outcomes 6 months post-partum as those women who chose to receive their care at the ART clinic (22). Post-natal women and their infants were offered enrolment into post-natal clubs. These included both stable and high risk mother infant pairs until the infant reached 18 months. 18-month retention was 79.2% for those reaching 18 months with 96% viral suppression. 96.8% of infants completed 9-month HIV testing and 94.7% 18-month HIV testing (23). For patients who had re-suppressed after a nurse-led intervention and were immediately referred into an adult AC, 12-month retention and viral suppression after AC enrolment was 94.8% (CI 89.8-97.4) and 85.2% (CI 78.0-90.1) respectively (24).
Two early studies have evaluated medication adherence clubs (MACs) which adjusted the AC model to incorporate stable hypertension or diabetic patients. A retrospective descriptive study of 1432 patients in MACs reported LTFU in the first year after enrolment of 3.5% (25). A qualitative study found the model acceptable to both patients and healthcare workers saving patients time and reducing queues at the clinic (26).