Promising results have been found in models using fixed community points. Evidence has come from the community drug distribution point (CDDP) model in Uganda, the community ART distribution points (PODI) in the Democratic Republic of the Congo (DRC), external pick-up points in South Africa, community pick-up points in Zambia and community private pharmacy collection in Nigeria.
In Uganda, cross-sectional outcomes for clients initiating ART from 2004 to 2009 (median time on ART: 5.7 years; interquartile range, IQR: 4.1-7.2 years) in the CDDP model were that 69% were retained in care, 17% had died, 6% were transferred out and 9% were lost to follow up (LTFU). Among CDDP clients, viral load suppression (<1,000 copies/mL) was 93% (median time on ART: 7.0 years; IQR; 5.0-8.0) (1). In a subsequent conference abstract, LTFU was reported as 16.5% in the facility arm and 4.28% in the CDDP arm (p<0.0001) (2). A costing comparison study in Uganda put the model from The AIDS Support Organization (TASO), including TASO-run clinics for new initiations and the CDDP model for stable clients, at US$74/visit and $332/client/year compared with a mobile ART delivery model utilizing expert clients to dispense ART (US$45/visit; $404/client/year) and a facility-based nurse-led model (US$38/visit; $257/client/year) (3). In the DRC, a retrospective cohort analysis found LTFU and death among PODI clients to be at 2.2% and 0.1% at six months,4.8% and 0.2% (at 12 months) and 9% and 0.3% (at 24 months), respectively, with overall crude attrition of 5.66/100 person years with little variation over time (4).
In South Africa, external pick-up points were endorsed as one of its three differentiated ART delivery models. This model allows clients to choose a non-facility based venue for ART refill collection. These include fixed community points and private pharmacies. National retention and viral load suppression outcomes were evaluated in a 2019 study comparing 24 intervention and control facilities. External pick-up point patients had lower 12-month retention (81.5% versus 87.2%, aRD: −5.9%; CI: −12.5% to 0.8%) and comparable sustained viral suppression (<400 copies/mL any time ≤ 18 months) (77.2% versus 74.3%, aRD: −1.0%; CI: −12.2% to 10.1%). Interestingly, the study reported increased viral suppression among men (RD: 11.1%; 95% CI: −3.4% to 25.5%) (5).