CLOSER TO HOME
Delivering antiretroviral therapy
in the community: Experience from fourCountries in southern AfricA

Cover photo: Mozambique 2010 © Brendan Bannon
This page: South Africa 2010 © Reuters/Finbarr O'Reilly

INTRODUCTION
There has been remarkable progress in the past decade in increasing the access toantiretroviral therapy (ART) in resource-limited settings. Ambitious target setting by
the World Health Organization and UNAIDS1 backed by substantial financial support
from major donors has catalysed a global effort to scale up access to ART. At theend of 2011, more than eight million people were receiving ART in low- and middle-income countries; more than three quarters of all people on ART live in Africa2.
The benefits of ART in reducing mortality and morbidity have been convincingly
demonstrated. Despite initial concerns about the feasibility of large-scale HIVtreatment programming in resource-limited settings3, early reports showed comparable treatment outcomes to those reported from upper-income countries4,5. Morerecent data suggests that people receiving ART in sub-Saharan Africa can have analmost normal life expectancy6. Recent evidence also demonstrates that treating
people early with ART reduces HIV transmission7, which further supports the needto increase and sustain access to antiretroviral therapy.

TABLE 1: SUMMARY OF MSF COMMUNITY ART MODELS
Location

Clinicalmonitoring

Adherence
checksFrequencyof ART
dispensing

Frequencyof clinic
visitsReferralCumulative
mechanism
retention*back to clinic

Mozambique,
Tete

Every 6 months
in health facility

Every 6 months inhealth facility;
monthly in
Community ART
groups (CAG)

Monthly

Every 6months

97% after
Self referral /referral by other average follow
CAG members up time of 16monthsMalawi, Thyolo

Every 3 months
in health facility

Every 3 months inhealth facility

Every 3monthsEvery 3monthsSelf referral

98% after 15monthsMalawi,Chiradzulu

Every 6 months
in health facility

Every 6 months inhealth facility

Every 3monthsEvery 6monthsSelf referral

97% after 1
year and 93%
after 2 years**South Africa,
Khayelitsha

Every 2 months
in health facility

Viral load testing
every year inhealth facility

Every 2monthsEvery 6monthsLay person

90% at 2 years

Democratic
Republic of theCongo, Kinshasa

Peer counsellor,every 3 months(weight only)

Every 3 months inhealth facility

Every 3monthsyearly(hospital)

Self referral /referral by peer
counsellor

98% after 16months(cumulative)* These data are for patients after referral into a community group** Active discontinuation (e.g. pregnancy) are excluded from the denominator

Uganda 2009 © Brendan Bannon

Placing more than eight million people on ART in low- and middle-income countries in less than a decade represents important progress but this number is placing
a considerable strain on health systems, particularly in high-prevalence countries ofsub- Saharan Africa where health workers are already scarce8. In addition, substantial numbers of people eligible for ART are not receiving treatment: many still do
not know they are HIV-positive, many others do not have access to HIV care andtreatment due to programme or financing shortfalls and many who are identified
as HIV-positive leave care prior to the initiation of ART for a variety of reasons. To
maximize the individual and population-level benefits of HIV treatment, the numberof people accessing ART must be rapidly increased, while those receiving treatment
must continue to do so, which means ensuring that health services have the capacity to serve their needs. Recent systematic reviews have highlighted substantial
rates of attrition in HIV services for those who were not successfully linked to careand treatment, who did not require ART at the time of HIV diagnosis, and who initiated but did not remain on ART, underscoring the pressing need to improve accessand retention. A number of decentralized health facility and community modalities
have been implemented to reduce the burden on health workers and health centres and to improve retention in care for those on ART. As national, provincial anddistrict teams address the various challenges, lessons from these innovative models
can help shape the next stages of HIV care and treatment scale-up.
UNAIDS recognized that MSF projects may serve as inspiring examples on how
community service delivery can catalyze the benefits of antiretroviral treatment, insynergy with local health systems. Considering the importance of community mobilizations and strengthening of health delivery systems—two pillars of the WHO/UNAIDS Treatment 2.0 programmatic approach—UNAIDS supported this reportwhich describes MSF’s activities in supporting community based organizations intheir interaction with local health structures to scale-up access to ART.

Improving access and retention in care for those who initiate ART
There are, broadly speaking, two phases of ART. Even after 10 years of treatment
scale- up, most people initiating ART have advanced immunosuppression and associated illnesses that require urgent clinical services. In this first phase, patients
also require support to understand the need for lifelong therapy on medicines that
can have a range of side-effects. Beyond this first phase, once their health has stabilized and immune status improved, most patients do not require intensive clinical care and frequent visits to a health facility. With time, however, a proportionof patients may develop side-effects or resistance to treatment, or face adherence
challenges, all of which will require another period of intensive clinical and adherence support.

There can be an association between the ‘user friendliness’ of services and access and retention in care. Distance to clinic services and associated transport
costs, long queuing times and competing demands, such as the need to work,
have all been associated with poor adherence to treatment and patients leaving
care9–12. Decentralization of ART services to community clinics reduces the distance patients need to travel and has been found to help keep them in care andon treatment13–17.
Decentralization from hospital-based services to health centres is an important
strategy to improve retention and one that can also decongest health services.
A priority for the World Health Organization and UNAIDS, endorsed under theTreatment 2.0 initiative, is to decentralize HIV care to primary health-centre level,
which often means the integration of HIV treatment services with other HIV and
non-HIV health services. There are increasing systemic changes in the way ART
services are delivered. As health centres are rarely staffed by full-time physicians,
decentralization usually means that ART is managed principally by nurses and other non-physicians. Task shifting of ART services from physicians to other providers
is supported by WHO guidance, and its safety and efficacy has been demonstated.
This has been accompanied in many countries by changes in regulations to permit
nurses to initiate ART, or to continue prescribing ART once it has been initiated bya medical doctor, and by changes in pharmacy regulation or practice that allows forlonger supplies of antiretroviral drugs and fewer appointments.
In addition, WHO and UNAIDS support increased community engagement in service delivery to improve retention in care18. Several pilot programmes are testing
the feasibility of separating ART delivery and clinical care by establishing modelsof ART delivery at the community level for those patients deemed stable on treatment. Health centre or hospital services would still serve as a back-up when problems arise for patients who were previously stable or for those with complicatedclinical-care needs.

Community ART delivery
The relationship between providing social support and improved adherence totreatment is well established. It is also supported by evidence from systematic
reviews that have found that interventions to provide patient support and education
programmes have improved adherence to antiretroviral therapy19,20. Communitybased ART helps build patient self-efficacy and the social networks that encourage
patient autonomy within a supportive environment21, and can be adjunct to a moregeneral decentralization of ART service delivery.
The feasibility of providing ART beyond the health-service setting has been demonstrated in several studies. In Uganda it was demonstrated that home-based ART
delivery matched facility-based ART delivery in patient survival and suppressing

patient viral load22. In western Kenya, people living with HIV have been trained andsalaried to provide follow-up care to other, clinically stable patients living with HIV
in their communities and to deliver ART23. In Tanzania, a model of ART delivery
by community-based volunteers linked to trained medical workers has led to fewer
patients being lost to follow-up treatment24.
The international medical aid agency Médecins Sans Frontières (MSF), in association with health facilities and medical practitioners, has been an early innovatorand implementer of community-based models of ART delivery in sub-SaharanAfrica. MSF has supported ART and pre-ART in resource-limited settings over the
past decade, including the piloting of innovative models of ART delivery and theirevaluation through operational research25. Other governmental and nongovernmental organizations also have expanded HIV care in innovative ways. Four countries
with MSF-supported community-based programmes (Malawi, Mozambique, South
Africa and the Democratic Republic of the Congo) are highlighted below and summarized in Table 1. They provide a range of models for potential wider implementation depending on the epidemiological and health system contexts.
Each model has developed specific solutions to cover the following core activities
for providing ART over the long term: minimal clinical screening; ARV refills; adherence support and defaulter tracing; strict monitoring of attendance and problem
solving; and encouraging self-efficacy and mutual support.

Kenya 2011 © Bruno De Cock

Kenya 2011 © Sven Torfinn

MALAWI
Malawi, with a population 14.4 million, ranks 171 of 187 on the Human
Development Index26. 85% of the population live in rural areas and 40% of the
population lives below the poverty line. Malawi is among the top 10 countries
most affected by the HIV epidemic14. Adult HIV prevalence is 10.6% and an estimated 920 000 people are living with HIV.
There is a severe shortage of human resources for health in Malawi, with just two
doctors and 50 nurses per 100 000 population27. Despite these challenges, theGovernment of Malawi has implemented one of the most successful ART programmes in southern Africa. Malawi has achieved high levels of ART coverage bytaking a public- health approach to HIV care, which includes: a limited number oftreatment regimens; simplified laboratory requirements; task shifting from doctors to nurses and other health workers; and decentralizing care from hospitals
to health centres14. By June 2011, 276 987 patients were on ART, a coverage of
67% of those estimated to be eligible for ART28.
MSF supports the Government of Malawi in the rural districts of Thyolo andChiradzulu in the southern part of the country. In these districts, MSF-backed
facilities have implemented several models to expand the reach of HIV programmes
and developed sustainable models for ART delivery despite the shortage of humanresources for health.

Decentralizing into the community in Thyolo District
MSF, working with the Ministry of Health, has supported HIV care in Malawi’s
southern Thyolo District (population 587 093) since 1997. Adult prevalence was
21% in 2004, which represented 63 963 people living with HIV. ART coverage ishigh: 20 601 on ART out of 22 376 eligible for ART in June 2011.
In 2003, MSF and the Ministry of Health launched a model of care adapted tothis rural and impoverished district. By 2007, the Thyolo programme had scaled
up to provide universal access to treatment in the district14. Decentralized ART
is provided in Thyolo at health centres and relies on task shifting from doctors to
non-physicians, as health centres in Malawi are generally staffed by nurses, medical assistants and health surveillance assistants (lay workers who receive 10 weeks’basic training).
In 2009 the Ministry of Health began to extend primary-care services to healthposts. Health posts, unlike health centres, are not routinely staffed by nurses, andare overseen by community health workers. The health posts receive regular visitsfrom a community nurse and are staffed by health surveillance assistants and peer
counsellors. Patient support groups, consisting of people living with HIV in pre-ARTand ART services, provide psychosocial and practical support, such as incomegenerating activities. Treatment literacy sessions are provided in these groups. In
Thyolo, this strategy means ART is dispensed at 14 community health posts as wellas in health centres.
Health posts are typically less than 10 km away from patient homes and can provide HIV testing, screening, staging and pre-ART services, collect blood samples
for CD4 assays, and offer ART counselling, ARV refills and treatment for minor
opportunistic infections. Adherence to treatment has been improved by decreasing
the distances patients have to travel and patient waiting times, while the burdens
on health centres and hospitals have also decreased. Health posts, the entry point
for primary care, provide a range of other basic services, including nutritional
screening, reproductive health support, childhood immunizations and basic carefor chronic health conditions.
Between January and June 2011, 10 644 consultations were performed at these
new health posts, of which 65% were for people living with HIV. Between April
2009 and December 2011, 925 patients on ART were down-referred from healthcentres to health posts and 98% remained in care; fewer than 1% were lost tofollow-up and 1% had died.

Reducing appointment frequency in Chiradzulu district
MSF started its programme in the rural district of Chiradzulu (population 290000) in 1997. Adult HIV prevalence is 14.5%. ART was introduced in 2001 andby November 2011, 30 402 patients were being provided with HIV care, among
them, 21 843 on ART. HIV care has been progressively decentralized from the hospital to the 10 district health centres in order to support scale-up and improve retention in care. In 2008 a new protocol for appointments was established, whereby
stable patients were required to attend the clinic only once every six months forclinical visits and once every three months to collect antiretroviral drugs (Table2). Health surveillance assistants provide the three-monthly ART refills at healthcentres and check patient adherence in the community according to a standardized
assessment tool. When problems arise, the assistants refer patients back to thehealth centre for a clinical consultation. By mid 2011, 4382 patients were enrolled in the six-monthly appointment programme. A recent review found that 97%of these patients were still in care after one year, none were lost to follow-up andonly 15 (1%) had died.

DRC 2011 © Robin Meldrum

TABLE 2: ELIGIBILITY CRITERIA FOR COMMUNITY ART DISTRIBUTION
Criteria

Malawi,ThyoloMalawi,Chiradzulu

Mozambique

South Africa

Democratic
Republic of the
Congo

Voluntary
participation

Yes

Yes

Yes

Yes

Strongly
recommended for
those meetingreferral criteria

Adults only

Yes

Yes

No

No

Yes

Duration onART

6 months

12 months

6 months

12 months(will likely be
reduced)Yes

Eligibility
according to CD4

Yes (CD4 > 300)

Yes (CD4 > 300)

Yes

No

Yes (CD4 > 350)

No active OI

WHO Stage
I/II

No

No

Yes (no missed
previous visits)

No

No

Yes

Yes

No active
opportunistic
infections

Clinical criteria
Eligibility
according toadherence check
Pregnant

YesMOZAMBIQUE
Mozambique ranks 184 of 187 on the Human Development Index26. With an average of 0.3 doctors and 2.1 nurses per 10 000 inhabitants, Mozambique has one of
the lowest health-worker densities in Africa29. HIV prevalence in adults is 11.5%30
and an estimated 1.4 million people are HIV-positive.
ART first became available in the public sector in 2003, initially only in specialized HIV clinics primarily located at provincial and district hospitals. To improveaccess to services and decongest hospitals, the Government of Mozambique began
to decentralize HIV services from hospitals to health centres in 200631; between
2005 and 2008, the number of HIV treatment sites increased 10-fold from 20 to229. However, this still represents fewer than one fifth of health facilities32. By theend of 2009, only about 42% of the 373 000 eligible for ART were receiving treatment; for children the figure was even lower (19% of 73 000 eligible)33. By April
2011, 320 000 patients had been initiated on ART. However, at least one quarterof those patients have not been retained in care34 and it is estimated that among
those lost to follow-up, 40% have died35.
The increasing numbers of patients required to travel to a health facility every
month to collect medications and the limited number of clinics providing ART havemeant the facility-based model has not been sufficient for further ART scale-up.

Community ART Groups in Tete province, Mozambique
MSF began supporting the Government of Mozambique to provide ART in 2003;
by March 2012 MSF had provided support to more than 4000 patients on ART in
Tete province. Concern about the high rates of loss to follow-up among patients ontreatment prompted the government, with support from MSF, to launch in 2008 apilot programme of community-based ART distribution and adherence monitoringin Tete. This programme encourages patient self-management within a communitybased peer support network36. The model was designed to reduce both the need forpatients to attend clinics every month to collect ART and the burden on the healthfacilities.
In this programme, groups of patients were established, with patients taking turns
to collect antiretroviral medicines for group members. This means that each groupmember attends the clinic at least once every six months. Group members haveassumed four functions: to collect and deliver ART each month to other membersin the community; to provide community-based adherence support and treatment
outcome monitoring; to establish a community-based treatment social support network; and to ensure each group member has a clinical consultation at least once
every six months.
To join a group, patients need to be clinically stable on ART (CD4 >200 cell/mm3)
for at least six months. Interested patients are advised to form groups of up to six,
elect a leader and be assessed at the nearest clinic to determine their eligibility forthe programme. Lay counsellors provide training for newly formed groups on theapproaches, roles and responsibilities of members; monitor the adherence of members on a monthly basis; and provide group counselling and education sessions.
Group leaders arrange monthly meetings, conduct monthly pill counts, monitor
attendance and ensure that possible ART side-effects are reported to clinicians.
Group members conduct simple health checks and advise patients to seek medicalcare at clinics when needed. The group must be linked to a clinic that is able toprovide appropriate HIV-related services: HIV counselling and testing; a clinician
authorized to prescribe ART; a guaranteed supply of ART and drugs to prevent andtreat opportunistic infections; and transport for CD4 samples and results.
The pilot programme of Community ART groups (CAGs) was implemented in 20
health facilities in seven districts of Tete province in April 2008. By December
2012, 96.8% of the 4177 patients enrolled in a CAG remained in care. Of these,
5.5% had left the CAG and were transferred to another health centre (3%) or standard care (2.5%). Of the others initially enrolled, 3.1% had died and 0.1% had
been lost to follow-up treatment from the CAG programme.
Following this early success, the Ministry of Health recommended in July 2011that CAGs become part of the national HIV care strategy and plans to scale up
CAGs37. MSF is refining the model, in particular to adapt CAGs to specific key
populations, such as children, adolescents, pregnant women, patients not yet eligible for ART, patients co- infected with tuberculosis (TB) and HIV, sex workers andpatients on second-line regimens.
Delegations from the health ministries of Malawi, South Africa, Swaziland andZimbabwe have visited this programme to assess its feasibility and appropriatenessfor replication. Malawi has plans to pilot community ART groups in 2012.

Mozambique © Brendan Bannon

SOUTH AFRICA
South Africa has the fourth highest adult HIV prevalence (17.8%) in the world, andwith 5.3 million people estimated to be HIV-positive, the largest number of people
living with HIV worldwide38. In 2003, the Government of South Africa launched acomprehensive HIV care and treatment programme and has progressively scaled up
HIV care services. By mid 2011, 1.79 million people had been initiated on ART,
about 55% of those considered eligible.
MSF began to provide ART in 2001 at three dedicated HIV clinics in Khayelitsha,
a township of 500 000 inhabitants located on the outskirts of Cape Town.
Khayelitsha carries one of the highest burdens of both HIV and TB in the country.
As ART was introduced prior to the national programme, it provided the opportunity
to demonstrate feasibility and acceptability of treatment in a resource-poor urban
setting. The ART delivery was initially doctor-based and located in three community
health centres. However, scale-up has been exponential: in June 2002, 100 people
had been initiated on ART; by June 2003 the number had increased to 400; thefollowing year it was 1000, and by June 2011, more than 20 000 people had been
initiated on ART.
As the number of patients on ART increased rapidly, the proportion of patients being
lost to follow-up also began to rise as clinics became saturated39. In response, acare model was adapted to relieve pressure on these large clinics by moving towards a nurse- based, doctor-supported decentralized model of care and by developing out-of-clinic approaches to adherence support for stable patients.

Community adherence clubs
ART adherence clubs were established in November 2007 as a way to decongest
health centres by shifting the majority of consultations and ART collections forstable patients to ‘clubs’ organized by lay counsellors or peer educators. The adherence club model builds on a pre-existing approach to community delivery of medicines for chronic diseases such as diabetes, hypertension and epilepsy.
In the ART adherence clubs, groups of up to 30 patients meet every two months,
either at the facility or in a community setting. Participation is voluntary and offered to all adults who have been on ART for at least 12 months and are considered clinically stable (CD4 count >200 cells/mm3 and undetectable viral load). In
these groups, essential tasks such as measuring weight and conducting symptombased general health assessments are provided by a trained counsellor. Medicines
are pre-packaged for each participant and brought to the group by the facilitator.
Any patient reporting symptoms suggesting illness, adverse drug effects or weightloss are referred back to the clinic for assessment by a nurse. All club patients
attend the clinic twice a year; once for blood taking and two months later whenattended by a health worker.

The adherence clubs began as an in-clinic innovation, with specific days and hours
to reduce time spent at the clinic (no more than two hours), but they have evolved
into a community-based programme. By December 2011 there were 98 clubs
linked to six clinics in Khaleyitsha. MSF has assisted with the broad replicationof this model by city and provincial authorities; by March 2012 there were 251
adherence clubs across Cape Town.
An analysis comparing the outcomes among 502 patients who joined adherence
clubs with those among 2327 patients who remained in clinic care found that
retention in care was significantly higher in the clubs (97%) than in clinical-basedcare (85%). Club participation reduced loss to follow-up by two thirds and nearly
halved the proportion with virologic rebound or breaks in monitoring comparedwith patients who remained in clinic-based care. As burdens on the formal healthsystem increase with additional scale- up of ART, there do not seem to be negative
consequences of moving significant components of HIV care and treatment to thecommunity.

Kenya 2011 © Sven Torfinn

Kenya 2011 © Sven Torfinn

DEMOCRATIC
REPUBLIC OF THE
CONGO
While adult HIV prevalence (1.5%) is relatively low in the Democratic Republic of
the Congo, ART coverage is among the lowest in the world, with fewer than 15%of those eligible receiving treatment40. In addition, in a population of 71 million,
there are more than one million people living with HIV41.
MSF has helped provide ART services in Kinshasa since 2002. Early identificationof patients eligible for treatment has been hampered by a general lack of access tohealth services, a shortage of HIV diagnostic tests and limited availability of CD4
testing, and by the requirement for patients to partly pay for these tests. Many ofthe patients at MSF-supported clinics first enter into care with advanced HIV illness, with complications reminiscent of the pre-ART era.
ART was initially provided at the Centre Hospitalier de Kabinda but by 2005 thehospital had reached capacity, with more than 1500 patients on ART and another1300 in pre- ART care. To try to decongest the hospital, a process of down-referralbegan in mid- 2005, with stable patients referred to one of three health centres.
Even this innovation was insufficient to cope with the overwhelming number ofpatients and new enrolment into care was closed. Enrolment began again in 2009
once those patients on the pre-ART waiting list had been initiated on ART.

Patient-managed ART distribution in Kinshasa
By the latter part of 2010 MSF, working with a local network of people living withHIV (Réseau National des Organisations des Assises Communautaires), establishedcommunity ART distribution points in Kinshasa. These distribution points are managed by people living with HIV who have received training. They provide ART refills,
adherence counselling and basic health follow-up, including measuring weight andperforming basic symptom screening. Patients who have been on ART for morethan six months and belong to a support group (see Table 2) are considered stableand eligible for participation in these community ART distribution points. As of
December 2011, 195 patients had been down-referred from the facility-based HIV
treatment centre to the community ART distribution points.

Initial analyses of a limited number of patients have found that the average
cost in human resources expenditure per patient is more than 25 times lower
at community distribution points (US$ 9 per patient) than at the hospital clinic(US$ 230 per patient). A linked qualitative survey of patient perspectives foundthat transport costs are about three times higher for patients receiving care at
the hospital compared with those receiving care at the community distribution
points. Patients at the community ART distribution points spend an average 12
minutes collecting ART refills, seven times less than patients receiving ART at
the hospital (85 minutes)42.

Mozambique 2012 © Brendan Bannon

COMMON ELEMENTS
OF COMMUNITY ART
DELIVERY MODELS
These innovative models of providing HIV care and treatment have been implemented in a range of settings (urban/rural; high/lower prevalence) but share several
key elements. These are summarized in Table 1 and detailed below.

Inclusion criteria
The most recent WHO guidelines recommend earlier ART initiation, at CD4 350
cells/mm3, although the timing for adopting these guidelines has varied. However,most HIV treatment programmes in Africa still report average baseline CD4 at initiation < 200 cells/mm3. Due to an elevated risk of immune reconstitution syndrome(IRIS) and concomitant opportunistic infections in patients with low CD4, initiation and early follow-up of patients on ART will continue to require facility-basedcare. The models of community-based ART discussed in this report may assess bydifferent means patient eligibility for transfer to out-of-facility care but all focus on
patients who have been on ART for a minimum of six months, and who are adults,
positively responding to treatment and willing to attend clinic care less regularly.
As HIV programmes initiate people living with HIV with higher CD4, it may bepossible to offer community-based care sooner, as patients will arrive less sick andrequiring less intensive early clinical supervision.

ART delivery
The highest level of health worker in many health centres and community settings
is likely to be a nurse. Most programmes described in this report have health assistants, peer counsellors or expert patients (sometimes under the supervision of anurse) managing ART delivery. In many countries, such a practice may be limited
by prescribing and dispensing regulations but there is room for negotiation, given
the precedents for such lay dispensing in other areas of health care, such as themodel of community case management of malaria43. Utilizing non-formal healthworkers can be problematic if they are not a recognized occupational cadre or not
remunerated.

Health checks and referral mechanisms
Self-management and peer support critically depend on rapid self- or programmereferral to health professionals if a participant’s health deteriorates. Peer groupmembers must be trained to systematically detect early signs and symptoms, andeach patient must have direct contact with the health services at least every 6–12
months. At the education session during the initial months on ART, each patient
should be clearly told the potential symptoms which would require them to present
back to health services. These would certainly include any signs of TB or ARTspecific toxicity. In general, the risk of other new opportunistic infections is limited
for those who have remained on ART for more than six months.

TABLE 3: ADVANTAGES AND DISADVANTAGES OF COMMUNITY ART MODELS
Advantages

Disadvantages

Relieves burden on health facilities

Requires more intensive initial education of patients andlay staff to minimize risk of problems not being identified

Relieves burden on stable/adherent patients who need
only refills

Not all patients are eligible according to current criteria,with those most likely to be lost to follow-up excluded

Promotes self-efficacy and patient involvement consistent
with chronic disease management

Requires disclosure at community levels, with potential
negative impact on individuals where stigma is high

Empowers individuals and develops community networks
with potential for activism, support etc

New forms of decentralized monitoring and supervision
required, without which, outcomes may worsen

Potential to support other community-based activities (HIVtesting, tracing, TB screening etc)

Some models may lead to competition for scarce community human resources between HIV care and other healthpriorities

May hold health sector more accountable to meeting needsof patients and communities (i.e. prevent stock-outs

Tighter drug control needs to be instituted toprevent leakages

Likely to be more cost effective than facility-based
drug refills

Need strong referral system for those patients who require
urgent medical assistance

Reduces need for routine tasks being carried out by
scarce, highly trained health professionals (task shifting)KEY CHALLENGES
The programmes outlined in this document present several options for delivering
ART at the community level. Programme managers will need to evaluate the various
elements. Table 3 provides a summary of possible advantages and disadvantages ofcommunity ART models.

Balancing options
In many countries, HIV care has evolved from being a service delivered by specialized HIV clinics to one that is delivered by integrated primary health centres, orvia clinic outreach and community-based models. Choosing the most appropriate
model (clinic appointment spacing, outreach to health posts or community ART
groups) will be context specific and conditioned by a range of factors, including:geography; the extent of existing decentralization; HIV prevalence; average CD4 attreatment initiation; likelihood of side-effects with a particular ART regimen; thecapacity of health services; and, in some cases, regulatory or logistical constraints
to ART delivery. Other regular health needs such as family planning, or co-morbidities such as hypertension and diabetes, will also determine which model is mostappropriate for individual patients. To ensure the intervention is accepted, deciding
the most appropriate model must be done in collaboration with the patients livingwith HIV.

Defining inclusion criteria
Many models of community-based delivery or decentralized care have specificinclusion criteria, most of which limit participation to patients beyond the first
6–12 months on treatment. While patients during the first 6–12 months of treatment require the greatest clinical support, earlier initiation thresholds being introduced in national guidelines may allow for certain patients to benefit from thesemodels earlier in their treatment history. Use of viral load for detecting early nonadherence at three or six months may allow earlier referral to these models and, asa monitoring tool, clearly identify those needing referral for more intensive clinicaland adherence interventions.

Monitoring, evaluation, and supervision
Simplified monitoring systems with a minimum set of indicators are needed toensure quality is maintained and to support drug supply. Systematic supervisionof the implementation and outcomes of the model should also be a prerequisiteof any community-based model. There is a growing interest in the potential contribution mHealth (the use of mobile devices to support health-care delivery) could
make in transferring information between clinic-based functions and community
groups and/or individuals. Further operational research is needed to determine thepotential benefits of mHealth.

Drug supply
Procurement, pharmacy management and supply-chain management to peripheral sites are critical for implementing community-based and health-post models.
Supply-chain weaknesses can lead to ART stock-outs and such weaknesses must
be critically monitored and reported. Community models will often require policies
and supply-chain integrity that permit ART being delivered for periods of more thana month. Consistent with the goals of Treatment 2.0, developing appropriate pricing and providing less toxic, heat-stable ART regimens in fixed-dose combinations
will further simplify these community-based approaches. Finally, advances in theavailability of certain drugs (heat-stable, fixed-dose combinations) and point-ofcare diagnostics will help expedite community models of ART delivery.

Community participation
The extent to which patient groups engage in mutual support will probably be context- specific and should be community/patient driven. As a minimum, community
stakeholders should be involved in planning and implementing community-basedmodels.

Supporting specific groups
Certain groups of key patients, such as pregnant women, children and adolescents,
may require specific counselling or medical interventions beyond what is normallyprovided in the community model. Health systems must ensure that appropriate
services are available for such patients alongside the community-based models.

Preserving patient choice
Although there are several advantages to the community-based models, including reducing visits and time spent at the clinic, some patients may choose not toaccess services close to their home in order to avoid the risk of being stigmatized,
because of their preference not to disclose their HIV status, or the desire to see ahealth professional more often. This requires flexibility within the health system tooffer clinic- and community-based services.

Zimbabwe 2011 © Brendan Bannon

1.

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