Adherence clubs

Adherence clubs are a grouping of around 30 patients stable on ART. This model is well adapted to urban environments where especially time spent at the clinic is an issue for patients.

How does it work
Every two months the group gathers at a health facility or at a community venue close to their clinic to quickly collect the drugs that have been pre-prepared for each of them. During club meetings each patient goes through a general health assessment done by lay workers.

The meeting lasts less than an hour. Patients whose health seems to not be optimal are referred to the club clinician who is immediately available at the clinic to see them. They do not need to wait a long time or come back to see the clinician. 

Advantages of the model
An MSF study showed that 97% of club patients were still in care after 40 months, against 85% of those with the same profile but who chose to remain in the mainstream health system. Clubs have also proven to increase how well the treatment works in patients.

An MSF study showed that club patients had 67% less chances to experience a virological rebound, which means that there was a problem with their treatment, either because they didn’t take it properly or because they had developed resistance to the drugs. Finally a MSF study showed that adherence clubs almost halves the average cost per patient per year: $58 in the model against $109 in standard care in South Africa.
Siyabonga Mhlongo is a member of the community ART group in Eshowe, KwaZulu Natal in South Africa
Where can we find it?
Adherence clubs are a replicable model and have been implemented outside of MSF’s support. Since the pilot phase that started in 2007 in Khayelitsha they have progressively been handed over to the department of health in the Western Cape that has replicated the model and expanded it region-wide. By mid-2014, 27800 patients, in the Cape Metro were receiving their treatment through clubs. Clubs and adaptions of the club model have been implemented in a few districts in Gauteng, Mpumulanga and KwaZulu Natal provinces of South Africa. 

Read the 'Adherence club Report and toolkit 

Community ART distributuon (PODI)

Community ART distribution points, also called PODI in French (“Points de distribution communautaires”) were pioneered in urban Kinshasa, in the Democratic Republic of Congo.

How does it work?
Patients individually come once every three months to a community distribution point managed by a network of people living with HIV. Lay workers of this network dispense ART to the patients. Patients attend once a year the health facility for a clinical consultation and CD4 monitoring to check how well their treatment is working.

Advantages of the model
Whilst the key advantage of PODIs is to facilitate people’s access to free testing and HIV drugs, PODIs also have retention rates of 91% after two years, and preliminary research evaluates its cost at $8 per patient per year against $27 in a public health center.

An analysis in DRC with the Community ART distribution points also show that patients spend on average three times less money to get their drugs at the PODI than if they would have continued to get their drugs at the hospital. Patients were spending an average of 14 minutes to pick up their drugs at PODI against 85 minutes at the hospital.
Text on the board reads " It’s at the community ART distribution point  that I found the support I needed to not be facing alone AIDS alone"  Jean Pierre Tshibuyi
Where can we find it?
This strategy was launched in urban Kinshasa, in a context of very low ART coverage with only few health facilities offering ART, and high stigma. The situation of HIV patients in the DRC is extremely difficult: less than 20% of HIV-infected people are on ARV, drug stock outs are frequent, and as a consequence treatment outcome is poor.

In the MSF HIV reference hospital of Kabinda, or CHK, mortality is as high as 25%. Close to half the people who die there do so within two days of arriving in the clinic. There we see scenes we haven’t seen since the height of the pandemic in the 1990’s, before the arrival of ARVs. Maintaining people on effective treatment in this context is therefore crucial.

In Kinshasa MSF has opened three PODI (distribution posts) throughout the city, enabling 2500 HIV patients to access ARVs in their community. The PODI were purposefully set up independently from public health centers, where patients are invariably made to pay for consultations, tests and drugs. 

Community ART Groups

A last model is the community ART groups (CAGs) that were piloted in rural Tete, Mozambique. 

How does it work?
In this model patients form groups in the community and the group members rotate to attend the health facility to pick up ART for the whole group. When the group member on duty returns from the clinic, he dispenses drugs to the other members in a patient’s home. While a group member picks up drugs for the group at the clinic, he also gets his 6 monthly or yearly clinical consultation and blood drawing for CD4 or viral load.

Advantages of the model
This model is especially well adapted to rural environments with long distance to clinics and a tight sense of community.

Because patients do not need to go as often to the clinic, it is cheaper and more convenient for them to stay on treatment. MSF’s experience shows that among stable patients on ART over 90% of patients in the Tete province of Mozambique were still in care after four years in CAGs, against 64% of patients with the same profile who didn’t belong to the model.

With the CAG there is a 59% reduction in ART refill visits and a 43% reduction in overall clinic visits, which means a big reduction in health staff’s workload. Finally people belonging to CAG model say that peer support brought by the group increases solidarity among them and contributes to lowering stigma.

Where can we find it?
The first CAG groups were piloted in the Tete province of Mozambique, and the model has quickly spread with versions, each adapted to specific local contexts, being implemented in South Africa, Lesotho, Malawi, Zimbabwe and Guinea.

Watch the video: Patient centered care