ART adherence clubs in the Western Cape of South Africa: what does the sustainability framework tell us? A scoping literature review

Abstract

Introduction In 2007, the antiretroviral therapy (ART) adherence club (AC) model was introduced to South Africa to combat some of the health system barriers to ART delivery, such as staff constraints and increasing patient load causing clinic congestion. It aimed to absorb the growing number of stable patients on treatment, ensure quality of care and reduce the workload on healthcare workers. A pilot project of ACs showed improved outcomes for club members with increased retention in care, reduced loss to follow‐up and a reduction in viral rebound. In 2011, clubs were rolled out across the Cape Metro District with promising clinical outcomes. This review investigates factors that enable or jeopardize sustainability of the adherence club model in the Western Cape of South Africa. Methods A scoping literature review was carried out. Electronic databases, organizations involved in ACs and reference lists of relevant articles were searched. Findings were analysed using a sustainability framework of five key components: (1) Design and implementation processes, (2) Organizational capacity, (3) Community embeddedness, (4) Enabling environment and (5) Context. Results and Discussion The literature search identified 466 articles, of which six were included in the core review. Enablers of sustainability included the collaborative implementation process with collective learning sessions, the programme's flexibility, the high acceptability, patient participation and political support (to some extent). Jeopardizing factors revolved around financial constraints as non‐governmental organizations are the main supporters of ACs by providing staff and technical support. Conclusions The results showed convincing factors that enable sustainability of ACs in the long term and identified areas for future research. Community embeddedness of clubs with empowerment and participation of patients, is a strong enabler to the sustainability of the model. Further policies are recommended to regulate the role of lay healthcare workers, ensure the reliability of the drug supply and the funding of club activities.

Retention in care and factors critical for effectively implementing antiretroviral adherence clubs in a rural district in South Africa

“…Clients and healthcare workers both reported that clubs provide an overall positive experience and a better quality ART service compared with visiting the clinic monthly. Clients and healthcare workers were in agreement on key health systems issues for effective club implementation, which largely reinforced issues highlighted in previous publications , These included: (i) referral of stable clients to the club, (ii) an ideal club size of ≥20 members (the desired upper limit was not reported), (iii) club services led by a counsellor (iv) using churches or community halls as venues (v) effective communication between all parties, and (vi) timely delivery of prepacked medication.…”

Long‐term virologic responses to antiretroviral therapy among HIV‐positive patients entering adherence clubs in Khayelitsha, Cape Town, South Africa: a longitudinal analysis

“…As the number of people requiring lifelong ART increases, the need for DSD models will grow. ACs are increasingly seen as an alternate method to improve clinical outcomes in burdened healthcare settings, with the flexibility, acceptability and implementation of the programme strongly contributing to its sustainability [47]. Additionally, patients have reported improved satisfaction with the convenience of ACs [28,48].…”

Outcomes of patients on second‐ and third‐line ART enrolled in ART adherence clubs in Maputo, Mozambique

“…Hence, innovative strategies such as adherence clubs can help to improve national retention in care for new and long-term HIV patients. Much can be learned from more than 10 years of experience with AC in South Africa [27]. The AC model is being rolled out by the Ministry of Health of Mozambique, and second-line patients from CRAM were transferred to other healthcare centres where new AC have been formed based on our model.…”