Frivold, Collrane

JHSPH

MSPH

South Africa

South Africa - Community versus clinic-based ART adherence clubs to enhance provider task-shifting and patient long-term retention in care

Adherence clubs are groups of 25-30 stable HIV patients who meet once every two months with club facilitators (counselors, and nurses on dates of blood draws) for a one hour session during which counseling and ART medication is provided.  Clinic-based adherence clubs implemented in Khayelitsha, South Africa have demonstrated that patients participating in clubs have reduced loss to follow up and viral load rebound compared to stable patients receiving routine clinic-based care. Key questions remain as to whether the effectiveness of adherence clubs differs when based at the clinic compared to those based in the community.  We are conducting an unblinded, randomized controlled trial of community-based versus clinic-based adherence clubs for patients who are stable on ART.  The overall goal of this study is to evaluate whether, compared to clinic-based adherence clubs, community-based clubs result in improved patient outcomes and greater retention in care without compromising overall quality of patient medical care.

Global Health PI/Mentor: Colleen Hanrahan

            I had a very rich experience in South Africa during my Global Health Established Field Placement researching antiretroviral therapy (ART) adherence clubs. I was initially very impressed by the clinic I was placed at and by the scope of the services offered. I previously worked in Madagascar where most of the clinics were only a single room with no electricity. At Witkoppen Health and Welfare Centre, there was an entire department dedicated to research where I was fortunate enough to work. The research team was very welcoming and I was well supported throughout my field placement. My first few weeks I spent the majority of my time observing the adherence clubs and assisting with clubs visit, which was one of the most impactful parts of my experience. I enjoyed interacting with the patients and hearing their concerns about living with HIV and their treatment.

            One of the deliverables I completed during my field placement was a costing analysis of the adherence clubs. Through this task, I documented all the costs related to running the adherence clubs ranging from the box used to carry medication to the physical buildings where the adherence clubs are held. This research experience made me approach global health from a broader perspective and enabled me to identify factors impacting global health and HIV care that I had not considered before doing this analysis. For instance, during my analysis I had to account for the physical infrastructure and for costs such as the physical space, utilities, security, and pest control associated with the buildings where adherence clubs were conducted. Even though these costs are always present when I think about the costs of a global health intervention I initially think about the costs associated with personnel, training, medical equipment and devices. This research experience helped me evaluate a global health intervention in a more holistic way and that I must be conscious of all the underlying costs of a global health intervention moving forward in my career.

            One challenge that South Africans face when accessing care is the long wait times associated with seeing medical practitioners and filling prescriptions at a clinic. In order to see a medical practitioner, patients wait in queues for hours and then have to spend additional time waiting for their prescriptions to be filled afterwards. As a result, many patients spend the entire day at the clinic even if they are just getting a prescription refill. Adherence clubs are one strategy that South Africa is employing to fast track patient care and reduce wait times at the clinic. Using this intervention, patient medication is pre-packed so that patients do not spend time waiting at the pharmacy. They also attend club visits instead of going through the general queue at the clinic to shorten visit times. By fast tracking patients that are stable and virally suppressed it also allows medical practitioners to devote more of their time to patients who have defaulted or are not responding well to their medication regimen. Therefore, adherence clubs do effectively address issues related to minimizing the time that patients have to spend at the clinic. Patient interviews also suggest that patients prefer adherence clubs to general care. However, there are also some disadvantages compared to general care. One such shortcoming of the adherence club model is that a lay counselor usually sees patients for their club visits instead of a medical practitioner. As such, some medical conditions could be missed that a clinician would likely recognize. However, task shifting is still very valuable and necessary in an environment with staff shortages.

            Through this research experience, I learned that I enjoy being based at one field site, which enables me to build stronger relationships with the local staff. In my previous research experience in a developing country, I spent the majority of my time traveling to clinics throughout the country and usually having only one visit at each clinic. I thought I would miss the traveling and interacting with more global health professionals, but I think I developed my global health skills more by working closely with one team of researchers. Building these close relationships also gave me more flexibility with the types of tasks I worked on and the complexity of my projects. This was also my first experience working on a randomized controlled trial. I enjoyed this type of work and would be interested in working on clinical trials in the future. 

Collrane working on clinical file reviews for the family planning clinical file review of female adherence club patients:

Collrane measuring the boardroom at Witkoppen Health and Welfare Centre where clinic-based adherence clubs are held for a costing analysis. All spaces that were used for the adherence clubs were measured to account for physical infrastructure costs:

Shown above are some of the items that were included in the adherence club costing analysis. These items include the table, plastic box with ART medication inside, the club register, pens, a binder, scale, and blood pressure machine:

This is a room at a community center that is used for the community-based adherence clubs. Shown in this photo is Sister Thobile, a nurse at the clinic, who is cleaning up after a blood draw club visit:

This is another site that is used for the community-based adherence clubs. This site is also used for the Witkoppen Health and Welfare Centre mobile clinic that visits the townships:

People

Robert Bollinger Jr., MD MPH

Director, Johns Hopkins Center for Clinical Global Health Education (CCGHE); Associate Director, Johns Hopkins Center for Global...

Caitlin Kennedy, PhD MPH,BA

Co-Director, MPH concentration in Social and Behavioral Sciences in Public Health; Associate Director, Center for Qualitative...

Yukari C. Manabe, MD

Associate Director of Global Health Research and Innovation

Joanne Katz, ScD MS,BSc

Associate Chair, Director of Academic Programs

Noreen Hynes, MD MPH

Director, Geographic Medicine Center of the Division of Infectious Diseases

Stefan Baral, MD MPH,MBA,MSc

Director, Key Populations Program
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February 2020

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