Community HIV treatment re-fill groups are positively received in Zimbabwe
Innovative HIV service delivery models are well received and have the potential to improve health outcomes.
Community Antiretroviral Treatment Re-fill Groups (CARGS) – where people from the same area take it in turns to travel to the clinic to pick up HIV treatment for the rest of the members of their group – have been positively received by both healthcare workers (HCWs) and people living with HIV in Zimbabwe.
According to a qualitative evaluation of the CARGS initiative, people living with HIV appreciated having fewer clinic visits and spending less money on transportation to collect their treatment. HCWs said it freed up more time for in-need patients and reduced their overall workload.
Differentiated service delivery (DSD) is a widely embraced strategy based on the idea that HIV services should be offered in innovative ways to fit the diverse needs of people living with HIV, therefore addressing the costs and challenges of treatment access. The CARGs model is one such initiative designed to help time-poor clients, as well as those living in rural areas far away from treatment dispensaries.
The Zimbabwe Ministry of Health and Child Care (MoHCC) have five antiretroviral treatment (ART) refill options included in their guidelines: fast‐track (patients collect ART from the pharmacy without a clinical exam), club refill (facility‐based HCW‐led group refills), outreach (individual ART delivery through mobile outreach), family member refill (one individual collects ART for all family members) and CARGs.
The MoHCC started national roll-out of CARGs in late 2016, following the example of Mozambique’s CARG programme – which they called Community ART Groups (CAGs). Studies here found higher rates of HIV care retention among ART clients in these groups, while qualitative analyses indicated positive acceptance of this model.
In Zimbabwe, stable ART clients from the same geographic location are encouraged to self-form into groups of anywhere between four and 12 members, and elect a person every three months to collect treatment for the group. The group will then normally travel to the clinic together for their annual health and viral load check. Before each ART pick-up they will also screen each other for tuberculosis or any other opportunistic infections and are encouraged to visit the clinic if they feel unwell.
At the time of this evaluation, programmatic data from 19 districts of Zimbabwe indicated that there were 35,810 active CARG members, representing 9% of ART clients in these districts. Using a combination of surveys, in‐depth interviews (IDIs), and focus group discussions (FGDs) with HCWs and ART clients, this study sought to evaluate the perceived effects of the CARG model for both HCWs and ART clients.
Across 10 facilities, 30 ART clients participated in IDIs: 19 CARG members, 6 former CARG members and 5 clients who declined to join a CARG. At these same facilities, 46 HCWs participated in FGDs. They included 30 nurses, and 16 other counsellors or facilitators across lay and professional cadres.
ART clients were overall extremely satisfied with the CARG model, saying that it helped to improve their ART adherence by removing the challenge of travelling to the clinic.
Support provided by being a member of a CARG group was identified as an additional way CARGs improved ART adherence.
“We actually remind each other when to take our drugs… if you are part of a WhatsApp group and you see a message reminding people to take their drugs you are prompted to take them on time.”
CARG members also largely felt confident enough within their groups to ask questions, and they said it was an opportunity to share knowledge and information. They also noted that the clinics were a lot nicer to be in, with less waiting time.
While views were mostly positive, some clients noted that they faced challenges around group eligibility criteria for their family, having a child or becoming pregnant, as barrier to membership. Another issue that was raised was around respecting each other’s right to confidentiality around their status. Others simply wanted more engagement with their HCW.
HCWs felt that the CARGs made it easier for them to do their own work because it freed up more time in the long run. In a survey, 97% of HCWs reported that implementing CARGs had reduced their workload. Although some did note that new groups required more administration in the on-boarding phase, as clients were still understanding the process.
“It's now easy for us since we no longer have a lot of people coming to the facility at the same time like we used to have in the past… in the afternoon we can actually concentrate on other tasks that we failed to do in the past because of a large number of clients coming in.”
HCWs also noted that the number of clients who defaulted on ART had declined since the inception of the CARG model, which meant that fewer clients needed to be tracked. On top of this, communicating with clients was much easier through the groups, because they only needed to relay the message to the next person coming in for pick-up.
Both HCWs and ART clients indicated that the CARG model had improved their quality of care. One nurse remarked:
“I think the quality of patient care has actually improved, let's take for example if one comes in with some ailment you have to examine that patient… So if they come in as an individual you take ample time to examine the client without any pressure.”
While a patient remarked:
“The nurses are actually serving us wholeheartedly because they are not under pressure.”
Given the rapid roll-out of the CARGs model and the short time frame that the strategy has been put in place, it’s important to continue evaluating whether patient and HCWs positive views are sustained over time. According to the authors, the Zimbabwe MoHCC does not yet collect national data on CARG implementation, so results from this evaluation cannot be applied nationally.
They note, “quantitative analyses will be needed to confirm that CARGs are improving patient outcomes. Overall, these early results from implementation appear promising and suggest that CARGs may promote the objectives of DSD models by simultaneously improving patient care and reducing HCW workloads.”