Implementation of community-based adherence clubs for stable antiretroviral therapy patients in Cape Town, South Africa

Introduction: Community-based models of antiretroviral therapy (ART) delivery have been recommended to support ART expansion and retention in resource-limited settings. However, the evidence base for community-based models of care is limited. We describe the implementation of community-based adherence clubs (CACs) at a large, public-sector facility in periurban Cape Town, South Africa. Methods: Starting in May 2012, stable ART patients were down-referred from the primary care community health centre (CHC) to CACs. Eligibility was based on self-reported adherence, >12 months on ART and viral suppression. CACs were facilitated by four community health workers and met every eight weeks for group counselling, a brief symptom screen and distribution of pre-packed ART. The CACs met in community venues for all visits including annual blood collection and clinical consultations. CAC patients could send a patient-nominated treatment supporter ("buddy") to collect their ART at alternate CAC visits. Patient outcomes [mortality, loss to follow-up and viral rebound (>1000 copies/ml)] during the first 18 months of the programme are described using Kaplan-Meier methods. Results and Discussion: From June 2012 to December 2013, 74 CACs were established, each with 25-30 patients, providing ART to 2133 patients. CAC patients were predominantly female (71%) and lived within 3 km of the facility (70%). During the analysis period, 9 patients in a CAC died (<0.1%), 53 were up-referred for clinical complications (0.3%) and 573 CAC patients sent a buddy to at least one CAC visit (27%). After 12 months in a CAC, 6% of patients were lost to follow-up and fewer than 2% of patients retained experienced viral rebound. Conclusions: Over a period of 18 months, a community-based model of care was rapidly implemented decentralizing more than 2000 patients in a high-prevalence, resource-limited setting. The fundamental challenge for this out of facility model was ensuring that patients receiving ART within a CAC were viewed as an extension of the facility and part of the responsibility of CHC staff. Further research is needed to support down-referral sooner after ART initiation and to describe patient experiences of community-based ART delivery.