Evidence for reducing the frequency of clinical visits and extending the duration of antiretroviral therapy (ART) refills for clients who are stable on ART is increasing. The World Health Organization (WHO) recommends both clinical visits and ART refills to be delivered every 3-6 months and is currently reviewing this guidance .
A recent systematic review to assess the impact of reduced frequency of clinic visits and drug dispensing on client outcomes reported that less frequent clinic visits led to high rates of retention in care (odds ratio, OR: 1.90; 95% confidence interval, CI: 1.21-2.99). Although no differences were found in virological failure, morbidity or mortality, most estimates favoured reduced clinical visits. Reduced frequency of antiretroviral (ARV) pickups also supported improved retention (OR: 1.93; 95% CI: 0.62-6.04) . Client-managed groups are one example of a differentiated ART delivery model that utilizes the principle of differentiating between the need for a clinical visit versus an ART refill visit, which can reduce the frequency of clinic attendances.
The most common example of a client-managed group is a self-forming group of people living with HIV who meet at an agreed community location and nominate a member to collect ART for the group from the facility on a rotational basis. That member then distributes ART to the group at the agreed community location. Data from client-managed group models have shown improved client outcomes with qualitative evidence supporting reduced costs and increased time savings.
The earliest evidence for client-managed groups came from a large cohort of clients enrolled in community ART groups (CAGs) in Tete, Mozambique. In a 2014 descriptive cohort study , retention outcomes at 12, 24, 36 and 48 months were 97.7%, 96.0%, 93.4% and 91.8%, respectively, with a mortality rate of 2.1 and loss-to-follow-up (LTFU) rate of 0.1/100 per client year. Data from three qualitative studies found cost and time savings for clients and improved certainty of ART access and mutual peer support, including health educational benefits, which facilitated better adherence [4,5]. The most recent of these qualitative studies across 10 health facilities also showed that CAG participation preserved social capital for members by providing a supportive extended family, access to mutual savings and financial assistance from other group members . A descriptive editorial explains the step-wise scale-up approach that was taken from the pilot site, to the district, and eventually nationally in Mozambique .
Scaled-up CAG model outcomes were published in late 2016 in an evaluation of trends observed after a decade of ART scale up in Mozambique . From 2004 to 2013, 455,600 people over 15 years of age had initiated ART, with 6,766 enrolling in a CAG at 69 facilities from 2011 to 2013. CAG participation was associated with a 35% lower LTFU but similar mortality. Incidence of LTFU and mortality after ART initiation for CAG and non-CAG participants was 2.9% and 0.3% at two years and 10.1% and 1.4% at four years. In a further study  reporting outcomes for the same cohort of CAG clients matched with eligible non-CAG clients (37% of cohort) at facilities offering the CAG model, eligible non-CAG clients had a significantly higher LTFU rate (hazard ratio, HR: 2.36; 95% CI: 1.54-3.17) but also similar mortality. Interestingly, the study also compared outcomes of clients in CAGS who were eligible for CAGS with those in CAGs who were ineligible (19% of cohort). One-year retention was 92.5% and 86.4%, respectively (LTFU: 6.7% and 9.6%; mortality: 0.8% and 4%).
A recent retrospective study undertaken in northern Mozambique assessed all ART clients over 15 years of age who were eligible to join a CAG (n=1,306) from 2010 to 2015 for associations between baseline characteristics and total days late for appointments in the first six months on ART (prior to CAG eligibility) and CAG participation. It found no associations other than female sex. Only 13.8% joined a CAG, with CAG participation reducing mortality by 55.1% (adjusted hazard ratio, aHR: 0.449; 95% CI: 0.264-0.762) and reducing the risk of LTFU by 84.3% (aHR: 0.157; 95% CI: 0.086-0.288) .
In Uganda, The AIDS Support Organization (TASO), a non-governmental organization supporting more than 100,000 people living with HIV, has reported encouraging adherence outcomes of 89% from its community client-led ART delivery model (CCLAD). Interventions that enabled the model included:
i) A simple data collection tool that facilitates peers to collect information, which is then transcribed to national monitoring and evaluation tools
ii) Pre-packing of drugs with clear labelling, which facilitates accurate distribution of ART
iii) Jointly contributing to the costs for the member collecting the medication, clients are empowered to provide the transport costs .
Data from three smaller cohorts in Lesotho, Eswatini and Haiti also report positive outcomes. In Lesotho, a mixed-method comparison cohort study found 12-month retention of 98.7% (95% CI: 94.9-99.7) of stable clients who joined a CAG (n=199 with median time on ART of 54 months) versus 90.2% (95% CI: 86.6-92.9) for those who did not join the CAG (n=397 with median time on ART of 21 months) . In Eswatini, health facilities were offered a choice of three ART delivery models for implementation. Twelve clinics implemented CAGs; one health centre implemented ART adherence clubs (ACs); and one health centre and one clinic implemented an outreach service to support remote communities. Twelve-month retention was 81% in CAGs (n=336), 96% in ACs (n=289) and 77% for the outreach service model (n=102) . In Haiti, cross-sectional retention for a cohort of 80 CAG clients was 88.4% .
Recent qualitative work has also demonstrated positive outcomes for both healthcare workers and clients. In Zimbabwe, CAGs have been endorsed in the national Operational and Service Delivery Manual. They collect ART refills every three months; members attend once a year as a group for clinical review and viral load. Healthcare workers reported a reduction in workload, but not in paperwork, and improvement in quality of care provided due to reduced workload; all recommended the model for scale up. Some expressed concern at the level of CAG leader responsibility with limited training and they highlighted the risk that early diagnosis of minor symptoms may be missed. New CAG members reported savings in transport costs, and reduced clinic visits allowed for increased focus on productive activities and improved quality of care received when they attended the clinic. Challenges cited included having to leave the CAG when a family member was not eligible (such as a child) or during pregnancy, reduced interaction with a healthcare worker and limited access to condoms .
In Malawi, similar positive experiences regarding peer support were reported, but CAG uptake was hindered by limited awareness of the existence of CAGs or how they functioned .
In Zambia, qualitative work demonstrated that both healthcare workers and clients favoured CAGs due to their ability to decongest the clinics and reduce workload. Several health system issues were, however, cited as problematic. Challenges included inadequate supplies of ARVs and the inability to have monitoring tests performed according to the CAG schedule due to stock-outs of specimen bottles. It was also reported that some CAG members primarily wanted to participate in order to collect drugs and did not want to be included in the group health discussions. The additional monitoring tools also required additional space at the clinic .A small study, which offered clients with elevated viral loads (VLs) enrolment in a CAG alongside attendance at a dedicated VL clinic, reported high CAG uptake (89.6%), but limited re-suppression (27.8%) among those with a documented follow-up VL .
In conflict settings, client-managed groups have also been implemented to support continuity of ART. In the Central African Republic and the Democratic Republic of the Congo, CAGs, combined with extended refills, enabled continuity of care throughout several outbreaks of violence .
Client-led groups have also been implemented for female sex workers. In Uganda, the CCLADs described above were introduced for female sex workers. The model responded to the challenges faced by sex workers in conventional care, including facing long waiting times, inconvenient clinic times and discrimination when attending the clinic. Clinically stable female sex workers chose to become part of a CCLAD group. The group selected a leader who was assigned responsibilities for the group, such as recording weight, filling the CCLAD documentation and delivering condoms and ART. To date, two CCLADs of seven members each have been formed. Retention rates of 100% were achieved in each group and all female sex workers in the group remained virologically suppressed. ART adherence improved from 75% to 95% . Promotion of the model through peers caused other female sex workers in the same hotspots to ask to join the CCLADs.