Data from client-managed group models shows improved client outcomes with qualitative evidence supporting reduced costs and increased time savings. The majority of the evidence for client-managed groups comes from the large cohort of patients enrolled in Tete community ART groups (CAGs) in Mozambique. In a 2014 descriptive cohort study (1), retention outcomes at 12, 24, 36 and 48 months were 97.7%, 96.0%, 93.4% and 91.8%, respectively, with a mortality and loss-to-follow-up (LTFU) rate of 2.1 and 0.1/100 per patient year, respectively. Data from two qualitative studies found cost and time savings for clients and improved certainty of ART access and mutual peer support, which facilitated better adherence (2, 3). 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 (4).
Scaled CAG model outcomes were published in late 2016 in an evaluation of trends observed after a decade of antiretroviral therapy scale-up in Mozambique (5). From 2004 to 2013, 455 600 persons over 15 years had initiated ART with 6766 enrolling in a CAG from 2011-2013 at 69 facilities. CAG participation was associated with 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 2 years and 10.1% and 1.4% at 4 years. In a further study (6) reporting outcomes for the same cohort of CAG patients matched with eligible non-CAG patients (37% of cohort) at facilities offering the CAG model, eligible non-CAG patients had a significantly higher LTFU (HR 2.36 95% CI1.54-3.17) but also similar mortality. Interestingly, the study also compared outcomes of patients 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%).
Data from three smaller cohorts in Lesotho, Swaziland 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 Lesotho CAG (n=199 with median time on ART of 54 months) versus 90.2% (95% CI, 86.6-92.9) among those who did not join the CAG (n=397 with median time on ART of 21 months) (7). In Swaziland, 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) (8). In Haiti, cross-sectional retention for a cohort of 80 CAG clients was 88.4% (9).
A recent retrospective study undertaken in northern Mozambique assessed all ART patients over 15 years 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) (10). Zamibia which is piloting CAGS in 5 study sites also looked at early outcomes of CAG participation. 90% of individuals offered CAG participation accepted, 82% were placed in a CAG and 79% attended the first CAG meeting (11). Outcomes of a qualitative study that assessed the benefits and challenges of CAGs in Thyolo, Malawi reported that CAG uptake was hindered by limited awareness of the existence of CAGS or how they functioned (12).