What are we learning about the process of implementing community client led HIV care?
In Uganda, health facilities have traditionally been responsible for distributing antiretroviral medications (ARVs) to HIV-positive clients; however, the health facilities are often crowded, which can lead to delays in service and discourage clients from adhering to their lifesaving antiretroviral treatment (ART). To reduce congestion within health facilities and better distribute essential medications to those in need, the new ART policy guidelines recommend a differentiated care approach to HIV care and treatment. One such differentiated approach is the community client-led ART distribution (CCLAD), a model for drug delivery that provides treatment to HIV-positive clients in their communities; thus, making care more accessible to these clients and reducing the burden on health facilities.
Group leaders being oriented in taking MUAC as one of the parameters in the community ART card. Photo by Julius Elweu, Community QI Officer for the USAID ASSIST Project, North Uganda.
CCLAD is best implemented with HIV-stable clients who are on ART. A stable client is one who is virally suppressed, has been on ART for at least 12 months, has no opportunistic infections, is not pregnant, and is an adult over 20 years of age.
While trying to implement this model in the community, we asked the health facility teams to generate a list of stable clients and mobilize them for a meeting. We asked these clients to group themselves according to their villages so that they could get the same appointment for receiving their ARVs. The health worker then used the prepared facility list to confirm the stable clients.
It was at this point when the health worker discovered that some of the clients were not fulfilling the stability criteria. Some of the clients were HIV-positive, but not yet on ART. Another group was only on contrimoxazole prophylaxis (a type of treatment to prevent secondary opportunistic infections but not directly treat HIV), so they did not meet the criteria. Health workers informed them that this process is only for clients who have been on ARVs for more than 12 months.
One father came with the health cards for his wife and children hoping that his whole family could participate. However, per the MOH guidelines, children are not supposed to receive ARVs from the community because they do meet the stability criteria. He walked away with disappointment.
The working team did not realize the big number of clients who would show up, and the major challenge of sorting through them all. Through this experience, we realized that sorting out CCLAD-eligible clients in the community turned out to be a long and tedious process that led to many disappointments for clients who had come a long way.
Following the above findings, the USAID ASSIST Project team worked with the health workers to revise the process of utilizing the facility data to form the CCLAD groups. For the next communities, they supported the health facility teams to cluster/group the clients according to villages and this was done at the health facility before mobilizing the community. Next, the linkage facilitators were asked to mobilize only these CCLAD-eligible persons for the meeting and to seek their consent for CCLAD and harmonize their ART refill appointments. This was a more successful approach and the team decided to take it to scale.
Our key learning from piloting this approach is that clustering of clients for CCLAD is best done at the health facility because it saves time and the “right” persons are placed in their rightful villages, making it easier to seek their consent and harmonize the appointments.