title: Community-supported models of care for people on HIV treatment in sub-Saharan Africa.
abstract: OBJECTIVE
  Further scale-up of antiretroviral therapy (ART) to those in need while supporting the growing patient cohort on ART requires continuous adaptation of healthcare delivery models. We describe several approaches to manage stable patients on ART developed by Médecins Sans Frontières together with Ministries of Health in four countries in sub-Saharan Africa.
  
  
  METHODS
  Using routine programme data, four approaches to simplify ART delivery for stable patients on ART were assessed from a patient and health system perspective: appointment spacing for clinical and drug refill visits in Malawi, peer educator-led ART refill groups in South Africa, community ART distribution points in DRC and patient-led community ART groups in Mozambique.
  
  
  RESULTS
  All four approaches lightened the burden for both patients (reduced travel and lost income) and health system (reduced clinic attendance). Retention in care is high: 94% at 36 months in Malawi, 89% at 12 months in DRC, 97% at 40 months in South Africa and 92% at 48 months in Mozambique. Where evaluable, service provider costs are reported to be lower.
  
  
  CONCLUSIONS
  Separating ART delivery from clinical assessments was found to benefit patients and programmes in a range of settings. The success of community ART models depends on sufficient and reliable support and resources, including a flexible and reliable drug supply, access to quality clinical management, a reliable monitoring system and a supported lay workers cadre. Such models require ongoing evaluation and further adaptation to be able to reach out to more patients, including specific groups who may be challenged to meet the demands of frequent clinic visits and the integrated delivery of other essential chronic disease interventions.
authors.affiliation: Médecins Sans Frontières, Operational Centre Brussels, Brussels, Belgium.
authors.forename: Marielle
authors.initials: M
authors.lastname: Bemelmans
authors.forename: Saar
authors.initials: S
authors.lastname: Baert
authors.forename: Eric
authors.initials: E
authors.lastname: Goemaere
authors.forename: Lynne
authors.initials: L
authors.lastname: Wilkinson
authors.forename: Martin
authors.initials: M
authors.lastname: Vandendyck
authors.forename: Gilles
authors.initials: G
authors.lastname: van Cutsem
authors.forename: Carlota
authors.initials: C
authors.lastname: Silva
authors.forename: Sharon
authors.initials: S
authors.lastname: Perry
authors.forename: Elisabeth
authors.initials: E
authors.lastname: Szumilin
authors.forename: Rodd
authors.initials: R
authors.lastname: Gerstenhaber
authors.forename: Lucien
authors.initials: L
authors.lastname: Kalenga
authors.forename: Marc
authors.initials: M
authors.lastname: Biot
authors.forename: Nathan
authors.initials: N
authors.lastname: Ford
mesh_terms: D017954:Africa South of the Sahara; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D003695:Delivery of Health Care / Q000379:methods*; D015658:HIV Infections / Q000188:drug therapy*; D006295:Health Resources; D006301:Health Services Needs and Demand; D006801:Humans; D008962:Models, Theoretical; D009938:Organizations; D012111:Residence Characteristics
chemical_list: D019380:Anti-HIV Agents
keywords: Afrique du Sud; HIV/AIDS; Malawi; Mozambique; República Democrática del Congo; République Démocratique du Congo; Sudáfrica; VIH; adherencia de pacientes; adhésion du patient; antiretroviral therapy; community health services; retention in care; services de santé communautaires; servicios comunitarios sanitarios; terapia antirretroviral; traitement antirétroviral