Whilst there has been great progress in rolling out access to antiretroviral treatment (ART), there are also many challenges in ensuring that patients adhere to treatment, especially those living in complex social situations. At the 19th International AIDS Conference in Washington, DC (AIDS 2012) yesterday a press conference held by Médecins Sans Frontières (MSF) drew attention to a range of initiatives for traditionally hard to reach populations – including mobile populations and adolescents living with HIV – whose success confirms that tailoring programmes for specific groups and populations can result in higher levels of retention and adherence than other ‘easier to reach’ groups.
Closer to home and Providing antiretroviral therapy for mobile populations are reports describing MSF-associated programmes in four countries: Malawi; Democratic Republic of the Congo; Mozambique; and South Africa. In each, there were specific challenges in ART delivery, requiring initiatives to maximise access. In Musina, South Africa for example, rural workers are highly mobile, moving out of an area up to five times a year – usually to neighbouring Zimbabwe – especially when work is unavailable. In a MSF-supported project to ensure treatment adherence for these workers a range of options have been made available such as a ‘safe travel pack’ containing three months of ART and a ‘transfer letter’ to be taken to receiving ART sites if treatment is sought. Evaluation of the project confirms that only 17% of patients never return – and overall retention is 93% at six months, and 90% at 12 months – outcomes that are better than general populations. Tambu Matambo, Medical Coordinator for MSF in Medina, South Africa, said “it is possible to provide HIV treatment to migrants if you tailor the programme to their specific needs.”
Another difficult-to-reach group are adolescents living with HIV. Dr Mary Nyathi, Consultant Paediatrician at Mpilo Hospital in Zimbabwe, described a package of activities such as life skills support and income generating activities for adolescents. This includes Teen Club, initiated by the adolescents themselves. Here, counsellors not only provide information around sexual and reproductive health, but are also on constant ‘call’ if support is required urgently (this includes home visits). In addition, healthcare workers are trained in supporting adolescents, and all this serves to maximise ‘adolescent customer service’. Much of the programme is shaped by adolescents’ stated needs, and this approach is certainly effective – after two years retention is as high as 85%. For Nyathi, this is a direct result of services being shaped by those who use it. “Adolescents are training us to manage their care”, she said.
A community-led initiative in Mozambique – where the health system is seriously understaffed and congested – was described by Dr Tom DeCroo, from the MSF Tete Project, Mozambique. Here, there is a ‘community ART group’, which consists of people forming a group then taking turns to visit the clinics for check ups and to collect ART refills for the rest of the group. Retention among the 5229 members of the 1000 groups is 97%. When this approach was expanded to include 312 children no child was lost to follow up, and the attrition rate was four times lower than the global average.
The common factor in these three initiatives is that they are tailored to meet local needs. There is decentralisation, away from the clinical setting to the community, and the positive results achieved confirm that this model would be beneficial to other countries. As the HIV sector continues to strive for universal access to treatment by 2015, responding to those affected by HIV is bound to facilitate this goal, and prove it is possible to attain treatment efficacy in the most complex of social situations.