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Six neighbours from the same village, all of them HIV-positive and stable patients on antiretroviral therapy (ART) – the treatment that manages to keep the virus in check – take turns to go and pick up their medicines. Every month, one of them goes to the hospital in everyone’s name.
This is the essence of the so-called Community ART Groups (CAG), a simple, inexpensive initiative benefiting both members of the group and health facilities, started by Médecins Sans Frontières/Doctors Without Borders (MSF) in 2013 in Tsholotsho district, Zimbabwe.
Sehlelo Ndlovu, 41, is a member of the Lindani CAG. She started taking antiretrovirals in 2009 after her husband died. “I think that my health worsened due to the stress caused by his loss as he was the family’s breadwinner,” explains Sehlelo.
Thanks to the CAG, she has managed to cope better with the disease.
“Each one of us in the group plays a role, we monitor how to take the medicines, we count the pills of each member every month and note down what we discuss in the group,” she says.
“What I always thought was very difficult has now become easy in the group.”
The aim of CAGs is to improve the retention of patients on ARV, reducing the number of visits to the health centre or hospital to collect their medicines.
Avoiding treatment interruptions or discontinuations is one of the main challenges in the countries most affected by the pandemic. A recent study of the programmes in Sub-Saharan Africa concludes that, on average, nearly a third of the patients had been lost during follow-up within the first two years on antiretroviral therapy.
There may be many reasons behind the interruption or discontinuation of antiretroviral treatment. According to the MSF team in Tsholotsho, a lack of means to travel from the community to the health centres and the incompatibility of travelling due to work or family commitments are among the most common reasons.
Once at the health centre, patients have to face long waiting times and, sometimes, a lack of support or discrimination.
“This initiative was designed jointly with the patients and as a response to the barriers to treatment adherence that they themselves were reporting. This is why it is a good alternative model for giving ARV to stable patients,” explains Susana Villén, MSF medical coordinator in Zimbabwe.
Pregnant women, children and patients with tuberculosis or other opportunistic diseases cannot be part of CAGs, because they need a more exhaustive medical follow-up.
In 2013, CAGs started in three health centres in Tsholotsho: Nkunzi, Sipepa and Pumula. These locations were chosen because there were many people on ARV treatment who lived far away and had to travel there to collect their medicines and because public transport was lacking. 720 people formed 121 groups.
MSF was responsible for training the CAG members and liaising with the health centres.
“For the CAGs to work, the participation of the health centre staff is essential,” says Villén. “It is important to explain very well how these groups work. For the health centre, it is also an advantage. Rather than attending six people, they only see one.”
“What we are trying to do is get the person in charge of dispensing the medication to have it ready beforehand. Thus, the consultation is shorter and we decongest the already very over-congested health centres.”
Despite major progress in the past few years, Zimbabwe is still one of the countries most affected by HIV/AIDS in the world, with nearly 15 percent of the adult population infected by the virus (1.3 million people). According to the Ministry of Health and Child Welfare, about 72 percent of adults and 43 percent of children in need of ART were in treatment in 2012.
“For the health system to be sustainable and successful in the long term in countries such as Zimbabwe, we need healthcare models that separate clinical patient management, which require trained health professionals, and the dispensing of medicines that non-medical people can do,” explains Luis Encinas, MSF operations manager responsible for the Zimbabwe projects.
“In the second case, patients play a much more active and informed role in the physical, social and psychosocial aspects of their health.”
Clorence Masango, 48, is married and has seven children, all of them HIV-negative. “I live 18 kilometres from Pumula, but the distance shortened when I joined the Damulocingo CAG,” he explains.
“The group has helped us a lot. We no longer waste the whole day in hospital. The CAG members are easily identified and seen in less than two hours. It’s a big improvement; we used to spend more than six hours at the hospital. Thanks to CAGs, we have more time to work for our families.”
“Now I am more relaxed and live positively. I think that this is the happiness I need to go on. I learned a new purpose in life…helping others is good.”
Since late last year, MSF has been gradually handing over its activities in Tsholotsho to the Ministry of Health in Zimbabwe. Within this process, the CAGs started to work without the organisation’s support from early this year.
“This is a very sustainable initiative. We know that many people have created new CAGs, because they see their advantages very quickly,” explains Susana.
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