Differentiated Models of Care: Encouraging ART Patient Retention into Care

 

Nessia Tembo on her way to Matero Main Clinic to collect her medication

Community based ART delivery models have been shown to reduce the burden and strain on the local health system. These models have shown improved outcomes that include better patient retention in care, reduced clinic congestion, and patient satisfaction.

Nessia Tembo of Matero was one of the over 400 participants  who took part in the CIDRZ Fast Track Model, one of the four differentiated models of care implemented during the Community ART for Retention in Zambia study through funding from the Bill and Melinda Gates Foundation. The other three were Community Adherence Group(CAG), Urban Adherence Group (UAG) and Streamlined ART Initiation (START).

Nessia shared her experience, “I was working part time and usually getting leave from work to go the health facility would be a challenge and for fear of losing my job, I would default going for my clinical  appointment just to keep my job. The hours I would spend from having my file pulled to collecting my drugs were long. When the Fast Track model was introduced, I spent less time at the health facility during my ART visits giving me enough time to go back to work and even attend to other family engagements.”.

Nessia receiving her ARV’s from the Pharmacist at Materos Main Clinic

“It is sad that the study has come to an end. If only those of us that took part in the study could be trained and mentored, we would form groups to ensure continuity of the model”.

The Zambian Ministry of Health had authorised  implementing partners to pilot different models of community-based ART service delivery to determine best models of dealing with retention into care of HIV positive clients.

This was in response to the challenges that the health sector was facing. Under the Community ART Study (CommART), CIDRZ conducted a study whose objectives were:

  1. To determine the acceptability, appropriateness, and feasibility of a differentiated care system in Zambia.
  2. To evaluate the effectiveness, efficiency, and health care quality of a differentiated care system that includes targeted models of care.
  3. To develop a “methodologic” toolkit for assessment of local needs and preferences and for implementation during scale-up of differentiated care models in this and in other contexts.

Four models were piloted: one Community model and three facility models. These were the Community Adherence Groups (community model), and the Urban Adherence Groups, FastTrack and Streamlined ART Initiation (facility models).

Better Drug Storage Conditions Equals Quality Medication for Patients

Aircon installed at Katoba RHC in Chongwe

Even though there were adequate drugs to supply the patients, facilities in Chongwe district faced challenges in ensuring appropriate storage conditions for drugs.

The Centre for Infectious Disease Research in Zambia (CIDRZ) is currently supporting 29 facilities in Chongwe District. All the facilities including the district pharmacy had no functional air conditioners in the pharmacy store rooms to maintain appropriate temperatures for storage of drugs at the time CIDRZ started supporting Chongwe District. The few facilities with room thermometers recorded temperatures of above 35˚C to 40˚C especially in the hotter seasons. This is above the recommended temperature range of 15˚C to 30˚C. This exposure of drugs to uncontrolled temperatures is a risk to reduced potency of drugs, hence lowering their efficacy. Some facilities opted to ordering and storing fewer drugs so as to reduce on the period of exposure to the unfavorable storage conditions.

“I just notice color change in some drugs and guess that heat has damaged the product,” said the nurse at Katoba Rural Health Center.

The solution to this challenge was not to reduce stored quantities, but to have an effective temperature control system – air conditioners accompanied by room thermometers and temperature charts for daily monitoring of room temperatures.

In November 2017, CIDRZ, through the Pharmaceutical Services Department began an air conditioner installation exercise in Chongwe District. The District was supported with 14 air conditioners paired with installation accessories. This activity was done in close collaboration with the Chongwe district medical office whose technician was the installer.  In February 2018, we also distributed room thermometers and temperature charts to 10 facilities in Chongwe district.

Facility staff are confident that the improved storage conditions will help maintain drug’s effectiveness during the shelf life. This came with mentorship on the use of the equipment, temperature monitoring and maintaining the pharmacy store room in order. They gave an assurance of taking care of the items given to them.

“Temperature will be maintained in appropriate range all year round! I will no longer feel guilty when dispensing drugs because they were kept within recommended temperature range as I am assured of safety and efficacy.” said pharmacy technologist Ngwerere Main Clinic.

“The community of Katoba will no longer complain of coming across discoloured brittle-tearing latex male condoms.” said a peer based at Katoba Rural Health Center.

“Facilities can now keep adequate quantity of stock without worrying on the products deteriorating during its storage period.” said the district pharmacist.

Based on the success of improving storage conditions, the district medical office also supported 2 facilities with air conditioners. The status for storage now stands at 58% of facilities installed with air conditioners, 73% have room thermometers all with temperature logs and 86% have the store room arranged in appropriate order.

CIDRZ has in its plan to continue improving storage conditions of drugs to ensure that quality drug product is dispensed to the patient for desired therapeutic outcomes. It is planned that by the end of 2020, 90% of CIDRZ supported facilities in Chongwe adhere to recommended storage guidelines. This is one of the organisations ways to improve access to quality healthcare in Zambia.