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Clubs for managing large numbers of patients on ARVs
Western Cape Provincial Health Department
South Africa

The Problem

South Africa has more than 5.6 million people infected with HIV/AIDS and has an adult infection prevalence rate of 17.9%. If this group goes untreated, many children will be orphaned. The associated consequences will be devastating for the country. South Africa’s health clinics are congested with thousands of patients burdened with the disease of HIV, TB, and other infections. This puts a severe strain on medical professionals and the resources of clinics. Between 2007 and 2011 treatment increased from a low base to reaching 80% of eligible adults. This initiation was done on the basis of a CD4 count below 200. Towards the end of 2011, government began initiating patients with a CD4 count of 350 and below. Under the new criteria, only 52% of eligible patients are on antiretrovirals (ARVs); a large number of new patients need to be initiated onto treatment. Currently, Primary Health Clinics are burdened with an increasing patient load across the Cape Metropole. Over the past five years, high volume HIV clinics in the public health sector in Cape Town have successfully enrolled thousands of patients on ARVs, resulting in a large number of patients in long term care. As patient numbers increase, programme outcomes are negatively affected as space becomes congested, waiting lines increase, infection control and quality of care for individual patients is compromised and staff burnout increases. As a result, patients already on ART are being lost to care, the waiting time for new patients needing to start ARVs increases, and patients at risk of failing are not being appropriately managed, putting all such patients at risk of dying. By September 2010, half of Cape Town’s 47 Antiretroviral Therapy (ART) facilities each had over 1000 patients on ARVs and numbers were growing. Nurses and doctors had to attend to well HIV/AIDS patients stable on ARVs when they could be assisting acutely ill individuals needing to be initiated on ARVs. This also increases the waiting list for starting ARVs and length of time patients attending the general clinic have to wait before being helped. The need for an effective and efficient model for managing these large patient loads was urgent.

Solution and Key Benefits

 What is the initiative about? (the solution)
To address this challenge, the ARV Adherence Club Model was identified as a patient-friendly best practice for managing large numbers of stable HIV+ patients on life-long ART. By managing these stable patients on ARVs, overcrowding is reduced in facilities and clinical staff can focus on sick patients. The ART clubs allow stable ART patients to access their treatment quickly within a more patient-friendly environment. The clubs maximize the use of limited resources by managing clinically stable patients in groups of 30 using a non-clinical club facilitator, supported by a clinical team. Enrollment in the clubs is voluntary for patients who meet the criteria. Patients are assigned to specific clubs allowing supportive bonds to develop between group members. Care is streamlined to reduce time spent at the clinic: patients are managed using a club register so there is no need for patients to collect their individual patient files. Clubs meet every second month, medication is pre-packed and issued in the clubroom and the patient’s friends of patients can collect medication on alternate visits. Annual blood tests and clinical visits for each club are synchronized. Patients are only removed from the ARV Clubs and returned to routine clinical care if clinical or adherence issues arise. Clinic staff focuses on sick patients, while stable HIV+ patients are able to continue working. A quality improvement methodology, named the “Breakthrough Series Collaborative” was introduced. This structured approach spread the ARV Clubs Model to multiple high volume public health care facilities in Cape Town and addressed implementation and sustainability challenges.Freeing clinicians to initiate new patients on ART by reducing patient volumes in the clinics also reduces burnout of clinicians allowing for a healthier workforce and better service delivery. The reduction in overcrowding also reduces the risk of TB infections in waiting rooms, thus saving on health-care costs for families and the health-care system. Reducing time spent at clinics for club patients allows less time off work and more time for normal activities. Better use of limited resources allows more lives to be positively affected within current resource constraints. The beneficiaries of the project include patients and clinic staff who participated in the project. There are currently over 550 clubs at37 ART facilities catering for nearly 14,500 patients who did not have to wait in the queues for medication and treatment. This is more than 15% of patients currently receiving ART, and can be expected to continue expanding to cater for at least 30% of the Metro’s patients. Anecdotal evidence suggests that around 90% of initiated patients stay within the club system, while the Langa Clinic has a retention rate of 97%. Experienced mentors from the first project are now able to support new mentors as the second group of facilities joins the rollout of the clubs. In this way skills are embedded and spread within the DoH.

Actors and Stakeholders

 Who proposed the solution, who implemented it and who were the stakeholders?
The project is a partnership between the Western Cape Government Health (DoH) HIV Directorate, the City of Cape Town Health Department (CoCTHD), and two international NGOs, namely, MSF and the IHI. MSF recognized the problem at the clinics initially and developed the ARV Clubs Model to address it, and piloted the project at Khayelitsha Ubuntu Clinic in Cape Town. Once the ARV Clubs were replicated across the Cape Metropole, they also actively supported a number of facilities, assisted with the provision of the workshops and training to club mentors, and assisted with the development of support materials, including the club patient management register. IHI introduced the BTS model and assisted in the design and execution of the workshops for clinic staff, and provided technical advice and support for running the project, and took the lead in obtaining ethics approval for the project. The DoH and the CoCTHD also participated in the design, and took the lead in the execution of the project, selecting the facilities and the mentors, running regular mentor meetings, and actively participating in the workshops. They developed and provided support materials, established off-site pre-dispensing of medication and participated in data management. Partners have actively disseminated the best practice model project, and have included it in the South African National Department of Health’s publication ‘Tried and Tested’ models for the scale up of HIV prevention, treatment and care from South Africa and beyond, and poster presentations at international conferences. Partners are continuing to work together to spread the model beyond the first group of clinics using the same methodology.

(a) Strategies

 Describe how and when the initiative was implemented by answering these questions
 a.      What were the strategies used to implement the initiative? In no more than 500 words, provide a summary of the main objectives and strategies of the initiative, how they were established and by whom.
The primary objective of the programme is to manage large number of stable HIV+ patients on life-long ARVs, and enable clinical staff to focus on ill and new patients. Medecins Sans Frontiere (MSF) had previously developed and piloted the ARV Clubs Model and the object was to rapidly spread the model to high volume ARV sites in the Cape Town Metro District. The project was overseen by a steering committee made up of managers of the HIV/AIDS programmes from provincial and municipal Departments of Health, and representatives from MSF and the Institute for Health-care Improvement (IHI). IHI’s Breakthrough Series Collaborative (BTS) model for large-scale change was used to get ARV Clubs started simultaneously in multiple facilities. This “all learn, all teach” quality improvement model brings multiple facilities together for a defined period of time to achieve a common aim. 15 of the largest ARV clinics in the Metro District were invited to participate in an 18-month long project. The project was punctuated every six months by daylong workshops (Learning Sessions) attended by multidisciplinary teams from the facilities. At the First Learning Session, facilities collectively set a clear aim to have 30% of their ARV patients managed in clubs within the 18-month period, learn about the ARV club model from staff at MSF who had developed and run clubs, and introduce an improvement methodology that encouraged them to start small and to test out new ideas using iterative cycles of change. At the two subsequent workshops, facilities shared challenges and solutions thus accelerating learning and improvement. In the six-month long period between workshops, facilities were supported by mentors (selected from existing clinical or managerial staff), and were required to submit monthly data (on the number of patients enrolled in clubs, and the number of patients remaining in clubs) to keep track of progress. The project offered an opportunity for facilities to inform changes in the guidelines and standard operating systems as they learned how best to run clubs in their individual settings. Once the first wave of facilities was successfully set up and clubs managed, a second group of facilities was selected to start clubs in another BTS project. Participants from the first group were on hand to share ideas and encourage the newcomers.

(b) Implementation

 b.      What were the key development and implementation steps and the chronology? No more than 500 words
In 2007, the ARV Club Model was piloted by MSF at Khayelitsha Ubuntu Clinic, to deal with the ever-increasing number of stable HIV+ patients who needed medication. Between 2007 and 2011 treatment increased from a low base to reaching 80% of eligible adults. This initiation was done on the basis of a CD4 count below 200. By September 2010, a large amount of Cape Town’s ART facilities each had over 1000 patients on ARVs and numbers were increasing constantly, causing overcrowding at public clinics. The stakeholders realized that the system required a model that would efficiently and effectively manage large patient loads. In December 2010 the four partners held the first workshop to discuss how the Quality Improvement Methodology can be used to replicate the model in the clinics across the Cape Metropole. The ARV Adherence Club Model was identified as a patient-friendly best practice for managing large numbers of stable patients on life-long ART. A partnership was formed between the Provincial and Local Government Health Departments and the 2 international NGOs to spread the ARV Chronic Clubs Model to multiple high volume public health-care facilities in Cape Town and to address challenges of implementation and sustainability. Towards the end of 2011, government began initiating patients with a CD4 count of 350 and below. Under the new criteria, only 52% of eligible patients are on ARVs; a large number of new patients needed to be initiated onto treatment in addition to an ever-increasing number of stable and unstable ART patients needing to be retained in care. By August 2012, the ARV Clubs were rolled out to 37ART facilities catering for nearly 14,500 HIV+ patients.

(c) Overcoming Obstacles

 c.      What were the main obstacles encountered? How were they overcome? No more than 500 words
The lack of space is an obstacle in many facilities, by engaging frontline staff this challenge was solved. Some of the solutions include utilizing space in the boardroom, the staff tearoom and the blood room by moving venesection (blood taking) to other parts of the clinic for the duration of the meeting. Space outside the health-care structure is also being used, such as the local library. Another option was to adjust the size of the clubs to fit the available space, thus reducing the groups of 30 patients to 20 in each club. This contributed to the increase in the number of groups. The biggest problem occurred when facilities started by jumping to a large number of ARV Clubs before systems were in place to support them and mentors were not readily available when old mentors moved, thus leaving the facilities unsupported. WC Government Health has now learnt where their mistakes were made and what to avoid as the project is spread beyond the first group of facilities. Experienced mentors from the initial project are now able to support new mentors as the second group of facilities joins the roll out of the clubs. Another problem was that data was initially collected in a parallel system because the data elements were not part of the routine data set. But as clubs have become established, club data is now being integrated into routine reporting.

(d) Use of Resources

 d.      What resources were used for the initiative and what were its key benefits? In no more than 500 words, specify what were the financial, technical and human resources’ costs associated with this initiative. Describe how resources were mobilized
R25 000 seed finance for the project came from a shared Impumelelo Award. These funds were used to design the project, for workshop facilitation for part of the project, and for refreshments for the first Learning Session. Administration of the award money was done by the IHI through the Wits Health Consortium, on the submission of receipts by the Improvement advisor. Aspen Pharmaceuticals provided refreshments for the second and the Provincial Department of Health for the third Learning Session. Venues for the workshops were provided free of charge by the DoH and UCT Medical School. The DoH and MSF staff participated in the project as part of their normal activities, with salaries covered by employers. The two IHI staff had only partial funding for their involvement and donated 21 days each of their time over the 18-month period. Clubs data was reported monthly, initially to the IHI project coordinator and subsequently directly to the provincial DoH once reporting requirements had been streamlined and standardized. Integration into the routine programme reporting structure is currently in development. DoH project managers report project progress to senior management monthly.

Sustainability and Transferability

  Is the initiative sustainable and transferable?
The ARV Clubs model has been consolidated in participating facilities and will become ‘standard work’ in all Cape Town Metro District ARV facilities within the next few years, which will support sustainability. There is funding for continuing the intervention as a project. The project allowed many barriers to be identified and resolved. Processes, procedures and support materials for the ARV Clubs were developed during the project and have now been standardized. Developing the capacity of the DoH managers in Quality Improvement Methodology was a key objective to support sustainability. The project gave a cadre of existing DoH managers the opportunity to use the BTS model and to develop mentoring skills to support sustainability and spread of the ARV Club model beyond the life of the project. These lessons are now being spread to new mentors as the project is replicated in a second group of facilities. The project is applicable to all ART programmes where success in initiating patients on ART has resulted in large numbers of patients needing to be managed within resources constraints. All the project materials for the ARV Clubs are accessible from the Western Cape Provincial Department of Health and on the MSF South Africa website (http://www.msf.org.za/publication/art-club-toolkit). The department is willing to share experiences in order to replicate the project across facilitates in the Western Province. Where large numbers of facilities are involved, it would be advisable to use the BTS starting with a pilot group and expanding to additional facilities as confidence and experience grow.

Lessons Learned

 What are the impact of your initiative and the lessons learned?
The key element to the success of this initiative is the partnership between the provincial and local governments’ Health Departments, the MSF and IHI. MSF foresaw the congestion at local facilities with the treatment of HIV+ patients with a CD4 count below 350 and piloted the initial project. IHI provided the quality improvement methodology that supports the implementation of the ARV Club Model, which is a patient-centred approach and which decreases congestion at the facilities. The management of large numbers of HIV+ stable patients in groups frees up clinical staff to focus on patients who need immediate attention. Patients who are relatively well are separated from the sick patients, thus decreasing the risk of opportunistic infections. This model treats patients with respect and values their time as employees as jobs are valuable in a climate of high unemployment. So when patients/employees take a day-off to collect their medication, this places an additional burden on the employer and employee. The ARV Club model enables access to treatment quickly which allows them to go to work and not fall through the gaps. They live more productive lives and decrease the burden on the State. With this model it is more likely that the Western Cape Province will be able to reach its target of getting all HIV+ patients on ARV treatment in the future, as the project is replicated across all facilities.

Contact Information

Institution Name:   Western Cape Provincial Health Department
Institution Type:   Government Department  
Contact Person:   Jannie Mouton
Title:   Dr  
Telephone/ Fax:   021 483 3116/ 021 483 6033
Institution's / Project's Website:   http://www.pgwc.gov.za
E-mail:   jannie.mouton@pgwc.gov.za  
Address:   P O Box 2060
Postal Code:   8000
City:   Cape Town
State/Province:   Western Cape
Country:   South Africa

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