Charles Ssonko of Médecins sans Frontières describes the role of community groups in maintaining access to antiretroviral drugs for patients in Central African Republic, even under the most difficult and dangerous circumstances.
On June 28th, 2017 intra community violence broke out in the town of Zemio, Central African Republic (CAR). The departure of a protective force once based there, prompted by shifting global politics, left the town vulnerable. Seven months prior, MSF had initiated Community ART Groups (CAGs) within a Zemio-based HIV treatment programme. The rapid-emergence of conflict unexpectedly tested the ability of CAGs to sustain access to medication for the patients in the programme.
MSF introduced the CAG healthcare model in Zemio because it offers more autonomy to patients. Crossing the front line with bullets flying, in order to reach the clinic and return to their hide-outs, CAG leaders played a crucial role in maintaining access to HIV medication for hundreds of patients during the conflict. CAGs are meant to meet regularly, and drugs are distributed to the group by a designated member who obtains the supply from the health center. These CAG leaders took on a high level of personal risk while picking up drugs on behalf of their group members. So did the health centre staff that maintained their presence at the clinic for as long as possible to support the CAGs and the pharmacy fast track (PFT) patients picking up their anti-retroviral (ARV) medications.
The challenges to patients in remote areas like Zemio are distinct even in the absence of conflict. Home to 20,000 people, Zemio sits along a trade route connecting Bangui, the capital of CAR, to Juba and Kampala, the capitals of South Sudan and Uganda, respectively. The Ministry of Health employs one nurse to run the local health center. And secouriste— health care workers with three months basic medical training— staff the center. Some patients travel as far as 250km (about 155 miles) to access even this level of care because the journey from Zemio to a major health center, or hospital, located in Bangui, is a 3-hours by plane ride or 7 to 10 days traveling by land.
In 2010, MSF first arrived in Zemio to provide care for Congolese refugees. HIV prevalence in the region is 12%, estimated as the highest in CAR. MSF undertook HIV activities in 2011. During the six-years that followed, attacks throughout CAR increased while Zemio remained relatively stable. By December 2016, the HIV program had registered 1650 patients and about 1500 were receiving anti-retroviral therapy (ART).
Conflict in the rest of the country and the need to direct resource toward these other areas, led to MSF’s decision to phase out its programmes in Zemio. MSF started discussions with the MOH regarding the hand-over. While many of MSF’s activities could be absorbed by the MoH, the HIV program presented a much greater challenge. Consequently, how to best support the continuation of the HIV program within the country’s limited healthcare structure became a pressing question.
By bringing ARV drug supply, patient care and support closer together, the CAG healthcare model provides patients with more autonomy. That autonomy seemed a necessary step to fostering the continuity of care. So we set up and promoted CAGs through the patient support groups taking place at the healthcare centre and used local radio announcements to reach the wider population. By June 2017, of the 1500 patients on ART, we had enrolled 1057 (70.5%) patients into 74 CAGs (2 -34 patients per CAG) and 443 (29.5%) patients had transferred to the pharmacy fast track programme. CAGs included patients with no less than six months of using ARVs and no presence of any other serious illness. Uniquely, they also included pregnant women. That way, these women could be encouraged to take their HIV medication, attend their antenatal care appointments and deliver in a health facility.
A total of 413 (39.1%) CAG patients had access to ART during the conflict, of which 41.9% obtained access through 31 CAGs. While some CAGs and members were lost to the conflict, and direct clinical monitoring, viral load testing and data collection stopped, the ability for these patients to remain on ARVs demonstrates the value of programmes that foster patient autonomy.
The collaboration between the CAG leaders or members with the health staff enabled medication pickup during the acute conflict and reduced the risk of travel for many during the period of insecurity. And, the 6 months drug supply reduced workload in the health facility while safeguarding against treatment interruption.
The CAGs also provided economic gains for patients by reducing travel costs and saving people time (previously spent visiting the clinic). Due to the greater awareness of HIV patients in through their meeting engagements, we also saw the support for HIV patients in the community increase and stigma decrease. The CAGs fostered peer support for the sick, adherence and transport facilitation and allowed HIV care to be implemented within the community.
Charles Ssonko is HIV/TB/Hep advisor for MSF-UK. Dr. Ssonko has extensive MSF field experience in HIV/TB programming in countries such as Zambia, Zimbabwe, Nigeria and Myanmar. He is currently the technical referent for HIV/TB programmes in Central African Republic (CAR), Chad, Swaziland and Haiti. He is also directly involved in technical support for the implementation of the differentiated models of HIV care in Zemio CAR.
Feature image: MSF base in Zemio, Central African Republic following attacks that took place during the summer 2017. Establishment of Community ART Groups established in Zemio prior to the attacks enabled patients to access ART during the time of conflict. Photo by Mia Hejdenberg.