Local East African programmes are discovering the benefits of bringing HIV services closer to rural communities, with mobile drug distribution improving HIV-positive patients' adherence to antiretroviral treatment (ART).
"While there might be health facilities in rural areas, they are normally far flung; by using mobile care and treatment centres, it is easy to reach populations, many of whom are normally too poor to have transport to the established health centres," Waziri Rashid Njau from the Support for International Change (SIC), a local HIV-focused NGO in Tanzania, told IRIN/PlusNews.
"We have used this in northern Tanzania and we have seen reduced cases of loss [of contact with patients] to follow up; local health facilities record higher cases of drop-out amongst patients than we do," he added.
Patients must visit a hospital for their initial diagnosis and ART prescription, and are required to visit the health centre periodically, but in between visits, SIC uses community-based volunteers and trained medical workers to drive around villages refilling prescriptions as well as providing education on condom use and the prevention of opportunistic infections.
SIC in Tanzania reaches nearly 2,500 people with mobile ART clinics and has so far trained around 200 health workers in Babati District in northern Tanzania.
Bridging health system gaps
Tanzania suffers from a critical shortage of medical personnel, so the mobile drug distribution is performing a much-needed function. The Ministry of Health reported in 2007 that the country had 1,339 doctors; many regions have a doctor-to-patient ratio as low as 0.1 to 10,000.
Community drug distribution has also been successful in neighbouring Uganda, where a 2008 study carried out in the eastern district of Tororo by local NGO The AIDS Support Organization (TASO) found that out of 2,115 active clients enrolled for antiretroviral therapy at the community drug distribution points, only 22 - about one percent - were lost to follow up.
In comparison, a 2009 Ugandan study found that about a quarter of HIV-positive patients in clinical settings dropped out of programmes during the clinical assessment stage, even before they were put on ART. One of the main reasons given for not returning to health centres was the high cost of transport.
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"Our experience is that it is a lot easier to deal with large numbers of antiretroviral clients with this model… Space at health centres is limited, and it is easy to visit them where they are," said Emmanuel Patta, a field officer with TASO.
TASO has 77 community drug distribution points in Tororo, each catering for an average of 30 antiretroviral therapy clients.
Involving HIV-positive people
"Because follow-up is normally done by people living with HIV themselves, this provides an avenue to use them as a resource in the fight against HIV/AIDS," SIC’s Njau noted.
"You get to create awareness among community members and not only those who are infected, but even those who are not infected or might not know their status," he added. "Through these models, you get an opportunity that is community-owned to reach out to them and create awareness."
At the community drug distribution points, clients have the opportunity to share experiences and support each other on issues related to side effects, adherence, community awareness and stigma, and this also provides an opportunity for optimal use of limited resources.
Njau noted that despite efforts to involve people living with HIV in the programme, and to teach their communities to accept them, stigma remained a concern. "Stigma might make these clients not want to go where people will know them ... [They] would rather go far away [for treatment]," he said.
And in many areas poor nutrition remains a challenge to the adherence of clients of community-based drug distribution. "Poverty inhibits good nutrition among many ART clients, which can at times hinder the effectiveness of treatment programmes," Njau said.
Despite the problems, TASO’s Patta said community drug distribution had for the most part worked extremely well and could "work effectively in places that experience shortages of staff and health facilities".