Abstract
The advent of antiretroviral therapy (ART) in 1996 brought with it an urgent need to develop models of health care delivery that could enable its effective and equitable delivery, especially to patients living in poverty. Community-based care, which stretches from patient homes and communities—where chronic infectious diseases are often best managed—to modern health centers and hospitals, offers such a model, providing access to proximate HIV care and minimizing structural barriers to retention. We first review the recent literature on community-based ART programs in low- and low-to-middle-income country settings and document two key principles that guide effective programs: decentralization of ART services and long-term retention of patients in care. We then discuss the evolution of the community-based programs of Partners In Health (PIH), a nongovernmental organization committed to providing a preferential option for the poor in health care, in Haiti and several countries in sub-Saharan Africa, Latin America, Russia and Kazakhstan. As one of the first organizations to treat patients with HIV in low-income settings and a pioneer of the community-based approach to ART delivery, PIH has achieved both decentralization and excellent retention through the application of an accompaniment model that engages community health workers in the delivery of medicines, the provision of social support and education, and the linkage between communities and clinics. We conclude by showing how PIH has leveraged its HIV care delivery platforms to simultaneously strengthen health systems and address the broader burden of disease in the places in which it works.
Highlights
Over the last twelve years, since the establishment of the Global Fund to Fight AIDS, Tuberculosis and Malaria (2002) and the President’s Emergency Plan for AIDS Relief (2003), access to HIV treatment has been expanded to millions of people across the globe [1, 2]
Adherence to the daily schedule of antiretroviral therapy (ART) and lifelong retention in care are both critical to building strong HIV prevention and treatment programs and achieving optimal patient outcomes
With many countries approaching over a decade of experience scaling up ART and achieving good, clinical outcomes, these two principles—the decentralization of care and the establishment of programs to foster retention and adherence—have been underscored in the recent literature on community-based ART
Summary
Over the last twelve years, since the establishment of the Global Fund to Fight AIDS, Tuberculosis and Malaria (2002) and the President’s Emergency Plan for AIDS Relief (2003), access to HIV treatment has been expanded to millions of people across the globe [1, 2]. To address patients’ social and economic needs and overcome structural barriers to good health, community-based, decentralized care became the norm for HIV care delivery in the global scale-up of ART. Studies included in this review were those published in the last 10 years that described or evaluated community based ART ptrogram in low or low-middle incomce countries. There are a variety of approaches to improving adherence to ART, including the use of community health workers (CHWs), peer counselors, and support groups; the provision of food and nutritional support; the coverage of transportation fees and school fees for children; and forms of psychosocial support. With many countries approaching over a decade of experience scaling up ART and achieving good, clinical outcomes, these two principles—the decentralization of care and the establishment of programs to foster retention and adherence—have been underscored in the recent literature on community-based ART
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