Background: The Community Adherence Group (CAG) is a model adopted across resource-constrained facilities to improve ART retention. A CAG consists of approximately six stable patients who visit the clinic on a rotational basis for their clinical visit, during which they collect drugs for themselves and other CAG members. In anticipation of wider rollout in Zambia, we piloted CAGs in five facilities in Lusaka, Eastern and Southern Province to identify unforeseen challenges faced by health service providers (HSP) and patients during implementation.
Methods: Using a qualitative exploratory study design, from August to November 2017, we conducted 12 focus group discussions with HSP and 16 in-depth interviews with CAG members to understand their experiences after approximately 6 months of implementation. Discussions and interviews were recorded on digital audio recorders and transcribed directly into English. Thematic analysis was conducted using inductive and deductive reasoning.
Results: Both HSP and patients favoured CAGs because of its ability to decongest the clinics and reduce work load but reported several health system issues that compromised intervention fidelity. CAG members had to return to the clinic more times than scheduled due to inadequate supply of anti-retroviral (ARV) drugs and specimen bottles to collect blood for CD4 testing as well as a malfunctioning CD4 machine. Patients reported challenges posed by eligibility criteria leading to, for example, exclusion of pregnant women. Lay healthcare workers (LHCWs) could not always cover the distances between clinic and CAG meeting venues or pick up attendance registers due to lack of transport. Additionally, they reported that some CAG members were keen to only pick up their drugs and did not participate in full CAG meetings that included health discussions and symptom checks. HSP reported lack of office space for document storage which could compromise patient confidentiality.
Conclusions: While CAGs have the potential to ease the health system, health systems must adapt to the needs of the CAG model. Supply chain management, laboratory services and management of patient and programme monitoring tools must be strengthened to allow LHCWs and HSP to perform their duties and to maintain fidelity to visit schedules.