July 31, 2012

MSF HIV/AIDS Policy Adviser Sharonann Lynch discusses a community-based HIV care initiative in Mozambique.

Mozambique 2010 © Niklas Bergstrand

HIV patients gather to share and discuss their experiences in a CAG.

Sharonann Lynch is MSF’s HIV/AIDS Policy Adviser and a veteran of the HIV advocacy and policy arena. Based in New York, she recently traveled to Mozambique to study the use of Community Antiretroviral-Therapy Groups, or CAGs, in which groups of patients support each other and individuals take turns picking up medications for other members. CAGs are part of MSF’s broader effort to decentralize HIV care by bringing it closer to where patients live and empowering nurses and community health workers to carry out treatment and testing tasks that only doctors had done in the past.

Initiatives like these, MSF believes, would make it possible to scale up treatment programs to the level necessary, even where resources are severely limited, if the political will and financial backing are there. This will be part of the message Lynch and others from MSF will bring to the International AIDS Conference being held in Washington, DC, in late July. Here, Lynch discusses her recent trip:

I wanted to see how community ART groups were functioning in Mozambique’s Tete Province. There’s been a lot of excitement about this model because we’ve seen that it makes treatment more feasible and that it can help improve adherence to treatment.

Essentially, CAGs came out of an idea from Win Van Dam, who worked for MSF and has been advising MSF on strategies for providing chronic care strategies in resource poor settings. It was fascinating to see how this creative, innovative strategy—which came not from headquarters, but from the field, as they so often do—was being implemented more than a year after it was originally piloted. It also ties in with a challenge laid out by Eric Gomare, medical director for MSF in South Africa. Most of our HIV projects are still facility-based, meaning patients have to cross the threshold to get to us. Eric said, “what can we do to leave the clinic, to step over that threshold ourselves and to have more outreach in the community?”

The Mozambique project focuses on community-based services that bring care closer to patients so they don’t have to travel to hospitals or larger health facilities. In this context, the CAGs are a fantastic strategy. They are self-formed groups, a group of seven in which one takes a turn each month fetching medicine for everyone else. It’s what they call in science an “elegant” strategy—a simple solution, even if it’s still adaptive rather than mitigative.

Is it operationally feasible? And is it affordable? And we can say yes, to the first and yes, with action, to the second.

It’s evolved, too. There were community ART groups made up of adults on ARVs. Then, they’ve piloted—and they’re presenting data already at the International Aids Conference this July—children's CAGs, which are CAGs with children and their caregivers. They also have a sex worker CAG and two TB [tuberculosis] CAGs, because there’s a lot of co-infection, and a PMTCT [prevention-of-mother-to-child-transmission] CAG, too.

Overall, the CAGs have been incredibly popular, one, because it’s an elegant strategy, as I said, and, two, because it’s so effective. You’ve got people who are committed to looking out for each other, who are united by mutual self-interest, and who are showing the lowest attrition rates we’ve ever seen, just 2.3 percent. And I think that’s because the distance they had to travel to get treatment in the first place was so long and so frustrating. They really had to fight for it, and now they want to protect it.

And now they’ve been on ARVs for a while. And it was really inspiring to hear CAG members say, “Don’t worry about us. We’re fine. We’ve got our treatment. It would be great if you could bring it even closer to our nearest clinics, but even more importantly: help us fight HIV in our community. We are still raising HIV positive babies. We are still caring for HIV positive neighbors who are ill.”

They were saying, “We don’t only want to take care of our own treatment. We also want to help fight HIV in our community.” One member said, “Look, HIV is much like malaria. Everyone in the community knows who we are and that we’re in a community ART group. Now use us, and use us well.”

These people are living, walking, breathing, talking proof of the benefits of HIV treatment. Not only can they attest to it for their own benefit, but they are hell-bent on helping their communities get the benefits as well. So they convince other people to seek treatment. They convince other people to get tested. It wasn’t anything MSF asked them to do. They essentially took it on by themselves.

They are as fed up as people in MSF about the limitations that still exist on HIV care, how centralized it still is. In a sense, both MSF and the CAGs are demanding a shift in the paradigm—a shift from the focus on the individual, even from the patient perspective, to family, to community, to the larger beyond.

There’s this great science* that shows, yes, treatment saves lives, that it reduces new HIV infections, prevents orphanhood, all that great and good stuff. The big two barriers that MSF can help with are the two questions the New York Times asked in their editorial about this new science: is it operationally feasible? And is it affordable? And we can say yes, to the first and yes, with action, to the second. You have to take certain steps in order to make it affordable.**

These CAGs are very poignant examples of how massive scale-up can be feasible and also be successful. Government officials from neighboring countries have gone to see the CAGs for themselves, and are pondering whether it would be suitable for their own contexts, which is great. The point is that even for such a resource-poor setting as rural Mozambique, this is something that works.

*Studies released last year showed that HIV treatment can reduce transmission by 96 percent.

**MSF has advocated for a minimal Financial Transaction Tax, among other measures.