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The simple solution devised by Dr. Tom Decroo, a Belgian physician working here in Tete Province for the aid group Doctors Without Borders, was to organize patients into groups of six. They would then take turns making the monthly trip to pick up refills, cutting the number of times each had to go to town — to just two a year, from 12.It seems so simple. Create patient groups, organize them so that instead of six people each paying every month to go from their village to the nearest clinic, only one has to. Except it isn't simple.
The culture of HIV treatment, at least in this region, is that patients must see a clinician every time they pick up their medicine. In the best scenario, that clinician takes a few measurements (height, weight, etc.), asks a few questions to identify potential side effects or other treatment challenges, dispenses medicine, and the patient goes on their way. If they are sick, they are referred to a doctor or further examined for potential regimen changes. Again, simple. Except it isn't.
We like to think that every patient gets at least that basic level of care each time they go to a clinic, but all it takes is one visit to a busy facility to see how there's not enough time in a day for the staff to provide both the basic care for all patients and the necessary follow up for patients who are not doing well. It seems like we can ask for one or the other, but not both.
What Doctors Without Borders and others have recognized is that there is a major difference between a stable patient on ARVs and a new patient, and that many stable patients only need to see a clinician once every six months for updated lab tests and a general checkup. Doing this significantly reduces the burden on both healthcare workers AND the patients themselves, who often have to scrape together whatever funds they have in order to get from their home to the clinic and back. By reducing the number of required visits by between 60% and 80%, that's money that can obviously be used for other, better purposes, and the healthcare workers can devote more individual time to patients who are in the clinic that month.
Are there tradeoffs to this approach? Sure. Most worryingly, some patients will wait until their turn to go to the clinic even if they are sick or having side effects, and therefore increasing the risk of death in between visits -- though in the "study" mentioned the article no patients died during treatment. This risk, along with a general reluctance to change, makes such changes very difficult to implement at a large scale.*
That said, these kinds of creative, and simple-at-least-on-the-surface solutions are exactly the kind of thing we need to be trying to get and keep more patients on treatment. I believe strongly that the easier we make it for patients to get medicine, the more patients are going to get it. In Swaziland, we just recently crossed the 70,000 mark for patients on treatment. We'd like to have 90,000+ patients on treatment soon, but the next 20,000 will be a lot harder to reach than the first 20,000. Without innovations like this, practices that reduce patient and healthcare worker burden and improve the overall experience at clinics, I don't see how we'll ever get there.
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*In Swaziland, unfortunately, we're going the opposite way right now. As I wrote in August, the financing challenges facing the government have limited our ability to purchase ARVs at a national level. And while fortunately we again have plenty of medicine in the country, patients are now being asked to come to the clinic every month to collect their medicines. Previously, we had been dispensing two- or three-months' worth of medicines to stable patients, again in an effort to reduce the burden on patients and healthcare workers. The argument for giving one-month refills only is that at least all patients will receive some medicine, instead of some patients getting "too much" while others get none. In an acute crisis, this makes sense to me, but as I look at the next six months and the fact that we have enough ARVs to last at least until then, it just seems like we'll be asking more from the healthcare staff (70,000 vists/month instead of 35,000) and requiring two or three- times as many visits from patients. Fingers crossed we'll change that policy soon.
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