A realist evaluation of the antiretroviral treatment adherence club programme in the metropolitan area of the Western Cape Province, South Africa

Introduction: In South Africa, 7.1 million people living with HIV/AIDS (PLWHA) of whom about 56% were accessing antiretroviral therapy (ART) in 2016, accounted for approximately 20% of people on ART globally. The successful initiation of PLWHA on ART has engendered challenges of poor retention in care and suboptimal adherence to medication. While standard treatment and care schemes show the potential to retain patients in ART care, their success is challenged by congested health-care facilities, long waiting times and shortages of health-care providers. The antiretroviral adherence club intervention was rolled out in primary health-care facilities in the Western Cape Province of South Africa to relieve clinic congestion and improve retention in care, and treatment adherence in the face of growing patient loads. Evidence from the literature suggests that these models of ART service delivery are more effective than corresponding facility-based care. Nevertheless, there is little understanding of how these care models work to achieve their intended outcomes. To this end, a theory-driven approach to evaluate the adherence club intervention was proposed.
Methods: We adopted the realist evaluation approach to evaluate what aspects of antiretroviral club intervention works, for what sections of the patient population, and under which community and health systems contexts, to inform guidelines for scaling up of the intervention. The study was conducted in three phases. First, we elicited the initial programme theory of the adherence club intervention using the elicitation approach. Second, we applied an explanatory theory-building multi-case study approach to testing the initial programme theory in three contrastive sites. Following the retroduction logic of making inferences, we configured information obtained from quantitative and qualitative approaches using the intervention-context-actor-mechanism-outcome heuristic tool to formulate generative theories. Third, we did a cross-case analysis to delineate the combination of the intervention, context and mechanism components from the three cases, which is used to explain the outcomes of the adherence club intervention.
Results: The initial programme theory revealed two plausible hypotheses. The first theory supposes that patients become encouraged, empowered and motivated, through the adherence club intervention to remain in care and adhere to the treatment. The second theory suggests that stable patients on ART are being nudged to remain in care and adhere to the treatment with the goal to
decongest the primary health-care facilities. The refined programme theory showed that grouping clinically stable patients on ART a convenient space to receive a quick and uninterrupted supply of medication, health talks, counselling, immediate access to a clinician when required while guided by rules and regulations works because their self-efficacy improves and they become motivated and nudged to remain in care and adhere to medication.
Conclusions: The successful implementation and rollout of the adherence club intervention are contingent on some important health system conditions. Prominent among these is the separation of the adherence club programme from other patients who are HIV-negative as much as possible. In addition, there should be available convenient space for the adherence club meetings, continuous support of the adherence club facilitators by clinicians and buy-in from the health workers at the health-care facility. In the context of chronic care integration, caution must be taken when integrating HIV-treatment services with other non-communicable chronic disease care as this has the potential to de-establish mechanisms that are critical to the success of ART service delivery.