22May2017

Small Fixes: Patient Groups Help Share the Burdens of Living With AIDS

Rogerio Bernardo slung a black satchel over his shoulder and waited by the roadside in the morning mist for a bush taxi. In dusty wingtips, frayed pants and a gray pinstripe suit coat so big it swallowed his slender frame, he looked like any peasant farmer dressed up for a trip to town.

In fact, Mr. Bernardo, who has AIDS, is in the vanguard of a promising new effort to reverse one of the most worrisome trends in treating the disease: the growing number of patients across Africa who fail to collect their lifesaving antiretroviral medicines.

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.

A two-year test of his brainstorm here in Tete, comparing about 300 of these groups with patients who continued going alone, found that almost none of those in the groups stopped taking their medicines and only 2 percent died, according to results published in The Journal of Acquired Immune Deficiency Syndromes. By contrast, 20 percent of the other patients quit treatment or died.

“No one abandons treatment in the group,” said Inocencio Alface, a talkative, slightly built farmer who has become Nkondedzi’s champion for people with AIDS and leads one of the village’s four patient groups. “We give each other courage.”

On a recent morning, it was Mr. Bernardo’s turn to go to town. Before he joined the group, if he was short of cash for taxi fare he needed to hike four hours through the bush to the district hospital in Zobue.

But as his group huddled against the chill, each member contributed 15 meticais, or about 50 cents, for taxi fare. They also counted out their leftover pills and noted the tally on their medical cards, so a clinician could tell whether they had taken the previous month’s pills. Mr. Bernardo tucked the cards into his satchel.

As he watched the express taxi go by, waiting for a slower one to save 35 cents on the fare, village life floated past him through the mist — women balancing buckets on their heads, men on bicycles with jangling bells, schoolchildren carrying stalks of sugar cane as long as fishing poles.

When the bush taxi finally arrived at 7:50 — it was just a pickup truck loaded with people and bags of charcoal — Mr. Bernardo clambered in for the 18-mile ride.

The study of this new approach also found that it profoundly lightened the load on the health professionals who are one of this poor country’s scarcest resources, sharply reducing their caseloads at public hospitals and clinics — and, health economists say, trimming the cost of treatment.

“We went up there and were blown away,” Dr. Kebba Jobarteh, who heads the H.I.V. care and treatment program in Mozambique for the United States Centers for Disease Control and Prevention, said after his visit to Tete. “We met five groups. They were amazing. This is a potential game changer for H.I.V.”

Dr. Decroo acknowledged in an interview that the study design for his approach did not produce as high a quality of evidence as a randomized trial would. And Dr. Tim Farley, an AIDS expert with the World Health Organization who was not involved in the research, cautioned in an e-mail that because the program was limited to clinically stable patients, the comparison with other patients might be skewed.

But Dr. Farley added, “Reducing the health-system burden from these patients is fantastic and allows the scarce clinical resources to be used for more complicated patients.”

The shifting of responsibilities for AIDS treatment from doctors to nurses to community health workers and even patients has been necessitated by Africa’s extreme shortage of medical professionals. Mozambique has only 2.7 doctors per 100,000 people, according to World Health Organization estimates; the United States has 100 times that.

When Doctors Without Borders began providing antiretroviral drug treatment to AIDS patients here in 2003, there were fears that illiterate rural Africans would not take their medicines properly. Before the expatriate doctors would even prescribe the complicated combination therapy, patients were required to show up on time for eight appointments. For the sickest, poorest patients, the bar was impossibly high. “Before the eight consultations were done they would die,” Dr. Decroo recalled.

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