Bridging the distance for ART services in Namibia

 {Photo credit: Stanley Stephanus for SIAPS Namibia}Pehovelo Ndahangoudja (left), a registered nurse documents feedback on CBART from Know your Status CASG member Julia Sheepo (2nd from right) and leader Marian Ndahafo Lilonga (right) at Ndamono clinic, Onandjokwe district.Photo credit: Stanley Stephanus for SIAPS Namibia

Health leaders in Namibia had a geographic challenge in delivering antiretroviral (ARV) treatment. The country is among the most affected by the HIV and AIDS epidemic in Southern Africa, with an estimated HIV prevalence among adults of 16.9% as of 2014. Yet, in a vast country in which two-thirds of the people live in sparsely settled rural sites, how could these leaders make sure essential ARV treatment is accessible to those in need?

Although the country has successfully expanded its antiretroviral therapy (ART) patient coverage to 84%, and more than 160,000 patients were on ART as of December 2017, helping patients start ART is not enough. Achieving viral suppression and minimizing the development of HIV drug resistance requires adherence to treatment.

To solve this issue, the Ministry of Health and Social Services (MoHSS) shifted from a district hospital-based care services model to a decentralized model. Supporting this effort, the USAID-funded Systems for Improved Access to Pharmaceuticals and Services (SIAPS) program, implemented by MSH, helped launch the differentiated care model, an approach that simplifies HIV services while also making sure that the health system is accountable and efficient.

New dispensing method leads to fewer patient trips

SIAPS supported pharmacy staff training on multi-month dispensing procedures to provide ARVs to ART patients for two to six months at once instead of standard monthly refills, reducing the number of patient visits to the pharmacy for ARV pick-ups. SIAPS also helped Namibia revise its ART guidelines to include multi-month dispensing.

In addition, the program helped implement the Electronic Dispensing Tool (EDT) for community-based ART (CBART), a model based on recommendations to reduce congestion and bring ART services closer to rural communities. Community adherence support group (CASG) leaders distribute individually packaged ARVs for patients who meet the clinical criteria of suppressed viral load and good adherence to treatment.

SIAPS supported the MoHSS in adapting the EDT for dispensing to CBART groups and in developing and implementing standard operating procedures for guiding and monitoring the movement of ARVs between health facilities and the community.

These interventions also reduced transportation costs and improved waiting times at facilities. Julia Sheepo, a member of the Know your Status CASG, could spend up to 13 hours travelling to and from the clinic where she collected her medicines, paying 40 Namibian dollars (approximately USD 3) for each trip. It now takes her four hours at the CBART group ARV refill meeting, during which group members receive comprehensive counseling within the community.

Less crowding, better adherence

Decentralizing also cut down on crowding in hospitals. Intra-health Clinical Mentor Dr. Johnface Mdala said that the country’s decentralization policies have significantly reduced congestion at the Onandjokwe clinic (Oshikoto region): “I used to see between 400 and 500 patients a day at the ART clinic. This number has reduced to about 100 patients per day.”   

While CBART clearly benefits stable clients, clients with poor adherence to ART are reportedly trying to improve their adherence to meet the CBART refill eligibility criteria. At the Onyaanya health center (Oshikoto region), overall ART adherence improved to more than 85% from an initial low of less than 25% among some group members.  

All of these efforts have helped bring services closer to people. As of June 30, 2017, there were 55 CBART groups, and approximately 1,000 ART patients were accessing their ARV refills through CBART. Dr. Evans Sagwa, SIAPS Country Project Director in Namibia, observed that “The willingness of group leaders to pick up ARVs, their patience, and the good working relationship between health workers and CASG leaders have contributed to reduced congestion at ART sites and improved access to ART services through community support groups.”  

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