Lessons Learned During Adherence Club Implementation

The study involved 12 pairs of clubs, with a total of 770 participants, who were randomized into either clinic-based or community-based clubs. A nested acceptability study was conducted to assess the acceptability of the adherence clubs among participants. The implementation of adherence clubs required careful consideration of several general factors, including facility readiness and recruitment efforts. Facility readiness involved ensuring that facility staff were supportive of the initiative and that the infrastructure was adequate to support the clubs. This included having sufficient filing, booking systems, space, scripting, prepacking, and dispensing capacity. Recruitment efforts involved a structured process to ensure that eligible patients were synchronized into clubs. Community-based clubs required additional considerations, including community stakeholder buy-in and venue selection. Community stakeholders were engaged through meetings, such as the Diepsloot stakeholder meeting and the CAF meeting, to ensure their support for the initiative. Venues for the community-based clubs were selected based on specific criteria, including being spacious, easily accessible, multi-purpose, and free. The selected venues included churches, multi-purpose halls, DoSD halls, and NGO facilities, and memoranda of understanding (MOUs) were established with all partners to ensure smooth operations. Despite the efforts to establish community-based clubs, several challenges were encountered, including the transport of medication, personnel, and blood (cold chain), as well as the distribution of pre-packed medication to avoid incorrect medication distribution. Additionally, referrals of positive medical screens required careful management, with the facilitator driving cases needing immediate attention to the clinic and referring other cases. Annual medical visits were also performed at the facility. The acceptability sub-study, which involved 590 questionnaires, found that participants preferred the adherence clubs to standard clinic care and that satisfaction was similar regardless of club location. However, concerns over lack of privacy, HIV disclosure, and personal safety were low. The study also highlighted the logistical challenges faced by community-based clubs and emphasized the need for individualized and flexible planning and design. Further evidence on clinical outcomes by adherence club location is needed to inform implementation and scale-up.