Haiti’s community-based ART distribution strategy and its role in supporting patient retention

Abstract

Haiti developed a community-based ART distribution strategy (by its French acronym, “DAC”) to reduce barriers to active ART participation and adherence. Patients who are stable on ART after the first six months of treatment are eligible for DAC. For patients interested in receiving ART in the community, health care staff distribute medications in the patient’s home or at other agreed locations determined by the patient. We sought to evaluate the scale-up of the DAC approach and assess the relationship between DAC participation and active ART participation. In this mixed-methods descriptive study, we used secondary data on medication dispenses from 92 health facilities participating in Haiti’s national-level electronic medical record system, iSanté. The data source covered person-level data on ART prescriptions from 92 health facilities, from January 2017 through March 2018. We examined documentation of DAC participation via pharmacy encounter forms, assessed patient, facility, and health network factors associated with DAC, and described outcomes of active ART participation among DAC and non-DAC patients. We purposively sampled 8 facilities with greater and lesser documented use of DAC from two health networks, interviewing two key informants from each, to identify practices and challenges in implementing DAC and monitoring patient outcomes. Seventy-three facilities (79.3%) documented at least one DAC dispense, and 57 facilities that documented DAC (78.1%) showed reliable DAC documentation from January 2017 to March 2018. 18.0% of patients at the 92 facilities had at least once dispense delivered through DAC from January 2017 to March 2018, compared to 23.8% of patients at the 57 reliable DAC facilities. After adjusting for covariates, patients with a DAC dispense had an odds of being actively retained on ART following a dispense which was 16% lower compared to patients whose ART was dispensed in the clinic. We conclude that the DAC approach has scaled up in a variable way across health facilities. Documentation of the DAC approach within the national electronic medical record system could be improved.