OFCAD Impact assessment report

July 16

2021

Abstract

The Out of Facility Community ART Distribution model is one of the various low cost Differentiated Service Delivery models piloted and implemented by BHASO with the support of MSF. Its primary objective was to simplify community access to ART by removing barriers to access such as cost, distance and other hurdles to access to health services and commodities by people living with HIV. Interviews, desktop review and key informant interviews were used to collect data while the OECD/DAC evaluation framework was adopted for assessment. Evidence obtained suggests that OFCAD simplified access to ART in ward 17 of Mwenezi district. Through this simplification, OFCAD increased retention in care to 100%, 99% of the clients had suppressed viral Load, reduced HIV related deaths to 0.28%, and zeroed out lost to follow. In order to include children, considerations should be done to enroll children with stable viral load.

Acknowledgements

This report was prepared by Nzara Mpumelelo, the Monitoring, Evaluation, Research and Learning lead for Batanai HIV/AIDS Service Organisation. The assessment was commissioned by BHASO Director and the Chief Operations manager who provided strategic and technical guidance, coordination, and methodological and logistical support.

Due acknowledgement is accorded to partners and funders whose support has seen OFCAD being established, supported and strengthened. Primarily, MSF Belgium for supporting the establishment of OFCAD. Funds for Development and Partnership in Africa (FEPA) is acknowledged for supporting OFACADs and outreach visits which in a way maintained constant touch among BHASO team, MoHCC staff, community cadres and clients. Much appreciation is also due to Germany-Zimbabwe society for surfacing during COVID- 19 when need was really needed. For similar gesture, AIDS Health Care Foundation (AHF) is accorded much appreciation. The two organisations offered support during the COVID-19 period facilitating constant monthly visits and hamper support for those affected and infected by HIV.

The evaluator is also grateful for the support provided by its constituent partners such as NAC, AFRICAID; OFCAD focal persons; MoHCC-Nurses, EHT, DEHO, and DNO. Their cooperation throughout the data collection and evaluation process is really valuable. Review and readership of programs team, COM, and director provided valuable comments, suggestions and invaluable input.

The views expressed in this report are those of the author and do not necessarily reflect the views of BHASO.

Executive Summary

1. The Out of Facility Community ART Distribution model is one of the various low cost Differentiated Service Delivery models piloted and implemented by BHASO with the support of MSF. Its primary objective was to simplify community access to ART by removing barriers to access such as cost, distance and other hurdles to access to health services and commodities by people living with HIV. This would in effect reduce the number of lost to follow up clients, improve retention in care, Improve wellbeing of PLHIV and thus zeroing down the number of HIV related deaths. Aside that, the model also provided a proxy for preventive care such as condom distribution and health education. In the context of COVID-19, was and is providing needed decongesting mechanisms, information dissemination and prevention practices.

2. The evaluation used a mixed-methods approach consisting of three different data-gathering and analysis techniques:

i. A documentary review of the model documentation.

ii. Key informant interviews with selected stakeholders from Mwenezi District, district office bearers, OFCAD focal persons, Rural health facility staff and outreach participants to gather qualitative and quantitative data and to corroborate key findings from different sources.

iii. On-site survey

iv. Face to face interviews with OFCAD clients (30 from across the 11 sites)

Introduction

Out of Facility Community ART Distribution (OFCAD) was initiated in 2018. According to one key informant this came after a request from the Community Health Workers to cover the gaps which were left during facility and out-reach ART distribution. Before OFCAD, HIV patients would receive their medication individually and as groups at Chirindi RHC and at out-reach sites once a month or once in three months and they would travel 40km or even more kilometres for these services. The whole of Ward 17 was served from two outreach points which are Chovelele and Makugwe. For this reason, there was a lot of pressure which in effect led to delays in service and staff stress. Against this backdrop, it was piloted to easy pressure and the burden of travelling long distances to outreach sites and health facility.

Context /background

The OFCAD model has been piloted against the backdrop of long distance travelled by clients to collect the medication. Some patients would more than 40km to get to the outreach point considered to be the nearest. The long distance meant that patients spent long time walking to the outreach point or clinic. The several hours dedicated to walking and waiting for the medication were time lost for household chores and development. Some patients were sometimes too sick to walk this long and had only the carer at home hence death due to failure to access the medication. Clinics and out-reach points were usually overwhelmed or in simple terms heavily congested thereby discouraging patients turn over. This also led to exhaustion of health workers which in effect compromised the quality of service.

Access to health care was also affected by bad weather. Due to heavy rains, scotching sun or very cold weather, clients accessed care with a cost. Flooded rivers associated with lack of bridges or at least proper bridges during rainy season acted as barriers to access to treatment and care for PLHIV. Other barriers include farms, conservative areas/game parks. All these hindered access to treatment and care by PLHIV in Mwenezi district, ward 17 specific.

The impact of these challenges on PLHIV wellbeing and treatment was very ugly. The challenges elevated defaulter rate hence HVL. On another note, patient confidentiality compromised due to delays at outreach sites hence the patients felt exposed due to being served in makeshift structures. As a result, stigma and discrimination became more pronounced. For this reason and prohibitive distance, lost to follow clients became significant as there were no individual health workers responsible for a particular patient. Also, clientele satisfaction was left unchecked due to pressure of work. High death rates due to treatment default, lack of care and lack of close monitoring.

Figure 1: ZIMBABWE - All Districts - Overview of the national coverage of primary health care facilities (As of 28 February 2020). Map by MSF

Literature review

There is vast literature on Differentiated Service Delivery Models (DSDs). DSDs have gained ascendancy in the fight against ending HIV globally. The (International Aids Society, 2015) holds that since 2015, the World Health Organization has endorsed a differentiated service delivery approach to providing HIV services to support reaching the Joint United Nations Programme on HIV/AIDS (UNAIDS) 95-95-95 targets by 2030. Differentiated service delivery has been defined as “a client-centred approach that simplifies and adapts HIV services across the cascade, in ways that both serve the needs of people living with HIV better and reduce unnecessary burdens on the health system”, (WHO, 2017). Scaling up of DSD for HIV would catalyse country and community advocacy and amplify global best practices, tools and evidence to effectively reach the 37 million people worldwide in need of high-quality life-saving HIV care, (IAS, 2015). In Sub Saharan Africa, ministries responsible for health have endorsed the adoption and by now, almost all countries are implementing DSDs. In Zimbabwe, DSD model finds expression in Community Art Refill Groups (CARGs) which refer to community-based groups formed voluntarily by persons living with HIV who are taking lifelong antiretroviral drugs; Community client-led ART delivery (CCLAD) which is delivery of antiretroviral drugs at community level to a community ART refill group by one of the community ART refill group members on a rotational basis; Community ART distribution points (CADP) which are designated points within the community where antiretroviral drugs are dispensed to persons who are on lifelong antiretroviral therapy; and Family Member Refill Groups which comprise of family members with one member collecting medication for the rest of the family, (MoHCC Zimbabwe, 2019). The OFCAD as a model came into life in 2019, (MSF, 2019).

Evaluation Criteria

The evaluator adopted the broadly accepted (OECD/DAC) quality standards and criteria. As such, the evaluation was planned and implemented in a transparent and participatory manner respecting stakeholders’ views while ensuring the independence of the evaluator. The evaluation applied the DAC criteria for evaluating development assistance: relevance, efficiency, effectiveness, impact, and sustainability. These criteria are summarised in the table below.

OECD DAC Criteria	Description
Relevance	The extent to which the intervention is suited to the priorities and policies of the target group, recipient, and funder.
Effectiveness	A measure of the extent to which an intervention attains its objectives.
Efficiency	Efficiency measures the outputs (qualitative and quantitative) in relation to the inputs. This criterion looks at whether the activities were cost-efficient, and whether the objectives were achieved on time.
Potential Impact	The potential for positive and negative changes produced by a development intervention, directly or indirectly, intended or unintended.
Sustainability	Sustainability is concerned with measuring whether the benefits of an activity are likely to continue after the funding has been withdrawn.

Table 1: OECD DAC revised Criteria 2019

MAIN FINDINGS

Data collection was done to respond to several questions on issues to do with relevance, efficiency, drug safety, sustainability and context applicability. The following presentation of data is done according to these important questions around OFCAD.

Relevance

The OFCAD model is an innovative low cost and useful model that has brought highly needed yield in community HIV management in Mwenezi district. The model has contributed to raising awareness through health education, prevention through condom distribution and treatment adherence through personal contact between caregiver and clients. It has impacted positively the average distance to access services and commodities to within 5km. On another note, it removed the burden of cost, time and distance from many PLHIV in the area. OFCAD clients can now access services and commodities at zero cost within a short space of time and distance. Thus the model transformed issues of access in hard to reach areas in Mwenezi. In essence, the model has become relevant in both the hard to reach context and COVID-19 context. In an outright manner, the model is relevant to various other contexts such as that of shortage of medicine and commodities. It services better in these contexts.

In terms of the COVID-19 context, the model, despite being piloted before the pandemic, it suited greatly to serve the communities in health regards. Given that COVID-19 induced control measures that negatively impacted on people’s access to health services and commodities, the OFCAD model offered a ready-made solution. By serving PLHIV in their communities, the model debunked travel restrictions imposed to control the spread of the virus by restricting client movement to facilities, client gatherings and facility congestion. In actual terms, by decongesting Chirindi clinic, the model helped greatly to control the spread of Corona Virus. On the same note, OFCAD focal persons became important medium for COVID-19 health education, who also are seen practicing what they teach. For example, with much emphasis to washing of hands as a low cost control measure, tip taps (Chigubhu giya) have been put on entry points in the bid to control viral infection.

Figure 3: Picture one showing tip tap (chigubhu giya) installed at entry point of one of the focal persons, and picture 2 showing a person washing hands from the tip tap. (Pictures by Mpumelelo Nzara)

In Makugwe and Chovelele area, tip tap are a fashion with residents professing to have learnt from the OFCAD focal persons. In real terms, the focal persons are sensitive of the COVID-19 requirements and safe practices. Besides the community level technologies, the focal persons also receive support from the parent facility. Below is a picture of sanitizer received from the facility.

Figure 4: Hand sanitiser supplied from health facility. (Picture by Mpumelelo Nzara)

In the context of COVID-19, access to SRH commodities was also affected, but with the model in place, distribution of commodities such as condoms was effectively done. A picture below shows stocks of condoms, blue/gold the current rollout from National Aids Council.

Figure 5: Blue/gold Condoms distributed by OFCAD focal persons. (Pictures by Mpumelelo Nzara)

In a way, evidence indicates that the OFCAD model provides eclectic services and commodities clients and communities at large.

Efficiency

The OFCAD model is cost, time and result efficient. The model has promoted family savings by providing services at their door step. Cost is one burden that comes along with being HIV infected and affected. Thus by bringing services to clients’ door step, OFCAD enabled families to save. From the interviews done clients expressed deep relief from cost related to travelling to health facilities to access treatment and care. A bus fare index drawn from the findings reflects that the least payment to health facilities by those living in areas serviced through OFCADS is USD7 and the highest is USD20 for a one way. Other costs relate to food since transport available has designated times (i.e) they travel from communities in the morning and return in the evening. What this means is that clients would need breakfast, lunch and dinner and this adds to the cost. Thus for those in 15km radius, they would require at least USD20 to access treatment and for those in 40km radius, USD50 would serve them. Considering that OFCAD serve 355 people, it means that it has a gross saving of more than USD15000 per single refill. This comes to effect noting that more than 200 clients live in more than 20km radius hence needing USD50 or slightly less.

At family level, the model saves +/-USD50. Some families with two or more clients would require more than USD150 if they are in different cohorts. To such families, the models helped them save +/-USD150. Given that most of the time clients receive 3 months treatment, it means OFCAD has a gross saving of USD60 000 per year and USD200 family savings per year and for those with more than 3 cohorts, the model saved them more than USD600 per year. All these costs are now covered by one trip by a focal person. Given that prior the model, focal persons would visit health facility every month for services as a Village Health Worker, the model took advantage of that and applied for a no cost refill. Now that we are in a third year after the pilot year, it means the OFCAD model has saved more than USD180 000 already thereby surpassing the cost of establishing all sites, USD90 000. At family level, the model has saved an average of USD600 for single cohort families and an average of USD1800 for more two cohorts families. Such savings would go a long way to relieve families, communities and the nation of the burden that comes along with access to ART treatment. Besides that, the money can be used for other pressing issues or development. One client highlighted how she took advantage of the savings to expand her livestock base.

The model is not only cost efficient but time efficient. For example, it would require a whole day for clients to receive services and treatment but now it is a matter of hours. According to clients, the model saved time for other day to day activities. Unlike before where they would need a day travel and comeback, and a one day rest, they now need some hours only and they are served both in care and treatment. The model is functional in rural communities where in most cases money is a real problem. In most cases, clients would walk 40km or more to access ART and other related services. The model rescued those who would walk. In interviews done, clients reflected that sometimes they walked four days to and from health facility to access ART and services, after which they would need more than two days to rest. To them the model saved them more time because prior they lost more than six days to travelling for treatment. Since it is now a matter of hours, clients can now dedicate their time for other productive activities.

Having saved time and money, the OFCAD model is in effect result efficient. The burden of cost, distance and time was inhibitive to adherence and retention in care. Because of these hurdles, it was difficult to retain a client in care for consistent 6 month period. According to one senior staff, before the model, adherence to ART was very poor in those hard to reach areas. Following the model, the results are not only positive but they seem permanent. OFCAD helped to raise retention in care to 100% in areas of operation. Adherence is high in these areas as evidenced by suppressed viral load. So by removing hurdles to health access by PLHIV, OFCAD model has improved well-being of such and reduced HIV related deaths to almost zero in areas of influence.

Notwithstanding the benefits, evidence shows that OFCAD model is more adult than it is child focused. The effect of this is that it has failed to capture issues of family dynamics. One key informant highlighted that the silence of the model on family dynamics means that other families are still burdened with both cost and time. I observed that across all the 11 OFCAD sites, there are no children below 14 years of age. What this means is that families who are in OFCAD but with children below 14 are still carrying the burden. It becomes even more burdening if that family has 2 or 3 children in different cohorts. The cost has not gotten away. In an interview, one client accessing services through OFCAD highlighted that the height of this as a problem became more definitive during the COVID-19 era where there were one month refill only. It means they would require travelling every month in order to support their children. This problem is in agreement with what (UNAIDS, 2014) said that, “Children and adolescents living with HIV (CALHIV) have a lifetime of antiretroviral therapy (ART) ahead of them,” yet “An estimated 95% of HIV service delivery is currently facility-based, largely undifferentiated for individual need.”

Against this backdrop, considerations for including children should be done. As ascended by (MacKenzie RK, van Lettow M, Gondwe C, et al., 2017), Differentiated ART delivery for clinically stable children and adolescents is supported by global agencies, and a growing body of evidence highlights how differentiated ART provides a significant opportunity to improve treatment adherence among children and adolescents living with HIV.

Effectiveness

The effectiveness of the model is measurable against its primary objective. The primary objective was to simplify community access to ART by removing barriers to access such as cost, distance and other hurdles to access to health services and commodities by people living with HIV. This would in effect reduce the number of lost to follow up clients, improve retention in care, Improve wellbeing of PLHIV and thus zeroing down the number of HIV related deaths. From inception, OFCAD model has managed to improve retention in care. From the data gathered, all clients (351) are still in care and there are no defaulters. One OFCAD focal person cited that the reason for this total retention lies in the fact that just like support group, OFCAD model has built personal attachment, strong ties, mutuality, cohesion

and above all strength to adhere to ART by the clients. Because of the model, clients in hard to reach have been organised into a community, constituent and a unified people hence the encouragement to adherence. One client ascended that we, as a people, a community of PLHIV, we are there for each other, we support one another, we encourage each other, and we share stories and even go beyond to offer material support. Thus, as at the time of data collection, retention in care was 100%. As such, there was 10% increase from the initial assessment made in 2019 where retention was >90%. As noted, the psychological prowess offered by OFCAD has pivoted ART adherence and retention. All focal persons also cited the importance of removal of burden as a contributing factor to retention. As quoted from one of the clients, “…now the time needed to refill our ART is very short, no cost, no need travel, what else would we cite if we do not collect ART?” From focal persons’ point of view, the knowledge of each client’s residence helps us to trace if there is delay for collection. All these factors help to retain clients in care.

Owing to adherence, there was highly encouraging viral load for the rest of the clients except for 3 clients. At the time of visit, all clients had been bled for VL in 2020 and had their results. Information provided suggest that one of the clients with high viral load was bled at a time she had lost 2 of her children in a tragic incident. The responsible focal person (OFCAD 9) cited this as a trigger of stress, emotional fall up and deteriorating health as a consequence. Another focal person (OFCAD 2) where the remaining two clients with high viral load come from cited chronic illness as a trigger for one of the clients. She cited that the patient is diabetic, which may be the cause for this. Thus at the time of the visit, 99% of the clients in OFCADs had their viral suppressed. This gives a 9% increase from the previous assessment done in 2019. VL for 2021, results were yet to come but all clients looked healthy at glance.

With regard to HIV related deaths, the numbers are also encouraging. From inception, there are three incidences of death concerning OFCAD clients. While one is due to active opportunistic infection, wherein the focal person had for twice referred the patient to the hospital for management using red flagging; two other deaths relate to suspected food poisoning and sugar diabetes. Narrations by the responsible focal persons suggest that one of the clients died after a short illness where people suspect he drank poisoned beer while the other client’s card was marked diabetes as the cause of death. Thus with OFCAD, HIV related deaths are kept so low as to 0.28%.

OFCAD model has also dealt great work with regard to lost to follow up clients. As at the time of visit for data collection, there was zero lost to follow up clients. According to focal persons, clients who migrate for job seeking, inform them before departure. Quoting one of them speaking, “when they come to inform us, we sit them down and teach them how they should continue on their treatment even away from home and upon return they let us know and we refer them to Chirindi clinic for assessments before readmission.” Another one added that the reason why we do not lose trace of our clients is that we know their residence and as a ‘community’, there is a bond that is so strong so much so that we do not want to lose one another. With the evidence, OFCAD model has helped to bring down lost to follow from <5% to 0%.

The evidence above attests that OFCAD model has been effective in simplifying access to ART. The outcome of simplified access has been, as evidence suggest adherence to ART, suppressed VL, well-being of PLHIV, and reduced HIV related deaths as a result.

Drug safety

At inception, major worries on OFCAD model were on the safety of drugs. A baseline survey done revealed that fears were that focal persons may cause serious drug pilferage. However, at the time of data collection, evidence shows that from the start, there was no drug pilferage, damage or mishandling. Support visit and supervision reports were utilised to this effect. Interviews with supervisors and sister in charge also attest to the fact that as of the 21^st of June, no drug damage or pilferage has been reported, identified and or observed. Stock balancing reports and

Drugs are stored in trunks with double locks. The safety of the drugs is also guaranteed by the fact that families of focal persons support their work. Interviews with spouses and children of sites visited attest that they (children and spouses) support them and they do not tamper around with drugs, materials and resources used in drug distribution. Drug tracking is easy as there are records from collection, storage and distribution. This makes reconciliation of records very doable.

Simplicity-quality intersection

Data collection would not have been of more value if it had ignored the simplicity-quality question. I extended this question in order to denote if quality was note traded off for simplicity and low cost. This was measured by focal person’s Knowledgeability of their roles, important signs (OIs and red Flags), and the services they offer to people. In this regard, client satisfaction was also tested and supervisors’ reports were utilised in the same regard. Across all the 11 facilities, focal persons exuded greater understanding of their roles and responsibilities. They also showed understanding of the procedures for example education, counselling, recording and issuance of treatment. They all attested that they do their roles diligently, reading expiry dates before issuance and also writing review dates. All clients who took part in the interviews attested to the above and that the focal persons show greater concern.

Regarding TB screening, focal persons still have knowledge of the important indicators. 27 of the 30 clients who took part in the interviews reported that focal persons ask questions regarding TB for example continuous coughing, headache, sweating and loss of weight. On the same note, focal persons ascended that they refer clients with symptoms and those due for TB Prevention Therapy are also earmarked for refill. This shows that on top simplifying access and removing cost associated with access, OFCAD offer extended services critical to quality measure of care and support for PLHIV.

Sustainability

The model provides a sustainable way of delivering ART, SRH and other related services to people in hard to reach areas. In real terms, the model has been in the first place conceived with sustainability as the priority. It is indeed a low cost initiative that promotes a zero cost access to ART and SRH services. After establishment, it has minor expenses by the focal person only, who even without the responsibilities of manning OFCAD will on monthly basis travel to Chirindi clinic once or twice per month. This is because, focal persons were chosen from those cadres who were already supported by government. Thus the model is built upon an already running system hence easy and cheap to maintain.

Notwithstanding this, focal persons expressed concern over the weight, portability of stocks from the facility but a motor cycle available will now help to distribute stocks to OFCAD sites as supported by the clinic and BHASO. The EHT who does supervision of OFCAD sites indicated that per month, only 20 litres petrol is required to supply stocks across 11 sites. This means the model would require insignificant amount of money to sustain with cycle cost added. In essence, the model remains within a community level affordability. The model is also sustained by the fact that most of the focal persons are constituent members (PLHIV). This helps them to reach out to clients with easy.

Even at that, the model includes a sustainability strategy beyond the initial grant. Outreaches were cited as hubs for refresher training and clarification for focal persons. These outreach activities are done once every month. Commendable attention was given to the follow-up and monitoring of the OFCAD sites and activities, thus in the post-grant phase the EHT continues with the role with travelling facilitated by the donated motorcycle specifically for that. Given that the model identified local “cadres, a greater percent of which is constituent members” they continue their services in the post grant period.

Context applicability

Against the backdrop of the prevailing COVID-19 regulations, OFCAD has proved to be useful in a variety of contexts. It has proven efficient in the Covid-19 era and can be applicable in different other contexts like that of natural disasters such as cyclones.

With the coming of COVID19 prevention measures which included lockdowns, wearing of face masks, intensive hand-hygiene, social-physical distancing and vaccination. This led to a restricted number of patients being served at health facilities. In this context, OFCAD helped to decongest the health facilities by serving a good number of clients. OFCAD sites became centre and source of COVID19 information as some VHWs finally got some training or received some posters and literature. They also became ideal centres for short family planning methods such as condoms and pills however they were not well equipped especially with control and secure pills.

Impact of OFCAD/Analysis of findings

The capacitation of Community health workers with knowledge, equipment and the ART medicines brought a great sigh of relief to communities in ward 17. There was reduced distance travelled to collect medication for willing and stable patients. This saved time which opened room to uninterrupted productivity time at home hence good diet and better CD4 count and viral load management. Given the reduced distance, there was increased family savings, money which can be used for other things. There is also, quality health service delivery as the OFCAD Village health workers helped to decongest both the health facilities and the outreach points thereby promoting one to one. There is improved confidentiality as the clients can contact and visit the OFCAD health worker upon appointment. Also, stigma and discrimination reduced due to sizeable group of clients being treated uniformly and being served by an individual from the same community as theirs, which also was kind of morale booster and motivator to both the clients and the VHWs. The model has gone a long way to promote a healthy and productive community with improved health seeking behaviour. Lost to follow reduced since the OFCAD cadre is from the same locality hence could access adequate information pertaining client movement/travelling. Thus in ultimate terms life for PLHIV in ward 17 has improved to the effect that there is massive strides in reducing HIV related deaths.

Conclusions

The overall project objective of “simplifying access to ART by removing cost, distance and time barriers for PLHIV in hard to reach areas” was achieved. The ultimate outcome achieved is reduction of HIV related deaths which was achieved through increased retention in care, adherence, and support. Notwithstanding the above, focal persons highlighted that they need support during drug stocking because of portability and handling issues. Although a motorcycle to support in this regard was donated, the OFCAD monitors and supervisors emphasised support with fuel. Despite the burden, focal persons continue their services at their sites and they have really done great work to enjoy fruits of the OFCAD model.

In order to counter the problem above, commitment was made by BHASO to support with 20l fuel every month. Also, there is need to tailor make OFCAD in order to provide space for children and adolescent living with HIV. Given the benefits of outreach, the author recommends continued support for outreaches.

Bibliography

Grimsrud, A. W. (2019). Providing differentiated delivery to children and adolescents. Retrieved 07 09, 2021, from World Health Organization.: https://apps.who.int/iris/handle/10665/327143

International Aids Society. (2015). Differentiated Service Delivery (DSD). Retrieved 7 9 , 2021, from International Aids Society : https://www.iasociety.org/Differentiated-Service-Delivery

MacKenzie RK, van Lettow M, Gondwe C, et al. (2017). Greater retention in care among adolescents on antiretroviral treatment accessing “Teen Club” an adolescent-centred differentiated care model compared with standard of care: a nested case-control study at a tertiary referral hospital in Malawi. J Int AIDS Soc, 20(3).

Massaquoi M, Zachariah R, Manzi M, Pasulani O, Misindi D, Mwagomba B, et al. . (2009). Patient retention and attrition on antiretroviral treatment at district level in rural Malawi. Trans R Soc Trop Med Hyg, 103(6), 594-600.

MoHCC Zimbabwe. (2019). TRANSFORMING COMMUNITY HEALTH SYSTEMS TO IMPROVE HEALTH OUTCOMES IN ZIMBABWE Differentiated Care Services Operational Manual for National AIDS Council Community ART Treatment & Care Facilitators 2019. Harare: Ministry of Health and Child Care.

Rosen S, Fox MP, and Gill CJ. (2007). Patient retention in antiretroviral therapy programs in sub-Saharan Africa: a systematic review. PLoS Med, 4(10), 298.

UNAIDS. (2014). Fast-track: Ending the AIDS epidemic by 2030. . Geneva: UNAIDS.

WHO. (2011). Retention in HIV Programmes: defining the challenges and identifying solutions. Geneva: World Health Organisation.

WHO, W. H. (2017). Key considerations for differentiated antiretroviral therapy delivery for specific populations: children, adolescents, pregnant and breastfeeding women and key populations. World Health Organisation.