An Observational Cohort Comparison of Facilitators of Retention in Care and Adherence to Anti-Eetroviral Therapy at an HIV Treatment Center in Kenya

Abstract

BackgroundMost HIV treatment programs in resource-limited settings utilize multiple facilitators of adherence and retention in care but there is little data on the efficacy of these methods. We performed an observational cohort analysis of a treatment program in Kenya to assess which program components promote adherence and retention in HIV care in East Africa.MethodsPatients initiating ART at A.I.C. Kijabe Hospital were prospectively enrolled in an observational study. Kijabe has an intensive program to promote adherence and retention in care during the first 6 months of ART that incorporates the following facilitators: home visits by community health workers, community based support groups, pharmacy counseling, and unannounced pill counts by clinicians. The primary endpoint was time to treatment failure, defined as a detectable HIV-1 viral load; discontinuation of ART; death; or loss to follow-up. Time to treatment failure for each facilitator was calculated using Kaplan-Meier analysis. The relative effects of the facilitators were determined by the Cox Proportional Hazards Model.Results301 patients were enrolled. Time to treatment failure was longer in patients participating in support groups (448 days vs. 337 days, P<0.001), pharmacy counseling (480 days vs. 386 days, P = 0.002), pill counts (482 days vs. 189 days, P<0.001) and home visits (485 days vs. 426 days, P = 0.024). Better adherence was seen with support groups (89% vs. 82%, P = 0.05) and pill counts (89% vs. 75%, P = 0.02). Multivariate analysis using the Cox Model found significant reductions in risk of treatment failure associated with pill counts (HR = 0.19, P<0.001) and support groups (HR = 0.43, P = 0.003).ConclusionUnannounced pill counts by the clinician and community based support groups were associated with better long term treatment success and with better adherence.

Community-Based Interventions to Improve and Sustain Antiretroviral Therapy Adherence, Retention in HIV Care and Clinical Outcomes in Low- and Middle-Income Countries for Achieving the UNAIDS 90-90-90 Targets

“…We excluded 17 studies [44], three studies were excluded due to non-inclusion of community-based data [55–57] while seven studies were excluded because the studies were non-comparative [19, 58–62]. One study was also excluded because only baseline data were reported [63] while four did not show outcome data for different arms of the studies [17, 64–66]. …”

Impact of Support Groups for People Living With HIV on Clinical Outcomes

“…Six articles reported on multiple outcomes while 14 addressed one outcome of interest (Table 1). The majority of studies were conducted in sub-Saharan Africa: South Africa, n=7 15, 18, 22, 26, 32, 35, 36 ; Kenya, n=2 23, 30 ; Mozambique, n=2 17, 17 ; and one each from Nigeria 25 , Rwanda 24 , Tanzania 21 , Uganda 31 and Zimbabwe. 27 Two studies were conducted in Vietnam 33, 34 ; the remaining two reported multi-country results.…”

“…Seven studies 15, 18, 21, 23–26 reported on the impact of support group interventions on a range of morbidity outcomes (Table 1). …”

“…Other benefits included improved access to ART, adherence to ART and treatment success 15, 23, 24, 27 , measured as time to treatment failure and reduced risk of detectable viremia or change in CD4 cell count. For example, Achieng et al reported that time to treatment failure was longer in patients participating in support groups (448 days vs. 337 days, P=0.001).…”

From Three Ones to Four Ones – Towards a Better Coordinated and Effective AIDS Response

“…Indeed, the World Health Organization (WHO) and President's Emergency Plan for AIDS Relief (PEPFAR) propose the engagement of support groups as an intervention to address retention and adherence among PLHIV receiving antiretroviral therapy (ART) [8][9][10]. Many studies have already reported the impact that PLHIV support groups have on increased adherence to ART [11][12][13][14]. More strategically and given the shortage of trained health human resource in many sub-Saharan African countries, support groups can play an increasingly larger role with regard to the bottom lines of improved adherence to treatment and retaining HIV-infected persons in care.…”