Bridging the HIV treatment gap in Nigeria: examining community antiretroviral treatment models

Abstract

IntroductionSignificant gaps persist in providing HIV treatment to all who are in need. Restricting care delivery to healthcare facilities will continue to perpetuate this gap in limited resource settings. We assessed a large‐scale community‐based programme for effectiveness in identifying people living with HIV and linking them to antiretroviral treatment.MethodsA retrospective secular trend study of 14 high burden local government areas of Nigeria was conducted in which two models of community antiretroviral treatment delivery were implemented: Model A (on‐site initiation) and Model B (immediate referral) clusters. Model A cluster offered services within communities, from HIV diagnosis to immediate antiretroviral therapy initiation and some follow‐up. Model B cluster offered services for HIV diagnosis up to baseline evaluation and provided referral for antiretroviral therapy initiation to nearest health facility providing HIV services. For controls, we selected and cluster‐matched 34 local government areas where community antiretroviral treatment delivery was not implemented. Outcomes of interest were: the number of people identified as HIV positive and the number of HIV‐positive individuals started on antiretroviral treatment; from June 2014 to May 2016. We used interrupted time‐series analysis to estimate outcome levels and trends across the pre‐and post‐intervention periods.ResultsBefore community antiretrovial treatment introduction, Model A cluster identified, per 100,000 catchment population, 500 HIV‐positives (95% CI: 399.66 to 601.41) and initiated 216 HIV‐positives on antiretroviral treatment (95% CI: 152.72 to 280.10). Model B cluster identified 32 HIV‐positives (95% CI: 25.00 to 40.51) and initiated 8 HIV‐positives on antiretroviral treatment (95% CI: 5.54 to 10.33). After commART introduction, Model A cluster showed an immediate significant increase in 744 HIV‐positive persons (p = 0.00, 95% CI: 360.35 to 1127.77) and 560 HIV‐positives initiated on treatment (p = 0.00, 95% CI: 260.56 to 859.64). Model B cluster showed an immediate significant increase in 30 HIV‐positive persons identified (p = 0.01, 95% CI: 8.38 to 51.93) but not in the number of HIV‐positives initiated on treatment. Model B cluster showed increased month‐on‐month trends of both outcomes of interest (3.4, p = 0.02, 95% CI: 0.44 to 6.38).ConclusionBoth community‐models had similar population‐level effectiveness for rapidly identifying people living with HIV but differed in effectively transitioning them to treatment. Comprehensiveness, integration and attention to barriers to care are important in the design of community antiretroviral treatment delivery.

Rapid initiation of antiretroviral therapy for people living with HIV

“…Data from general adult population cohort studies have shown better uptake and time to viral suppression among those initiating ART early compared to more delayed ART initiation, and no difference in retention in care in the one cohort reporting on this outcome (Pilcher 2017). Oladele 2018 evaluated different rapid ART delivery methods and determined that community‐based rapid ART was more effective than referral for facility‐based rapid ART. Among pregnant women, same‐day ART initiation appeared to result in similar retention or viral suppression compared to delayed treatment (median seven days; Langwenya 2018).…”

Multilevel modelling and multiple group analysis of disparities in continuity of care and viral suppression among adolescents and youths living with HIV in Nigeria

“…Gradual decentralisation since then has resulted in an increased mix in types and levels of healthcare facilities delivering HIV services. 26 While this has significantly increased access to HIV services, it has also brought about heterogeneity in terms of how national HIV guidelines are interpreted and implemented. The extent to which these differences in service delivery channels have shaped HIV-related outcomes have received little attention partly because of little information sharing between the public and private health sectors.…”

Effect of community treatment initiative on antiretroviral therapy uptake among linkage-resistant people living with HIV in Northern Nigeria

“…The significance of the study results is the fact that the CTI, as an intervention, improved ART uptake in the community and could therefore be used in rural communities. Low-and middle-income countries thatoften battlewith poor health infrastructure underpinned by poor human resource for health (HRH) will benefit from community interventions in order to control the HIV epidemic (Oladele et al, 2018). The conventional method for ART includes self/community referrals to the facility, the use of linkage coordinators/escort services, and redeemable coupons as an incentive for linkage.…”

“…It is expected that this study will contribute to the body of knowledge by providing evidence on how a community intervention such as a CTI can ensure that PLHIV who refuse treatment at the facility for one reason or another are placed on treatment in the community (Busza et al, 2018;Oladele et al, 2018). Additionally, this study presents the CTI as an alternative treatment method in a resource-poor setting such as Nigeria.…”