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

Abstract

Little is known about the effect of community versus health facility-based interventions to improve and sustain antiretroviral therapy (ART) adherence, virologic suppression, and retention in care among HIV-infected individuals in low-and middle-income countries (LMICs). We systematically searched four electronic databases for all available randomized controlled trials (RCTs) and comparative cohort studies in LMICs comparing community versus health facility-based interventions. Relative risks (RRs) for pre-defined adherence, treatment engagement (linkage and retention in care), and relevant clinical outcomes were pooled using random effect models. Eleven cohort studies and eleven RCTs (N = 97,657) were included. Meta-analysis of the included RCTs comparing community- versus health facility-based interventions found comparable outcomes in terms of ART adherence (RR = 1.02, 95 % CI 0.99 to 1.04), virologic suppression (RR = 1.00, 95 % CI 0.98 to 1.03), and all-cause mortality (RR = 0.93, 95 % CI 0.73 to 1.18). The result of pooled analysis from the RCTs (RR = 1.03, 95 % CI 1.01 to 1.06) and cohort studies (RR = 1.09, 95 % CI 1.03 to 1.15) found that participants assigned to community-based interventions had statistically significantly higher rates of treatment engagement. Two studies found community-based ART delivery model either cost-saving or cost-effective. Community- versus facility-based models of ART delivery resulted in at least comparable outcomes for clinically stable HIV-infected patients on treatment in LMICs and are likely to be cost-effective.

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“…Specific interventions that appear to be most effective in HIV include weekly SMS reminders, treatment supporters, and enhanced counseling 27 . A large meta-analysis has also highlighted the benefits of decentralizing care and task shifting, demonstrating a more favorable effect for community-based vs. clinic-based ART programs on engagement in care in low- and middle-income countries 28 . Although both community- and clinic-based interventions demonstrated similar effects on adherence, virologic suppression, and mortality in this meta-analysis, interim data from the contemporary SEARCH study in east Africa suggest that community-based testing and treatment may lead to even greater improvements in ART coverage and viral suppression that meet 90-90-90 goals 29 .…”

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“…Such screeners can however be geographically and socially distant from populations at high risk for the disease screened. To address this issue, peer-led interventions have been piloted and have shown a positive impact on the control of diseases such as human immunodeficiency virus (HIV), 7 , 8 malaria 9 and tuberculosis 10 , 11 …”

UNAIDS 90–90–90 targets to end the AIDS epidemic by 2020 are not realistic: comment on “Can the UNAIDS 90–90–90 target be achieved? A systematic analysis of national HIV treatment cascades”

“…Active research and development of community friendly interventions are highly needed 14. This can lead to an increase in screening rates; also, early identification of patients lost to follow-up and addressing of special psychosocial concerns could be achieved 14.…”

“…Active research and development of community friendly interventions are highly needed 14. This can lead to an increase in screening rates; also, early identification of patients lost to follow-up and addressing of special psychosocial concerns could be achieved 14. Getting good and uniform data constitutes a priority to better monitor, plan and act appropriately within the context of evolving towards meeting these, for the moment elusive targets, especially in LMICs 4.…”