Engagement in Care, Viral Suppression, Drug Resistance, and Reasons for Nonengagement After Home-Based Same-Day Antiretroviral Therapy Initiation in Lesotho: A Two-Year Follow-up of the CASCADE Trial

Abstract

Background The CASCADE trial showed that compared with usual care (UC), offering same-day (SD) antiretroviral therapy (ART) during home-based human immunodeficiency virus testing improved engagement in care and viral suppression 12 months after diagnosis. However, questions remain regarding long-term outcomes and the risk of propagating drug resistance. Methods After completion of the primary endpoint at 12 months, participants not in care in both arms were traced and encouraged to access care. At 24 months, the following outcomes were assessed in both arms: engagement in care, viral suppression, and reasons for nonengagement. Furthermore, we explored the acquisition of drug resistance mutations (DRMs) among SD arm nonlinkers. Results At 24 months, 64% (88/137) in the SD arm vs 59% (81/137) in the UC arm were in care (absolute difference [AD], 5%; 95% confidence interval [CI], −6 to16; P = .38) and 57% (78/137) vs 54% (74/137) had documented viral suppression (AD, 3%; 95% CI, −9 to 15; P = .28). Among 36 participants alive and not in care at 24 months with ascertained status, the majority rejected contact with the health system or were unwilling to take ART. Among 8 interviewed SD arm nonlinkers, 6 had not initiated ART upon enrollment, and no acquired DRMs were detected. Two had taken the initial 30-day ART supply and acquired DRMs. Conclusions SD ART resulted in higher rates of engagement in care and viral suppression at 12 months but not at 24 months. Leveling off between both arms was driven by linkage beyond 12 months in the UC arm. We did not observe compensatory long-term disengagement in the SD arm. These long-term results endorse SD ART initiation policies.

Effects of community-based antiretroviral therapy initiation models on HIV treatment outcomes: A systematic review and meta-analysis

“…When compared to standard of care (facility-based ART initiation and refills), retention did not appear to differ by population type, ART initiation site, refill site, or frequency of ART refill ( Fig 5 ). One study additionally reported retention among HIV-positive individuals at 24 months and found no difference between community ART initiation and facility ART initiation and maintenance (RD 5%, 95% CI −16% to 16%, p = 0.380) at this time point [ 33 ]. In pooled analyses restricted to those who initiated ART, retention was no different between study arms ( S6 Fig ; RR 1.15, 95% CI 0.99 to 1.33).…”

“…Three studies compared viral suppression between community ART initiation and facility ART initiation and maintenance (standard of care) arms among HIV-positive individuals at 12 months; this comparison showed better viral suppression in the community ART group (RR 1.31, 95% CI 1.15 to 1.49) ( Fig 6 ). One study additionally reported 24-month outcomes, which showed no difference in viral load suppression in the community ART arm compared to the facility ART arm (RD 3%, 95% CI −9% to 15%, p = 0.28) at this time point [ 33 ]. The threshold for viral load suppression ranged from less than 100 copies/mL [ 23 ], to 1,000 copies/mL [ 28 ].…”

“…There was variable adverse event reporting, including mild, serious, and severe adverse events, social harms, and opportunistic infection incidence ( Table 6 ). Severe adverse events in community ART initiation arms ranged from 1% to 6% and in facility ART initiation arms ranged from 1% to 2% [ 23 , 25 , 30 , 33 ]. There were very few opportunistic infections or social harms; this was however infrequently reported in the included studies.…”

“…Two studies included HIV self-testing strategies; in one this was the primary method of HIV testing [26], and in another HIV self-tests were distributed to those who declined testing and those away from home in a subset of participants [27]. The location AU : Pleasecheckthattheeditstothesentenc of ART refill collection (after ART initiation) varied, with half of the studies having participants collect ART refills in the community [28,30,31] and the other half having participants collect ART refills at the health facility [23,26,29]; 1 study compared community and facility ART refills in 2 community ART initiation arms [33]. Once stabilized on ART, those receiving facility-based ART refills received ART refills every 3 months.…”

Community-based antiretroviral therapy versus standard clinic-based services for HIV in South Africa and Uganda (DO ART): a randomised trial

“…24 If clients are transferred to ART refills outside the clinic (eg, decentralised dispensing, adherence groups, community, and home) compared with clinic ART, they remained virally supressed. [25][26][27] Offering convenient locations and times after hours and on weekends, being flexible to meet travel or mobility needs, offering quarterly refills, and streamlining monitoring and resupply had better viral suppression outcomes, especially for men.…”