Long‐term virologic responses to antiretroviral therapy among HIV‐positive patients entering adherence clubs in Khayelitsha, Cape Town, South Africa: a longitudinal analysis

Abstract

Introduction In South Africa, an estimated 4.6 million people were accessing antiretroviral therapy (ART) in 2018. As universal Test and Treat is implemented, these numbers will continue to increase. Given the need for lifelong care for millions of individuals, differentiated service delivery models for ART services such as adherence clubs (ACs) for stable patients are required. In this study, we describe long‐term virologic outcomes of patients who have ever entered ACs in Khayelitsha, Cape Town. Methods We included adult patients enrolled in ACs in Khayelitsha between January 2011 and December 2016 with a recorded viral load (VL) before enrolment. Risk factors for an elevated VL (VL >1000 copies/mL) and confirmed virologic failure (two consecutive VLs >1000 copies/mL one year apart) were estimated using Cox proportional hazards models. VL completeness over time was assessed. Results Overall, 8058 patients were included in the analysis, contributing 16,047 person‐years of follow‐up from AC entry (median follow‐up time 1.7 years, interquartile range [IQR]:0.9 to 2.9). At AC entry, 74% were female, 46% were aged between 35 and 44 years, and the median duration on ART was 4.8 years (IQR: 3.0 to 7.2). Among patients virologically suppressed at AC entry (n = 8058), 7136 (89%) had a subsequent VL test, of which 441 (6%) experienced an elevated VL (median time from AC entry 363 days, IQR: 170 to 728). Older age (adjusted hazard ratio [aHR] 0.64, 95% confidence interval [CI] 0.46 to 0.88), more recent year of AC entry (aHR 0.76, 95% CI 0.68 to 0.84) and higher CD4 count (aHR 0.67, 95% CI 0.54 to 0.84) were protective against experiencing an elevated VL. Among patients with an elevated VL, 52% (150/291) with a repeat VL test subsequently experienced confirmed virologic failure in a median time of 112 days (IQR: 56 to 168). Frequency of VL testing was constant over time (82 to 85%), with over 90% of patients remaining virologically suppressed. Conclusions This study demonstrates low prevalence of elevated VLs and confirmed virologic failure among patients who entered ACs. Although ACs were expanded rapidly, most patients were well monitored and remained stable, supporting the continued rollout of this model.

Twenty‐four‐month outcomes from a cluster‐randomized controlled trial of extending antiretroviral therapy refills in ART adherence clubs

“…VL completion was high in the first 12 months, and lower in the second year of the study (85.2% in SoC and 90.8% in intervention), but still equivalent or better than published data on similar AC cohorts (85.2% [43], 79.7% to 86.5% [7], 82% to 85% [14]).…”

“…Retention was also comparable to the six-monthly dispensing arms of the recently published non-inferiority trials from Zimbabwe (93.6%) and Lesotho (94.7%) [30,31]. VL completion was high in the first 12 months, and lower in the second year of the study (85.2% in SoC and 90.8% in intervention), but still equivalent or better than published data on similar AC cohorts (85.2% [43], 79.7% to 86.5% [7], 82% to 85% [14]).…”

“…Patients generally see a clinician annually for a comprehensive clinical consultation, but are referred for additional clinical care if necessary. ACs have shown good retention and viral suppression outcomes both at site level and at scale and are acceptable to patients [7][8][9][10][11][12][13][14].…”

Health Worker Experiences of and Perspectives on Engaging Men in HIV Care: A Qualitative Study in Cape Town, South Africa

“…Adherence clubs are groups attached to a clinic and facilitated by a community HW, where patients who are stable and adherent on ART can come and collect their medication without a formal clinic visit. 26 Health Worker Perceptions of Factors Shaping Men's Engagement in HIV Care…”

Understanding Engagement in HIV Programmes: How Health Services Can Adapt to Ensure No One Is Left Behind

“…Further, with the advent of dolutegravir offering quicker viral suppression and the scale-up of differentiated ART delivery models, eligibility for differentiated ART delivery after one suppressed viral load should be considered to support patientcentred care. Patients may also benefit from increased knowledge of and access to differentiated ART delivery modelsincluding group models such as Adherence Clubs [63] and community ART groups [64,65] and community-based individual models including collection from private pharmacies [66] and through community drug distribution points [67].…”