Retention in care and factors critical for effectively implementing antiretroviral adherence clubs in a rural district in South Africa

Böck, Peter; Gunst, Colette; Maschilla, Leonard; Holtman, Rory; Grobbelaar, Nelis; Wademan, Dillon; Dunbar, Rory; Fatti, Geoffrey; Kruger, James; Ford, Nathan; Hoddinott, Graeme; Meehan, Sue‐Ann

doi:10.1002/jia2.25396

Cited by 21 publications

(26 citation statements)

References 23 publications

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“…These strategies may include increased patient surveillance and strengthened patient tracing mechanisms to reduce LTFU at health facilities, strengthened community-based caregiver and peer support, 14 and nutritional aid support especially for adolescents and young adults (15-34 years). In addition, interventions that minimise 'leakages' in the HIV treatment cascade including the use of ART adherence clubs to reduce ART resistance 53 and advice on sexual abstinence should remain the cornerstone of HIV prevention and control. As much as most of the observed LTFU outcome at higher levels of care (district, provincial and central hospitals) could be 'silent transfers', most patients who become LTFU are likely to have poor ART adherence if not dead.…”

Section: Resultsmentioning

confidence: 99%

Competing risk of mortality on loss to follow-up outcome among patients with HIV on ART: a retrospective cohort study from the Zimbabwe national ART programme

et al. 2020

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ObjectiveTo determine the loss to follow-up (LTFU) rates at different healthcare levels after antiretroviral therapy (ART) services decentralisation among ART patients who initiated ART between 2004 and 2017 using the competing risk model in addition to the Kaplan-Meier and Cox regressions analysis.DesignA retrospective cohort study.SettingThe study was done in Zimbabwe using a nationwide routinely collected HIV patient-level data from various health levels of care facilities compiled through the electronic patient management system (ePMS).ParticipantsWe analysed 390 771 participants aged 15 years and above from 538 health facilities.OutcomesThe primary endpoint was LTFU defined as a failure of a patient to report for drug refill for at least 90 days from last appointment date or if the patient missed the next scheduled visit date and never showed up again. Mortality was considered a secondary outcome if a patient was reported to have died.ResultsThe total exposure time contributed was 1 544 468 person-years. LTFU rate was 5.75 (95% CI 5.71 to 5.78) per 100 person-years. Adjustment for the competing event independently increased LTFU rate ratio in provincial and referral (adjusted sub-HRs (AsHR) 1.22; 95% CI 1.18 to 1.26) and district and mission (AsHR 1.47; 95% CI 1.45 to 1.50) hospitals (reference: primary healthcare); in urban sites (AsHR 1.61; 95% CI 1.59 to 1.63) (reference: rural); and among adolescence and young adults (15–24 years) group (AsHR 1.19; 95% CI 1.16 to 1.21) (reference: 35–44 years). We also detected overwhelming association between LTFU and tuberculosis-infected patients (AsHR 1.53; 95% CI 1.45 to 1.62) (reference: no tuberculosis).ConclusionsWe have observed considerable findings that ‘leakages’ (LTFU) within the ART treatment cascade persist even after the decentralisation of health services. Risk factors for LTFU reflect those found in sub-Saharan African studies. Interventions that retain patients in care by minimising any ‘leakages’ along the treatment cascade are essential in attaining the 90–90–90 UNAIDS fast-track targets.

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Section: Resultsmentioning

confidence: 99%

Competing risk of mortality on loss to follow-up outcome among patients with HIV on ART: a retrospective cohort study from the Zimbabwe national ART programme

et al. 2020

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“…Cassidy T et al Journal of the International AIDS Society 2020, 23:e25649 http://onlinelibrary.wiley.com/doi/10.1002/jia2.25649/full | https://doi.org/10.1002/jia2.25649 reported 95% to 97% [8,35,43,44], and higher than 89.5% reported from a South African AC model evaluation comparing 24 randomly allocated intervention and control facilities undertaken in Gauteng, Kwa-Zulu Natal, Limpopo and North West provinces at the same time point [9]. 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].…”

Section: Discussionmentioning

confidence: 99%

“…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].…”

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confidence: 99%

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

Cassidy

Grimsrud²,

Keene

et al. 2020

J. Intern. AIDS Soc.

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Introduction The antiretroviral therapy (ART) adherence club (AC) model has supported clinically stable HIV patients’ retention with group ART refills and psychosocial support. Reducing visit frequency by increasing ART refills to six months could further benefit patients and unburden health systems. We conducted a pragmatic non‐inferiority cluster randomized trial comparing standard of care (SoC) ACs and six‐month refill intervention ACs in a primary care facility in Khayelitsha, South Africa. Methods Existing community‐based and facility‐based ACs were randomized to either SoC or intervention ACs. SoC ACs met five times annually, receiving two‐month refills with a four‐month refill over year‐end. Blood was drawn at one AC visit with a clinical assessment at the next. Intervention ACs met twice annually receiving six‐month refills, with an individual blood collection visit before the annual clinical assessment AC visit. The first study visits were in October and November 2017 and participants followed for 27 months. We report retention in care, viral load completion and viral suppression (<400 copies/mL) 24 months after enrolment and calculated intention‐to‐treat risk differences for the primary outcomes using generalized estimating equations specifying for clustering by AC. Results Of 2150 participants included in the trial, 977 were assigned to the intervention arm (40 ACs) and 1173 to the SoC (48 ACs). Patient characteristics at enrolment were similar across groups. Retention in care at 24 months was similarly high in both arms: 93.6% (1098/1173) in SoC and 92.6% (905/977) in the intervention arm, with a risk difference of −1.0% (95% CI: −3.2 to 1.3). The intervention arm had higher viral load completion (90.8% (999/1173) versus 85.1% (887/977)) and suppression (87.3% (969 /1173) versus 82.6% (853/977)) at 24 months, with a risk difference for completion of 5.5% (95% CI: 1.5 to 9.5) and suppression of 4.6% (95% CI: 0.2 to 9.0). Conclusions Intervention AC patients receiving six‐month ART refills showed non‐inferior retention in care, viral load completion and viral load suppression to those in SoC ACs, adding to a growing literature showing good outcomes with extended ART dispensing intervals.

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“…Similarly, clients reported time saved for other activities as the greatest bene t derived from another DSD intervention in Uganda (42). Relatedly, reduced travel time has been identi ed as bene cial for DSD participants and enabling its success though it was not independently associated with HRQoL in our study (43,44).…”

Section: Discussionmentioning

confidence: 54%

Beyond Viral Suppression: Quality of Life among stable ART Clients in a Differentiated Service Delivery Intervention in Tanzania

Okere

Censi

Machibya³

et al. 2020

Preprint

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Background: More people living with HIV (PLHIV) in resource-limited settings are virally suppressed and living longer, mainly due to an increased access to effective antiretroviral therapy (ART). With the expansion of ART programmes, the World Health Organisation recommended differentiated service delivery (DSD) as an alternative less resource-demanding way of accessing HIV services. While maintaining quality of care and continued adherence among patients are health system’s priorities, monitoring patient’s quality of life is key to ensure sustainability and uptake of services. However, health-related quality of life (HRQoL) is understudied in sub-Saharan Africa (SSA). We aimed to assess HRQoL among stable ART clients accessing ART care in adherence clubs implemented in Tanzania. Methods: We conducted a cross-sectional survey from May to August 2019 among stable ART clients randomly sampled among those accessing clinics and clubs daily in two sites, a rural and peri-urban setting in the Shinyanga region. HRQoL data was collected, after obtaining informed consent, using the interviewer-administered Functional Assessment of HIV infection (FAHI), a validated HIV-specific HRQoL instrument. We also collected on socio-demographic, HIV care and service accessibility factors. Descriptive analysis, modified Poisson regression with robust variance and a stepwise multiple linear regression were performed to analyse HRQoL and its determinants.Results: A total of 629 participants were enrolled, of which 40% were DSD patients. DSD and clinic participants showed similar HRQoL scores [mean (SD), p value]; FAHI total [152.2 (22.2) vs 153.8 (20.6), p 0.687]. Accessibility factors, e.g. less time spent during and less frequent DSD meetings, contributed to emotional wellbeing among DSD participants compared to those in clinic (53.4% vs 18.5%,p=<0.001). Satisfactory (>80% of achievable) HRQoL scoring was independently associated with (relative risk [95% confidence interval], p value) being male (1.18[1.06-1.31], p 0.002); being married (1.22 [1.01-1.45, p 0.043); and living in an urban setting (1.28 [1.09-1.49], p 0.001). Conclusions: DSD does not appear to compromise HRQoL and, encouragingly, it could contribute to an improvement in emotional wellbeing among patients. While DSD shows promise in improving acceptability among patients and, therefore, sustainability of such services, our research highlights future research avenues to identify supporting interventions to improve other HRQoL domains among PLHIV.

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Retention in care and factors critical for effectively implementing antiretroviral adherence clubs in a rural district in South Africa

Cited by 21 publications

References 23 publications

Competing risk of mortality on loss to follow-up outcome among patients with HIV on ART: a retrospective cohort study from the Zimbabwe national ART programme

Competing risk of mortality on loss to follow-up outcome among patients with HIV on ART: a retrospective cohort study from the Zimbabwe national ART programme

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

Beyond Viral Suppression: Quality of Life among stable ART Clients in a Differentiated Service Delivery Intervention in Tanzania

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