Outcomes of patients enrolled in an antiretroviral adherence club with recent viral suppression after experiencing elevated viral loads

Antiretroviral therapy programme outcomes at Senkatana antiretroviral therapy clinic, Lesotho: a four-year retrospective cohort study

Introduction

sub-Saharan Africa, home to over 10% of the world´s population, is the worst Human Immunodeficiency Virus (HIV)-affected region in the world. HIV/AIDS is a major public health challenge in Lesotho, with an HIV prevalence of 25.6% in 2018. The aim of this study was to evaluate the treatment outcomes of people living with HIV (PLHIV) on antiretroviral therapy (ART) after 48 months of initiation.

Methods

we conducted a register-based retrospective cohort study for all patients registered at the Senkatana ART Clinic from January to December 2014 and followed them for 48 months until 2018. The ART treatment register and treatment cards were the primary source of data. Data were captured and cleaned in Epi info version 7 and exported into Stata version 14 for analysis. Descriptive statistics were used to describe participant characteristics. Due to the lack of incident data, the factors associated with treatment outcomes were determined using Chi-square tests and logistic regression.

Results

in 2014, 604 patients were enrolled on ART, of which the majority were female (59.4%) and married (54.8%). The mean age (standard deviation (SD)) at which ART was started was 36 years (10.5) years. After 48 months of initiation, the cohort consisted of 387 patients of which 365 (94.3%) were retained on treatment. In the multivariable logistic regression model, neither demographic characteristics nor clinical factors were associated with ART treatment outcome (viral load suppression, adherence, or ART retention), however, the univariable analysis showed that higher CD4 count at initiation was associated with viral load suppression.

Conclusion

retention, viral load suppression, and adherence were generally good in this cohort after 48 months of initiation. CD4 at initiation was a significant predictor of viral load suppression at 48 months. The ART programme has managed to maintain high viral load suppression and improve immunity in patients who are immunocompromised. Proper data quality management is required for adequate patient monitoring to enable clinical personnel to record and use individual patient data for guiding the clinical management of such patients. Strengthening patient support and tracing will help to reduce the number of patients lost to follow-up.

A Facility-based Family Support Intervention to Improve Treatment Outcomes for Adolescents on Antiretroviral Therapy in the Cape Metropole, South Africa

Adolescents living with human immunodeficiency virus (HIV) (ALHIV) globally, report worse treatment outcomes compared to adults and children on antiretroviral therapy (ART). We conducted a photovoice study with eighteen ALHIV to explore experiences and challenges of being on ART, and individual interviews with 5 health workers to describe the challenges in treating ALHIV. The facility implemented the Family club intervention to facilitate caregivers (parent/guardians) supporting ALHIV on treatment. The health workers revealed that "disclosing HIV status" to children was the biggest challenge for caregivers and health workers. Participating ALHIV reported that family support and having a positive mentality were instrumental for continued treatment adherence. However, disclosure of HIV status to friends remained a challenge due to pervasive community stigma. Treatment fatigue and side-effects were also barriers to adherence. Family support was instrumental in facilitating adherence support for ALHIV. However, this (intervention) should include peer support to improve positive mental well-being in ALHIV.

Differentiated service delivery for people using second-line antiretroviral therapy: clinical outcomes from a retrospective cohort study in KwaZulu-Natal, South Africa

Introduction

Evidence is needed to guide the inclusion of broader groups of people living with HIV (PLHIV) in differentiated service delivery (DSD) programmes. We assessed treatment outcomes among PLHIV on second‐line regimens in a community antiretroviral therapy (ART) delivery programme, compared to those who remained at clinics.

Methods

Using data from 61 public clinics, we did a retrospective cohort study among PLHIV receiving second‐line ART following rollout of the Centralized Chronic Medicines Dispensing and Distribution (CCMDD) programme in KwaZulu‐Natal, South Africa. We included PLHIV from the timepoint when they were first eligible, though not necessarily referred, for community ART within CCMDD and followed them for 18 months. We used multivariable logistic regression to compare 12‐month attrition and viraemia between clients referred for community ART and those remaining in clinic care.

Results

Among 209,744 PLHIV aged ≥ 18 years who collected ART between October 2016 and December 2018, 7511 (3.6%) received second‐line ART. Of these, 2575 (34.3%) were eligible for community ART. The median age was 39.0 years (interquartile range 34.0–45.0) and 1670 (64.9%) were women. Five hundred and eighty‐four (22.7%) were referred for community ART within 6 months of meeting eligibility criteria. Overall, 4.5% [95% confidence interval (CI) 3.0–6.6%] in community ART and 4.4% (95% CI 3.5–5.4%) in clinic care experienced attrition at 12 months post eligibility for community ART. Two thousand one hundred and thirty‐eight (83.0%) had a viral load recorded 6–18 months after becoming eligible, and of these, 10.3% (95% CI 7.7–13.3%) in community ART and 11.3% (95% CI 9.8–12.9%) in clinic care had viraemia > 200 copies/ml. In separate regressions adjusted for age, gender, district, time on second‐line ART, nucleoside reverse transcriptase inhibitor backbone and year of eligibility, no differences in the odds of attrition [adjusted odds ratio (aOR) 1.02, 95% CI 0.71–1.47] or viraemia (aOR 0.91, 95% CI 0.64–1.29) were observed between those in community ART and those remaining in clinic care.

Conclusions

We found good outcomes among PLHIV who were stable on second‐line regimens and referred for community ART. Efforts to expand DSD access among this group should be prioritized.

Exploring Sustainability in the Era of Differentiated HIV Service Delivery in Sub-Saharan Africa: A Systematic Review

INTRODUCTION

The World Health Organization recommends differentiated service delivery (DSD) to support resource-limited health systems in providing patient-centered HIV care. DSD offers alternative care models to clinic-based care for people living with HIV who are stable on antiretroviral therapy (ART). Despite good patient-related outcomes, there is limited evidence of their sustainability. Our review evaluated the reporting of sustainability indicators of DSD interventions conducted in sub-Saharan Africa (SSA).

METHODS

We searched PubMed and EMBASE for studies conducted between 2000 and 2019 assessing DSD interventions targeting HIV-positive individuals who are established in ART in sub-Saharan Africa. We evaluated them through a comprehensive sustainability framework of constructs categorized into 6 domains (intervention design, process, external environment, resources, organizational setting, and people involvement). We scored each construct 1, 2, or 3 for no, partial, or sufficient level of evidence, respectively. Interventions with a calculated sustainability score (overall and domain-specific) of >90% or domain-specific median score >2.7 were considered likely to be sustainable.

RESULTS

Overall scores ranged from 69% to 98%. Top scoring intervention types included adherence clubs (98%) and community ART groups (95%) which comprised more than half of interventions. The highest scoring domains were design (2.9) and organizational setting (2.8). The domains of resources (2.4) and people involvement (2.3) scored lowest revealing potential areas for improvement to support DSD sustainability.

CONCLUSIONS

With the right investment in stakeholder involvement and domestic funding, DSD models generally show potential for sustainability. Our results could guide informed decisions on which DSD intervention is likely to be sustainable per setting and highlight areas that could motivate further research.

Twelve-Month Outcomes of Community-Based Differentiated Models of Multimonth Dispensing of ART Among Stable HIV-Infected Adults in Lesotho: A Cluster-Randomized Noninferiority Trial

BACKGROUND

Lesotho adopted the test-and-treat approach for HIV treatment in June 2016, which increased antiretroviral treatment (ART) clinic volume. We evaluated community-based vs. facility-based differentiated models of multimonth dispensing of ART among stable HIV-infected adults in Lesotho.

METHODS

Thirty facilities were randomized to 3 arms, facility 3-monthly ART (3MF) (control), community ART groups (3MC), and 6-monthly community distribution points (6MCD). We estimated risk differences (RDs) between arms using population-averaged generalized estimating equations, controlling for baseline imbalances and specifying for clustering. The primary outcome was retention in ART care by intention-to-treat and virologic suppression as a secondary outcome (ClinicalTrials.gov: NCT03438370).

RESULTS

A total of 5,336 participants were enrolled, with 1898, 1558, and 1880 in 3MF, 3MC, and 6MCD, respectively. Retention in ART care was not different across arms and achieved the prespecified noninferiority limit (-3.25%) between 3MC vs. 3MF (control); 6MCD vs. 3MF; and 6MCD vs. 3MC, adjusted RD = -0.1% [95% confidence interval (CI): -1.6% to 1.5%], adjusted RD = -1.3% (95% CI: -3.0% to 0.5%), and adjusted RD = -1.2% (95% CI: -2.9% to 0.5%), respectively. After 12 months, 98.6% (n = 1503), 98.1% (n = 1126), and 98.3% (n = 1285) were virally load (VL) suppressed in 3MF, 3MC, and 6MCD, respectively. There were no differences in VL between 3MC vs. control and 6MCD vs. control, risk ratio (RR) = 1.00 (95% CI: 0.98 to 1.01) and RR = 1.00 (95% CI: 0.98 to 1.01), respectively.

CONCLUSIONS

There were no differences in retention and VL suppression for stable HIV-infected participants receiving multimonth dispensing of ART within community-based differentiated models when compared with the facility-based standard-of-care model.

Using Intervention Mapping methodology to design an HIV linkage intervention in a refugee settlement in rural Uganda

Nearly 80 million people have been forcibly displaced by persecution, violence, and disaster. Displaced populations, including refugees, face health challenges such as resource shortages, food and housing insecurity, violence, and disrupted social support. People living with HIV in refugee settings have decreased engagement with HIV services compared to non-refugee populations, and interventions are needed to enhance linkage to care. However, designing health interventions in humanitarian settings is challenging. We used Intervention Mapping (IM), a six-step method for developing theory- and evidence-based health interventions, to design a program to increase linkage to HIV care for refugees and Ugandan nationals in Nakivale Refugee Settlement in Uganda. We engaged a diverse group of stakeholders (N = 14) in Nakivale, including community members and humanitarian actors, in an interactive workshop focusing on IM steps 1–4. We developed a chronic care program that would integrate HIV care with services for hypertension and diabetes at accessible community sites, thereby decreasing stigma around HIV treatment and improving access to care. IM provided an inclusive, efficient method for integrating community members and program implementers in the intervention planning process, and can be used as a method-driven approach to intervention design in humanitarian settings.

Outcomes of patients on second- and third-line ART enrolled in ART adherence clubs in Maputo, Mozambique

Objectives

Adherence clubs (AC) offer patient‐centred access to antiretroviral therapy (ART) while reducing the burden on health facilities. AC were implemented in a health centre in Mozambique specialising in patients with a history of HIV treatment failure. We explored the impact of AC on retention in care and VL suppression of these patients.

Methods

We performed a retrospective analysis of patients enrolled in AC receiving second‐ or third‐line ART. The Kaplan–Meier estimates were used to analyse retention in care in health facility, retention in AC and viral load (VL) suppression (VL < 1000 copies/mL). Predictors of attrition and VL rebound (VL ≥ 1000 copies/mL) were assessed using multivariable proportional hazards regression.

Results

The analysed cohort contained 699 patients, median age 40 years [IQR: 35–47], 428 (61%) female and 97% second‐line ART. Overall, 9 (1.3%) patients died, and 10 (1.4%) were lost to follow‐up. Retention in care at months 12 and 24 was 98.9% (95% CI: 98.2–99.7) and 96.4% (95% CI: 94.6–98.2), respectively. Concurrently, 85.8% (95% CI: 83.1–88.2) and 80.9% (95% CI: 77.8–84.1) of patients maintained VL suppression. No association between predictors and all‐cause attrition or VL rebound was detected. Among 90 patients attending AC and simultaneously having VL rebound, 64 (71.1%) achieved VL resuppression, 10 (11.1%) did not resuppress, and 14 (15.6%) had no subsequent VL result.

Conclusion

Implementation of AC in Mozambique was successful and demonstrated that patients with a history of HIV treatment failure can be successfully retained in care and have high VL suppression rate when enrolled in AC. Expansion of the AC model in Mozambique could improve overall retention in care and VL suppression while reducing workload in health facilities.

"Patients are not the same, so we cannot treat them the same" - A qualitative content analysis of provider, patient and implementer perspectives on differentiated service delivery models for HIV treatment in South Africa

INTRODUCTION

In 2014, the South African government adopted a differentiated service delivery (DSD) model in its "National Adherence Guidelines for Chronic Diseases (HIV, TB and NCDs)" (AGL) to strengthen the HIV care cascade. We describe the barriers and facilitators of the AGL implementation as experienced by various stakeholders in eight intervention and control sites across four districts.

METHODS

Embedded within a cluster-randomized evaluation of the AGL, we conducted 48 in-depth interviews (IDIs) with healthcare providers, 16 IDIs with Department of Health and implementing partners and 24 focus group discussions (FGDs) with three HIV patient groups: new, stable and those not stable on treatment or not adhering to care. IDIs were conducted from August 2016 to August 2017; FGDs were conducted in January to February 2017. Content analysis was guided by the Consolidated Framework for Implementation Research. Findings were triangulated among respondent types to elicit barriers and facilitators to implementation.

RESULTS

New HIV patients found counselling helpful but intervention respondents reported sub-optimal counselling and privacy concerns as barriers to initiation. Providers felt insufficiently trained for this intervention and were confused by the simultaneous rollout of the Universal Test and Treat strategy. For stable patients, repeat prescription collection strategies (RPCS) were generally well received. Patients and providers concurred that RPCS reduced congestion and waiting times at clinics. There was confusion though, among providers and implementers, around implementation of RPCS interventions. For patients not stable on treatment, enhanced counselling and tracing patients lost-to-follow-up were perceived as beneficial to adherence behaviours but faced logistical challenges. All providers faced difficulties accessing data and identifying patients in need of tracing. Congestion at clinics and staff attitude were perceived as barriers preventing patients returning to care.

CONCLUSIONS

Implementation of DSD models at scale is complex but this evaluation identified several positive aspects of AGL implementation. The positive perception of RPCS interventions and challenges managing patients not stable on treatment aligned with results from the larger evaluation. While some implementation challenges may resolve with experience, ensuring providers and implementers have the necessary training, tools and resources to operationalize AGL effectively is critical to the overall success of South Africa's HIV control strategy.

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

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.