Community HIV Care as Effective as Facility-Based Care

Using community-based models of delivering antiretroviral therapy (ART) can be as effective as the standard facility-based, traditional model, according to a paper published in The Lancet HIV.

Investigators from the United Kingdom and Zambia conducted a 2-city study in Lusaka, Zambia in order to determine the efficacy and feasibility of alternative models of HIV care, home-based delivery (HBD) and adherence clubs (AC), compared to standard of care (SoC). To do this, the study authors looked at the participants’ virological suppression in the intervention arms compared to SoC after 12 months post-enrollment. They also wrote that ART delivered outside of a traditional facility for people with HIV might increase sustainable ART coverage in low- and middle-income countries.

In June 2016, when the study was initiated, the study authors estimated an HIV prevalence locally of about 20 percent in adults aged 18 to 44 years, and of those, about 70 percent accessed ART.

In the HBD group, the study authors described a process where a pair of community HIV care providers visited each participate in their home once every 3 months to provide adherence support, symptom screening using a checklist, and dispensed prepackaged drugs. The AC group had a club that consisted of 15 to 30 participants, the study authors said, and the groups met once every 3 months at a communal venue for adherence support, symptom screening, and prepackaged medication delivered by a pair of community HIV care providers. Both groups returned to the clinic at 6 and 12 months for clinical review, ART refill, and lab monitoring, the study authors added.

The investigators ultimately identified 2489 participants, of which 1757 were female. A third were assigned to SoC, a third were randomized to HBD, and a third were assigned to AC. The median age of the participants was 40 years and the median duration of ART was 4 years, the study authors added.

The study authors observed that a higher proportion of participants had a viral load measurement in the HBD and AC groups compared to the SoC group. They also found that throughout all 3 groups, about 1 percent were not virally suppressed. Viral load suppression was estimated by the study authors to be 98.3 percent in the SoC group compared to 98.7 in the HBD group and 99.2 percent in the AC group.

Additional analysis revealed that the proportion of participants who were virally suppressed remained very high with strong evidence of non-inferiority, the study authors said.

At the conclusion of the study, the investigators said that retention was highest in the AC group, followed by the HBD group, and last was the SoC group. There were no reports of adverse events or social harms throughout the study period, the study authors noted.

“Community models of ART delivery were as effective as facility-based care in terms of viral suppression in this urban setting in Zambia,” the study authors wrote in conclusion. “However, in settings with poor viral load resources, such frequent viral load monitoring in people receiving ART with stable HIV might not be optimal compared with efforts to enhance retention on ART or viral load monitoring in populations at higher risk of non-suppression.”