Lynne Wilkinson

Community‐supported models of care for people on HIV treatment in sub‐Saharan Africa

Further scale‐up of antiretroviral therapy (ART) to those in need while supporting the growing patient cohort on ART requires continuous adaptation of healthcare delivery models. We describe several approaches to manage stable patients on ART developed by Médecins Sans Frontières together with Ministries of Health in four countries in sub‐Saharan Africa.

Reframing HIV Care: Putting People at the Centre of Antiretroviral Delivery

The delivery of HIV care in the initial rapid scale‐up of HIV care and treatment was based on existing clinic‐based models, which are common in highly resourced settings and largely undifferentiated for individual needs. A new framework for treatment based on variable intensities of care tailored to the specific needs of different groups of individuals across the cascade of care is proposed here. Service intensity is characterised by four delivery components: (i) types of services delivered, (ii) location of service delivery, (iii) provider of health services and (iv) frequency of health services. How these components are developed into a service delivery framework will vary across countries and populations, with the intention being to improve acceptability and care outcomes. The goal of getting more people on treatment before they become ill will necessitate innovative models of delivering both testing and care. As HIV programmes expand treatment eligibility, many people entering care will not be ‘patients’ but healthy, active and productive members of society . To take the framework to scale, it will be important to: (i) define which individuals can be served by an alternative delivery framework; (ii) strengthen health systems that support decentralisation, integration and task shifting; (iii) make the supply chain more robust; and (iv) invest in data systems for patient tracking and for programme monitoring and evaluation.

Self-transfer and mortality amongst adults lost to follow-up in ART programmes in low- and middle-income countries: systematic review and meta-analysis.

To ascertain estimates of adult patients, recorded as lost to follow‐up (LTFU) within antiretroviral treatment (ART) programmes, who have self‐transferred care, died or truly stopped ART in low‐ and middle‐income countries.

Expansion of the adherence club model for stable antiretroviral therapy patients in the Cape Metro South Africa 2011-2015.

The ambitious ‘90‐90‐90’ treatment targets require innovative models of care to support quality antiretroviral therapy (ART) delivery. While evidence for differentiated models of ART delivery is growing, there are few data on the feasibility of scale‐up. We describe the implementation of the Adherence Club (AC) model across the Cape Metro health district in Cape Town, South Africa, between January 2011 and March 2015.

Adherence clubs for long-term provision of antiretroviral therapy: cost-effectiveness and access analysis from Khayelitsha, South Africa.

As the scale of the South African HIV epidemic calls for innovative models of care that improve accessibility for patients while overcoming chronic human resource shortages, we (i) assess the cost‐effectiveness of lay health worker‐led group adherence clubs, in comparison with a nurse‐driven ‘standard of care’ and (ii) describe and evaluate the associated patient cost and accessibility differences.

Cost per patient of treatment for rifampicin‐resistant tuberculosis in a community‐based programme in Khayelitsha, South Africa

The high cost of rifampicin‐resistant tuberculosis (RR‐TB) treatment hinders treatment access. South Africa has a high RR‐TB burden, and national policy outlines decentralisation to improve access and reduce costs. We analysed health system costs associated with RR‐TB treatment by drug resistance profile and treatment outcome in a decentralised programme.

High rates of retention and viral suppression in the scale-up of antiretroviral therapy adherence clubs in Cape Town, South Africa

Introduction: Increasingly, there is a need for health authority scale up of successfully piloted differentiated models of antiretroviral therapy (ART) delivery. However, there is a paucity of evidence on system‐wide outcomes after scale‐up. In the Cape Town health district, stable adult patients were referred to adherence clubs (ACs) – a group model of ART delivery with five visits per year. By the end of March 2015, over 32,000 ART patients were in an AC. We describe patient outcomes of a representative sample of AC patients during this scale‐up.

Programmatic treatment outcomes in HIV-infected and uninfected drug-resistant TB patients in Khayelitsha, South Africa

BACKGROUND South Africa has high burdens of HIV, TB and drug-resistant TB (DR-TB, rifampicin-resistance). Treatment outcome data for HIV-infected versus uninfected patients is limited. We assessed the impact of HIV and other factors on DR-TB treatment success, time to culture conversion, loss-from-treatment and overall mortality after second-line treatment initiation. METHODS A retrospective cohort analysis was conducted for patients initiated on DR-TB treatment from 2008 to 2012, within a community-based, decentralised programme in Khayelitsha, South Africa. RESULTS Among 853 confirmed DR-TB patients initiating second-line treatment, 605 (70.9%) were HIV infected. HIV status did not impact on time to sputum culture conversion nor did it impact treatment success; 48.1% (259/539) and 45.9% (100/218), respectively (p=0.59). In a multivariate model, HIV was not associated with treatment success. Death during treatment was higher among HIV-infected patients, but overall mortality was not significantly higher. HIV-infected patients with CD4 <=100 cells/ml were significantly more likely to die after starting treatment. CONCLUSIONS Response to DR-TB treatment did not differ with HIV infection in a programmatic setting with access to antiretroviral treatment (ART). Earlier ART initiation at a primary care level could reduce mortality among HIV-infected patients presenting with low CD4 counts.

Outcomes from the Implementation of a Counselling Model Supporting Rapid Antiretroviral Treatment Initiation in a Primary Healthcare Clinic in Khayelitsha, South Africa

Background Lengthy antiretroviral treatment (ART) preparation contributes to high losses to care between communicating ART eligibility and initiating ART. To address this shortfall, Médecins Sans Frontières implemented a revised approach to ART initiation counselling preparation (integrated for TB co-infected patients), shifting the emphasis from pre-initiation sessions to addressing common barriers to adherence and strengthening post-initiation support in a primary healthcare facility in Khayelitsha, South Africa. Methods An observational cohort study was conducted using routinely collected data for all ART-eligible patients attending their first counselling session between 23 July 2012 and 30 April 2013 to assess losses to care prior to and post ART initiation. Viral load completion and suppression rates of those retained on ART were also calculated. Results Overall, 449 patients enrolled in the study, of whom 3.6% did not return to the facility to initiate ART. Of those who were initiated, 96.7% were retained at their first ART refill visit and 85.9% were retained 6 months post ART initiation. Of those retained, 80.2% had a viral load taken within 6 months of initiating ART, with 95.4% achieving viral load suppression. Conclusions Adapting counselling to enable rapid ART initiation is feasible and has the potential to reduce losses to care prior to ART initiation without increasing short-term losses thereafter or compromising patient adherence.

Extending dispensing intervals for stable patients on ART.

To the Editors: Over the past decade, antiretroviral therapy (ART) programs have been rapidly expanded in resource-limited settings. South Africa has the largest ART program in the world with nearly 2 million people accessing treatment. ART Adherence Clubs (ACs) have been implemented in the Western Cape of South Africa to improve long-term retention in care for stable ART patients by providing quick and patient-friendly access to treatment and care while decreasing the burden on overstretched health care facilities. ACs are facilitated by a lay club facilitator and consist of approximately 30 stable patients who meet every 2 months either at the health facility or in a community venue. Patients are eligible to join an AC if they have been on the same ART regimen for 12 months or more, have had 2 consecutive undetectable viral loads, and do not have any other medical condition requiring more frequent follow-up. Each visit consists of a quick clinical assessment and on-site dispensation of prepacked ART with a nurse available for referral as necessary. Early evidence suggests ACs are effective in retaining stable patients in care with high levels of virologic suppression. Migration is common in subSaharan Africa where patients move away from home for economic reasons. This movement results in circular migration patterns that impact adherence and retention in antiretroviral care. In the Western Cape, many patients return to their province of origin over the holiday period of December/January and do not seek care while away. This migration puts patients at risk of ART interruptions and defaulting care, especially when time away from the Western Cape is extended beyond the period initially intended due to unforeseen circumstances. The extent of this seasonal migration has not been quantified, but experience at the clinics suggests that most patients are affected. Current ART pharmacy guidelines in South Africa require ART scripts to be written every 6 months despite national adult ART guidelines that only require an annual clinical assessment for stable ART patients. Although national policy allows 3-month dispensing, there is great variation between provinces and individual facilities. Accordingly, stable patients in the Western Cape receive a maximum of 2 months of ART per visit. To support ART patients who most commonly migrate over the holiday period, ACs that were scheduled to meet between mid-December 2012 and midJanuary 2013 were given 4 months of ART in their October/November 2012 AC visit. Four months of ART were dispensed as two 2 monthly supplies to align with national policy. Data are limited on how long ART dispensing intervals should be to optimize retention in care. The objective was to compare outcomes among AC members who received 2-month ART (normal standard of care) to 4-month ART. The Hannan Crusaid Treatment Center in Gugulethu and Ubuntu Site B Clinic in Khayelitsha are large treatment facilities in periurban, high-prevalence areas of Cape Town, South Africa. Both services have been described, in detail, previously and are or have previously been supported by the nongovernmental organizations Desmond Tutu HIV Foundation and Médecins Sans Frontières, South Africa, respectively. All adult ACs at the Hannan Crusaid Treatment Center and Ubuntu Site B Clinic who were enrolled in an AC before the end of 2012 were included in the analysis. Adult ACs include stable patients of 18 years or older. AC procedures at the 2 sites are similar. Data presented includes the number and proportion of patients receiving each interval of ARVs overall and by site. ACs were assigned to receive either 4 or 2 months of treatment based on when their December/ January visit was scheduled. ACs with a scheduled visit between 17 December and 18 January were assigned to the 4-month group. Outcomes of patients who received two 2-month prescriptions simultaneously (ie, 4 months) of ART (group A) are compared with those who received the standard 2 months of ART (group B). Outcomes include the proportion of patients defaulting from ACs 4 months after their final visit in 2012 and for those with blood results in 2013 the proportion of patients who were not virally suppressed (viral load above 400 copies/mL). Associations by group were assessed with x2 tests. A total of 1860 patients in 1 of 76 ACs were eligible for the analysis (Table 1). Over the holiday period, 42 ACs were given 4 months of ART and 34 ACs were given 2 months of ART. Four months after the final AC visit in 2012, 4.0% had defaulted care overall [group A, 41 of 1054 (3.9%); group B, 33 of 806 (4.1%)]. There was no difference in the risk of defaulting from an AC in group A who received 4 months of ART compared with group B who received 2 months of ART (risk ratio, 0.95; 95% confidence interval: 0.61 to 1.49; P = 0.82). Of the 1507 of patients with a blood draw at their first or second 2013 visit, 3.6% were not virally suppressed [group A, 31 of 842 (3.7%); group B, 23 of 665 (3.5%)]. No significant associations were observed between viral suppression and group (risk ratio, 1.06; 95% confidence interval: 0.63 to 1.81; P = 0.82). Between the last visit of 2012 and the first schedule visit of 2013, none of the club patients died. This analysis was limited to 2 sites where 4 months of ART was provided to those clubs whose 2-month return date would have fallen in December or the first part of January. These findings were presented at the International Conference on AIDS & STIs in Africa, December 2013, Cape Town, South Africa. The authors have no conflicts of interest to disclose. A. G. is supported by funding from the Canadian Institutes of Health Research and the South African Centre for Epidemiological Modeling and Analysis. L. M. is supported by an International Leadership Award from the Elizabeth Glaser Pediatric AIDS Foundation. Letters to the Editor J Acquir Immune Defic Syndr Volume 66, Number 2, June 1, 2014