Antiretroviral Therapy Refill Research Articles

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. Using routine programme data, four approaches to simplify ART delivery for stable patients on ART were assessed from a patient and health system perspective: appointment spacing for clinical and drug refill visits in Malawi, peer educator-led ART refill groups in South Africa, community ART distribution points in DRC and patient-led community ART groups in Mozambique. All four approaches lightened the burden for both patients (reduced travel and lost income) and health system (reduced clinic attendance). Retention in care is high: 94% at 36 months in Malawi, 89% at 12 months in DRC, 97% at 40 months in South Africa and 92% at 48 months in Mozambique. Where evaluable, service provider costs are reported to be lower. Separating ART delivery from clinical assessments was found to benefit patients and programmes in a range of settings. The success of community ART models depends on sufficient and reliable support and resources, including a flexible and reliable drug supply, access to quality clinical management, a reliable monitoring system and a supported lay workers cadre. Such models require ongoing evaluation and further adaptation to be able to reach out to more patients, including specific groups who may be challenged to meet the demands of frequent clinic visits and the integrated delivery of other essential chronic disease interventions.

Patients’ worries before starting antiretroviral therapy and their association with treatment adherence and outcomes: a prospective study in rural Uganda, 2004 - 2009

BackgroundIn HIV-infected persons, good adherence to antiretroviral therapy (ART) is essential for successful treatment outcomes. Patients’ worries before starting ART may affect their ART adherence and treatment outcomes.MethodsBetween 2004 and 2009, HIV-infected individuals in a prospective cohort study in rural Uganda were assessed for ART eligibility. A counsellor explained the ART eligibility criteria, adherence and side effects, and recorded the patients’ worries related to ART. Every quarter, patients who initiated ART had clinical, immunological (CD4 cell counts) and virological (viral loads) assessments, and data were collected on ART adherence using patients’ self-reports and pill counts. We describe the patients’ worries and examine their association with ART adherence, and immunological and virological outcomes.ResultsWe assessed 421 patients, 271 (64%) were females, 318 (76%) were aged 30 years and above and 315 (75%) were eligible for ART. 277 (66%) reported any worry, and the proportions were similar by sex, age group and ART eligibility status. The baseline median CD4 counts and viral loads were similar among patients with any worry and those with no worry. The commonest worries were: fear of HIV serostatus disclosure; among 69 (16%) participants, lack of food when appetite improved after starting ART; 50 (12%), concurrent use of other medications; 33 (8%), adherence to ART; 28 (7%) and problems concerning condom use; 27 (6%). After 24 months or more on ART, patients who reported any worry had made more scheduled ART refill visits than patients who reported no worry (p<0.01), but the annual CD4 cell increases were similar (p=0.12). After one year on ART, patients who reported any worry had greater virological suppression than patients who reported no worry (p<0.05).ConclusionsDespite the lack of significant associations of worries with unfavourable ART outcomes, physicians and counsellors should assist patients in overcoming their worries that can cause stress and discomfort. Food supplements may be desirable for some patients initiating ART.

PS1-04: Change in Adherence to Antiretrovirals After Initial Use of an Electronic Shared Medical Record Among HIV-infected Individuals

Background/AimsPatient web sites with shared medical records (SMR) allow patients to communicate with providers, view results of medical tests, refill prescriptions, and schedule appointments. We aimed to determine whether use of the SMR changed adherence to antiretroviral therapy (ART) in HIV-infected individuals.MethodsWe identified all HIV-infected adults who used the SMR one or more times within two years of initial rollout in two large integrated healthcare systems: Kaiser Permanente Northern California and Group Health Cooperative. The study population included enrollees with continuous membership during a 30-month period spanning 12 months prior to initial SMR use to 18 months after initial SMR use. The primary outcome was change in ART refill adherence comparing the 12-month period prior to initial SMR use with the 12-month period starting 6 months after initial SMR use to allow for SMR adoption; differences over time were evaluated by paired t-test. Next, using linear regression adjusted for age, sex, and health plan, we compared changes in adherence for users followed for at least 36 months after SMR rollout with changes for age- and sex-matched non-users over the same time span; non-users were assigned a random reference date. Finally, among users, we evaluated whether age, sex, race/ethnicity, HIV risk, health plan and an AIDS diagnosis influenced changes in adherence.ResultsWe identified 1,663 HIV-infected SMR users during follow-up, including 1,475 users with 36 months follow-up after roll-out; 1,036 individuals who did not use the SMR during 36 months post rollout were also identified. Among users, mean adherence did not change before (90.4%) and after (90.2%) SMR use (P=0.52). In contrast, among non-users, mean adherence declined over time by 2% from 88% to 86% (P=0.001 compared with users). Among users, only sex of all factors evaluated was associated with changes in adherence with an increase of 2.5% for women and decrease of 0.4% for men (P=0.033).DiscussionSMR users maintained adherence while non-users had small declines over time. Future studies should focus on amount of SMR use, longer-term effects, and identify additional subsets of patients that may particularly benefit from the enhanced access provided by SMR services.

Providing universal access to antiretroviral therapy in Thyolo, Malawi through task shifting and decentralization of HIV/AIDS care

To describe how district-wide access to HIV/AIDS care was achieved and maintained in Thyolo District, Malawi. In mid-2003, the Ministry of Health and Médecins Sans Frontières developed a model of care for Thyolo district (population 587, 455) based on decentralization of care to health centres and community sites and task shifting. After delegating HIV testing and counseling to lay counsellors, uptake of testing increased from 1300 tests per month in 2003 to 6500 in 2009. Shifting responsibility for antiretroviral therapy (ART) initiations to non-physician clinicians almost doubled ART enrollment, with a majority of initiations performed in peripheral health centres. By the end 2009, 23, 261 people had initiated ART of whom 11, 042 received ART care at health-centre level. By the end of 2007, the universal access targets were achieved, with nearly 9000 patients alive and on ART. The average annual cost for achieving these targets was € 2.6 per inhabitant/year. The Thyolo programme has demonstrated the feasibility of district-wide access to ART in a setting with limited resources for health. Expansion and decentralization of HIV/AIDS service-capacity to the primary care level, combined with task shifting, resulted in increased access to HIV services with good programme outcomes despite staff shortages.