Community-based care by PLWAs resulted in similar clinical outcomes as usual care but with half the number of clinic visits. This pilot study suggests that task-shifting and mobile technologies can deliver safe and effective community-based care to PLWAs, expediting ART rollout and increasing access to treatment while expanding the capacity of health care institutions in resource-constrained environments.

BackgroundA major obstacle facing many lower-income countries in establishing and maintaining HIV treatment programmes is the scarcity of trained health care providers. To address this shortage, the World Health Organization has recommend task shifting to HIV-infected peers.MethodsWe designed a model of HIV care that utilizes HIV-infected patients, community care coordinators (CCCs), to care for their clinically stable peers with the assistance of preprogrammed personal digital assistants (PDAs). Rather than presenting for the standard of care, monthly clinic visits, in this model, patients were seen every three months in clinics and monthly by their CCCs in the community during the interim two months. This study was conducted in Kosirai Division, western Kenya, where eight of the 24 sub-locations (defined geographic areas) within the division were randomly assigned to the intervention with the remainder used as controls.Prior to entering the field, CCCs underwent intensive didactic training and mentoring related to the assessment and support of HIV patients, as well as the use of PDAs. PDAs were programmed with specific questions and to issue alerts if responses fell outside of pre-established parameters. CCCs were regularly evaluated in six performance areas. An impressionistic analysis on the transcripts from the monthly group meetings that formed the basis of the continuous feedback and quality improvement programme was used to assess this model.ResultsAll eight of the assigned CCCs successfully passed their training and mentoring, entered the field and remained active for the two years of the study. On evaluation of the CCCs, 89% of their summary scores were documented as superior during Year 1 and 94% as superior during Year 2. Six themes emerged from the impressionistic analysis in Year 1: confidentiality and "community" disclosure; roles and responsibilities; logistics; clinical care partnership; antiretroviral adherence; and PDA issues. At the end of the trial, of those patients not lost to follow up, 64% (56 of 87) in the intervention and 52% (58 of 103) in the control group were willing to continue in the programme (p = 0.26).ConclusionWe found that an antiretroviral treatment delivery model that shifted patient monitoring and antiretroviral dispensing tasks into the community by HIV-infected patients was both acceptable and feasible.Trial registrationClinicalTrials.gov ID NCT00371540

Obesity is now a common problem among HIV-infected patients receiving antiretroviral therapy (ART). Gastric bypass surgery may be an option for some patients who have failed diet and therapeutic lifestyle changes, changes in ART or other treatment modalities for HIV/ART-related lipohypertrophy and obesity. However, few data are available regarding HIV-related outcomes after such surgery and its impact on ART tolerability. We present here a case series of seven subjects with HIV infection who underwent bariatric surgery. Viral suppression was maintained in five of the six subjects who were receiving ART prior to surgery, including three subjects who experienced surgical complications. The median (range) decrease in body mass index (BMI) postoperatively was 10 kg/m(2) (6-28 kg/m(2)). Improvements were also seen in serum lipid fractions with median (range) changes in total cholesterol of -19 mg/dL (-61 to +3 mg/dL) and triglycerides of -185 mg/dL (-739 to +35 mg/dL). Four of the subjects had a reduction in their metabolic medication prescriptions postoperatively. Three of the subjects experienced postsurgical complications. Based on our experience, bariatric surgery may provide an effective treatment modality for obesity and its related comorbidities in the HIV-infected population while not sacrificing virologic suppression. Larger studies are needed to verify these results, especially in regards to surgical complications.

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