Reimagining HIV service delivery: the role of differentiated care from prevention to suppression

Grimsrud, Anna; Bygrave, Helen; Doherty, Meg; Ehrenkranz, Peter; Ellman, Tom; Ferris, Robert; Ford, Nathan; Killingo, Bactrin; Mabote, Lynette; Mansell, Tara; Reinisch, Annette; Zulu, Isaac; Bekker, Linda‐Gail

doi:10.7448/ias.19.1.21484

Cited by 273 publications

(291 citation statements)

References 6 publications

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“…Increasing focus on differentiated service delivery models which adapt care to patient needs and preferences present particular opportunities for KP. For example, adherence clubs, CBO‐based HIV services and mobile services could all become venues for viral load monitoring . Moreover, the nature of KP‐dedicated programmes could support increased focus on quality, potentially resulting in greater clinical utilization of viral load results in patient management.…”

Section: Discussionmentioning

confidence: 99%

HIV viral load monitoring among key populations in low‐ and middle‐income countries: challenges and opportunities

et al. 2017

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IntroductionKey populations bear a disproportionate HIV burden and have substantial unmet treatment needs. Routine viral load monitoring represents the gold standard for assessing treatment response at the individual and programme levels; at the population‐level, community viral load is a metric of HIV programme effectiveness and can identify “hotspots” of HIV transmission. Nevertheless, there are specific implementation and ethical challenges to effectively operationalize and meaningfully interpret viral load data at the community level among these often marginalized populations.DiscussionViral load monitoring enhances HIV treatment, and programme evaluation, and offers a better understanding of HIV surveillance and epidemic trends. Programmatically, viral load monitoring can provide data related to HIV service delivery coverage and quality, as well as inequities in treatment access and uptake. From a population perspective, community viral load data provides information on HIV transmission risk. Furthermore, viral load data can be used as an advocacy tool to demonstrate differences in service delivery and to promote allocation of resources to disproportionately affected key populations and communities with suboptimal health outcomes. However, in order to perform viral load monitoring for individual and programme benefit, health surveillance and advocacy purposes, careful consideration must be given to how such key population programmes are designed and implemented. For example, HIV risk factors, such as particular sex practices, sex work and drug use, are stigmatized or even criminalized in many contexts. Consequently, efforts must be taken so that routine viral load monitoring among marginalized populations does not cause inadvertent harm. Furthermore, given the challenges of reaching representative samples of key populations, significant attention to meaningful recruitment, decentralization of care and interpretation of results is needed. Finally, improving the interoperability of health systems through judicious use of biometrics or identifiers when confidentiality can be maintained is important to generate more valuable data to inform monitoring programmes.ConclusionsOpportunities for expanded viral load monitoring could and should benefit all those affected by HIV, including key populations. The promise of the increasing routinization of viral load monitoring as a tool to advance HIV treatment equity is great and should be prioritized and appropriately implemented within key population programmatic and research agendas.

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Section: Discussionmentioning

confidence: 99%

HIV viral load monitoring among key populations in low‐ and middle‐income countries: challenges and opportunities

et al. 2017

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“…High burden countries, for example, South Africa, are now implementing this policy, which has led to an even greater number of HIV‐positive individuals starting ART at Primary Health Care (PHC) facilities, a trend associated with worsening clinical outcomes . For HIV treatment services, differentiated care is defined as a client‐centred approach that simplifies and adapts HIV services across the cascade, in ways that both serve the needs of PLHIV better and reduce unnecessary burdens on the health system . Referral of stable ART clients to adherence clubs as part of a differentiated care model is an important strategy for reducing clinic burden .…”

Section: Introductionmentioning

confidence: 99%

Retention in care and factors critical for effectively implementing antiretroviral adherence clubs in a rural district in South Africa

et al. 2019

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Introduction Differentiated models of care that include referral of antiretroviral treatment (ART) clients to adherence clubs are an important strategy to help clinics manage increased number of clients living with HIV in resource‐constrained settings. This study reported on (i) clinical outcomes among ART clients attending community‐based adherence clubs and (ii) experiences of adherence clubs and perceptions of factors key to successful adherence club implementation among clients and healthcare workers. Methods A retrospective cohort analysis of routine data and a descriptive analysis of data collected through self‐administered surveys completed by clients and healthcare workers were completed. Clients starting ART at the study clinic, between January 2014 and December 2015, were included in the cohort analysis and followed up until December 2016. The survey data were collected from August to September 2017. The primary outcome for the cohort analysis was a comparison of loss to follow‐up (LTFU) between clients staying in clinic care and those referred to adherence clubs. Survey data reported on client experiences of and healthcare worker perceptions of adherence club care. Results Cohort analysis reported on 465 participants, median baseline CD4 count 374 (IQR: 234 to 532) cells/μl and median follow‐up time 20.7 (IQR 14.1 to 27.7) months. Overall, 202 (43.4%) participants were referred to an adherence club. LTFU was lower in those attending an adherence club (aHR =0.25, 95% CI: 0.11 to 0.56). This finding was confirmed on analysis restricted to those eligible for adherence club referral (aHR =0.28, 95% CI: 0.12 to 0.65). Factors highlighted as associated with successful adherence club implementation included: (i) referral of stable clients to the club, (ii) an ideal club size of ≥20 members, (iii) club services led by a counsellor (iv) using churches or community halls as venues (v) effective communication between all parties, and (vi) timely delivery of prepacked medication. Conclusions This study showed good clinical outcomes, positive patient experiences and healthcare worker perceptions of the adherence club model. Factors associated with successful adherence club implementation, highlighted in this study, can be used to guide implementers in the scale‐up of adherence club services across varied high‐burden settings.

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“…A broad range of supportive interventions may improve retention (e.g. community‐based adherence support, health technology interventions) , potentially also under Treat‐All .…”

Section: Discussionmentioning

confidence: 99%

HIV programmatic outcomes following implementation of the ‘Treat‐All’ policy in a public sector setting in Eswatini: a prospective cohort study

et al. 2020

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Introduction The Treat‐All policy – antiretroviral therapy (ART) initiation irrespective of CD4 cell criteria – increases access to treatment. Many ART programmes, however, reported increasing attrition and viral failure during treatment expansion, questioning the programmatic feasibility of Treat‐All in resource‐limited settings. We aimed to describe and compare programmatic outcomes between Treat‐All and standard of care (SOC) in the public sectors of Eswatini. Methods This is a prospective cohort study of ≥16‐year‐old HIV‐positive patients initiated on first‐line ART under Treat‐All and SOC in 18 health facilities of the Shiselweni region, from October 2014 to March 2016. SOC followed the CD4 350 and 500 cells/mm3 treatment eligibility thresholds. Kaplan‐Meier estimates were used to describe crude programmatic outcomes. Multivariate flexible parametric survival models were built to assess associations of time from ART initiation with the composite unfavourable outcome of all‐cause attrition and viral failure. Results Of the 3170 patients, 1888 (59.6%) initiated ART under Treat‐All at a median CD4 cell count of 329 (IQR 168 to 488) cells/mm3 compared with 292 (IQR 161 to 430) (p < 0.001) under SOC. Although crude programme retention at 36 months tended to be lower under Treat‐All (71%) than SOC (75%) (p = 0.002), it was similar in covariate‐adjusted analysis (adjusted hazard ratio [aHR] 1.06, 95% CI 0.91 to 1.23). The hazard of viral suppression was higher for Treat‐All (aHR 1.12, 95% CI 1.01 to 1.23), while the hazard of viral failure was comparable (Treat‐All: aHR 0.89, 95% CI 0.53 to 1.49). Among patients with advanced HIV disease (n = 1080), those under Treat‐All (aHR 1.13, 95% CI 0.88 to 1.44) had a similar risk of an composite unfavourable outcome to SOC. Factors increasing the risk of the composite unfavourable outcome under both interventions were aged 16 to 24 years, being unmarried, anaemia, ART initiation on the same day as HIV care enrolment and CD4 ≤ 100 cells/mm3. Under Treat‐All only, the risk of the unfavourable outcome was higher for pregnant women, WHO III/IV clinical stage and elevated creatinine. Conclusions Compared to SOC, Treat‐All resulted in comparable retention, improved viral suppression and comparable composite outcomes of retention without viral failure.

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Reimagining HIV service delivery: the role of differentiated care from prevention to suppression

Cited by 273 publications

References 6 publications

HIV viral load monitoring among key populations in low‐ and middle‐income countries: challenges and opportunities

HIV viral load monitoring among key populations in low‐ and middle‐income countries: challenges and opportunities

Retention in care and factors critical for effectively implementing antiretroviral adherence clubs in a rural district in South Africa

HIV programmatic outcomes following implementation of the ‘Treat‐All’ policy in a public sector setting in Eswatini: a prospective cohort study

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