Home-based versus clinic-based care for patients starting antiretroviral therapy with low CD4+ cell counts

Abstract

Objectives:African health services have shortages of clinical staff. We showed previously, in a cluster-randomized trial, that a home-based strategy using trained lay-workers is as effective as a clinic-based strategy. It is not known whether home-based care is suitable for patients with advanced HIV disease.Methods:The trial was conducted in Jinja, Uganda. One thousand, four hundred and fifty-three adults initiating ART between February 2005 and January 2009 were randomized to receive either home-based care or routine clinic-based care, and followed up for about 3 years. Trained lay workers, supervised by clinical staff based in a clinic, delivered the home-based care. In this sub-analysis, we compared survival between the two strategies for those who presented with CD4+ cell count less than 50 cells/μl and those who presented with higher CD4+ cell counts. We used Kaplan–Meier methods and Poisson regression.Results:Four hundred and forty four of 1453 (31%) participants had baseline CD4+ cell count less than 50 cells/μl. Overall, 110 (25%) deaths occurred among participants with baseline CD4+ cell count less than 50 cells/μl and 87 (9%) in those with higher CD4+ cell count. Among participants with CD4+ cell count less than 50 cells/μl, mortality rates were similar for the home and facility-based arms; adjusted mortality rate ratio 0.80 [95% confidence interval (CI) 0.53–1.18] compared with 1.22 (95% CI 0.78–1.89) for those who presented with higher CD4+ cell count.Conclusion:HIV home-based care, with lay workers playing a major role in the delivery of care including providing monthly adherence support, leads to similar survival rates as clinic-based care even among patients who present with very low CD4+ cell count. This emphasises the critical role of adherence to antiretroviral therapy.

The economics, financing and implementation of HIV treatment as prevention: What will it take to get there?

“…One approach could be to use home-based care, including adherence support. A cluster-randomized trial in Uganda found that patients initiating ART and receiving home-based care had similar survival rates as those that received clinic-based care, even among those with very low CD4 counts (Woodd, Grosskurth, Levin, Amuron, Namara, Birunghi et al, 2014).…”

The impact of community health worker-led home delivery of antiretroviral therapy on virological suppression: a non-inferiority cluster-randomized health systems trial in Dar es Salaam, Tanzania

“…home delivery of ART may, however, also be feasible for patients who just initiated ART, or whose WHO clinical stage, CD4-cell count or viral load suggests that they are not stable ART patients. For example, in a sub-analysis in patients who started ART with a low CD4-cell count (<50 cells/μL) as part of the cluster-randomized trial in Uganda described in the introduction, Woodd et al did not find an increased rate of mortality among those who continued to receive ART at home after ART initiation as compared to those who received standard clinic-based care [ 43 ].…”

The Medical Research Council (UK)/Uganda Virus Research Institute Uganda Research Unit on AIDS – ‘25 years of research through partnerships’

“…; Woodd et al . ). These two studies had a significant impact on the roll‐out of ART in resource limited settings.…”

“…The Unit took part in other important clinical trials that included the DART (multicentre trial) and the Jinja trials, looking at simple ways of delivering ART; these showed that ART could be delivered safely using minimal laboratory monitoring and that structured treatment interruption regimens were not appropriate (DART Trial Team 2008). The Jinja trial showed that home-based ART delivery using trained lay workers was effective (Jaffar et al 2010;Woodd et al 2014). These two studies had a significant impact on the roll-out of ART in resource limited settings.…”