Community-Based Accompaniment with Supervised Antiretrovirals for HIV-Positive Adults in Peru: A Cluster-Randomized Trial

Abstract

We conducted a cluster-randomized trial to estimate effects of directly observed combination antiretroviral therapy (DOT-cART) on retention with viral suppression among HIV-positive adults in Peru. We randomly allocated facilities to receive the 12-month intervention plus the standard of care, including adherence support provided through accompaniment. In the intervention arm, health workers supervised doses, twice daily, and accompanied patients to appointments. Among 356 patients, intention-to-treat analyses showed no statistically significant benefit of DOT, relative to no-DOT, at 12 or 24 months (adjusted probability of primary outcome: 0.81 vs. 0.73 and 0.76 vs. 0.68, respectively). A statistically significant benefit of DOT was found in per-protocol and as-treated analyses at 12 months (0.83 for DOT vs. 0.73 for no DOT, p value: 0.02 per-protocol, 0.01 as-treated), but not 24 months. Rates of retention with viral suppression were high in both arms. Among adults receiving robust adherence support, the added effect of time-limited DOT, if any, is small-to-moderate.

Experienced HIV-Related Stigma and Psychological Distress in Peruvian Sexual and Gender Minorities: A Longitudinal Study to Explore Mediating Roles of Internalized HIV-Related Stigma and Coping Styles

“…Indeed, negative societal attitudes toward MSM and TW may contribute to the sexual risk factors described above in terms of cultural perceptions (e.g., connecting insertive sex roles with masculinity and reduced HIV risk), power dynamics (e.g., low condom use due to forced sex and power dynamics with heterosexual-identified partners and/or socioeconomically affluent clients), and limited culturally astute healthcare centers (36). Second, studies have shown wide variation in mental health among Peruvians living with HIV (e.g., 7–49% of samples with depressive symptoms; 40, 41, 42). These high rates underscore the importance of identifying determinants of mental health problems among Peruvian PLWH.…”

Patient and provider perceptions of a community‐based accompaniment intervention for adolescents transitioning to adult HIV care in urban Peru: a qualitative analysis

“…DOT for HIV has yielded mixed findings among adults [ 43 , 44 ], but ALWH found DOT supportive training for independent ART adherence rather than observed verification of medication ingestion; shifting to teledot did not change this viewpoint. The favourable view of HIV teledot corroborates a study among Peruvian adults with HIV reporting perceived psychosocial outcomes as the primary benefit of DOT [ 45 ].…”

Dynamics of Treatment Supporters and Patients Starting HIV Therapy in Lima, Peru

“…This was a nested study in the randomized-control trial community-based accompaniment with supervised antiretrovirals (CASA), which applied the community-based intervention of DOT to support PLWHA beginning ART. 9 The CASA cohort was composed of 356 participants living in poverty, who were enrolled between November 2010 and March 2012, within 30 days of ART initiation. Participants were at least 18 years of age, starting a new combined ART regimen, residing and receiving HIV care within 10 defined districts in Lima (selected from a total of 45 districts based on high prevalence of HIV), and amenable to receiving CHW visits for DOT.…”