Development, Assessment, and Outcomes of a Community-Based Model of Antiretroviral Care in Western Kenya Through a Cluster-Randomized Control Trial

Abstract

Objective:To develop and assess an alternative care model using community-based groups for people living with HIV and facilitate by lay personnel.Methods:Geographic locations in the Academic Model Providing Access to Healthcare Kitale clinic catchment were randomized to standard of care versus a community-based care group (ART Co-op). Adults stable on antiretroviral therapy and virally suppressed were eligible. Research Assistant–led ART Co-ops met in the community every 3 months. Participants were seen in the HIV clinic only if referred. CD4 count and viral load were measured in clinic at enrollment and after 12 months. Retention, viral suppression, and clinic utilization were compared between groups using χ2, Fisher exact, and Wilcoxon rank sum tests.Results:At 12 months, there were no significant differences in mean CD4 count or viral load suppression. There was a significant difference in patient retention in assigned study group between the intervention and control group (81.6% vs 98.6%; P < 0.001), with a number of intervention patients withdrawing because of stigma, relocation, pregnancy, and work conflicts. All participants, however, were retained in an HIV care program for the study duration. The median number of clinic visits was lower for the intervention group than that for the control group (0 vs 3; P < 0.001).Conclusions:Individuals retained in a community-based HIV care model had clinical outcomes equivalent to those receiving clinic-based care. This innovative model of HIV care addresses the problems of insufficient health care personnel and patient retention barriers, including time, distance, and cost to attend clinic, and has the potential for wider implementation.

Evaluation of HIV treatment outcomes with reduced frequency of clinical encounters and antiretroviral treatment refills: A systematic review and meta-analysis

“…Data from cohort studies were considered fair or poor quality primarily due to the comparison arm comprising a patient population with different eligibility than the intervention arm (e.g., different levels of “stability”) [ 32 , 37 ]. RCTs were judged as having some concerns when those enrolled did not meet eligibility criteria [ 25 ], those eligible for the intervention did not necessarily receive it [ 20 ], or there was high withdrawal in the intervention arm [ 31 ].…”

“…These findings were also consistent when stratified by 6- or 12-monthly clinical consultations (RR 1.03, 95% CI 0.98–1.08, p = 0.313, and RR 0.99, 95% CI 0.94–1.04, p = 0.672, respectively) ( Fig 2B ) and delivery strategy ( S1 Fig ). There was substantial statistical heterogeneity in study design and clinical consultation frequency subgroups, in part due to the inclusion of 1 study with high withdrawal from the intervention (community-based care) arm [ 31 ]. Among studies rated as high quality or having low risk of bias, heterogeneity remained substantial ( S2 Fig ).…”

Attrition from HIV treatment after enrollment in a differentiated service delivery model: a cohort analysis of routine care in Zambia

“…Previous studies found high retention of patients in adherence clubs and home-based care models in South Africa and Kenya, among other countries (13,14). Studies in Zambia have showed that DSD models achieve comparable or better outcomes than conventional care (15,16).…”

“…It is likely that patients offered DSD model enrollment were believed by facility staff to be "good adherers," while those thought to be at higher risk 16 of attrition were held in frequent refill care or conventional care, where they could potentially be monitored more closely. Similarly, the same model may be assigned to different dispensing intervals for a slightly different population of patients (14). For example, the different retention levels observed in fast track (i.e., lower retention for ≤2 month and better retention for 3 and 4-6 month dispensing groups) reflect the patient population served rather than the model of care itself.…”

Reciprocal innovation: a new approach to equitable and mutually beneficial global health research and partnerships

“…In partnership with the Kenyan Government, AMPATH serves a population of 8 million people across western Kenya at more than 500 clinical sites, with comprehensive care programs in HIV/AIDS, oncology, chronic diseases, and maternal child health, among others, and pioneering population health and community-based approaches to care [29]. The partnership facilitates bilateral exchanges for Kenyan and North American faculty, residents, and students, and leverages academic partnerships to build critical clinical and research infrastructure in Kenya, train global health researchers, and conduct research to improve the health of under-served populations in Kenya and globally [30][31][32].…”