Differentiated service delivery for people using second‐line antiretroviral therapy: clinical outcomes from a retrospective cohort study in KwaZulu‐Natal, South Africa

Abstract

IntroductionEvidence is needed to guide the inclusion of broader groups of people living with HIV (PLHIV) in differentiated service delivery (DSD) programmes. We assessed treatment outcomes among PLHIV on second‐line regimens in a community antiretroviral therapy (ART) delivery programme, compared to those who remained at clinics.MethodsUsing data from 61 public clinics, we did a retrospective cohort study among PLHIV receiving second‐line ART following rollout of the Centralized Chronic Medicines Dispensing and Distribution (CCMDD) programme in KwaZulu‐Natal, South Africa. We included PLHIV from the timepoint when they were first eligible, though not necessarily referred, for community ART within CCMDD and followed them for 18 months. We used multivariable logistic regression to compare 12‐month attrition and viraemia between clients referred for community ART and those remaining in clinic care.ResultsAmong 209,744 PLHIV aged ≥ 18 years who collected ART between October 2016 and December 2018, 7511 (3.6%) received second‐line ART. Of these, 2575 (34.3%) were eligible for community ART. The median age was 39.0 years (interquartile range 34.0–45.0) and 1670 (64.9%) were women. Five hundred and eighty‐four (22.7%) were referred for community ART within 6 months of meeting eligibility criteria. Overall, 4.5% [95% confidence interval (CI) 3.0–6.6%] in community ART and 4.4% (95% CI 3.5–5.4%) in clinic care experienced attrition at 12 months post eligibility for community ART. Two thousand one hundred and thirty‐eight (83.0%) had a viral load recorded 6–18 months after becoming eligible, and of these, 10.3% (95% CI 7.7–13.3%) in community ART and 11.3% (95% CI 9.8–12.9%) in clinic care had viraemia > 200 copies/ml. In separate regressions adjusted for age, gender, district, time on second‐line ART, nucleoside reverse transcriptase inhibitor backbone and year of eligibility, no differences in the odds of attrition [adjusted odds ratio (aOR) 1.02, 95% CI 0.71–1.47] or viraemia (aOR 0.91, 95% CI 0.64–1.29) were observed between those in community ART and those remaining in clinic care.ConclusionsWe found good outcomes among PLHIV who were stable on second‐line regimens and referred for community ART. Efforts to expand DSD access among this group should be prioritized.

Prevalence and trends of advanced HIV disease among antiretroviral therapy-naïve and antiretroviral therapy-experienced patients in South Africa between 2010-2021: a systematic review and meta-analysis

“…The 53 studies published between January 2010 to January 2022 consisted of a total of 11,545,460 individuals who were HIV positive. Twenty-four of the studies were cross-sectional [ 13 , 28 – 50 ]; two were cross-sectional population surveys [ 51 , 52 ], thirteen were longitudinal analyses using routine electronic HIV programmatic data [ 2 – 4 , 53 – 62 ]; ten were prospective cohort studies [ 63 – 72 ] and the remaining 4 were retrospective cohort studies [ 73 – 76 ]. The study population for 48 studies was among adults: two studies enrolled adolescents [ 50 , 62 ] and three enrolled children [ 30 , 38 , 39 ].…”

Record linkage without patient identifiers: proof of concept using data from South Africa’s national HIV program

“…We were unable to accurately link 28% of CD4 count and viral load results in TIER.Net to NHLS. We cannot be sure why they were not linked; however, other studies have noted inconsistencies between information recorded in patient les and that captured in TIER.Net (12,13,34,44). Fifth, our approach requires the availability of data on the same patient characteristics -here, laboratory test results -to facilitate linkage, and would not be suitable for linking databases that do not contain some shared data points.…”

Clinical outcomes with second-line dolutegravir in people with virological failure on first-line non-nucleoside reverse transcriptase inhibitor-based regimens in South Africa: a retrospective cohort study

“…This finding highlights the need to improve interventions such as adherence counselling in the HIV care cascade during second-line treatment, to better support medication adherence, as regimen choice is only one factor for improving HIV treatment outcomes. Dedicated adherence clinics or community ART delivery programmes 28 and other evidence-based adherence support strategies, particularly among younger people and those at higher risk of poor outcomes, could improve outcomes during second-line treatment.…”