Improved virologic outcomes in postpartum women living with HIV referred to differentiated models of care

Abstract

Objectives: Differentiated service delivery (DSD) models are used to deliver antiretroviral therapy (ART) but data are limited in postpartum women, who are at high risk of non-adherence and elevated viral load (VL) over the extended postpartum period.Design: Randomized controlled trial. Methods:We enrolled consecutive postpartum women who initiated ART during pregnancy and met local DSD eligibility (clinically stable, VL less than 400 copies/ ml) at a large primary healthcare (PHC) clinic. Women were randomized to a community-based 'adherence club' (AC, the local DSD model: community health worker-led groups of 20-30 patients with ART dispensing at a community venue) or routine PHC clinics (local standard of care with nurse/doctor-led services). Follow-up visits with VL separate from routine care took place at 3, 6, 12, 18 and 24 months postpartum. Endpoints were time to VL of at least 1000 copies/ml (primary) and VL of at least 50 copies/ml (secondary) by intention-to-treat.Results: At enrolment (n ¼ 409), the median duration postpartum was 10 days, all women had a VL less than 1000 copies/ml and 88% had a VL less than 50 copies/ml; baseline characteristics did not differ by arm. Twenty-four-month retention was 89%. Sixteen and 29% of women in AC experienced a VL of at least 1000 copies/ml by 12 and 24 months, compared to 23 and 37% in PHC, respectively (hazard ratio [HR] ¼ 0.71; 95% confidence interval [CI] ¼ 0.50-1.01). Thirty-two and 44% of women in ACs had a VL of at least 50 copies/ml by 12 and 24 months, compared to 42 and 56% in PHC, respectively (HR ¼ 0.68; 95% CI ¼ 0.51-0.91). Conclusions:Early DSD referral was associated with reduced viraemia through 24 months postpartum and may be an important strategy to improve maternal virologic outcomes.

Impact of differentiated service delivery models on retention in HIV care and viral suppression among people living with HIV in sub‐Saharan Africa: A systematic review and meta‐analysis of randomised controlled trials

“…18,19 Disagreement was resolved using arbitration by a third reviewer. A total of 16 RCTs were assessed, of which seven studies had low risk, 11,14,[20][21][22][23][24] seven studies had some concerns, 12,13,[25][26][27][28] and two articles had high risk of bias. 29,30 (Figure 2).…”

“…In total 1596 records were screened for inclusion, of which 16 RCTs met eligibility criteria. 10,11,13,14,[20][21][22][23][24][25][26][27][28][29][30][31] The trials included more than 13,800 PLHIV (Table 1). Most of the trials were conducted in South Africa, [12][13][14]22,23,25,29,31 with most (11 studies) conducted among adult men and women (≥18 years).…”

“…10,11,13,14,[20][21][22][23][24][25][26][27][28][29][30][31] The trials included more than 13,800 PLHIV (Table 1). Most of the trials were conducted in South Africa, [12][13][14]22,23,25,29,31 with most (11 studies) conducted among adult men and women (≥18 years). [12][13][14]20,23,[25][26][27][28]30,31 Two studies were conducted in postpartum women, 22,29 and three were conducted in mixed adolescent and adult populations (Ferrand et al 2017 24…”

“…Most of the trials were conducted in South Africa, [12][13][14]22,23,25,29,31 with most (11 studies) conducted among adult men and women (≥18 years). [12][13][14]20,23,[25][26][27][28]30,31 Two studies were conducted in postpartum women, 22,29 and three were conducted in mixed adolescent and adult populations (Ferrand et al 2017 24…”

“…We describe the impact of ACs in the retention in HIV care, timely refill and viral suppression. Generally, the ACs comprised of 15-30 members per group, [11][12][13][14]22,23,29,31 club members could choose the meeting place either be at the clinic or community locations. Club members met for 1 hour every 2-6 months [11][12][13][14]22,23,29,31 medications re-fill.…”