Models of service delivery for optimizing a patient’s first six months on antiretroviral therapy for HIV: an applied research agenda

Abstract

Differentiated models of service delivery (DSD models) for HIV treatment in sub-Saharan Africa were conceived as a way to manage rapidly expanding populations of experienced patients who are clinically “stable” on antiretroviral therapy (ART). Entry requirements for most models include at least six months on treatment and a suppressed viral load. These models thus systematically exclude newly-initiated patients, who instead experience the conventional model of care, which requires frequent, multiple clinic visits that impose costs on both providers and patients. In this open letter, we argue that the conventional model of care for the first six months on ART is no longer adequate. The highest rates of treatment discontinuation are in the first six-month period after treatment initiation. Newly initiating patients are generally healthier than in the past, with higher CD4 counts, and antiretroviral medications are better tolerated, with fewer side effects and substitutions, making extra clinic visits unnecessary. Improvements in the treatment initiation process, such as same-day initiation, have not been followed by innovations in the early treatment period. Finally, the advent of COVID-19 has made it riskier to require multiple clinic visits. Research to develop differentiated models of care for the first six-month period is needed. Priorities include estimating the minimum number and type of provider interactions and ART education needed, optimizing the timing of a patient’s first viral load test, determining when lay providers can replace clinicians, ensuring that patients have sufficient but not burdensome access to support, and identifying ways to establish a habit of lifelong adherence.

Offering ART refill through community health workers versus clinic-based follow-up after home-based same-day ART initiation in rural Lesotho: The VIBRA cluster-randomized clinical trial

“…In 2017, UNAIDS launched an initiative to recruit 2 million African community health workers (CHWs) with the aim of contributing to its 90-90-90 strategy of ending AIDS and ensuring sustainable health for all in Africa [ 16 ]. Out-of-facility ART dispensing in the community is a common HIV DSD model in sub-Saharan Africa, but generally excludes newly initiated patients, thus triggering a research priority in this field [ 3 , 18 ]. The VIBRA trial aimed to fill this knowledge gap while aligning with the UNAIDS policy initiative, and was based on the fact that the majority of the population in our study districts live in rural areas that are hard to access but that have an established network of VHWs who serve as a trusted cadre for the follow-up of HIV self-testing [ 11 , 13 ].…”

Provider‐ and patient‐level costs associated with providing antiretroviral therapy during the postpartum phase to women living with HIV in South Africa: A cost comparison of three postpartum models of care

“…Mother–infant pairs may have different needs in terms of the care they require. The clinical presentation of mothers may be that they are well or not well; this could be the first time that they are starting ART or they could have experience in taking ART [38]. Prior ART experience could mean that mothers access to care was previously negatively impacted, for instance that they were lost to follow up at some point in the treatment cascade or defaulted.…”

Simplifying TREAtment and Monitoring for HIV (STREAM HIV): protocol for a randomised controlled trial of point-of-care urine tenofovir and viral load testing to improve HIV outcomes

“…4 Early identification of poor adherence, particularly before a client's first VL test when clients are most likely to be lost to follow-up, could be crucial for implementing timely adherence support interventions. [9][10][11] However, early identification of adherence difficulties remains a challenge for healthcare providers due to reliance on subjective and unreliable adherence metrics, such as self-reported adherence, prescription refill records and pill counts. [12][13][14][15][16][17][18][19][20][21] The recently developed and validated Abbott-manufactured POC test that objectively measures recent ART adherence via tenofovir (TFV) levels in urine shows promise as a rapid and inexpensive adherence monitoring tool to identify non-adherence when the establishment of optimal adherence patterns is critical, such before a client's first VL test.…”