Multi‐month prescriptions, fast‐track refills, and community ART groups: results from a process evaluation in Malawi on using differentiated models of care to achieve national HIV treatment goals

Prust, Margaret L.; Banda, Clement; Nyirenda, Rose; Chimbwandira, Frank; Kalua, Thokozani; Jahn, Andreas; Eliya, Michael; Callahan, Katie; Ehrenkranz, Peter; Prescott, Marta R.; McCarthy, Elizabeth; Tagar, Elya; Gunda, Andrews

doi:10.7448/ias.20.5.21650

Cited by 141 publications

(177 citation statements)

References 13 publications

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“…The results showed 97% retention in care for the club patients compared with 85% for other patients not enrolled in the model . Other alternative models have been reported elsewhere including fixed community points, mobile outreach ART delivery and home delivery .…”

Section: Introductionmentioning

confidence: 75%

Retention on ART and predictors of disengagement from care in several alternative community‐centred ART refill models in rural Swaziland

et al. 2018

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IntroductionA broad range of community‐centred care models for patients stable on anti‐retroviral therapy (ART) have been proposed by the World Health Organization to better respond to patient needs and alleviate pressure on health systems caused by rapidly growing patient numbers. Where available, often a single alternative care model is offered in addition to routine clinical care. We operationalized several community‐centred ART delivery care models in one public sector setting. Here, we compare retention in care and on ART and identify predictors of disengagement with care.MethodsPatients on ART were enrolled into three community‐centred ART delivery care models in the rural Shiselweni region (Swaziland), from 02/2015 to 09/2016: Community ART Groups (CAGs), comprehensive outreach care and treatment clubs. We used Kaplan–Meier estimates to describe crude retention in care model and retention on ART (including patients who returned to clinical care). Multivariate Cox proportional hazard models were used to determine factors associated with all‐cause attrition from care model and disengagement with ART.ResultsA total of 918 patients were enrolled. CAGs had the most participants with 531 (57.8%). Median age was 44.7 years (IQR 36.3 to 54.4), 71.8% of patients were female, and 62.6% fulfilled eligibility criteria for community ART. The 12‐month retention in ART was 93.7% overall; it was similar between model types (p = 0.52). A considerable proportion of patients returned from community ART to clinical care, resulting in lower 12 months retention in care model (82.2% overall); retention in care model was lowest in CAGs at 70.4%, compared with 86.3% in outreach and 90.4% in treatment clubs (p < 0.001). In multivariate Cox regression models, patients in CAGs had a higher risk of disengaging from care model (aHR 3.15, 95% CI 2.01 to 4.95, p < 0.001) compared with treatment clubs. We found, however, no difference in attrition in ART between alternative model types.ConclusionsConcurrent implementation of three alternative community‐centred ART models in the same region was feasible. Although a considerable proportion of patients returned back to clinical care, overall ART retention was high and should encourage programme managers to offer community‐centred care models adapted to their specific setting.

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Section: Introductionmentioning

confidence: 75%

Retention on ART and predictors of disengagement from care in several alternative community‐centred ART refill models in rural Swaziland

et al. 2018

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“…Within a facility‐based setting, additional service delivery modifications may affect PrEP costs. For example, providing multiple months of PrEP prescription for established clients could improve retention by requiring fewer visits, as has been demonstrated in some ART programmes . Additionally, task shifting PrEP screening counselling to HTS counsellors may reduce costs and alleviate nurse time burden.…”

Section: Discussionmentioning

confidence: 99%

The role of costing in the introduction and scale‐up of HIV pre‐exposure prophylaxis: evidence from integrating PrEP into routine maternal and child health and family planning clinics in western Kenya

et al. 2019

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Introduction Understanding the cost of strategies to reach and deliver pre‐exposure prophylaxis (PrEP) to priority populations is essential to assess the cost‐effectiveness and budget impact of HIV prevention programmes. Providing PrEP through maternal and child health and family planning clinics offers a promising strategy to reach women in high HIV burden settings. We estimated incremental costs and explored the cost drivers of integrating PrEP delivery into routine maternal and child health and family planning services in Kenya. Methods We conducted a costing study from the provider perspective within the PrEP Implementation for Young Women and Adolescents programme in western Kenya. We identified all within‐ and above‐facility activities supporting PrEP delivery and measured clinical service time using time‐and‐motion studies. We obtained input costs from programme budgets, expenditure records and staff interviews. We estimated changes in costs if creatinine testing were postponed from initiation to first follow‐up visit and if PrEP were prioritized to clients at high HIV risk using a behavioural risk assessment tool. We also projected costs under Ministry of Health (MOH) implementation assuming MOH salaries and programme supervision. We estimated annual numbers of PrEP visits from programme data abstracted from 16 facilities between November 2017 and June 2018. We report the cost per client‐month of PrEP dispensed in 2017 USD. Results For an annual programme output of 24,005 screenings, 4198 PrEP initiations and 4427 follow‐up visits, the average cost per client‐month of PrEP dispensed in the study was $26.52. Personnel, drugs and laboratory tests comprised 43%, 25% and 14% of programme costs respectively. Postponing creatinine testing and prioritizing PrEP delivery to clients at high HIV risk reduced total programme costs by 8% and 14% respectively. In the MOH scenario assuming no changes in outputs, the projected cost per client‐month of PrEP dispensed decreased to $16.54 and total programme costs decreased by 38%. Conclusions Incremental PrEP costs are sensitive to the service delivery strategy used to engage priority populations. Postponing creatinine testing and prioritizing PrEP delivery to clients at high HIV risk may reduce costs. Context‐specific cost data are crucial to assess the cost‐effectiveness and affordability of PrEP delivery models.

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“…Differentiated HIV care has been proposed to provide appropriate care to different populations within clinics. The modest body of rigorous evidence on differentiated care to date, however, largely focuses on strategies for stable patients [30][31][32][33][34][35][36]. Far less has been written about strategies for unstable patients, a population much harder to manage.…”

Section: Discussionmentioning

confidence: 99%

Effectiveness of interventions for unstable patients on antiretroviral therapy in South Africa: results of a cluster‐randomised evaluation

Fox

Pascoe

Huber

et al. 2018

Tropical Med Int Health

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Background As loss from HIV care is an ongoing challenge globally, interventions are needed for patients who don't achieve or maintain ART stability. The 2015 South African National Adherence Guidelines (AGL) for Chronic Diseases include two interventions targeted at unstable patients: early tracing of patients who miss visits (TRIC) and enhanced adherence counselling (EAC). Methods As part of a cluster‐randomised evaluation at 12 intervention and 12 control clinics in four provinces, intervention sites implemented the AGL interventions, while control sites retained standard care. We report on outcomes of EAC for patients with an elevated viral load (>400 copies/ml) and for TRIC patients who missed a visit by >5 days. We estimated risk differences (RD) of 3 and 12‐month viral resuppression (<400 copies/ml) and 12‐month retention with cluster adjustment using generalised estimating equations and controlled for imbalances using difference‐in‐differences compared to all eligible in 2015, prior to intervention roll‐out. Results For EAC, we had 358 intervention and 505 control site patients (61% female, median ART initiation CD4 count 154 cells/μl). We found no difference between arms in 3‐month resuppression (RD: −1.7%; 95%CI: −4.3% to 0.9%), but <20% of patients had a repeat viral load within 3 months (19.8% intervention, 13.5% control). Including the entire clinic population eligible for EAC with a repeat viral load at all evaluation sites (n = 934), intervention sites showed a small increase in 3‐month resuppression (28% vs. 25%, RD 3.0%; 95%CI: −2.7% to 8.8%). Adjusting for baseline differences increased the RD to 8.1% (95% CI: −0.1% to 17.2%). However, we found no differences in 12‐month suppression (RD: 1.5%; 95% CI: −14.1% to 17.1% but suppression was low overall at 40%) or retention (RD: 2.8%; 95% CI: −7.5% to 13.2%). For TRIC, we enrolled 155 at intervention sites and 248 at control sites (44% >40 years, 67% female, median CD4 count 212 cells/μl). We found no difference between groups in return to care by 12 months (RD: −6.8%; 95% CI: −17.7% to 4.8%). During the study period, control sites continued to use tracing within standard care, however, potentially masking intervention effects. Conclusions Enhanced adherence counselling showed no benefit over 12 months. Implementation of the tracing intervention under the new guidelines was similar to the standard of care. Interventions that aim to return unstable patients to care should incorporate active monitoring to determine if the interventions are effective.

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Multi‐month prescriptions, fast‐track refills, and community ART groups: results from a process evaluation in Malawi on using differentiated models of care to achieve national HIV treatment goals

Cited by 141 publications

References 13 publications

Retention on ART and predictors of disengagement from care in several alternative community‐centred ART refill models in rural Swaziland

Retention on ART and predictors of disengagement from care in several alternative community‐centred ART refill models in rural Swaziland

The role of costing in the introduction and scale‐up of HIV pre‐exposure prophylaxis: evidence from integrating PrEP into routine maternal and child health and family planning clinics in western Kenya

Effectiveness of interventions for unstable patients on antiretroviral therapy in South Africa: results of a cluster‐randomised evaluation

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