‘Only twice a year’: a qualitative exploration of 6-month antiretroviral treatment refills in adherence clubs for people living with HIV in Khayelitsha, South Africa

Keene, Claire; Zokufa, Nompumelelo; Venables, Emilie; Wilkinson, Lynne; Hoffman, Risa M.; Cassidy, Tali; Snyman, Leigh; Grimsrud, Anna; Voget, Jacqueline; Heyden, Erin von der; Zide-Ndzungu, Siphokazi; Bhardwaj, Vinayak; Isaakidis, Petros

doi:10.1136/bmjopen-2020-037545

Cited by 25 publications

(34 citation statements)

References 17 publications

(29 reference statements)

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“…Reducing the frequency of AC visits ostensibly reduces the opportunity for peer and facilitator support, which patients have described as an important component of the AC model [10,13]. Paradoxically, in a qualitative sub‐study of our trial, patients reported that less frequent visits increased peer and facilitator support as AC members were able to set aside time for the visit and peer interaction if it was only twice a year [49]. Our sub‐analysis of AC patients on ART for less than three years at baseline suggests that extended dispensing intervals may result in inferior retention for this group, indicating more frequent group contact initially may support less frequent interaction later on.…”

Section: Discussionmentioning

confidence: 99%

Twenty‐four‐month outcomes from a cluster‐randomized controlled trial of extending antiretroviral therapy refills in ART adherence clubs

Cassidy

Grimsrud²,

Keene

et al. 2020

J. Intern. AIDS Soc.

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Introduction The antiretroviral therapy (ART) adherence club (AC) model has supported clinically stable HIV patients’ retention with group ART refills and psychosocial support. Reducing visit frequency by increasing ART refills to six months could further benefit patients and unburden health systems. We conducted a pragmatic non‐inferiority cluster randomized trial comparing standard of care (SoC) ACs and six‐month refill intervention ACs in a primary care facility in Khayelitsha, South Africa. Methods Existing community‐based and facility‐based ACs were randomized to either SoC or intervention ACs. SoC ACs met five times annually, receiving two‐month refills with a four‐month refill over year‐end. Blood was drawn at one AC visit with a clinical assessment at the next. Intervention ACs met twice annually receiving six‐month refills, with an individual blood collection visit before the annual clinical assessment AC visit. The first study visits were in October and November 2017 and participants followed for 27 months. We report retention in care, viral load completion and viral suppression (<400 copies/mL) 24 months after enrolment and calculated intention‐to‐treat risk differences for the primary outcomes using generalized estimating equations specifying for clustering by AC. Results Of 2150 participants included in the trial, 977 were assigned to the intervention arm (40 ACs) and 1173 to the SoC (48 ACs). Patient characteristics at enrolment were similar across groups. Retention in care at 24 months was similarly high in both arms: 93.6% (1098/1173) in SoC and 92.6% (905/977) in the intervention arm, with a risk difference of −1.0% (95% CI: −3.2 to 1.3). The intervention arm had higher viral load completion (90.8% (999/1173) versus 85.1% (887/977)) and suppression (87.3% (969 /1173) versus 82.6% (853/977)) at 24 months, with a risk difference for completion of 5.5% (95% CI: 1.5 to 9.5) and suppression of 4.6% (95% CI: 0.2 to 9.0). Conclusions Intervention AC patients receiving six‐month ART refills showed non‐inferior retention in care, viral load completion and viral load suppression to those in SoC ACs, adding to a growing literature showing good outcomes with extended ART dispensing intervals.

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Section: Discussionmentioning

confidence: 99%

Twenty‐four‐month outcomes from a cluster‐randomized controlled trial of extending antiretroviral therapy refills in ART adherence clubs

Cassidy

Grimsrud²,

Keene

et al. 2020

J. Intern. AIDS Soc.

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“…Other service delivery models, for example six‐monthly appointments with reduced frequency of clinic visits by increasing months between ART refills may reduce patient‐incurred costs further. However, preference for this model still varies showing the complexity of preferences [42‐44].…”

Section: Discussionmentioning

confidence: 99%

Patient‐incurred costs in a differentiated service delivery club intervention compared to standard clinical care in Northwest Tanzania

Okere

Corball

Kereto³

et al. 2021

J Int AIDS Soc

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Introduction Placing all clients with a positive diagnosis for HIV on antiretroviral therapy (ART) has cost implications both for patients and health systems, which could, in turn, affect feasibility, sustainability and uptake of new services. Patient‐incurred costs are recognized barriers to healthcare access. Differentiated service delivery (DSD) models in general and community‐based care in particular, could reduce these costs. We aimed to assess patient‐incurred costs of a community‐based DSD intervention (clubs) compared to clinic‐based care in the Shinyanga region, Tanzania. Methods Cross‐sectional survey among stable ART patients (n = 390, clinic‐based; n = 251, club‐based). For each group, we collected socio‐demographic, income and expenditure data between May and August 2019. We estimated direct and indirect patient‐incurred costs. Direct costs included out‐of‐pocket expenditures. Indirect costs included income loss due to time spent during transport, accessing services and off work during illness. Cost drivers were assessed in multivariate regression models. Results Overall, costs were significantly higher among clinic participants. Costs (USD) per year for clinic versus club were as follows: 11.7 versus 4.17 (p < 0.001) for direct costs, 20.9 versus 8.23 (p < 0.001) for indirect costs and 32.2 versus 12.4 (p < 0.001) for total costs. Time spent accessing care and time spent in illness (hours/year) were 38.3 versus 13.8 (p < 0.001) and 16.0 versus 6.69 (p < 0.001) respectively. The main cost drivers included transportation (clinic vs. club: 67.7% vs. 44.1%) for direct costs and income loss due to time spent accessing care (clinic vs. club: 60.4% vs. 56.7%) for indirect costs. Factors associated with higher total costs among patients attending clinic services were higher education level (coefficient [95% confidence interval]) 20.9 [5.47 to 36.3]) and formal employment (44.2 [20.0 to 68.5). Differences in mean total costs remained significantly higher with formal employment, rural residence, in addition to more frequent visits among clinic participants. The percentage of households classified as having had catastrophic expenditures in the last year was low but significantly higher among clinic participants (10.8% vs. 5.18%, p = 0.014). Conclusions Costs incurred by patients accessing DSD in the community are significantly lower compared to those accessing standard clinic‐based care. DSD models could improve access, especially in resource‐limited settings.

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“…In addition, the results do not imply that second-and third-line patients should be separated from first-line patients, and where healthcare workers have been trained to manage different ART lines, these different groups of patients could be mixed. In CRAM, due to medication stock challenges, the clubs were meeting once per month, whereas in other settings, they were reconvening less regularly, for example every 2, 3 or 6 months [15,24,25]. Having less frequent sessions, when medication stocks allow, like in South Africa where patients reconvened every 6 months, proved to be more convenient for the patients [25].…”

Section: Discussionmentioning

confidence: 99%

“…In CRAM, due to medication stock challenges, the clubs were meeting once per month, whereas in other settings, they were reconvening less regularly, for example every 2, 3 or 6 months [15,24,25]. Having less frequent sessions, when medication stocks allow, like in South Africa where patients reconvened every 6 months, proved to be more convenient for the patients [25]. Having longer intervals between club meetings would simultaneously create new slots for early morning clubs and enable recruiting of new patients.…”

Section: Discussionmentioning

confidence: 99%

Outcomes of patients on second‐ and third‐line ART enrolled in ART adherence clubs in Maputo, Mozambique

Finci¹,

Flores²,

Zamudio³

et al. 2020

Tropical Med Int Health

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objectives Adherence clubs (AC) offer patient-centred access to antiretroviral therapy (ART) while reducing the burden on health facilities. AC were implemented in a health centre in Mozambique specialising in patients with a history of HIV treatment failure. We explored the impact of AC on retention in care and VL suppression of these patients. methods We performed a retrospective analysis of patients enrolled in AC receiving second-or thirdline ART. The Kaplan-Meier estimates were used to analyse retention in care in health facility, retention in AC and viral load (VL) suppression (VL < 1000 copies/mL). Predictors of attrition and VL rebound (VL ≥ 1000 copies/mL) were assessed using multivariable proportional hazards regression. results The analysed cohort contained 699 patients, median age 40 years [IQR: 35-47], 428 (61%) female and 97% second-line ART. Overall, 9 (1.3%) patients died, and 10 (1.4%) were lost to follow-up. Retention in care at months 12 and 24 was 98.9% (95% CI: 98.2-99.7) and 96.4% (95% CI: 94.6-98.2), respectively. Concurrently, 85.8% (95% CI: 83.1-88.2) and 80.9% (95% CI: 77.8-84.1) of patients maintained VL suppression. No association between predictors and all-cause attrition or VL rebound was detected. Among 90 patients attending AC and simultaneously having VL rebound, 64 (71.1%) achieved VL resuppression, 10 (11.1%) did not resuppress, and 14 (15.6%) had no subsequent VL result. conclusion Implementation of AC in Mozambique was successful and demonstrated that patients with a history of HIV treatment failure can be successfully retained in care and have high VL suppression rate when enrolled in AC. Expansion of the AC model in Mozambique could improve overall retention in care and VL suppression while reducing workload in health facilities. keywords HIV care continuum, retention, differentiated care, adherence clubs, VL suppression, second-and third-line ART patients Sustainable Development Goals (SDGs): SDG 3 (good health and well-being), SDG 17 (partnerships for the goals)

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‘Only twice a year’: a qualitative exploration of 6-month antiretroviral treatment refills in adherence clubs for people living with HIV in Khayelitsha, South Africa

Cited by 25 publications

References 17 publications

Twenty‐four‐month outcomes from a cluster‐randomized controlled trial of extending antiretroviral therapy refills in ART adherence clubs

Twenty‐four‐month outcomes from a cluster‐randomized controlled trial of extending antiretroviral therapy refills in ART adherence clubs

Patient‐incurred costs in a differentiated service delivery club intervention compared to standard clinical care in Northwest Tanzania

Outcomes of patients on second‐ and third‐line ART enrolled in ART adherence clubs in Maputo, Mozambique

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