Outcomes from the implementation of a counselling model supporting rapid antiretroviral treatment initiation in a primary healthcare clinic in Khayelitsha, South Africa

Wilkinson, Lynne; Duvivier, Hélène; Patten, Gabriela; Solomon, Suhair; Mdani, Leticia; Patel, Shariefa; Azevedo, Virginia De; Baert, Saar

doi:10.4102/hivmed.v16i1.367

Cited by 11 publications

(18 citation statements)

References 24 publications

(27 reference statements)

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“…The observational studies provided additional data on pregnant women [ 19 , 20 , 23 – 25 ] and people diagnosed with an acute HIV infection [ 21 , 22 , 26 , 27 ]. Four of the observational studies were noncomparative studies [ 19 , 21 , 27 , 28 ]; one study compared data pre and postintervention [ 29 ], and the remainder provided contemporaneous comparisons for patients starting ART at different time points within the same cohort [ 20 , 22 – 26 ].…”

Section: Resultsmentioning

confidence: 99%

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Benefits and risks of rapid initiation of antiretroviral therapy

Ford

Migone

Calmy

et al. 2018

Aids

208

190

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Background:Recent attention has focused on the question of how quickly antiretroviral therapy (ART) should be started once HIV diagnosis is confirmed. We assessed whether rapid ART initiation improves patient outcomes.Methods:We searched five databases from inception up to August 2017. Rapid ART initiation was defined as initiation within 14 days of HIV diagnosis. Data were pooled using random effects meta-analysis.Results:Across the randomized trials, ART start on the same day increased viral suppression at 12 months [three trials: relative risk (RR) 1.17, 95% confidence interval (CI) 1.07–1.27], retention in care at 12 months (RR 1.11, 95% CI 0.99–1.26), and the likelihood of starting ART within 90 days (four trials: RR 1.35, 95% CI 1.13–1.62) and 12 months after eligibility was established (three trials: RR 1.17, 95% CI 1.07–1.27). There was a nonsignificant trend toward reduced mortality (three trials: RR 0.53, 95% CI 0.24–1.08), as well as reduced loss to follow-up at 12 months (2 trials: RR 0.66, 95% CI 0.42–1.04). In the observational studies, offering accelerated ART initiation resulted in a greater likelihood of having started ART within 3 months (two studies: RR 1.53, 95% CI 1.11–2.10). There was a trend toward an increased risk of being lost to follow-up at 6 months (three studies: RR 1.85, 95% CI 0.96–3.55).Conclusion:Accelerated ART initiation can lead to improved clinical outcomes and is likely to be of particular benefit in those settings where extensive patient preparation prior to starting ART results in long delays. These findings informed a WHO recommendation supporting accelerated ART initiation, including same day ART start.

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Section: Resultsmentioning

confidence: 99%

“…The remaining four observational studies [ 19 , 21 , 27 , 28 ] did not provide within-study comparisons and were not included in the meta-analysis. A study from South Africa reported that 75.8% of pregnant women were virally suppressed at the time of delivery following same day ART initiation [ 19 ].…”

Section: Resultsmentioning

confidence: 99%

Benefits and risks of rapid initiation of antiretroviral therapy

Ford

Migone

Calmy

et al. 2018

Aids

208

190

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“…In order for ART to be more effective, both in reducing AIDS mortality and in preventing HIV transmission, it will be critical to ensure more timely ART initiation after HIV diagnosis. Simplified models of ART initiation are needed in order to achieve greater uptake of ART following diagnosis, for example, same-day ART initiation or expedited ART initiation [ 86 , 87 ]. In addition, education programmes may be required in order to raise awareness of the benefits of early ART initiation, and to address misconceptions about ART [ 88 ].…”

Section: Discussionmentioning

confidence: 99%

Estimating the impact of antiretroviral treatment on adult mortality trends in South Africa: A mathematical modelling study

et al. 2017

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BackgroundSubstantial reductions in adult mortality have been observed in South Africa since the mid-2000s, but there has been no formal evaluation of how much of this decline is attributable to the scale-up of antiretroviral treatment (ART), as previous models have not been calibrated to vital registration data. We developed a deterministic mathematical model to simulate the mortality trends that would have been expected in the absence of ART, and with earlier introduction of ART.Methods and findingsModel estimates of mortality rates in ART patients were obtained from the International Epidemiology Databases to Evaluate AIDS–Southern Africa (IeDEA-SA) collaboration. The model was calibrated to HIV prevalence data (1997–2013) and mortality data from the South African vital registration system (1997–2014), using a Bayesian approach. In the 1985–2014 period, 2.70 million adult HIV-related deaths occurred in South Africa. Adult HIV deaths peaked at 231,000 per annum in 2006 and declined to 95,000 in 2014, a reduction of 74.7% (95% CI: 73.3%–76.1%) compared to the scenario without ART. However, HIV mortality in 2014 was estimated to be 69% (95% CI: 46%–97%) higher in 2014 (161,000) if the model was calibrated only to HIV prevalence data. In the 2000–2014 period, the South African ART programme is estimated to have reduced the cumulative number of HIV deaths in adults by 1.72 million (95% CI: 1.58 million–1.84 million) and to have saved 6.15 million life years in adults (95% CI: 5.52 million–6.69 million). This compares with a potential saving of 8.80 million (95% CI: 7.90 million–9.59 million) life years that might have been achieved if South Africa had moved swiftly to implement WHO guidelines (2004–2013) and had achieved high levels of ART uptake in HIV-diagnosed individuals from 2004 onwards. The model is limited by its reliance on all-cause mortality data, given the lack of reliable cause-of-death reporting, and also does not allow for changes over time in tuberculosis control programmes and ART effectiveness.ConclusionsART has had a dramatic impact on adult mortality in South Africa, but delays in the rollout of ART, especially in the early stages of the ART programme, have contributed to substantial loss of life. This is the first study to our knowledge to calibrate a model of ART impact to population-level recorded death data in Africa; models that are not calibrated to population-level death data may overestimate HIV-related mortality.

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“…For example, our finding that a substantial proportion (over a third) of participants linked to care, but did not start treatment within 3 months, aligns with qualitative evidence indicating significant clinicrelated barriers to ART initiation. 28 These findings suggest that models of ART initiation that are patient centered, such as same-day ART initiation and models with more efficient ART preparation, 29,50,51 may improve ART uptake.…”

Section: Discussionmentioning

confidence: 99%

A Conditional Economic Incentive Fails to Improve Linkage to Care and Antiretroviral Therapy Initiation Among HIV-Positive Adults in Cape Town, South Africa

Maughan-Brown

Kuo

et al. 2018

AIDS Patient Care and STDs

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Interventions to improve antiretroviral therapy (ART) access are urgently needed to maximize the multiple benefits from ART. This pilot study examined the effect of a conditional economic incentive on linkage to care and uptake of treatment following ART referral by a mobile health clinic. Between April 2015 and May 2016, 86 individuals (≥18 years old) referred for ART in a resource-limited setting were randomized (1:1) to a control group or to an incentive: R300 cash (∼$23, or 3.5 days minimum wage in the domestic worker sector), conditional upon starting ART within 3 months. Outcome data were obtained from clinic records. The incentive effects on linkage to care (first clinic visit within 3 months) and ART initiation (treatment uptake within 3 months) were assessed using logistic regression. Overall, 67% linked to care and 42% initiated ART within 3 months after referral. No significant differences were found between the incentive and non-incentive group in terms of linkage to care [adjusted odds ratio (aOR): 0.70, 95% confidence interval (CI): 0.26-1.91] and initiation of ART (aOR: 0.67, 95% CI: 0.26-1.78). Ordinary least-squares regression analysis showed that incentivized individuals linked to care in fewer days (-7.9, 95% CI: -18.09 to 2.26) and started treatment in fewer days (-7.3, 95% CI: -27.01 to 12.38), but neither result was statistically significant. Our findings demonstrate poor treatment uptake by both the intervention and control participants and further highlight the challenge in achieving universal early treatment access. Further research is required to understand how economic incentives, which have been shown to have many benefits, can be applied to improve linkage to HIV care and treatment.

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Outcomes from the implementation of a counselling model supporting rapid antiretroviral treatment initiation in a primary healthcare clinic in Khayelitsha, South Africa

Cited by 11 publications

References 24 publications

Benefits and risks of rapid initiation of antiretroviral therapy

Benefits and risks of rapid initiation of antiretroviral therapy

Estimating the impact of antiretroviral treatment on adult mortality trends in South Africa: A mathematical modelling study

A Conditional Economic Incentive Fails to Improve Linkage to Care and Antiretroviral Therapy Initiation Among HIV-Positive Adults in Cape Town, South Africa

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