Participation in adherence clubs and on-time drug pickup among HIV-infected adults in Zambia: A matched-pair cluster randomized trial

Abstract

Background Current models of HIV service delivery, with frequent facility visits, have led to facility congestion, patient and healthcare provider dissatisfaction, and suboptimal quality of services and retention in care. The Zambian urban adherence club (AC) is a health service innovation designed to improve on-time drug pickup and retention in HIV care through off-hours facility access and pharmacist-led group drug distribution. Similar models of differentiated service delivery (DSD) have shown promise in South Africa, but observational analyses of these models are prone to bias and confounding. We sought to evaluate the effectiveness and implementation of ACs in Zambia using a more rigorous study design. Methods and findings Using a matched-pair cluster randomized study design (ClinicalTrials.gov: NCT02776254), 10 clinics were randomized to intervention (5 clinics) or control (5 clinics). At each clinic, between May 19 and October 27, 2016, a systematic random sample was assessed for eligibility (HIV+, age � 14 years, on ART >6 months, not acutely ill, CD4 count not <200 cells/ mm 3) and willingness to participate in an AC. Clinical and antiretroviral drug pickup data were obtained through the existing electronic medical record. AC meeting attendance data were collected at intervention facilities prospectively through October 28, 2017. The primary outcome was time to first late drug pickup (>7 days late). Intervention effect was estimated

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

“…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].…”

“…Patients generally see a clinician annually for a comprehensive clinical consultation, but are referred for additional clinical care if necessary. ACs have shown good retention and viral suppression outcomes both at site level and at scale and are acceptable to patients [7][8][9][10][11][12][13][14].…”

Differentiated Care Preferences of Stable Patients on Antiretroviral Therapy in Zambia: A Discrete Choice Experiment

“…To date, several DSD models have been shown to be effective in retaining patients in care, and their features are generally acceptable to patients in the short to medium term. 4,7–11,29 Scale-up, however, increases complexity, and the choice of model, design, resource requirements, method of implementation, and monitoring is highly context-specific. 3,30 As a result, national health ministries will have to decide which models to prioritize.…”

“…At this juncture, some settings have reported slow enrollment into DSD models 2,3 while others have concerning levels of drop-out. 4–6 Given the large number of models which national agencies must choose from, data on the comparative desirability of DSD model features to patients can help national health agencies prioritize their use.…”

“…Research on DSD to date has largely focused on comparisons between a model and traditional, facility-based care with frequent visits, but has less frequently compared different DSD models with each other, in particular through soliciting patient preferences for different models. Experimental studies suggest 4,7–9 that, in general, patients benefit from peer support and other model components, which reduce visit frequency and waiting time. 10,11 But these studies do not address what services patients most want.…”