Retention in care among clinically stable antiretroviral therapy patients following a six‐monthly clinical consultation schedule: findings from a cohort study in rural Malawi

Abstract

IntroductionLonger intervals between clinic consultations for clinically stable antiretroviral therapy (ART) patients may improve retention in care and reduce facility workload. We assessed long‐term retention among clinically stable ART patients attending six‐monthly clinical consultations (SMCC) with three‐monthly fast‐track drug refills, and estimated the number of consultations “saved” by this model of ART delivery in rural Malawi.MethodsStable patients (aged ≥18 years, on first‐line ART ≥12 months, CD4 count ≥300 cells/mL 3, without opportunistic infections, not pregnant/breastfeeding) were eligible for SMCC, with three‐monthly drug refills from community health workers. Early enrollees were those starting SMCC within six months of eligibility, while late enrollees started at least 6 months after first eligibility. Kaplan–Meier methods were used to calculate cumulative probabilities of retention, stratified by timing of their enrolment and from first six‐monthly clinical consultation. Cox regression was used to measure attrition hazards from the first six‐monthly clinical consultation and risk factors for attrition, accounting for the time‐varying nature of their eligibility and enrolment in this model of care.ResultsFrom 2008 to 2015, 22,633 clinically stable patients from 11 facilities were eligible for SMCC for at least three months, contributing 74,264 person‐years of observation, and 18,363 persons (81%) initiated this model of care. The median time from eligibility to enrolment was 12 months and the median cumulative time on SMCC was 14.5 months. Five years after first SMCC eligibility, cumulative probabilities of retention were 85.5% (95% CI: 84.0% to 86.9%) among early enrollees and 93% (95% CI: 92.8% to 94.0%) among late enrollees. The cumulative probability of retention from first SMCC was 97.0% (95% CI: 96.7% to 97.3%) and 86% (95% CI: 85% to 87%) at one and five years respectively. Among eligible patients initiating SMCC, the adjusted hazards of attrition were 2.4 (95% CI: 2.0 to 2.8) times higher during periods of SMCC discontinuation compared to periods on SMCC. Male sex, younger age, more recent SMCC eligibility and WHO Stage 3/4 conditions in the past year were also independently associated with attrition from SMCC. Approximately 26,000 consultations were “saved” during 2014.ConclusionAfter five years, retention among patients attending SMCC was high, especially among women and older patients, and its scale‐up could facilitate universal access to ART.

Outcomes of Three- Versus Six-Monthly Dispensing of Antiretroviral Treatment (ART) for Stable HIV Patients in Community ART Refill Groups: A Cluster-Randomized Trial in Zimbabwe

“…Observational studies have suggested that clinical outcomes of patients receiving MMD of ART in sub-Saharan Africa are favorable. [9][10][11][12] However, the quality of evidence from observational studies of this intervention is rated as very low to low due to selection bias. 13,14 Early results from one trial have shown favorable outcomes of MMD within adherence clubs in South Africa, 15 but there is little other evidence from large-scale randomized trials of the safety and clinical effectiveness of MMD.…”

Qualitative exploration of perceived benefits of care and barriers influencing HIV care in trans Nzoia, Kenya

“…Shortages in healthcare personnel [12,14,17], long distance to health facilities [4,11,15,18] and poor interactions with patients are commonly reported barriers to HIV care [5,11,12,14]. Other health systems barriers have included frequent appointments [11,19,20], unfriendly health staff with a breakdown of patient-provider trust [5,7,11,14], and poor reimbursement for services by government and other financial support programs [9,14,16,17].…”

Investigating the implementation of differentiated HIV services and implications for pregnant and postpartum women: A mixed methods multi-country study

“…However, South Africa and Tanzania adopted DSD policies in 2016 and 2017 respectively, with differentiated service delivery models for the general adult population in alignment to those recommended by WHO (Ministry of Health Community Development Gender Elderly and Children, 2017; South Africa Department of Health, 2015a, 2016, 2017a). In Malawi, multi-month scripting (of up to 3 months) was included in the 2016 ART guidelines (Ministry of Health Malawi, 2016) following evidence that appointment-spacing reduced patient volumes in clinics (Wringe et al, 2018), but policy documents describing differentiated service delivery approaches more generally had not been produced by 2018 (Table 2).…”

“…In South Africa, spaced and fast-lane appointment systems for stable patients, adherence clubs, and a central chronic medication dispensing and distribution (CCMDD) system have been endorsed in national policy documents from 2014 (Meyer et al, 2017;South Africa Department of Health, 2016;Wringe et al, 2018). In Tanzania, the 2017 national policy on the management and treatment of HIV allowed facility-based individual fast-track services, health worker-managed groups and community-level ART groups (Ministry of Health Community Development Gender Elderly and Children, 2017).…”