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Community-based Adherence Clubs improve outcomes for stable ART patients:Outcomes from Cape Town, South Africa
Anna Grimsrud1, Maia Lesosky1,2, Cathy Kalombo3, Linda-Gail Bekker2,4, Landon Myer1
1 Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town
2 Department of Medicine, University of Cape Town
3 Provincial Government of the Western Cape, Cape Town
4 Desmond Tutu HIV Foundation, Cape Town
IAS 2015, Vancouver
July 22nd 2015
Background• Gugulethu ART cohort
• Innovative models of care
• “Adherence Club” model of ART delivery
Gugulethu ART cohort
Model of ART delivery
Hospital-based, doctor-led, with frequent visitsCommunity health centre, nurse-led, CHW supported, less frequent clinical consultations
• Introduce Adherence Clubs• Background
An Adherence Club:• CHW-led, nurse-supported
• ~30 stable patients• Meets 5 times/year• Receives pre-packed ART
• Introduce Adherence Clubs• Background
Stable patients - • On ART > 6-12-months• Suppressed viral load• No condition requiring
frequent clinical consultation
Community-based Adherence Clubs (CACs)• All visits are outside of the health
facility• Emphasis on peer-based support
and patient self-management• ART can be collected by a
treatment “buddy”
Methods• Community adherence club (CAC) patients enrolled from
June 2012-December 2013
• Describe profile of Club patients and their outcomes• LTFU (no visit in the first 12 weeks of 2014) • Viral rebound (VL>1000 copies/ml after suppression)
• Time to outcomes analysed by gender and age
• Outcome of CAC patients using proportional hazards models• Adjusted for demographic, programmatic and clinical variables
(time-updated viral load and CD4)
Methods (2)• Compare outcomes to standard of care (SoC) patients
• Proportional hazards models with CAC participation as a time-varying covariate
• Modelled the probability of CAC participation using inverse probability weighting • Restricted to patients for whom CACs with available
• Further sensitivity analysis with greater restriction, not incorporating the IPW, logistic regression model and propensity scores.
• Stratified hazard ratios by sub-group
Results - 2000+ patients in 74 CACsPre-ART characteristic Community-based Adherence Club
n=2 113
Gender
Females, n(%) 1 489 (70.5)
Age (years), n(%)
16-24 156 (7.4)
25-34 1 026 (48.6)
35-44 656 (31.1)
≥45 275 (13.0)
Median (IQR) 33.9 (29.4-39.8)
CD4 cell count (cells/μl), n(%)
<50 275 (16.2)
50-99 336 (19.8)
100-199 688 (40.6)
≥200 397 (23.4)
Median (IQR) 134 (73-195)
Results – Description of CAC patients (2)Patient characteristics Community-based
Adherence Clubn=2 113
Year of ART initiation, n(%) 2002-2004 191 (9.0)
2005-2007 758 (35.9)
2008-2010 803 (38.0)
2011-2012 361 (17.1)
Every sent a “buddy”, n(%) Yes 573 (27.1)
Time on ART before CAC, Median (IQR) 4.4 (2.5-6.6)
2002-2004 8.6 (8.2-9.2)
2005-2007 6.4 (5.7-7.1)
2008-2010 3.3 (2.6-4.0)
2011-2012 1.4 (1.2-1.7)
Results• LTFU – 94% retained at 12-months
• Viral rebound – 98% suppressed at 12-months
In final models of LTFU & viral rebound• No difference by gender or in those who sent a “buddy”• Increased risk in patients 16-24 years at ART initiation
CACs associated with reduced risk of LTFU in all approaches compared to SoC
67% reduction in the risk of LTFU compared to the standard of care
In summary
Key Findings
• CACs may achieve favourable programmatic outcomes for stable patients in resource-limited settings
• CAC participation was associated with a substantial decrease in the risk of LTFU compared to facility-based care
Limitations
• Limited follow-up time at a single site
• Selection bias into the intervention • Residual confounding
Patient populations
End points
Model components and flexibilities
Policy and regulations
Model expansion
Research agenda going forward
Let’s define the conversation
Task shifting Decentralization
• Demedicalization of HIV• Community-based
services• Increased patient self-
management• Simplified ART delivery
MODELS OF CARE
For more [email protected]
At IAS 2015-
Wilkinson L et al. "Implementation scale up of the Adherence Club model of care to 30,000 stable antiretroviral therapy patients in the Cape Metro: 2011-2014”. Abstract #MOAD0105LB.
Grimsrud A et al. “Implementation of community-based adherence clubs for stable antiretroviral therapy patients”. Abstract #TUPED791
Adherence Club toolkit -
https://www.msf.org.za/msf-publications/how-to-keep-art-patients-long-term-care-art-adherence-club-report-and-toolkit