Page 135 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 2 of 7 Original Research

Differentiated ART delivery models such as ART adherence single undetectable VL. Adherence clubs were composed of
clubs (ACs) have been shown to be successful and cost- approximately 30 patients who met with an LHCW five times
effective in providing treatment, care and support. 14,15,16,17 a year (every 2 months except over year-end holidays when a
These models have traditionally been restricted to clinically 4-month ART refill was provided) for a short symptom
stable patients, defined as patients on ART for 12 months or screen, peer support and distribution of pre-packed ART
more with two undetectable viral loads (VLs). Differentiated refills. Some ACs were facility based and met at the Ubuntu
ART delivery models promote adherence by reducing the Clinic, while others were decentralised to community venues.
frequency of visits and time spent in a clinic, allowing for Adherence club patients had an annual blood draw and an
increased peer and lay healthcare worker (LHCW) support annual clinical consultation as part of their AC visit schedule.
and ensuring longer ART supply. 18,19,20,21,22,23 If such models of If a patient experienced viral rebound (VL > 400) in the AC,
ART delivery remain restricted to low-risk stable patients on failed to attend their AC or became clinically unstable for any
first-line treatment, the growing cohort of patients struggling reason, the patient was referred back into routine clinic care
with adherence may be left behind, stuck in delivery models for ongoing management. The AC model was brought to
that already failed them. Furthermore, it may be the patients scale in the Cape Town health district with 40.9% (62 874
who are not stable, those at risk of treatment failure, who patients) of all ART patients in the district accessing ART care
stand to gain the most from simplifying their ART refill and support through ACs by the end of 2016. Twenty-four-
30
24
delivery mechanism. While differentiated ART delivery month retention, annual VL completion and viral suppression
models have received widespread attention and have been outcomes were 89.3%, 88.1% and 97.2%, respectively.
31
incorporated into the World Health Organization’s treatment
25
guidelines, they have been restricted to low-risk stable In 2012, the ROTF intervention was piloted at Ubuntu
patients. Data on the outcomes of patients at high-risk of Clinic by Médecins Sans Frontières (MSF) and the
experiencing viral rebound who access differentiated ART Western Cape Department of Health. 32,33, The Western
delivery models do not currently exist. We describe the Cape Department of Health has subsequently adopted the
outcomes of patients referred directly to ACs after viral intervention to manage all patients failing or at risk of failing
suppression following specific adherence support. ART with phased implementation in all its Cape Town
facilities starting at the end of 2015. The intervention was
Research methods and design designed to provide integrated adherence support and
Study design clinical management for all patients in routine clinical care
with VLs above 400 copies/mL, irrespective of treatment
A descriptive retrospective cohort study was undertaken regimen. Patients who experienced a single VL > 400 copies/mL
using routine data collected under programmatic conditions were enrolled in an LHCW support group, while those with
at Ubuntu Clinic, Khayelitsha, Western Cape, South Africa, two consecutive VLs > 400 copies/mL experienced more
for patients who joined ACs between February 2012 and intensive counselling with a nurse trained to provide
February 2014 after viral suppression following the risk of integrated adherence and clinical management. Adherence
treatment failure (ROTF) intervention. was managed through structured steps including VL
monitoring and switching patients to second-line ART
Setting regimens in accordance with national guidelines (two
consecutive VLs > 1000 copies/mL).
The study was conducted at Ubuntu Clinic in Khayelitsha,
South Africa. Khayelitsha is a township in Cape Town with After suppression (VL < 400 copies/mL) – whether on first
a population of approximately half a million people and line, after switch to second line or on second line – patients
high rates of HIV and tuberculosis (TB). In 2011, the antenatal were given the choice to enrol directly into an AC or return
HIV prevalence was 34%. 26,27 The community is largely poor, to routine clinician-led facility-based care. Patients who
with 55% of the population living in informal housing and suppressed and enrolled in an AC following the ROTF
60% unemployment among working age individuals. In intervention are hereafter referred to as ‘high-risk patients’
28
2001, Ubuntu Clinic became the first public sector clinic in as they were regarded to be at a higher risk of interrupting
29
the country to provide ART; by March 2017, 10 252 patients their treatment again. 34,35 High-risk patients were enrolled in
were retained in ART care at Ubuntu Clinic, with close to ACs on a rolling basis, and therefore ACs are composed of
40 000 patients in ART care in Khayelitsha sub-district both stable and high-risk patients.
(a sub-district in the Cape Metro district).

Adherence club model and risk of treatment Data collection and analysis
failure intervention Analysis inclusion and exclusion
The AC model has been described in detail previously. 15,16,17,18 Patients who joined ACs between February 2012 and
Briefly, in the Western Cape, clients were initially regarded as February 2014 after suppressing in the ROTF intervention
stable and eligible for the AC model if on ART for 12 months were identified retrospectively by comparing the clinic’s
or more with two undetectable VLs and no co-morbidities electronic monitoring records (EMR), which identified
requiring frequent clinical assessment. In 2015, stability patients participating in the ROTF and AC programmes.
criteria changed to on ART for 6 months or more with a Additional data were gathered from AC registers on those

http://www.sajhivmed.org.za 128 Open Access