Page 139 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 6 of 7 Original Research

AC when information was missing for a selective subset of L.W. collected the data for analysis. J.S., L.W., C.C., G.v.C.
patients in that AC. Despite these limitations, we find these and A.G. contributed to the plan of the analysis and
results promising in introducing the idea that patients who interpretation of the data. L.W. and V.C. developed the ROTF
experienced a recent elevated VL can have positive outcomes to AC protocol. All authors commented on drafts of the
if care is differentiated to meet their specific needs at a article and approved the final version to be published.
particular time point in their treatment pathway.
References
Conclusion 1. Johnson L, Mossong J, Dorrington E, et al. Life expectancies of South African adults

Further research is needed to fully understand how less starting antiretroviral treatment: Collaborative analysis of cohort studies. PLoS
Med. 2013;10(4):e1001418. https://doi.org/10.1371/journal.pmed.1001418
intense, differentiated ART delivery models can collectively 2. Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early
support the heterogeneous population of patients currently antiretroviral therapy. N Engl J Med. 2011;365(6):493–505. https://doi.org/
10.1056/NEJMoa1105243
ineligible for these models. We recommend both small- 3. Mills EJ, Nachega JB, Buchan I, et al. Adherence to antiretroviral therapy in sub-
scale implementation in diverse contexts to assess the Saharan Africa and North America: A meta-analysis. JAMA. 2006;296(6):679–690.
https://doi.org/10.1001/jama.296.6.679
generalisability of our findings and randomised control trials 4. Nachega JB, Marconi VC, Van Zyl GU, et al. HIV treatment adherence, drug
to directly compare the outcomes of patients experiencing resistance, virologic failure: Evolving concepts. Infect Disord Drug Targets.
2011;11(2):167–174. https://doi.org/10.2174/187152611795589663
elevated VLs recently suppressed or resuppressed 5. UNAIDS. 90-90-90: An ambitious treatment target to help end the AIDS epidemic.
immediately accessing a simplified ART delivery model Geneva: UNAIDS; 2014.
versus routine care. Tests of association should be employed 6. Tse W, Yang W, Haung W. A narrative review of cost-effectiveness analysis of
people living with HIV treated with HAART: From interventions to outcomes.
to determine the populations who could most benefit. Clinicoecon Outcomes Res. 2015;7:431–439. https://doi.org/10.2147/CEOR.
Finally, retention in AC care had its sharpest decline between S85535
12 and 18 months, and longer term follow-up is needed to 7. Madi D, Gupta P. Achappa B, et al. HIV status disclosure among people living with
HIV in the era of combination antiretroviral therapy (cART). J Clin Diagn Res.
determine if differentiated ART delivery models can support 2015;9(8):14–16. https://doi.org/10.7860/JCDR/2015/12511.6373
patient retention over the long run. In summary, criteria for 8. Bemelmans M, Baert S, Goemaere E, et al. Community-supported models of care
for people on HIV treatment in sub-Saharan Africa. Trop Med Int Health.
differentiation must continue to be re-evaluated. Using the 2014;19(8):968–977. https://doi.org/10.1111/tmi.12332
criteria of proven ‘stability’ may exclude those who have the 9. Okoboi S, Ding E, Persuad S, et al. Community-based ART distribution system can
effectively facilitate long-term program retention and low-rates of death and
most to gain from streamlining access to ART, including virologic failure in rural Uganda. AIDS Red Ther. 2015;12(37)e1–e9. https://doi.
those who have recently suppressed. org/10.1186/s12981-015-0077-4
10. Fox M, Sydney R. Retention of adult patients on antiretroviral therapy in low- and
middle-income countries: Systematic review and meta-analysis 2008–2013.
In conclusion, our findings suggest that patients who J Acquir Immune Defic Syndr. 2015;16(1):98–108. https://doi.org/10.1097/QAI.
0000000000000553
struggled to achieve or maintain viral suppression in routine 11. UNAIDS. 2006 report on the global AIDS epidemic. Geneva: UNAIDS; 2006.
clinic care can have good retention and viral suppression 12. UNAIDS. Global HIV & AIDS statistics – 2018 fact sheet. Geneva: UNAIDS; 2018.
outcomes in differentiated ART delivery models, such as 13. Kaplan SR, Oosthuizen C, Stinson K, et al. Contemporary disengagement from
ACs, immediately following suppression support. These antiretroviral therapy in Khayelitsha, South Africa: A cohort study. PLoS Med.
2017;14(11):e1002407. https://doi.org/10.1371/journal.pmed.1002407
models may remove health system barriers imposed by 14. Decroo T, Rasschaert F, Telfer B, Remartinez D, Laga M, Ford N. Community-based
clinician-led facility-based models. Further studies are antiretroviral therapy programs can overcome barriers to retention of patients
and decongest health services in sub-Saharan Africa: A systematic review. Int
required to evaluate both retention and viral suppression Health. 2013;5(3):169–179. https://doi.org/10.1093/inthealth/iht016
benefits of expanding access to differentiated ART delivery 15. Luque-Fernandez MA, Van Cutsem G, Goemaere E, et al. Effectiveness of patient
adherence groups as a model of care for stable patients on antiretroviral therapy
models to patients who have struggled with adherence. in Khayelitsha, Cape Town, South Africa. PLoS One. 2013;8(2):e56088. https://doi.
org/10.1371/journal.pone.0056088
Acknowledgements 16. Grimsrud A, Lesosky M, Kalombo C, Bekker L G, Myer L. Community-based
adherence clubs for the management of stable antiretroviral therapy patients
in Cape Town, South Africa: A cohort study. J Acquir Immune Defic Syndr.
The authors thank all the staff at Ubuntu Clinic and 2015;71(1):16–23. https://doi.org/10.1097/QAI.0000000000000863
Khayelitsha and Eastern sub-structure for their ongoing 17. Bango F, Ashmore J, Wilkinson L, Van Cutsem G, Cleary S. Adherence clubs for long-
term provision of antiretroviral therapy: Cost-effectiveness and access analysis
dedication to their patients demonstrated through their from Khayelitsha, South Africa. Trop Med Int Heal. 2016;21(9):1115–1123. https://
doi.org/10.1111/tmi.12736
continued support for piloting models of care that better suit 18. Wilkinson L. ART adherence clubs: A long-term retention strategy for clinically
the needs of their patients. The authors would also like to stable patients receiving antiretroviral therapy. South Afr J HIV Med. 2013;14(2):
48–50. https://doi.org/10.4102/sajhivmed.v14i2.77
thank the MSF ROTF and AC nurses and counsellors who 19. Auld AF, Shiraishi RW, Couto A, et al. A decade of antiretroviral therapy scale-up in
mentor and support their colleagues at Ubuntu Clinic. Mozambique: Evaluation of outcome trends and new models of service delivery
among more than 300,000 patients enrolled during 2004–2013. J Acquir Immune
Defic Syndr. 2016;73(2):e11–e22. https://doi.org/10.1097/QAI.0000000000001137
Competing interests 20. Decroo T, Koole O, Remartinez D, et al. Four-year retention and risk factors for
attrition among members of community ART groups in Tete, Mozambique. Trop
Med Int Health. 2014;19(5):514–521. https://doi.org/10.1111/tmi.12278
The authors declare that they have no financial or personal 21. Wringe A, Cawley C, Szumilin E, et al. Retention in care among clinically stable
relationship(s) that may have inappropriately influenced antiretroviral therapy patients following a six-monthly clinical consultation
schedule: findings from a cohort study in rural Malawi. J Int AIDS Soc. 2018;21(11):
them in writing this article. e25207. https://doi.org/10.1002/jia2.25207
22. Mody A, Roy M, Sikombe K, et al. Improved retention with six month clinic return
intervals for stable HIV-infected patients in Zambia. Clin Infect Dis. 2017;66(2):
Authors’ contributions 237–243. https://doi.org/10.1093/cid/cix756
23. Vogt F, Kalenga L, Lukela J, et al. Decentralizing ART supply for stable HIV patients
J.S. was responsible for the writing of the article, with to community-based distribution centers: Program outcomes from an urban
context in Kinshasa, DRC. J Acquir Immune Defic Syndr. 2017;74(3):326–331.
statistical analysis completed by J.S. and A.G. J.S. and https://doi.org/10.1097/QAI.0000000000001215
http://www.sajhivmed.org.za 132 Open Access