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Page 7 of 9 Review Article

In comparison, the average cost per patient initiated on ART traditional healthcare (especially for key populations), which
was US$172.46. Data on estimated cost per participant in turn appear to result in better access to ART initiation for
from the DO ART study in Uganda and South Africa are still ‘hard-to-reach’ populations, such as men, FSWs and other
7
pending. key populations. 3,6,11,14
Discussion Concerns and barriers related to
Summary of the evidence community-based antiretroviral
A rapid review method was used to quickly capture the therapy initiation
current evidence on the essential elements of evidence-based There are concerns that CB-ARTi may shift scarce resources
models of community-based (out-of-facility) ART initiation and ART initiations from healthcare facilities, which may
and the reported outcomes amongst patients initiating ART result in their being unsustainable. However, CB-ARTi
4,9
in community-based settings in SSA. We searched two identified patients with higher median CD4 cell counts,
databases, five conference websites and two registers of which in turn may influence cost-effectiveness favourably
clinical trials for intervention studies evaluating CB-ARTi through reduced morbidity and mortality. In addition,
4
models, with four completed and two ongoing studies being studies in Malawi and Nigeria both reported that the rates of
included in this review.
facility-based ART initiations remained stable, whilst
community-based initiations provided extra numbers.
4,11
The review identified heterogeneity in interventions, study
design, location and definition of outcomes measured as a Another issue raised in the literature relates to the potential
4,11
major obstacle to interpreting and synthesising the data on for increased rates of loss to follow-up, which means
CB-ARTi. For example, some of the authors report on that additional adherence support measures should be put
retention in care and loss to follow-up at 6 months versus 12 in place as CB-ARTi moves from small pilot studies to
4,9
months, and linkage to care at 3 months versus 6 months. programmatic scale-up.
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3
3
These differences are highlighted in Tables 1 and 2.
Concerns have also been expressed about the perceived
4
However, despite the limitations noted above, the existing lack of confidentiality, especially in smaller communities.
data suggest that CB-ARTi could be more effective in However, participants from Uganda and Tanzania reported
increasing the uptake of HIV testing and improving case CB-ARTi to be an acceptable option that is perceived to
finding at a population level 4,11 than in facility-based ART have many advantages compared with facility-based
initiation. Other advantages include improved linkage to care. 6,9,13
ART initiation, 3,4,9,11 which results in similar rates of viral
suppression. One study conducted before the universal test Knowledge gaps and future
3
and treat (UTT) era reported a higher rate of loss to follow- directions
up amongst the home group, and two other studies
4
conducted in the UTT era reported significantly higher The purpose of this rapid review was to synthesise and
3,9
retention in care rates in the same-day group. In addition, describe what is currently known on the topic of CB-ARTi.
two studies found that there was no difference in self- Based on the findings, several considerations for future
reported medication adherence, and one reported low research and practice in the field of CB-ARTi are evident.
3,9
self-reported internalised stigma. The above results suggest Firstly, it is essential to consider the fit of CB-ARTi initiatives
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that CB-ARTi models are equal and certainly not inferior to within the context of the local epidemic conditions to ensure
facility-based healthcare. that they complement existing healthcare systems. This
includes addressing existing facility-level barriers, such as
Strengths and benefits of community-based long waiting times and poor staff attitudes, to increasing
antiretroviral therapy initiation uptake of ART.

Community-based HTS are an essential pillar towards
reaching HIV epidemic control. However, it is estimated that Secondly, given the results, which suggest that CB-ARTi
almost two-thirds of patients are lost in the process from models are possibly not inferior to facility-based ones, it is
community-based HIV testing to facility ART initiation crucial to revisit existing policies on decanting stable virally
without specific interventions, with higher loss to follow up suppressed patients to community ART distribution models
(LTFU) rates amongst African cohorts. Hence, many authors after 12 months. This is especially important for key and
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and technical experts believe that CB-ARTi has considerable other priority populations, such as men, adolescents and
potential to address the gap between HIV diagnosis and ART young people whose retention in care is often hindered by
initiation. 3,9,10,11 The strengths of the CB-ARTi models noted in facility-level barriers.
the literature include reducing the structural barriers, such as
cost of transport to the clinic, time saved otherwise spent Thirdly, it is important to consider the needs of the
on travel to clinics, flexibility of hours and location of population by developing partnerships with community
service delivery and addressing stigma associated with leaders and community-based organisations to overcome

http://www.sajhivmed.org.za 237 Open Access