Eligibility for simplified models of antiretroviral therapy (ART) care and delivery have to date been limited to low-risk stable patients. There is no evidence whether such models also provide retention and adherence benefits for patients who have struggled to achieve or maintain viral suppression.
Beginning in February 2012, a “Risk of Treatment Failure” (ROTF) intervention was implemented for patients with consecutive viral loads (VL) above 400 copies/mL at a high-burden ART clinic in Khayelitsha, South Africa. On their ART refill dates, ROTF patients attended a lay healthcare worker led group support session followed by a consultation with a nurse trained to provide integrated adherence and clinical management for patients failing ART. Patients who re-suppressed (VL<400 copies/mL) were enrolled in an Adherence Club (AC). ACs were comprised of ~30 stable patients who met 5 times per year and were facilitated by a lay healthcare worker who conducted a brief symptom screening and distributed pre-packed ART. We conducted a retrospective cohort analysis of patients who re-suppressed following the ROTF intervention and joined an AC. We describe patient characteristics and outcomes [mortality, loss to follow-up (LTFU) and viral rebound] using Kaplan-Meier methods with follow-up to mid-June 2015.
A total of 165 patients were enrolled in an AC following the ROTF intervention (81.8% female, median age 36.2 years). Seventy-nine percent (79.0%) were on second-line ART at AC enrolment. The median time from ART initiation to ROTF intervention was 3.4 years [inter-quartile range (IQR): 2.1-5.5 years) and from ART initiation to AC enrollment- 4.7 years (IQR: 3.4-7.2). Over the study period, two patients died (1.2%). Six-, 12- and 18-months after AC enrollment, retention in any form of care was 98%, 95% and 89%, respectively (Figure 1A). Thirty-six patients experienced viral rebound and 92%, 85% and 78% maintained viral suppression 6-, 12- and 18-months after AC enrollment (Figure 1B).
Our findings suggest that patients who struggled to achieve or maintain viral suppression in routine clinic care can have good outcomes in simplified models of ART care and delivery following re-suppression. These simplified models may remove barriers imposed by clinician-led models such as transport cost and time. Further research is necessary to understand how models of care can better prevent viral rebound and support previously non-adherent patients.