HIV differentiated service delivery (DSD) models are being scaled up in resource-limited settings for stable patients; less is known about DSD outcomes for patients newly linked or re-linked to care. We evaluated the effect of the SEARCH streamlined care intervention by comparing care engagement and viral suppression (VS) between intervention and control arms among HIV+ persons ART eligible by country guidelines at study start who were already enrolled or who linked to care after universal HIV testing in the SEARCH trial (NCT:01864603).
Our analysis included HIV+ adults (age ≥15 yrs) at baseline (2013) who were country guideline ART eligible (prior ART experience or CD4≤350) and had ≥1 clinic visit for HIV care between 2013-2017 in SEARCH communities randomized to intervention (N=16) or control (N=16). We assessed the effect of streamlined care (patient-centered care, increased appointment spacing, improved clinic access, reminders, and tracking) on time in care (TIC) and viral suppression (VS) at 3 years. TIC was defined as the proportion of total follow up time that patients adhered to visit schedules. Analysis was stratified by baseline care status, namely: 1) ART-experienced with baseline VS, 2) ART-experienced with baseline viremia, or 3) ART-naïve with baseline CD4≤350. Comparisons between study arms used cluster-level TMLE.
Among 4,391 HIV+ persons (35% men, 8% youth 15-24 yrs) in care and eligible for ART by country guidelines, 2,958 (67%) were ART-experienced with baseline VS, 568 (13%) were ART-experienced with baseline viremia, and 865 (20%) were ART-naïve with CD4≤350. Among ART-experienced patients with baseline viremia, streamlined care was associated with both higher TIC (RR 1.11, 95% CI 1.01-1.21) and VS (67% vs 47%, RR 1.41, 95% CI 1.04-1.92). Among ART-naïve persons, streamlined care was associated with higher TIC (RR 1.10, 95% CI 1.05-1.21) but VS was not significantly higher (83% vs 78%, RR 1.06, 95% CI 0.95 -1.19). Among ART-experienced persons with baseline VS, effects of streamlined care were observed on TIC (RR 1.07, 95% CI 1.01-1.13), although nearly all were virally suppressed after 3 years regardless of the care delivery model (97% intervention vs 95% control, RR 1.02, 95% CI 1.00-1.03).
Streamlined care was associated with better engagement in care for all groups and viral suppression for ART-experienced patients with viremia in this randomized comparison of patients ART eligible at study start who linked to care after universal HIV testing.