Haiti’s Ministry of Health recently endorsed a national initiative to lengthen prescribing intervals for HIV antiretroviral therapy (ART), known as multi-month scripting (MMS). With MMS, virally-suppressed patients on ART for >6 months are moved from monthly prescribing intervals to intervals of 2-6 months. This decreases patient travel and clinic waiting time, and reduces congestion in ART clinics. Differentiated models of HIV care seek to optimize quality and efficiency of HIV services; however, few studies have described results of MMS in resource-limited settings.
To describe the evolution of ART prescribing patterns in Haiti, we analyzed 867,449 ART prescription records from 65,460 patients in 82 health facilities from January 2012 to December 2016, drawn from the iSanté electronic medical record (EMR) system. We assessed the relationship between prescribing interval and being retained in care, defined as returning within 90 days of the next expected ART pick up date. The outcomes analysis used a subset of 45,604 ART patient records during 2015 – 2016. A multilevel logistic model was used to estimate the association between MMS and retention on ART, after adjustment for clinic site and for patient age, sex, baseline WHO stage, time on ART, and starting ART regimen.
By March 2016, MMS intervals of 36 – 70 days were most common in Haiti (see Figure). Among patients on ART for at least 6 months, MMS accounted for at least half of prescriptions in 81% of sites by December 2016 (increasing from 66% of sites 1 year earlier). Patients receiving MMS tended to be older, have been on ART longer, and have more advanced WHO stage at baseline. Retention was highest (80.8%) among patients with MMS intervals of 71-100 days, and lower (63.4%) among patients with intervals of 0-35 days. After adjustment, longer MMS intervals were positively associated with retention. Odds of retention were 2.3 times higher for intervals of 36-70 days (p<.001), and 2.6 times higher for intervals of 71+ days (p<.001), compared to intervals of 0 -35 days.
Haiti has aggressively moved toward MMS across a majority of ART sites. The association between longer MMS intervals and improved retention on ART is promising, although these favorable results may reflect the preferential selection of stable patients for MMS, rather than a direct causal effect of the strategy. Nevertheless, the fact that no unintended negative relationship was observed between MMS and retention is important.