Namibia is a sparsely populated country of 2.5 million people, with an HIV prevalence 12.6% (persons aged 15-64 years). About 52.1% of the population lives in rural areas, having to travel, on average, 25-59 km for HIV care. During 2007–2014, communities and health care facilities (HCF) in two high HIV burden districts in northern Namibia collaborated to establish Community-Based Antiretroviral Treatment (C-BART) services. Community members constructed basic structures close to their homes where healthcare workers visited quarterly to provide HIV clinical assessment, viral load (VL) and CD4 specimen collection, and antiretroviral (ARV) refills. We evaluated clinical outcomes at these C-BART sites to inform program expansion.
We conducted a retrospective cohort review of patients who were down-referred from HCFs to C-BART sites for continued HIV care during January 01, 2007–July 31, 2017, in Okongo (16 sites) and Eenhana (18 sites) Districts. We abstracted data on demographics, clinical encounters, ARV dispensation, and VL results from electronic and paper records. We measured C-BART retention (3-60 months), defined as being alive and on ART with a documented visit within 90 days of appointment date, and viral suppression (VS) (<1000 copies/ml) on a VL test at least 3 months after down-referral and closest to data abstraction date (November 30, 2017).
Of the 1031 patients (909 adults and 122 children) included in the analysis, 100% of patients were retained in C-BART at 3 months and 99% of adults (n=522) and children (n= 71) were retained at 12 months (Table). In Okongo District, 91% of adults (n=141) and 96% of children (n=28) were retained at 60 months. Overall, 98% of adults (n=568) and 87% of children (n=77) retained at CBART sites for ≥3 months had viral suppression; 98% of adults (n=427) and 84% (n=58) of children in CBART ≥12 months, and 98% of adults (n=121) and 83% (n=23) of children in CBART ≥60 months (Okongo) had VS. VS did not differ by the time on ART in CBART (range: 3 months−10 years) (p=0.49 and p=0.81, respectively).
The C-BART program demonstrates high retention and VS among patients and alleviates concerns about providing community-based ART to children. High retention rates were sustained up to 60 months after down-referral to C-BART, demonstrating the utility of C-BART as a long-term model for managing patients on ART, particularly in rural settings.