ART adherence clubs have proven a successful model for many stable patients to receive peer support and convenient ART refills while utilizing fewer clinic resources. In the Western Cape, South Africa, patients are eligible to join a club after 6 months on ART, provided they are clinically stable, with a suppressed viral load (VL) and are not pregnant. Current guidelines, requiring viraemic patients to leave clubs and return to clinic care, are not strictly implemented. We describe the implementation of guidelines and 12-month outcomes of club patients who experience viraemia.
We included data on all patients ever in a club at three large primary healthcare clinics in Khayelitsha, a high HIV-prevalence, low-income, peri-urban area in Cape Town, South Africa. We identified patients with viraemia (VL>1000 copies/mL) that occurred after joining the club, before they first exited the club (<3 months after last club visit), and before 1 October 2017. We describe characteristics of these patients at the time of the unsuppressed VL test result, subsequent 12-month outcomes, and we performed multivariate logistic regression to identify predictors of 12-month VL resuppression.
Of 8680 total club patients with a median time of 29.8 months in clubs (IQR:20-51) and VL testing data available, 503 (6%) experienced viraemia. Of the 494 patients who had any ART visits >2 months after viraemia, 345 (70%) returned to clinic care. Those who remained in clubs had the same chance of remaining in ART care 12 months later (93%), higher resuppression rates, similar VL completion rates, and a similar yet slightly lower median first high VL, compared to those returning to clinic (Table 1). A multivariate logistic regression showed 12-month VL resuppression was associated with remaining in clubs after one high VL result, compared to returning to clinic (OR:1.39; 95%CI:0.93-2.06), and the log of the first high VL (OR:0.84; 95%CI:0.75-0.93).
Inconsistent application of guidelines may result from clinical oversight or deliberate decisions based on patient-specific factors. Regardless, promising resuppression rates among those remaining in clubs suggest that there is scope to adapt adherence club guidelines to give patients and providers more flexibility, while providing safe clinical management of viraemic patients.