community-based adherence clubs improve outcomes for stable art patients: outcomes from cape town,...

Community-based Adherence Clubs improve outcomes for stable ART patients:Outcomes from Cape Town, South Africa

Anna Grimsrud1, Maia Lesosky1,2, Cathy Kalombo3, Linda-Gail Bekker2,4, Landon Myer1

1 Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town

2 Department of Medicine, University of Cape Town

3 Provincial Government of the Western Cape, Cape Town

4 Desmond Tutu HIV Foundation, Cape Town

IAS 2015, Vancouver

July 22nd 2015

Background• Gugulethu ART cohort

• Innovative models of care

• “Adherence Club” model of ART delivery

Gugulethu ART cohort

Model of ART delivery

Hospital-based, doctor-led, with frequent visitsCommunity health centre, nurse-led, CHW supported, less frequent clinical consultations

• Introduce Adherence Clubs• Background

An Adherence Club:• CHW-led, nurse-supported

• ~30 stable patients• Meets 5 times/year• Receives pre-packed ART

• Introduce Adherence Clubs• Background

Stable patients - • On ART > 6-12-months• Suppressed viral load• No condition requiring

frequent clinical consultation

Community-based Adherence Clubs (CACs)• All visits are outside of the health

facility• Emphasis on peer-based support

and patient self-management• ART can be collected by a

treatment “buddy”

Methods• Community adherence club (CAC) patients enrolled from

June 2012-December 2013

• Describe profile of Club patients and their outcomes• LTFU (no visit in the first 12 weeks of 2014) • Viral rebound (VL>1000 copies/ml after suppression)

• Time to outcomes analysed by gender and age

• Outcome of CAC patients using proportional hazards models• Adjusted for demographic, programmatic and clinical variables

(time-updated viral load and CD4)

Methods (2)• Compare outcomes to standard of care (SoC) patients

• Proportional hazards models with CAC participation as a time-varying covariate

• Modelled the probability of CAC participation using inverse probability weighting • Restricted to patients for whom CACs with available

• Further sensitivity analysis with greater restriction, not incorporating the IPW, logistic regression model and propensity scores.

• Stratified hazard ratios by sub-group

Results - 2000+ patients in 74 CACsPre-ART characteristic Community-based Adherence Club

n=2 113

Gender

Females, n(%) 1 489 (70.5)

Age (years), n(%)

16-24 156 (7.4)

25-34 1 026 (48.6)

35-44 656 (31.1)

≥45 275 (13.0)

Median (IQR) 33.9 (29.4-39.8)

CD4 cell count (cells/μl), n(%)

<50 275 (16.2)

50-99 336 (19.8)

100-199 688 (40.6)

≥200 397 (23.4)

Median (IQR) 134 (73-195)

Results – Description of CAC patients (2)Patient characteristics Community-based

Adherence Clubn=2 113

Year of ART initiation, n(%) 2002-2004 191 (9.0)

2005-2007 758 (35.9)

2008-2010 803 (38.0)

2011-2012 361 (17.1)

Every sent a “buddy”, n(%) Yes 573 (27.1)

Time on ART before CAC, Median (IQR) 4.4 (2.5-6.6)

2002-2004 8.6 (8.2-9.2)

2005-2007 6.4 (5.7-7.1)

2008-2010 3.3 (2.6-4.0)

2011-2012 1.4 (1.2-1.7)

Results• LTFU – 94% retained at 12-months

• Viral rebound – 98% suppressed at 12-months

In final models of LTFU & viral rebound• No difference by gender or in those who sent a “buddy”• Increased risk in patients 16-24 years at ART initiation

CACs associated with reduced risk of LTFU in all approaches compared to SoC

67% reduction in the risk of LTFU compared to the standard of care

In summary

Key Findings

• CACs may achieve favourable programmatic outcomes for stable patients in resource-limited settings

• CAC participation was associated with a substantial decrease in the risk of LTFU compared to facility-based care

Limitations

• Limited follow-up time at a single site

• Selection bias into the intervention • Residual confounding

Patient populations

End points

Model components and flexibilities

Policy and regulations

Model expansion

Research agenda going forward

Let’s define the conversation

Task shifting Decentralization

• Demedicalization of HIV• Community-based

services• Increased patient self-

management• Simplified ART delivery

MODELS OF CARE

For more informationagrimsrud@gmail.com

At IAS 2015-

Wilkinson L et al. "Implementation scale up of the Adherence Club model of care to 30,000 stable antiretroviral therapy patients in the Cape Metro: 2011-2014”. Abstract #MOAD0105LB.

Grimsrud A et al. “Implementation of community-based adherence clubs for stable antiretroviral therapy patients”. Abstract #TUPED791

Adherence Club toolkit -

https://www.msf.org.za/msf-publications/how-to-keep-art-patients-long-term-care-art-adherence-club-report-and-toolkit