Innovative methods of delivery of HIV care using home-based care and nurse-initiated antiretroviral treatment (ART) are feasible and can have good treatment outcomes in resource-limited settings such as Uganda and Lesotho, delegates heard on Monday at the Fifth International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention, held in Cape Town.
The shortage of healthcare workers and health facilities in settings where HIV prevalence is high means that there is a need for creative solutions to delivering care to ensure that the largest possible number of people can be reached within the constraints of existing resources.
This means that models such as home-based care and nurse -ed prescribing and monitoring of antiretroviral treatment are of particular interest, and good evidence of the effectiveness of such approaches is urgently needed.
In Uganda, a cluster randomised trial was conducted by The AIDS Support Organisation (TASO) in Jinja. Fourty-four clusters of patient groups of were randomised to receive either home-based HIV care (859 individuals in 22 clusters) or care at a healthcare facility (595 individuals in 22 clusters).
The home-based approach for access to HIV care is believed to be easier for patients and allowed for decongestion in the primary healthcare facilities.
In Lesotho, the international aid agency Médècins sans Frontiéres (MSF), in conjunction with the Lesotho health ministry, launched a project that allowed nurses to assume a high level of responsibility in the clinical management of HIV-positive patients, including the initiation of antiretroviral therapy in the Scott Hospital programme.
This approach meant that an increased number of patients could be started on ART despite staffing constraints and a lack of physicians.
In the TASO study in Uganda, antiretroviral therapy was initiated at the clinic. Individuals receiving home-based care were then provided with support and monitoring at home. This was done monthly by lay workers, who also delivered all ART and other necessary medication such as family planning and tuberculosis treatment and condoms. Every six months, this group of patients attended the clinic for a thorough check-up.
Individuals who were randomised to receive clinic-based care attended their clinic once a month for evaluation and to collect their antiretroviral drugs. All the patients received World Health Organization-approved fixed-dose antiretroviral combinations, and the study’s main outcome was the proportion of patients in each arm who experienced virological failure, defined as a sustained viral load above 500 copies/ml.
At baseline, 50% of individuals receiving home-based care and 41% of those receiving clinic-based care had severe immune suppression and a CD4 cell count below 100 cells/mm3. 14% of patients in both study arms experienced virological failure.
At the end of follow-up, 66% of patients in the home-based care group had an undetectable viral load compared to 65% of individuals who received clinic-based care. Similar CD4 count recovery and levels of adherence were reported in both groups.
While the differences in treatment outcomes in the patients appear negligible, the number of visits to the facility per patient differed significantly between those in the home-based care group (4.2 visits) and the facility-based group (7.2). The median cost to access care for patients also differed between the two groups with the cost for the home-based group being five times less than that of the facility-based group ($0.50 vs $2.50), rendering greater access to, and affordability of, services through the home-based care programme.
The Scott Hospital programme in Lesotho has a catchment area of 200,000 people, 35,000 of whom are infected with HIV and 10,000 of whom are in need of ART. The country has very limited healthcare resources with only five physicians and 62 nurses per 100,000 individuals.
A retrospective cohort analysis of the characteristics and outcomes of individuals in Lesotho who started nurse-prescribed HIV treatment over a two-year period between 2006 and 2008 showed that a total of 14,864 individuals (of whom 568 were children) were enrolled in HIV care in the region and 4347 of these started HIV treatment (of whom 282 were children). The vast majority (80%) of those initiating antiretroviral therapy did so in primary care, initiated by nurses. Additional capacity to treat patients was also generated through the appointment of HIV/TB lay counsellors who assisted in pre-ART counselling and patient education.
Key innovations included prescribing a regimen of tenofovir (Viread), 3TC (Epivir)and efavirenz (Sustiva or Stocrin) at a CD4 count threshold of 350 cells/mm3. This was to facilitate easier monitoring of side-effects by nurses, since tenofovir is less toxic than d4T (stavudine, Zerit), the more common component of first-line treatment in sub-Saharan Africa.
In 2006, 27% of individuals presenting for care had very advanced HIV disease as indicated by a CD4 cell count below 50 cells/mm3. This had decreased to 13% by 2008.
After two years, 80% of adults and 88% of children were still receiving care. The twelve-month mortality rate was described by the investigators as “highly satisfactory” at 9% for adults and 5% for children, indicating that nurse-initiated ART can have successful treatment outcomes and that a shortage of physicians should not be a barrier to providing ART to patients in resource-limited settings.