Retention in pre-ART care can be boosted by monthly visits from volunteer support workers

Retention in HIV care for patients not eligible for antiretroviral therapy (ART) can be boosted by monthly home visits from volunteer community support workers, investigators from Uganda report in the online edition of the Journal of Acquired Immune Deficiency Syndromes.

Results of the randomised controlled trial showed that 82% of patients who received the home counselling visits were retained in care compared to just 34% of patients who received the standard of care. Patients who were visited by the community support workers were also more likely than those in the control group to disclose their HIV status, use condoms and have only one sexual partner.

“Community support agents (CSAs) in resource poor settings can almost triple the retention of PLHIV [people living with HIV] under the critical stage of pre-ARV care, improve disclosure, and promote safer sexual behaviours,” comment the authors. “Our intervention retention rate (82%) is much higher than the comparable average rate of retention of PLHIV under pre-ART care (45-57%) in sub-Saharan Africa.”

Glossary

retention in care

A patient’s regular and ongoing engagement with medical care at a health care facility. 

standard of care

Treatment that experts agree is appropriate, accepted, and widely used for a given disease or condition. In a clinical trial, one group may receive the experimental intervention and another group may receive the standard of care.

disclosure

In HIV, refers to the act of telling another person that you have HIV. Many people find this term stigmatising as it suggests information which is normally kept secret. The terms ‘telling’ or ‘sharing’ are more neutral.

control group

A group of participants in a trial who receive standard treatment, or no treatment at all, rather than the experimental treatment which is being tested. Also known as a control arm.

loss to follow up

In a research study, participants who drop out before the end of the study. In routine clinical care, patients who do not attend medical appointments and who cannot be contacted.

WHO recommends that patients not eligible for antiretroviral therapy should attend routine HIV care follow-up visits every three months. But research conducted in sub-Saharan Africa suggests that large numbers of patients are lost to follow-up in the interval between HIV diagnosis and initiation of antiretroviral therapy. For instance, in the Iganga district, eastern Uganda, over 90% of 1400 newly diagnosed individuals did not enroll in care were lost to follow-up between 2004-2007.

An international team of investigators were alarmed by this poor retention rate. They therefore designed a randomised controlled trial involving 400 patients newly diagnosed with HIV and not eligible for antiretroviral therapy in the Iganda district. The patients were randomised to receive standard of care (test results, cotrimoxazole prophylaxis, post-test counselling on disclosure, living well with HIV and the importance of attending quarterly follow-up visits) or standard of care and monthly home visits from volunteer community support workers, involving counselling on positive living, disclosure and a reminder to attend follow-up appointments.

The primary end-point of the study was the proportion of patients attending six or more routine HIV care visits in the first 24 months after diagnosis.

After 24 months, patients receiving the monthly visits were almost three times more likely to be retained in care compared to patients in the standard of care arm (82% vs. 34%).

Primary analysis showed that monthly visits were significantly associated with retention in care (RR, 2.5; 95% CI, 1.3-2.0), as were gender, age, education, marital status, occupation, religion and antiretroviral therapy awareness.

After controlling for potential confounders, monthly home visits were still significantly associated with retention in care (RR = 2.5; 95% CI, 2.0-3.0).

Patients who were visited by community support volunteers were also more likely to disclose their HIV status than patients in the control group (RR = 1.7; 95% CI, 1.2-2.4), report consistent safer sex (RR = 1.8; 95% CI, 1.4-2.2) and to report sex with only one partner (RR = 1.2; 95% CI, 1.0-1.5).

“This trial thus demonstrates that use of CSAs in resource poor settings can more than double retention of PLHIV under care and also additionally improve status disclosure and other elements of positive living all of which are important pillars of HIV combination prevention,” conclude the investigators. “The authorities would, however, need to address other important system deficiencies such as stock-outs of HIV testing kits and cotrimoxazole, poor staff attitudes towards pre-ARV care and staff confidentiality that are common in similar settings.”

References

Muhamadi L et al. The effect of community support agents on retention of people living with HIV in pre-antiretroviral care – a randomized controlled trial in Eastern Uganda. J Acquir Immune Defic Syndr, online edition. DOI: 10.1097/QAI.0000000000000723, 2015.