Researchers have identified four intervention mechanisms that may have contributed to increased viral suppression rates with community-based delivery of antiretroviral therapy (ART) in sub-Saharan Africa. The community programme was flexible to patients’ needs, integrated multiple components into a single interaction with a healthcare provider, allowed for longer interactions with the provider, and reduced travel time to clinical services.
This comes from qualitative research carried out with participants in the Delivery Optimization for Antiretroviral Therapy (DO ART) study which was conducted in South Africa and Uganda between 2016 and 2019. The randomised study offered community-based ART initiation, monitoring and medication refills at mobile vans in community venues. As we previously reported, the community based ART delivery model contributed significantly to viral suppression and adherence to treatment, especially amongst men.
This qualitative analysis by Dr Hannah Gilbert of Harvard Medical School and colleagues was recently published in the Journal of the International AIDS Society. It sought to explain how the DO ART Study model of community ART delivery worked to increase viral suppression in Ugandan and South African adults living with HIV, compared to standard clinic-based care. A total of 150 DO ART Study participants took part in the qualitative component. Fifty-one interviewees were from Uganda; and 99 were from South Africa, where there were two DO ART Study sites. Drawing on participants' descriptions of community-based services, the analysis identified four intervention mechanisms that may have contributed to increased viral suppression rates with community ART.
Community-based ART delivery was distinguished by its flexible approach to visits as opposed to clinic-based ART provision. Staff shared phone contact information with participants and routinely called with reminders of upcoming appointments and to fix meeting times and places for the mobile van. Participants could draw on their knowledge of communities to select locations where interactions were unlikely to be observed, preserving privacy and reducing the risk of unwanted disclosure. Because they had phone numbers, participants could also easily contact staff to reschedule meeting times when the need arose, or for other reasons such as when they were running low on ART, had questions, or needed general health advice. Easy phone contact between participants and staff cut down on missed meetings and reduced the risk of adherence lapses resulting from running out of pills. The ability to contact staff was greatly appreciated by participants, who interpreted it as a sign of caring on the part of the healthcare system.
A key finding was that integration of services where a person would interact with one health care worker for the whole process of ART initiation and refill encouraged adherence to treatment. Interviewees said the integration of services simplified the process of keeping appointments, promoting continuity in medication re-supply and daily dosing as one health care worker took care of all these processes, without the need for the client to visit different desks or offices for each different service. This integration of services well received by participants, who valued their greater efficiency and privacy. Not having to wait in line for each procedure saved time and reduced the risk of being ‘outed’ as someone living with HIV. This made keeping appointments at a mobile van easier and more appealing, compared to visiting the clinic.
" Reduced travel time eliminated conflicts between the demands of treatment and of income generation."
Participants described their community-based visits with DO ART staff as relaxed – often in sharp contrast to clinic experiences. In DO ART visits, lay counsellors took the time to talk at length about participants’ experiences and concerns. This unhurried atmosphere encouraged questions, and the airing of worries about physical problems and larger life challenges. Counsellors responded by offering tailored counselling, seeking outside advice and referrals, and/or accompanying participants to points of care. A slower pace of visits increased staff time for answering questions and offering encouragement, thereby helping sustain participants’ determination to succeed at ART. The participants felt that the community-based visits were a more efficient way of delivering ART as they did not have to experience the hassle of clinic visits and that they got more time with lay counsellors which enabled them to ask questions.
Further to this, participants highlighted that the reduction in the time needed to travel for ART refills also encouraged adherence to treatment. Reduced travel time eliminated conflicts between the demands of treatment and of income generation. These time reductions were particularly well received by day labourers who explained that a visit to a clinic meant paying for transportation while also losing an entire day's paid work – a double financial burden. Salaried employees complained that supervisors often did not accept clinic appointments as a justifiable reason for absence from work and docked pay. Community ART delivery enabled employees to take a quick break from work to keep appointments, then quickly return to their jobs. Even self-employed people benefited from community-based ART refills as they did not have to shut down their premises for long periods of time to seek ART refills.
Whilst UNAIDS fast track targets for ending the AIDS epidemic by 2030 call for viral suppression in 95% of people using antiretroviral therapy (ART) to treat HIV infection, there are barriers which threaten efforts to reach these targets. This study suggests the DO-ART intervention helped break down some of these barriers. Researchers say that understanding the mechanisms through which HIV service delivery innovations can increase uptake and adherence to ART can contribute to better rates of viral suppression amongst people living with HIV.
Gilbert HN et al. How community ART delivery may improve HIV treatment outcomes: Qualitative inquiry into mechanisms of effect in a randomized trial of community-based ART initiation, monitoring and re-supply (DO ART) in South Africa and Uganda. Journal of the International AIDS Society 24: e25821, 2021 (open access).