The disruption associated with the new coronavirus has speeded up change in the delivery of HIV treatment services in sub-Saharan Africa, with three- and six-monthly ART refills now being much more widely implemented, although they have been recommended for stable patients since 2016.
The 23rd International AIDS Conference (AIDS 2020: Virtual) this week also heard the results of a randomised trial in South Africa, which demonstrated that outcomes for people getting six-monthly visits to an adherence club were as good as those with more frequent visits.
Multi-month prescribing involves clinics providing several months of antiretroviral drugs at one time to patients and reduces the need for monthly clinic visits to pick up refills of medication. Frequent clinic visits can be difficult to manage, especially if the clinic is a long way from home, transport is unaffordable or working hours prevent attendance at the clinic. COVID-19 and the associated travel restrictions and curfews have only added to the difficulty of attending clinics so frequently.
The World Health Organization has recommended multi-month prescribing as part of differentiated service delivery since 2016. The aim of differentiated care is for people with less complex medical needs to receive more care in the community so as to free up medical resources for people who are sicker, those starting treatment and those with more complex needs.
At the virtual conference, a poster from the HIV Coverage, Quality, and Impact Network (CQUIN) outlined the experience of 14 African countries, based on information provided by experts in their ministries of health in April and May. Within weeks of the first reported cases of COVID-19 in Africa, all countries had made substantive changes to the differentiated service delivery programmes.
Ten countries expanded eligibility for multi-month dispensing. For example, everyone on ART in Kenya is now eligible for three-monthly refills, regardless of viral load results. In Malawi, pregnant and breastfeeding women can now get their medication every three months, while adults and children on a dolutegravir-based regimen have six-monthly refills. However, South Africa suspended its plans to expand multi-month dispensing due to fears of ART stock outs.
"COVID-19 and the associated travel restrictions and curfews have only added to the difficulty of attending clinics so frequently."
Other models of differentiated care have been less affected, or have actually needed to be scaled back. Some adherence clubs and community ART groups (which involve groups of patients meeting regularly and receiving their medication at the same time) have been discouraged, modified or suspended in 12 countries. For example, in Zimbabwe, the community ART groups are still used to distribute ART to participants, but they do not meet as a group.
In the randomised controlled trial, run by Médecins Sans Frontières and the University of Cape Town, existing adherence clubs in the district of Khayelitsha were randomised to two or five visits a year. Adherence clubs are groups of around 25 people who are stable on ART, facilitated by a community healthworker. Group meetings include a brief symptom check and distribution of pre-packed ART, with referral to a nurse in the clinic if necessary. A total of 2150 patients in 88 adherence clubs were included, with outcomes assessed after 24 months.
There were no significant differences between the intervention and control arms in terms of retention in care (93% and 94%) or viral suppression (96% and 98%). More people actually completed their annual viral load test in the intervention arm (95% and 89%).
Unsurprisingly, qualitative findings showed that patients found the less frequent visits more convenient and flexible. They also found the schedule motivating, as one participant commented:
“We are trusted with the six months… We are given enough time to look after ourselves, that is where our confidence is built.”
A healthcare worker agreed:
“When they come back, they come back with that excitement. ‘We have been away from the clinic, how are you?’ They are happy! They are now enjoying the club.”
Preko PO et al. Rapid adaptation of HIV differentiated service delivery program design in response to COVID-19: Results from 14 countries in sub-Saharan Africa. 23rd International AIDS Conference, abstract LBPEE44, 2020.
Cassidy T et al. Twenty-four month retention and viral load outcomes from a non-inferiority cluster randomized trial of extending ART dispensing intervals to 6-monthly in adherence clubs. 23rd International AIDS Conference, abstract OAELB0102, 2020.
Keene C et al. "Only twice a year": A qualitative exploration of six-month antiretroviral treatment refills for people living with HIV in Khayelitsha, South Africa. 23rd International AIDS Conference, abstract PEE1497, 2020.
Full image credit: A basic pharmacy. Juliette Humble / DFID. Available at www.flickr.com/photos/dfid/11237114666/in/faves-189197567 under a Creative Commons licence CC BY 2.0.