RESUMO
OBJECTIVES: Differentiated service delivery (DSD) models are used to deliver antiretroviral therapy (ART) but data are limited in postpartum women, who are at high risk of non-adherence and elevated viral load (VL) over the extended postpartum period. DESIGN: Randomized controlled trial. METHODS: We enrolled consecutive postpartum women who initiated ART during pregnancy and met local DSD eligibility (clinically stable, VL less than 400âcopies/ml) at a large primary healthcare (PHC) clinic. Women were randomized to a community-based 'adherence club' (AC, the local DSD model: community health worker-led groups of 20-30 patients with ART dispensing at a community venue) or routine PHC clinics (local standard of care with nurse/doctor-led services). Follow-up visits with VL separate from routine care took place at 3, 6, 12, 18 and 24âmonths postpartum. Endpoints were time to VL of at least 1000âcopies/ml (primary) and VL of at least 50âcopies/ml (secondary) by intention-to-treat. RESULTS: At enrolment ( n â=â409), the median duration postpartum was 10âdays, all women had a VL less than 1000âcopies/ml and 88% had a VL less than 50âcopies/ml; baseline characteristics did not differ by arm. Twenty-four-month retention was 89%. Sixteen and 29% of women in AC experienced a VL of at least 1000âcopies/ml by 12 and 24âmonths, compared to 23 and 37% in PHC, respectively (hazard ratio [HR]â=â0.71; 95% confidence interval [CI]â=â0.50-1.01). Thirty-two and 44% of women in ACs had a VL of at least 50âcopies/ml by 12 and 24âmonths, compared to 42 and 56% in PHC, respectively (HRâ=â0.68; 95% CIâ=â0.51-0.91). CONCLUSIONS: Early DSD referral was associated with reduced viraemia through 24âmonths postpartum and may be an important strategy to improve maternal virologic outcomes.
Assuntos
Fármacos Anti-HIV , Infecções por HIV , Gravidez , Humanos , Feminino , Fármacos Anti-HIV/uso terapêutico , Infecções por HIV/tratamento farmacológico , Carga Viral , Período Pós-Parto , Encaminhamento e ConsultaRESUMO
OBJECTIVE: The ambitious '90-90-90' treatment targets require innovative models of care to support quality antiretroviral therapy (ART) delivery. While evidence for differentiated models of ART delivery is growing, there are few data on the feasibility of scale-up. We describe the implementation of the Adherence Club (AC) model across the Cape Metro health district in Cape Town, South Africa, between January 2011 and March 2015. METHODS: Using data from monthly aggregate AC monitoring reports and electronic monitoring systems for the district cohort, we report on the number of facilities offering ACs and the number of patients receiving ART care in the AC model. RESULTS: Between January 2011 and March 2015, the AC programme expanded to reach 32 425 patients in 1308 ACs at 55 facilities. The proportion of the total ART cohort retained in an AC increased from 7.3% at the end of 2011 to 25.2% by March 2015. The number of facilities offering ACs also increased and by the end of the study period, 92.3% of patients were receiving ART at a facility that offered ACs. During this time, the overall ART cohort doubled from 66 616 to 128 697 patients. The implementation of the AC programme offset this increase by 51%. CONCLUSIONS: ACs now provide ART care to more than 30 000 patients. Further expansion of the model will require additional resources and support. More research is necessary to determine the outcomes and quality of care provided in ACs and other differentiated models of ART delivery, especially when implemented at scale.