Improved Viral Suppression With Streamlined Care in the SEARCH Study

Matthew D Hickey, James Ayieko, Dalsone Kwarisiima, Fredrick J Opel, Asiphas Owaraganise, Laura B Balzer, Gabriel Chamie, Vivek Jain, James Peng, Carol Camlin, Edwin D Charlebois, Craig R Cohen, Elizabeth A Bukusi, Moses R Kamya, Maya L Petersen, Diane V Havlir, Matthew D Hickey, James Ayieko, Dalsone Kwarisiima, Fredrick J Opel, Asiphas Owaraganise, Laura B Balzer, Gabriel Chamie, Vivek Jain, James Peng, Carol Camlin, Edwin D Charlebois, Craig R Cohen, Elizabeth A Bukusi, Moses R Kamya, Maya L Petersen, Diane V Havlir

Abstract

Background: HIV differentiated service delivery (DSD) models are scaling up in resource-limited settings for stable patients; less is known about DSD outcomes for patients with viremia. We evaluated the effect on viral suppression (VS) of a streamlined care DSD model implemented in the SEARCH randomized universal test and treat trial in rural Uganda and Kenya (NCT:01864603).

Methods: We included HIV-infected adults at baseline (2013) who were country guideline antiretroviral therapy (ART) eligible (prior ART experience or CD4 ≤ 350) with ≥1 HIV clinic visit between 2013 and 2017 in SEARCH communities randomized to intervention (N = 16) or control (N = 16). We assessed the effect of streamlined care in intervention community clinics (patient-centered care, increased appointment spacing, improved clinic access, reminders, and tracking) on VS at 3 years. Analysis was stratified by the baseline care status: ART-experienced with viremia, ART-naïve with CD4 ≤ 350, or ART-experienced with VS.

Results: Among 6190 ART-eligible persons in care, year 3 VS was 90% in intervention and 87% in control arms (RR 1.03, 95% CI: 1.01 to 1.06). Among ART-experienced persons with baseline viremia, streamlined care was associated with higher VS (67% vs 47%, RR 1.41, 95% CI: 1.05 to 1.91). Among ART-naïve persons, VS was not significantly higher with streamlined care (83% vs 79%, RR 1.05, 95% CI: 0.95 to 1.16). Among ART-experienced persons with baseline VS, nearly all remained virally suppressed in both arms (97% vs 95%, RR 1.01, 95% CI: 1.00 to 1.03).

Conclusions: Streamlined care was associated with higher viral suppression among ART-experienced patients with viremia in this randomized evaluation of ART-eligible patients who were in care after universal HIV testing.

Trial registration: ClinicalTrials.gov NCT01864603.

Conflict of interest statement

The authors have no conflicts of interest to disclose.

Figures

FIGURE 1.
FIGURE 1.
Study flow diagram.

References

    1. Global AIDS Update 2019: Communities at the Centre: UNAIDS; 2019:316.
    1. Havlir D, Lockman S, Ayles H, et al. What do the Universal Test and Treat trials tell us about the path to HIV epidemic control? J Int AIDS Soc. 2020;23:e25455.
    1. Grimsrud A, Bygrave H, Doherty M, et al. Reimagining HIV service delivery: the role of differentiated care from prevention to suppression. J Int AIDS Soc. 2016;19:21484.
    1. Roy M, Bolton Moore C, Sikazwe I, et al. A review of differentiated service delivery for HIV treatment: effectiveness, mechanisms, targeting, and scale. Curr HIV/AIDS Rep. 2019;16:324–334.
    1. Fox MP, Pascoe S, Huber AN, et al. Adherence clubs and decentralized medication delivery to support patient retention and sustained viral suppression in care: results from a cluster-randomized evaluation of differentiated ART delivery models in South Africa. PLoS Med. 2019;16:e1002874.
    1. Jobarteh K, Shiraishi RW, Malimane I, et al. Community ART support groups in Mozambique: the potential of patients as partners in care. PLoS One. 2016;11:e0166444.
    1. Fox MP, Pascoe SJS, Huber AN, et al. Effectiveness of interventions for unstable patients on antiretroviral therapy in South Africa: results of a cluster-randomised evaluation. Trop Med Int Health. 2018;23:1314–1325.
    1. Bell Gorrod H, Court R, Schomaker M, et al. Increased mortality with delayed and missed switch to second-line antiretroviral therapy in South Africa. J Acquir Immune Defic Syndr. 2020;84:107–113.
    1. Petersen ML, Tran L, Geng EH, et al. Delayed switch of antiretroviral therapy after virologic failure associated with elevated mortality among HIV-infected adults in Africa. AIDS. 2014;28:2097–2107.
    1. Hermans LE, Carmona S, Nijhuis M, et al. Virological suppression and clinical management in response to viremia in South African HIV treatment program: a multicenter cohort study. PLoS Med. 2020;17:e1003037.
    1. Havlir DV, Balzer LB, Charlebois ED, et al. HIV testing and treatment with the use of a community health approach in rural Africa. N Engl J Med. 2019;381:219–229.
    1. Kwarisiima D, Kamya MR, Owaraganise A, et al. High rates of viral suppression in adults and children with high CD4+ counts using a streamlined ART delivery model in the SEARCH trial in rural Uganda and Kenya. J Int AIDS Soc. 2017;20(suppl 4):21673.
    1. Ayieko J, Petersen ML, van Rie A, et al. Effect of a patient-centered phone call by a clinical officer at time of HIV testing on linkage to care in rural Kenya. Open Forum Infect Dis. 2018;5:ofy126.
    1. Ayieko J, Petersen ML, Charlebois ED, et al. A patient-centered multicomponent strategy for accelerated linkage to care following community-wide HIV testing in rural Uganda and Kenya. J Acquir Immune Defic Syndr. 2019;80:414–422.
    1. The Integrated National Guidelines on Antiretroviral Therapy, Prevention of Mother to Child Transmission of HIV and Infant & Young Child Feeding. Republic of Uganda: Ministry of Health; 2011.
    1. Guidelines for Antiretroviral Therapy in Kenya. Kenya: National AIDS/STI Control Program (NASCOP); 2011.
    1. Addendum to the National Antiretroviral Treatment Guidelines. Republic of Uganda: Ministry of Health; 2013.
    1. Guidelines on Use of Antiretroviral Drugs for Treating and Preventing HIV Invection. Kenya: National AIDS/STI Control Program (NASCOP); 2014.
    1. Hickey MD, Salmen CR, Omollo D, et al. Implementation and operational research: pulling the network together: quasiexperimental trial of a patient-defined support network intervention for promoting engagement in HIV care and medication adherence on mfangano Island, Kenya. J Acquir Immune Defic Syndr. 2015;69:e127–e134.
    1. Balzer LB, Havlir DV, Schwab J, et al. Statistical Analysis Plan for SEARCH Phase I: Health Outcomes Among Adults. 2018. ArXiv180803231 Stat. Available at: . Accessed September 1, 2020.
    1. Balzer LB, van der Laan MJ, Petersen ML, SEARCH Collaboration. Adaptive pre-specification in randomized trials with and without pair-matching. Stat Med. 2016;35:4528–4545.
    1. Roy M, Czaicki N, Holmes C, et al. Understanding sustained retention in HIV/AIDS care and treatment: a synthetic review. Curr HIV/AIDS Rep. 2016;13:177–185.
    1. Shade SB, Chang W, Kahn JG, et al. SEARCH streamlined HIV care is associated with shorter wait times before and during patient visits in Ugandan and Kenyan HIV clinics. 21st International AIDS Conference. 2016; Durban, South Africa, Abstract FRAEO203.
    1. Ware NC, Wyatt MA, Geng EH, et al. Toward an understanding of disengagement from HIV treatment and care in sub-Saharan Africa: a qualitative study. PLoS Med. 2013;10:e1001369.
    1. Camlin CS, Neilands TB, Odeny TA, et al. Patient-reported factors associated with reengagement among HIV-infected patients disengaged from care in East Africa. AIDS. 2016;30:495–502.
    1. Zanolini A, Sikombe K, Sikazwe I, et al. Understanding preferences for HIV care and treatment in Zambia: evidence from a discrete choice experiment among patients who have been lost to follow-up. PLoS Med. 2018;15:e1002636.
    1. Brown LB, Getahun M, Ayieko J, et al. Factors predictive of successful retention in care among HIV-infected men in a universal test-and-treat setting in Uganda and Kenya: a mixed methods analysis. PLoS One. 2019;14:e0210126.
    1. Maclachlan EW, Shepard-Perry MG, Ingo P, et al. Evaluating the effectiveness of patient education and empowerment to improve patient-provider interactions in antiretroviral therapy clinics in Namibia. AIDS Care. 2016;28:620–627.
    1. Camlin CS, Charlebois ED, Geng E, et al. Redemption of the “spoiled identity:” the role of HIV-positive individuals in HIV care cascade interventions. J Int AIDS Soc. 2017;20:e25023.
    1. Kwarisiima D, Atukunda M, Owaraganise A, et al. Hypertension control in integrated HIV and chronic disease clinics in Uganda in the SEARCH study. BMC Public Health. 2019;19:511.
    1. Shade SB, Osmand T, Luo A, et al. Costs of streamlined HIV care delivery in rural Ugandan and Kenyan clinics in the SEARCH Studys. AIDS. 2018;32:2179–2188.
    1. Brown LB, Havlir DV, Ayieko J, et al. High levels of retention in care with streamlined care and universal test and treat in East Africa. AIDS. 2016;30:2855–2864.

Source: PubMed

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