Patients receiving care for HIV who were scheduled for clinic visits every six months were less likely to show up late, miss visits, have gaps in treatment, and drop off treatment rolls than patients scheduled every three months, a study in Zambia has shown.
The study analysed data from more than 62,000 patients with HIV who were healthy and had been on antiretroviral treatment for at least six months. Among them, they accounted for more than 500,000 clinic visits in Lusaka province, around Zambia’s capital between January 2013 and July 2015.
With the 11.8m people with HIV accessing antiretroviral treatment in sub-Saharan Africa now expected to swell to more than 19m by 2020, finding ways to reduce burdens on health systems and patients, improve efficiency and patient retention will be critical, the authors, led by Aaloke Mody of the University of California San Francisco, note.
Approaches have included community adherence groups, in which members rotate responsibility for pharmacy pick-ups. But although recommended in both World Health Organisation and Zambian guidelines, the idea of simply allowing more time between visits to individual patients, and dispensing sufficient treatment to cover longer periods has received little attention.
And yet, researchers note, visits at six-month intervals already are in place for some patients at public health clinics supported by the Zambian organisation CIDRZ – the Centre for Infectious Disease Research in Zambia. While most patients whose data were tracked were scheduled for visits from one to three months apart, slightly more than 10% only had to show up for clinic appointments every six months. Most of those, however, had to show up for medicine refills more frequently, with only 0.4% scheduled for six-month supplies of medicine.
Still, the researchers calculated, for every 13 patients assigned to six-month, instead of three-month intervals between clinic visits, a missed visit was averted, and for every 57 patients on a six-month, rather than a three-month schedule, a case of a patient dropping from the treatment rolls was averted. The six-month schedule reduces burdens on health systems and crowded clinics, while relieving patients of transportation costs and reducing time away from work and family, the authors note, and recommend further examination of the outcomes of more widely spaced clinic visits, as well as efforts to strengthen medicine supply management to enable longer durations between pharmacy visits.
Background: Extending appointment intervals for stable HIV-infected patients in sub-Saharan Africa can reduce patient opportunity costs and decongest overcrowded facilities.
Methods: We analyzed a cohort of stable HIV-infected adults (on treatment with CD4>200 cells/μl for over 6 months) presenting for clinic visits in Lusaka, Zambia. We utilized multilevel, mixed-effects logistic regression adjusting for patient characteristics—including prior retention—to assess the association between scheduled appointment intervals and subsequent missed visits (>14 days late to next visit), gaps in medication (>14 days late to next pharmacy refill), and loss to follow-up (LTFU, >90 days late to next visit).
Results: 62,084 patients (66.6% female, median age 38, median CD4 438 cells/μl) made 501,281 visits while stable on ART. Most visits were scheduled around 1 month (25.0% clinical, 44.4% pharmacy) or 3 month intervals (49.8% clinical, 35.2% pharmacy), with fewer patients scheduled at 6 month intervals (10.3% clinical, 0.4% pharmacy). After adjustment and as compared to patients scheduled to return in 1 month, patients with longer clinic return intervals were less likely to miss visits (6m aOR 0.20 [95% CI 0.17–0.24]); 3m aOR 0.50 [95% CI 0.49–0.52]; miss medication pickups (6m aOR 0.47 [95% CI 0.39–0.57]; 3m aOR 0.69 [95% CI 0.67–0.70]), and become LTFU prior to the next visit (6m aOR 0.41 [95% CI 0.31–0.54]; 3m aOR 0.79 [95% CI 0.76–0.82]).
Conclusion: Six month clinic return intervals were associated with decreased lateness, gaps in medication, and LTFU in stable HIV-infected patients and may represent a promising strategy to reduce patient burdens and decongest clinics.
Aaloke Mody, Monika Roy, Kombatende Sikombe, Thea Savory, Charles Holmes, Carolyn Bolton-Moore, Nancy Padian, Izukanji Sikazwe, Elvin Geng