Adherence clubs were linked to a 30% reduction in high viral load among postpartum South African women living with HIV, Aidsmap reports the Conference on Retroviruses and Opportunistic Infections (CROI 2020). Dr Jasantha Odayar of the University of Cape Town and researchers at the National Health Laboratory Service, presented these findings from a randomised controlled trial on behalf of the Postpartum Adherence Clubs for Antiretroviral Therapy (PACART) study team.
The authors evaluated adherence clubs to deliver long-term HIV care to postpartum women who started ART in pregnancy at the Gugulethu Community Health Centre and the associated Midwife Obstetric Unit in Cape Town.
This public sector primary care facility serves a population of around 350,000, most of low socioeconomic status. The centre includes an ART clinic providing HIV care to the general adult population. The Obstetric Unit provides services to over 4000 women each year. Antenatal care coverage is high (95%) as is antenatal HIV prevalence (30% in 2016).
Adherence club visits typically take an hour whereas an ART clinic visit can take most of the day. They are led by lay health workers rather than a nurse or doctor.
The primary objective was to compare maternal HIV viral suppression up to 24 months postpartum.
Odayar concluded adherence clubs have the potential to be an important intervention to improve women’s virologic outcomes. As a well-established system to which postpartum women were already being referred, it did not require additional resources or expertise, she added.
Abstract
Differentiated service delivery (DSD) models are used increasingly to deliver ART in high-burden settings but there are few data on DSD models for postpartum women, who are at high risk of non-adherence and elevated viral load (VL).
From Jan’16 to Sept’17 we enrolled consecutive postpartum women who initiated ART (TFV+XTC+EFV) during pregnancy and met local DSD eligibility (clinically stable with VL<400 c/mL) at a large urban primary care antenatal clinic (NCT03200054). Women were randomised to be referred to (i) a community-based “Adherence Club” (AC, the local DSD model: lay health worker-led groups of 20-30 patients with 2-4 monthly ART dispensing at a community venue) or (ii) routine primary health care clinics (PHC; the local standard with nurse/doctor-led care). Outcomes were measured through Nov’19 with study visits and batched VL separate from care in either arm at 3, 6, 12, 18 and 24m postpartum. Endpoints were time to VL>1000 c/mL (primary) and >50 c/mL (secondary) by intention-to-treat; per protocol analyses were restricted to women who attended the allocated service within 3m of referral.
Overall 412 women were randomised at a median of 10d postpartum (IQR, 6-20d; at enrolment median age 27y; median duration of prenatal ART 21w; 100% VL<1000 and 88% <50 c/mL); baseline characteristics did not differ by arm. Attendance at the allocated service within 3m of referral per protocol was higher in AC (77%) vs PHC (68%); 90% completed the final study visit at 24m postpartum with no difference by arm. For the primary endpoint, 16% and 29% of women in AC experienced a cumulative incidence of VL>1000 c/mL by 12m and 24m, compared to 23% and 37% in PHC, respectively (HR=0.71; 95%CI=0.50-1.01; p=0.056; Figure). For the secondary endpoint, 32% and 44% of women in AC had VL>50 c/mL by 12m and 24m, compared to 42% and 56% in PHC, respectively (HR=0.69; 95%CI=0.52-0.92; p=0.009). Findings were unchanged in per protocol analyses and across a priori demographic and clinical subgroups. Infant HIV testing, MTCT, breastfeeding duration, family planning use, and other outcomes were similar between AC and PHC arms.
Postpartum referral to DSD models such as Adherence Clubs is associated with an approximately 30% reduction in elevated VL and may be an important part of strategies to improve women’s virologic outcomes on ART.
Authors
Jasantha Odayar, Maia Lesosky, Thokozile R Malaba, Siti Kabanda, Joanna Allerton, Nai-Chung Hu, Elton E Mukonda, Stephanie Fourie, Shahieda Jacobs
[link url="http://www.aidsmap.com/news/mar-2020/adherence-clubs-linked-30-reduction-high-viral-load-among-postpartum-south-african"]Full Aidsmap report[/link]
[link url="http://www.croiconference.org/sessions/differentiated-care-postpartum-art-south-african-women-living-hiv-rct"]CROI 2020 abstract[/link]