Community-based treatment superior to clinic-based care in SA

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Starting antiretroviral treatment on the day of diagnosis in a community setting and picking up medication from a mobile van resulted in superior rates of viral suppression, especially in men in South Africa, the randomised DO ART trial has found. The findings were presented at the 2020 Conference on Retroviruses and Opportunistic Infections, which is taking place online this year in response to the risk of coronavirus transmission. Improving diagnosis and engagement in care among men living with HIV is essential to achieve the goals of 90% diagnosed, 90% on treatment and 90% virally suppressed that guide international efforts to reduce HIV transmission and mortality.

But engaging men in care has proved challenging in many countries. Work commitments, stigma, and clinical services geared towards the needs of women and children are often cited by men as obstacles to care.

Even community-based testing and treatment that involves door-to-door visits has run into a consistent challenge: men are less likely to be at home when health workers call. This is a critical challenge, as shifting testing and treatment into the community is a cornerstone of efforts to expand treatment access without overwhelming health facilities.

To test the impact of several models of community-based testing and treatment, Dr Ruanne Barnabas of University of Washington and colleagues in South Africa and Uganda designed the Delivery Optimisation for Antiretroviral Therapy (DO ART) study.

Across the entire study population, community- or hybrid ART delivery eliminated gender differences in viral response (65% in men and 69% in women in the hybrid group, 72% and 73% in the community group).

Abstract
Community-based HIV testing, same-day ART start, and decentralized monitoring and ART refills could increase viral suppression, particularly among priority groups who engage less in clinic-based HIV care, such as men who are more likely to have detectable HIV viral load.

We conducted a multi-site, household randomized trial of community-based ART compared to clinic services in rural and peri-urban areas of Sheema District, Uganda, and KwaZulu Natal, South Africa – the Delivery Optimization for ART (DO ART) Study. Community-based HIV testing was conducted at home and in mobile vans. People living with HIV (PLWH) who were not on ART with CD4>100 cell/mL were eligible for randomization to: 1) same-day community-based ART start with quarterly monitoring and ART refills through mobile vans, 2) ART start at the clinic with monitoring and refills through mobile vans in the community (hybrid approach); or 3) clinic-based ART (standard of care). The primary outcome was HIV viral suppression at 12 months, assessed by modified intent to treat analysis using regression analysis; testing first for superiority and then non-inferiority (relative 5%) if not superior.
Between May 2016 and March 2019, 1,531 PLWH not on ART were randomized: 708 (46%) were men and 36% were
Among PLWH who were not on ART, community-based HIV testing, same-day ART initiation, mobile van monitoring and ART resupply, significantly increased viral suppression compared to clinic-based ART. The UNAIDS 90-90-90 goal of 73% suppression was met for men and women in the community-based ART arm, eliminating disparities in viral suppression by gender. Combining decentralized ART initiation and refill is an effective strategy to increase viral suppression which should be implemented and evaluated in different contexts and populations who are not virally suppressed.

Authors
Ruanne V Barnabas, Heidi van Rooyen, Stephen Asiimwe, Alastair van Heerden, Deenan Pillay, Adam Szpiro, Torin Schaafsma, Meighan Krows, Kombi Sausi

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