Differentiated models of care needed for first six-months of ART

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With many HIV treatment programmes in sub-Saharan Africa still expecting new patients to attend a clinic monthly for their first six months of antiretroviral therapy (ART), but persistently high rates of loss to follow up during this time, research to develop differentiated models of care for the first six-month period is needed, argue Professor Sydney Rosen of Boston University and colleagues at the University of the Witwatersrand, International AIDS Society – Cape Town, Bill & Melinda Gates Foundation, Brigham and Women's Hospital, Harvard Medical School and Massachusetts General Hospital.

Aidsmap reports that care during this time should be streamlined and made more patient-friendly, to bring it more in line with innovations that have been introduced at other stages of the HIV care cascade. HIV self-testing, community testing and other programmes have brought testing out of clinical settings. Initiation of ART has been accelerated by programmes allowing treatment to be started within hours or days of diagnosis, as well as at home or in a community setting.

Once patients have been on ART for at least six months and have evidence of viral suppression, medication refills covering three or six months may be available. Moreover, other models of care may be offered, including medication pickup points outside of health facilities, “fast-track” procedures in clinics for patients to obtain refills quickly, and adherence clubs in which groups of people with HIV meet to receive their medication, basic monitoring and adherence support, sometimes in a community setting.

Experts consulted suggested that all patients should have at least one interaction with a health worker during their first month on treatment, both to confirm that they are responding well to treatment and to establish a pathway for communication. Research is needed to identify the groups of patients who would benefit from additional contact and how that should be provided.

Moreover, work is needed to identify the treatment education, adherence support and disclosure support that would help patients at this time.

Differentiated models of service delivery (DSD models) for HIV treatment in sub-Saharan Africa were conceived as a way to manage rapidly expanding populations of experienced patients who are clinically “stable” on antiretroviral therapy (ART). Entry requirements for most models include at least six months on treatment and a suppressed viral load. These models thus systematically exclude newly-initiated patients, who instead experience the conventional model of care, which requires frequent, multiple clinic visits that impose costs on both providers and patients. In this open letter, we argue that the conventional model of care for the first six months on ART is no longer adequate. The highest rates of treatment discontinuation are in the first six-month period after treatment initiation. Newly initiating patients are generally healthier than in the past, with higher CD4 counts, and antiretroviral medications are better tolerated, with fewer side effects and substitutions, making extra clinic visits unnecessary. Improvements in the treatment initiation process, such as same-day initiation, have not been followed by innovations in the early treatment period. Finally, the advent of COVID-19 has made it riskier to require multiple clinic visits. Research to develop differentiated models of care for the first six-month period is needed. Priorities include estimating the minimum number and type of provider interactions and ART education needed, optimizing the timing of a patient’s first viral load test, determining when lay providers can replace clinicians, ensuring that patients have sufficient but not burdensome access to support, and identifying ways to establish a habit of lifelong adherence.

Sydney Rosen, Anna Grimsrud, Peter Ehrenkranz, Ingrid Katz


Full Aidsmap report


Gates Open Research abstract

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