Community ART for Retention in Zambia: Urban Adherence

Community ART for Retention in Zambia: Urban Adherence

Community ART for Retention in Zambia: Urban Adherence Groups (UAG) Centre for Infectious Disease Research in Zambia (CIDRZ) In partnership with the Zambian Ministry of Health Sponsor: Bill & Melinda Gates Foundation 19th September 2018 Collaborators: James Cooke University, Johns Hopkins, UAB, UCSF, UNZA Measurements Outcomes after 12 months Electronic medical Primary Outcome Patient retention in care: record (Smartcare) missed drug pick-up > 7 days late UAG meeting Secondary Outcomes attendance register 14 or 28 days late, UAG departure log Implementation outcomes: In-depth interviews

acceptability, and focus group appropriateness, adoption, discussions with health feasibility, fidelity care workers and patients (Nvivo QSR) Patients (N=1096) similar in both groups at baseline Intervention n=594 Control n=502 371 (62) 42.0 (34.9-47.9) 331 (66) 40.8 (34.0-47.7) 219 (42) 131 (25) 156 (30)

13 (2.5) 441 (269-565) 218 (49) 98 (22) 113 (26) 13 (2.9) 475 (307-628) CD4 count attime of study enrolment 514 (328 653) 533 (372 677) Time since enrolmentin HIV care 5.2 (2.6 7.6) 5.7 (3.0 7.6) 4.8 (2.2 7.2) 5.0 (2.3 7.0)

83% (75% 95%) 82% (77% 91%) 338 (59) 304 (61) Characteristics Female sex Median age (years) (median, EnrollmentWHO Stage IQR) Stage 1 Stage 2 Stage 3 Stage 4 Initial CD4 count (cells/mm 3) (median, IQR) (cells/mm 3) (median, IQR) (years) (median, IQR)

Time since ART initiation (years) (median, IQR) Baseline Medication Possession Ratio (%) (median, IQR) Late Drug Pickup (> 14 days late) in year prior to study enrolment (median, IQR) 43(~7%) of UAG members had left their group by the end of the study Reason for UAG departure Pregnancy Transfer to another clinic Loss to follow-up from care Patient preference for facility-based care Patient not following UAG code of conduct Diagnosed with tuberculosis Other Death Total

n (%) 10 (23%) 9 (21%) 6 (14%) 4 (9%) 4 (9%) 4 (9%) 3 (7%) 3 (7%) 43 (100%) High level of acceptance 597 100% 100% 594 99% 594 592

99% 99% 90% 85% 80% 70% Percent 60% 50% 40% 30% 20% 10% 0% Offered a UAC Accepted a UAC

Placed into a UAC Attended first UAC meeting Attended any UAC meeting n u m b e r o f U A C p a r ti c ip a n t s Number of missed UAG visits per participant 250 237 200 161 150 100 91 65 50

0 38 0 1 2 Number of missed visits 3 >=4 Half of missed UAG meetings did not delay ART pickup by more than 7 days Of the 683 unattended visits, drug-pick up within 7 days still occurred in 350 (51%) of visits Time to drug pick-up after missed UAG meeting (N=455)

Cumulative incidence of return after missed drug pick-up: 26% at 7 days 37% at 14 days 47% at 28 days Patients valued group support At general ART I never had an opportunity to interact with the staff here maybe because by the time you are getting in, they are tired and sometimes they would look moody and shout at us. So you would fear to ask questions even when you want to find out about something that is troubling you. But from the time I joined this group, I am very free to ask any question and I have learnt a lot. FGD Manungu Male Participant Intervention group more likely to pick up drugs Control: 0.62 (95% CI: 0.58 0.66) Control: 0.46 (95% CI: 0.41 0.50) Intervention: 0.27 (95% CI: 0.24 - 0.31)

7 Days Late Log-rank test: p < 0.0001 Intervention: 0.20 (95% CI: 0.17 0.24) 28 Days Late Log-rank test: p < 0.0001 Predictors of late drug pick up at 7 days among intervention and control participants Unadjusted Odds Ratio 95% CI Adjusted Odds Ratio 95% CI Control (Standard of Care) 4.31

3.32 5.59 5.34 1.94 14.7 Male Sex 1.37 1.06 1.76 1.62 1.17 2.23 Age at enrollment 0.98 0.97 0.997 0.995

0.98 1.01 Time since ART Initiation 0.97 0.93 1.01 0.95 0.90 1.01 WHO Stage III or IV or CD4 < 200 cells/mm3 at HIV care enrollment 0.89 0.67 1.17 1.15 0.98 1.00 MPR at study enrollment 0.99 0.98 0.999 0.99 0.98 1.004 Predictor Study Limitations Duration of follow-up relatively short, limited ability to comment on sustainability and long term outcomes Challenges using routine data to determine study outcomes Viral load testing in progress, not yet reported Conclusions Twelve-month cumulative incidence of first missed drug pick-up significantly lower among intervention participants at 7 and 28 days compared to controls

UAGs were acceptable and feasible and patient adoption was high Most patients missed at least one visit, but recovery (drug pick-up within 7 days of missed visit) occurred in half of all unattended visits Migration out of UAGs occurred and was due to changes in clinical status (pregnancy, TB, etc) as well as less commonly, patient preference Implications UAGs are an effective tool in the DSD toolbox for reducing late drug pickup The frequency of alternative same day drugpick up argues for the need for DSD models to be flexible and patient-centered Successful monitoring and evaluation will need to account for migration into and out of DSD models THANK YOU Questions? We would like to thank the Zambian Ministry of Health and all participating patients and health workers.

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