Barcelona 2013
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| Abstract #121 - Adherence | ||||
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Session: 13.5: Adherence (Parallel) on Monday @ 14.30-16.00 in Teatre Chaired by Imma Serra, Stuart Gibson Authors: Presenting Author: Mr Geoffrey Fatti - Kheth Impilo, South Africa |
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| Additional Authors: Dr. Jorge Galindo-Sainz, | ||||
| Aim: As antiretroviral treatment (ART) patient numbers have expanded in low-income settings, increasing levels of patient attrition and virological failure have become evident. Community-based adherence support (CBAS) workers have been employed in South Africa to help improve adherence, address patient psychosocial problems impacting adherence and improve long-term patient retention. We evaluated the effect of a CBAS program on ART program outcomes at public facilities supported by a nongovernmental organization in four South African provinces. | ||||
| Method / Issue: Patient advocates (PAs) are community-based adherence workers who provide education, counselling and psychosocial support for ART patients through home visits to assess and address household challenges that affect adherence. Issues assessed and addressed by PAs include household nutrition security, substance abuse, domestic violence, non-disclosure, social grant eligibility, vital documentation including birth certification and household tuberculosis and HIV testing status. A multicentre cohort study was performed at 77 facilities including adults, children and adolescents starting ART. Prospectively collected routine electronic data were analysed. Outcome measures included mortality, loss to follow-up, patient retention and virological suppression (VS) after starting ART. Outcomes were compared between patients who received and did not receiving CBAS, using an intention-to-treat approach. Data were analyzed using Kaplan-Meier, multivariable Cox regression and generalised estimating equations. | ||||
| Results / Comments: 71,806 patients were included, of whom 20,650 (28.8%) received CBAS and 51,156 (71.2%) did not. At baseline in adults the median CD4 cell count was 125 cells/µl (IQR: 65-175) and the median CD4 cell percentage in children was 12.0% (IQR: 7.0-17.1%). After 5 years of ART in adults, retention in care was 79.1% amongst patients with CBAS vs. 73.6% for those without CBAS. After adjustment for confounding, adults with CBAS had a 35% reduction in mortality (aHR 0.65 [95% CI: 0.59-72]) and a 37% reduction in loss to follow-up (aHR 0.63 [95% CI: 0.59-0.68]) compared to those without CBAS. Adults with CBAS had a 49% improvement in virological suppression over 5 years (aOR 1.49 [95% CI: 1.40-1.58]). Improvement in virological suppression in CBAS patients increased in magnitude for longer durations of treatment. Children receiving CBAS had a 43% reduction in patient attrition (aHR 0.57 (95% CI: 0.35-0.94]), including a 61% reduction in mortality after starting ART (aHR 0.39 (95% CI: 0.15-1.04). Reductions in patient attrition and mortality were particularly evident in children under two years of age when starting ART. Children with CBAS were 60% more likely to achieve virological suppression after starting ART (aOR 1.60 [95% CI: 1.35-1.89]). Children under two years of age were 2.5 fold more likely to achieve virological suppression if they received CBAS (aOR 2.47 [95% CI: 1.59-3.84]). Adolescents and young adults with CBAS had a 33% reduction in mortality (aHR 0.67 [95% CI: 0.51-0.86] and a 32% reduction in loss to follow-up (aHR 0.68 [95% CI: 0.58-0.80]) over 5 years of ART compared to those without CBAS. Overall, virological suppression was 28% greater amongst those with CBAS (aOR 1.28 [95% CI: 1.16-1.41]). | ||||
| Discussion: CBAS was associated with improved ART program outcomes in a low-income setting in South Africa. Community adherence programs should be considered for the increasing number of people receiving ART in low-income settings to sustain long-term success in ART programs. | ||||
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