Adherence Clubs Promote Retention, HIV Control in Randomized Johannesburg Trial
August 1, 2016
Community- and clinic-based adherence clubs in Johannesburg, South Africa, promoted retention in care and high HIV suppression rates in a 785-person randomized, controlled trial. Retention after one year was moderately but significantly greater in clinic-based clubs than in community-based clubs, according to the study.
Retention in care and sustained suppression of HIV remain challenges in clinics across the world. Workers at the Witkoppen Health and Welfare Centre in Johannesburg addressed these issues by creating adherence clubs that enroll 25 to 30 patients taking a stable, suppressive antiretroviral regimen. This randomized trial compared retention in care, viral suppression and other outcomes in clinic-based adherence clubs versus community-based clubs.
Adherence club members meet every other month for counseling and medication pick-up. Clubs members receive annual viral load monitoring and an annual medical exam by a clinician. The analysis involved two paired clubs per residential area -- one clinic-based and one community-based -- created each month for 12 months. Club members must be at least 18 years old and must have an undetectable viral load for at least the past 12 months on the same antiretroviral regimens. Participants become ineligible for further club participation and return to clinic-based standard care if they (1) miss a club visit and do not pick up antiretrovirals within five days, (2) have a viral load rebound, (3) acquire an excluding comorbidity, (4) become pregnant, (5) send someone else to pick up antiretrovirals two consecutive times or (6) decide to leave the club.
The comparison focused on 399 people randomized to a community club and 386 randomized to a clinic club. The community and clinic groups were similar in age (median 38 years in both groups), proportion of women (68% and 64%), median CD4 count (475 and 527 cells/mm3) and proportion taking a fixed-dose antiretroviral combination (89% and 88%). Community clubs included a higher proportion of unemployed members (24% versus 17%, P = .041).
After 12 months of follow-up, 65% of participants remained in a community adherence club, compared with 77% in a clinic adherence club, a significant difference (P = .003). Only 3% in the community group and 3% in the clinic group had to leave the adherence club because of viral rebound. A Cox proportional hazards model adjusted for age, sex, regimen, baseline CD4 count and employment status determined that people in a community adherence club had a 60% higher chance of having to leave the adherence group (adjusted hazard ratio 1.6, 95% confidence interval 1.1 to 2.3, P = .006). In both the community group and the clinic group, the most frequent reason for leaving the adherence club was missing a club visit and failing to pick up antiretrovirals (68% in the community club and 58% in the clinic club, P = .088).
The researchers noted that the 65% community-club retention in their study lagged the 97% retention and the 94% retention in adherence clubs in Cape Town. They suggested several potential reasons for this gap, including lack of randomization in the other studies, differences in the definition of retention, differences in eligibility criteria and differences in timing outcomes.
The Johannesburg team concluded that "adherence clubs are currently a heterogeneous intervention, with different degrees of success." They see a need for further work to define which aspects of adherence clubs favor success.
Mark Mascolini writes about HIV infection.
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