Home-based HIV care strategy is as effective as clinic-based strategy in Uganda

November 23, 2009

Home-based care results in similar outcomes as clinic-based strategies for HIV patients in Africa, concludes an Article published Online First (www.thelancet.com) and in an upcoming edition of The Lancet. The Article is written by Dr Shabbar Jaffar, London School of Hygiene and Tropical Medicine, UK, and colleagues.

Antiretroviral drug therapy has been scaled up rapidly in Africa, and is now given to more than 2 million people. A global commitment has been made to provide universal coverage, but another 5 million people, mostly living in rural and semiurban areas, are estimated to need such treatment. Achievement of high coverage in these populations will be a challenge. Two major barriers to increasing coverage exist--a severe shortage of clinically qualified staff, which has reached crisis point in most of Africa, and difficulty for patients in accessing clinics because of high costs and poor availability of transport and low cash incomes. In this study, the authors assessed whether home-based HIV care was as effective as was facility-based care. The team worked with TASO--a non-governmental organisation in Uganda which offers a range of services to HIV patients.

In this cluster-randomised trial in Jinja, Uganda, 44 geographical areas in nine regions were defined according to the ratio of urban and rural participants and distance from the nearest clinic. These areas were randomised to home-based or facility based care. For the clinic-treated patients, conditions at the clinic were representative of those nationally, with similar numbers of nurses, laboratory and pharmacy staff. For the home-based group, trained field officers travelling on motorcycles visited patients at home every month to deliver drugs, monitor participants with a checklist that included signs and symptoms of drug toxicity or disease progresion, and provide adherence support.

All patients were in the later stages of HIV (late WHO stage III or stage IV, or CD4-cell counts fewer than 200 cells per μL of blood), and had started antiretroviral therapy between Feb 2005 and December 2006. Follow-up continued until January 2009. The primary endpoint was virilogical failure, defined as HIV RNA of 500 copies per mL after 6 months of treatment.

A total of 859 patients were randomly assigned to home and 594 to facility care. During the first year, 93 (11%) receiving home care and 66 (11%) receiving facility care died, 29 (3%) receiving home and 36 (6%) receiving facility care withdrew, and 8 (1%) receiving home and 9 (2%) receiving facility care were lost to follow-up. 117 of 729 (16%) in home care had virological failure versus 80 of 483 (17%) in facility care. The rates of virologicial failure per 100 person-years were 8.19 for home and 8.67, for facility care, meaning the two treatment modes were statistically equivalent.

The authors conclude: "We have shown that home-based HIV care with antiretroviral therapy is an effective strategy, which relies less on clinical staff and hospital services than does facility-based care and provides large savings for patients. Such community-based strategies could enable improved and equitable access to HIV treatment--especially in areas in which clinical infrastructure is scarce and patient access to clinic-based care is poor."

In an accompanying Comment, Dr Eline L Korenromp and Dr Kirsi M Viisainen, Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland, say: "TASO's package of home-based care is especially appealing because it combines ART with free voluntary HIV counselling and testing in the home for household members of patients. The twice-lower cost to patients on ART probably contributed to relatively good adherence in the home-based clusters, which may become even more crucial as patients accumulate years of treatment."

They conclude: "The current situation in which demand for scaling up ART in many high-burden countries meets or exceeds globally available HIV and health funds is unprecedented. Programme evaluations, including both health outcomes and cost, are more important than ever to plan and budget for optimum sustainable packages of treatment and prevention services."
Dr Shabbar Jaffar, London School of Hygiene and Tropical Medicine, UK. T) +44 (0) 20 7927 2418 / +44 (0) 7900 924 473 E) shabbar.jaffar@lshtm.ac.uk

Dr Eline L Korenromp, Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland. T) +41 58 791 1732 E) eline.korenromp@theglobalfund.org

Andrew Hurst.senior media specialist at the Global Fund to fight AIDS, Tuberculosis and Malaria. T) +41 58 791 1672 E) andrew.hurst@theglobalfund.org

For full Article and Comment, see: http://press.thelancet.com/hivcare.pdf


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