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Geoffrey Fatti, Ashraf Grimwood , Eula Mothibi, Mokgadi Malahlela, Alfeous Rundare

Community-Based Adherence Support Associated with Improved Virological Suppression in Adults Receiving ART: Five-Year Outcomes from a South African Multicentre Cohort Study. Geoffrey Fatti, Ashraf Grimwood , Eula Mothibi, Mokgadi Malahlela, Alfeous Rundare Kheth’Impilo, Cape Town, South Africa.

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Geoffrey Fatti, Ashraf Grimwood , Eula Mothibi, Mokgadi Malahlela, Alfeous Rundare

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  1. Community-Based Adherence Support Associated with Improved Virological Suppression in Adults Receiving ART: Five-Year Outcomes from a South African Multicentre Cohort Study Geoffrey Fatti, Ashraf Grimwood, Eula Mothibi, Mokgadi Malahlela, Alfeous Rundare Kheth’Impilo, Cape Town, South Africa

  2. Kheth’Impilo • SA NGO supports district scale up quality services for the management of HIV/AIDS at PHC level, focusing on providing a family centered comprehensive & integrated service • KI operates in: 142 sites in the Eastern Cape, KwaZulu Natal, Mpumalanga & the Western Cape with >145000 patients RIC • Programmes:Health Services Cluster (HSC) – ART (Adults & children), TB, HCT & PMTCT linked to Community Support Cluster (CSC) – for Adherence & Psychosocial support

  3. Community Adherence • Clinic based Community outreach adherence support (CBAS) health care workers called Patient Advocates (PAs) were introduced in 2004; • Link clinical services & community; trained in the basics of HIV, patient rights, confidentiality, ethics, etc. • Ensure ongoing adherence, counselling and psycho-social support at the community level and support community services to ensure the continuum of care; • Special attention paid to very important patients (VIPs); the ill, pregnant, TB, children & adolescents, those who have not disclosed & those showing early signs of defaulting; • VIPs make up 40% of PA’s workload; • Patients encouraged to contract with themselves & get a treatment buddy to facilitate adherence to positive lifestyle choices that include the taking of treatment & keeping appointments

  4. PA Support Structure • Doctor • Nurse • Pharmacist • PMTC Quality Mentor • Social Worker • Data Quality Manager NATIONAL OFFICE DISTRICT OFFICE • CSC District Coordinator • CSC Trainer Roving SWAT TEAM PA COMMUNITY HEALTH CENTRE PA • Site Facilitator PA PRIMARY HEALTH CARE CENTRE (Clinics) PRIMARY HEALTH CARE CENTRE (Clinics) • Site Facilitator • Site Facilitator PA PA PA PA PA PA AREA COORDINATOR

  5. Methods Objectives: • Estimate effect of CBAS on mortality, loss to follow up, & virological suppression in adults receiving ART. • Multicentre cohort analysis using routinely collected data. • ART naïve adults starting ART between Jan 2004 and Sep 2010 at 57 government ART sites in 4 provinces. • Patients categorised as receiving or not receiving CBAS from the start of ART. • Allocation was performed by clinic-based patient facilitators & area coordinators, based on patient consent, programmatic , clinical or psychosocial considerations. • Virological suppression (< 400 copies/ml) at six-monthly intervals until 5 years of ART, by intention to treat analysis. www.aids2012.org

  6. Analyses • Analyses were primarily by intention-to-treat (including all patients in each group as at allocation). • Extreme case sensitivity analyses performed to estimate potential bias due to missing viral load results. • Multivariable generalised estimating equations and logistic regression with multiple imputation of missing covariate values. www.aids2012.org

  7. Results: Patients included and baseline characteristics www.aids2012.org

  8. Results (cont) • Total observation time was 100,295 person-years • Deaths: 970 (4.9%) CBAS patients; 2,968 (6.3%) non-CBAS patients. (P < 0.0001) • LTFU: 1,185 (6.0%) CBAS patients and 4,498 (9.5%) non-CBAS patients. (P < 0.0001) • Virological suppression (at six months): -CBAS patients: 76.6% (95% CI: 75.8%-77.5%) -Non CBAS patients: 72.0% (95% CI: 71.3%-72.5%) (P < 0.0001) www.aids2012.org

  9. Virological suppression by intention-to-treat on ART Proportions with virological suppression Months on ART www.aids2012.org

  10. Multivariable analysis of virological suppression www.aids2012.org

  11. Sensitivity analysis: Considering all missing test results as suppressed. Proportions with virological suppression aOR 1.44 (95% CI: 1.37-1.52) Months on ART www.aids2012.org

  12. Sensitivity analysis: Considering all missing test results as unsuppressed. Proportions with virological suppression aOR 1.15 (95% CI: 1.11-1.19) www.aids2012.org

  13. On-treatment analysis Proportions with virological suppression RR 0.97 (95% CI: 0.96-0.97) www.aids2012.org

  14. Results: Mortality after starting ART without CBAS with CBAS P < 0.0001 Months on ART Multivariable analyses adjusted for confounding: Mortality in patients with CBAS independently reduced: aHR 0.65 (95% CI: 0.59-0.72)

  15. Results: LTF after starting ART without CBAS with CBAS P < 0.0001 Multivariable analyses adjusted for confounding: LTF in patients with CBAS independently reduced: aHR 0.63 (95% CI: 0.59-0.68)

  16. Conclusions • Adults receiving community based adherence support had reduced mortality, LTFU and improved virological suppression (ITT analyses) after starting ART. • Further scale-up of these programs should be considered in low-income settings. Limitations: • Non randomised allocation to groups • Observational, use of routine data • Lack of effect seen in on-treatment VS analyses: May be due to averted mortality and LTF amongst higher-risk patients who received CBAS, who would thus remain in care and at increased risk of viraemia.

  17. Acknowledgements Acknowledgements: This research was made possible by the President's Emergency Plan for AIDS Relief (PEPFAR) through the United States Agency for International Development (USAID) under the terms of grant no. P3121A0051.  The contents of the presentation are the sole responsibility of “Kheth’Impilo” and do not necessarily reflect the views of USAID, The United States Government or The Global Fund.

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