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Home-based versus clinic-based care for patients starting antiretroviral therapy with low CD4+ cell counts: findings from a cluster-randomized trial

Woodd, Susannah L.a; Grosskurth, Heinera,b; Levin, Jonathanb; Amuron, Barbarab; Namara, Geoffreyb; Birunghi, Josephinec; Coutinho, Alexd; Jaffar, Shabbara

doi: 10.1097/QAD.0000000000000056
Epidemiology and Social
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Objectives: African health services have shortages of clinical staff. We showed previously, in a cluster-randomized trial, that a home-based strategy using trained lay-workers is as effective as a clinic-based strategy. It is not known whether home-based care is suitable for patients with advanced HIV disease.

Methods: The trial was conducted in Jinja, Uganda. One thousand, four hundred and fifty-three adults initiating ART between February 2005 and January 2009 were randomized to receive either home-based care or routine clinic-based care, and followed up for about 3 years. Trained lay workers, supervised by clinical staff based in a clinic, delivered the home-based care. In this sub-analysis, we compared survival between the two strategies for those who presented with CD4+ cell count less than 50 cells/μl and those who presented with higher CD4+ cell counts. We used Kaplan–Meier methods and Poisson regression.

Results: Four hundred and forty four of 1453 (31%) participants had baseline CD4+ cell count less than 50 cells/μl. Overall, 110 (25%) deaths occurred among participants with baseline CD4+ cell count less than 50 cells/μl and 87 (9%) in those with higher CD4+ cell count. Among participants with CD4+ cell count less than 50 cells/μl, mortality rates were similar for the home and facility-based arms; adjusted mortality rate ratio 0.80 [95% confidence interval (CI) 0.53–1.18] compared with 1.22 (95% CI 0.78–1.89) for those who presented with higher CD4+ cell count.

Conclusion: HIV home-based care, with lay workers playing a major role in the delivery of care including providing monthly adherence support, leads to similar survival rates as clinic-based care even among patients who present with very low CD4+ cell count. This emphasises the critical role of adherence to antiretroviral therapy.

aFaculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK

bMRC/UVRI Research Unit on AIDS, Entebbe

cThe AIDS Support Organisation

dInfectious Disease Institute, Kampala, Uganda.

Correspondence to Professor Shabbar Jaffar, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK. Tel: +44 20 7927 2418; fax: +44 20 7637 4314; e-mail: Shabbar.jaffar@lshtm.ac.uk

Received 18 July, 2013

Revised 30 September, 2013

Accepted 30 September, 2013

Copyright © 2014 Wolters Kluwer Health, Inc.