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Implementation and Operational Research: Pulling the Network Together: Quasiexperimental Trial of a Patient-Defined Support Network Intervention for Promoting Engagement in HIV Care and Medication Adherence on Mfangano Island, Kenya

Hickey, Matthew D. MD*,†,‡; Salmen, Charles R. MD, MPhil†,‡,§; Omollo, Dan BSc; Mattah, Brian; Fiorella, Kathryn J. MPH†,‖; Geng, Elvin H. MD, MPH; Bacchetti, Peter PhD#; Blat, Cinthia MPH*; Ouma, Gor B.; Zoughbie, Daniel MSc, DPhil; Tessler, Robert A. MD†,**; Salmen, Marcus R. MD; Campbell, Harold PhD†,‡; Gandhi, Monica MD, MPH; Shade, Starley MS, PhD††; Njoroge, Betty MBChB, MPH‡‡; Bukusi, Elizabeth A. MBChB, MMed, MPH, PhD, PGD‡‡; Cohen, Craig R. MD, MPH§§

JAIDS Journal of Acquired Immune Deficiency Syndromes: 1 August 2015 - Volume 69 - Issue 4 - p e127–e134
doi: 10.1097/QAI.0000000000000664
Clinical Science

Background: Despite progress in the global scale-up of antiretroviral therapy, sustained engagement in HIV care remains challenging. Social capital is an important factor for sustained engagement, but interventions designed to harness this powerful social force are uncommon.

Methods: We conducted a quasiexperimental study evaluating the impact of the Microclinic Social Network intervention on engagement in HIV care and medication adherence on Mfangano Island, Kenya. The intervention was introduced into 1 of 4 similar communities served by this clinic; comparisons were made between communities using an intention-to-treat analysis. Microclinics, composed of patient-defined support networks, participated in 10 biweekly discussion sessions covering topics ranging from HIV biology to group support and group HIV status disclosure. Nevirapine concentrations in hair were measured before and after study.

Results: One hundred thirteen (74%) intervention community participants joined a microclinic group, 86% of whom participated in group HIV status disclosure. Over 22-month follow-up, intervention community participants experienced one-half the rate of ≥90-day clinic absence as those in control communities (adjusted hazard ratio: 0.48; 95% confidence interval: 0.25 to 0.92). Nevirapine hair levels declined in both study arms; in adjusted linear regression analysis, the decline was 6.7 ng/mg less severe in the intervention arm than control arm (95% confidence interval: −2.7 to 16.1).

Conclusions: The microclinic intervention is a promising and feasible community-based strategy to improve long-term engagement in HIV care and possibly medication adherence. Reducing treatment interruptions using a social network approach has important implications for individual patient virologic suppression, morbidity, and mortality and for broader community empowerment and engagement in healthcare.

*Division of Internal Medicine, Department of Medicine, San Francisco General Hospital, University of California, San Francisco (UCSF), San Fransisco, CA;

Mfangano Island Research Group, Organic Health Response, Homa Bay, Kenya;

Microclinic International (MCI), San Francisco, CA;

§Department of Family and Community Medicine, University of Minnesota, Minneapolis, MN;

Department of Environmental Science, Policy and Management, University of California, Berkeley, Berkeley, CA;

Department of Medicine, Division of HIV/AIDS, University of California, San Francisco (UCSF), San Francisco, CA;

#Department of Epidemiology and Biostatistics, University of California, San Francisco (UCSF), San Francisco, CA;

**Department of Surgery, University of California, San Francisco (UCSF) East Bay, Oakland, CA;

††Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco (UCSF), San Francisco, CA;

‡‡Centre for Microbial Research, Kenya Medical Research Institute, Nairobi, Kenya; and

§§Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco (UCSF), San Francisco, CA.

Correspondence to: Matthew D. Hickey, BS, 50 Beale Street, Suite 1200, San Francisco, CA 94121 (e-mail:

Supported by Google Inc via the Tides Foundation, the Craigslist Foundation, the Mulago Foundation, the Rise Up Foundation, the Horace W. Goldsmith Foundation, the Segal Family Foundation, the National Institute of Allergy and Infectious Diseases (NIAD)/National Institutes of Health (NIH) (R01 AI098472 to M.G., U01AI034989 WIHS), the Doris Duke Charitable Foundation (to M.D.H.), and the UCSF School of Medicine Dean's research fellowship (C.R.S.).

Portions of this data were presented as an oral abstract at the International Conference on HIV Treatment and Prevention Adherence, June 9, 2014, Miami, FL.

The authors have no conflicts of interest to disclose.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

M.D.H. and C.R.S. contributed equally to this study.

Received September 17, 2014

Accepted March 14, 2015

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