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Extending Visit Intervals for Clinically Stable Patients on Antiretroviral Therapy

Multicohort Analysis of HIV Programs in Southern Africa

Haas, Andreas D. PhDa; Johnson, Leigh F. PhDb; Grimsrud, Anna PhDc; Ford, Nathan PhDd; Mugglin, Catarina MDa; Fox, Matthew P. DSce,f,g; Euvrard, Jonathan MPHb; van Lettow, Monique PhDh,i; Prozesky, Hans MMedj; Sikazwe, Izukanji MDk; Chimbetete, Cleophas MPHl; Hobbins, Michael PhDm; Kunzekwenyika, Cordelia MPHn; Egger, Matthias MDa,b for IeDEA Southern Africa

JAIDS Journal of Acquired Immune Deficiency Syndromes: August 1, 2019 - Volume 81 - Issue 4 - p 439–447
doi: 10.1097/QAI.0000000000002060
Implementation Science
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Background: The World Health Organization recommends differentiated antiretroviral therapy (ART) delivery with longer visit intervals for clinically stable patients. We examined time trends in visit frequency and associations between criteria for clinical stability and visit frequency in ART programs in Southern Africa.

Methods: We included adults on ART from 4 programs with viral-load monitoring, 2 programs with CD4 monitoring, and 4 programs with clinical monitoring of ART. We classified patients as clinically stable based on virological (viral load <1000 copies/mL), immunological (CD4 >200 cells/µL), or clinical (no current tuberculosis) criteria. We used Poisson regression and survival models to examine associations between criteria for clinical stability and the rate of clinic visits.

Results: We included 180,837 patients. There were trends toward fewer visits in more recent years and with longer ART duration. In all ART programs, clinically stable patients were seen less frequently than patients receiving failing ART, but the strength of the association varied. Adjusted incidence rate ratios comparing visit rates for stable patients with patients on failing ART were 0.82 (95% confidence interval: 0.73 to 0.90) for patients classified based on the virological criterion, 0.81 (0.69 to 0.93) for patients classified based on the clinical criterion, and 0.90 (0.85 to 0.96) for patients classified based on the immunological criterion for stability.

Conclusion: Differences in visit rates between stable patients and patients failing ART were variable and modest overall. Larger differences were seen in programs using virological criteria for clinical stability than in programs using immunological criteria. Greater access to routine viral-load monitoring may increase scale-up of differentiated ART delivery.

aInstitute of Social and Preventive Medicine, University of Bern, Bern, Switzerland;

bCentre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa;

cInternational AIDS Society, Cape Town, South Africa;

dDepartment of HIV/AIDS World Health Organization, Geneva, Switzerland;

eDepartment of Internal Medicine, Health Economics and Epidemiology Research Office, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa;

Departments of fEpidemiology; and

gGlobal Health, Boston University School of Public Health, Boston, MA;

hDignitas International, Zomba, Malawi;

iDalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada;

jDivision of Infectious Diseases, Department of Medicine, Tygerberg Academic Hospital, University of Stellenbosch, Cape Town, South Africa;

kCentre for Infectious Diseases Research in Zambia, Lusaka, Zambia;

lNewlands Clinic, Harare, Zimbabwe;

mSolidarMed, Lucerne, Switzerland; and

nSolidarMed, Masvingo, Zimbabwe.

Correspondence to: Andreas D. Haas, PhD, Institute of Social and Preventive Medicine, University of Bern, Mittelstrasse 43, Bern CH-3012, Switzerland (e-mail: andreas.haas@ispm.unibe.ch).

Supported by the National Cancer Institute (NCI), the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Institute of Allergy and Infectious Diseases (NIAID), the National Institute of Mental Health (NIMH), the National Institute on Drug Abuse (NIDA) through the International epidemiology Databases to Evaluate AIDS (IeDEA) (grant number 5U01‐AI069924‐05), the Swiss National Science Foundation (SNF) (Grant number 174281), and National Institute of Health (NIH). A.D.H. was supported by an SNF Early Postdoc Mobility Fellowship (P2BEP3_178602).

The authors have no conflicts of interest to disclose.

A.D.H. wrote the first draft of the study protocol, which was revised by L.F.J. and M.E.; all authors critically reviewed the study protocol and contributed to its final version. A.D.H. did statistical analyses, with interpretation of results by all authors. L.F.J. advised on statistical analysis. A.D.H. wrote the first draft of the report, which was revised by L.F.J., A.G., N.F., M.E., C.M., J.E., H.P., M.P.F., M.v.L., and M.H. M.P.F., J.E., M.v.L., H.P., I.S., and C.C. & C.K. assisted in implementation, fieldwork, and data collection at study sites. M.E. obtained funding for the project. All authors reviewed and approved the final version for submission.

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Received September 18, 2018

Accepted March 18, 2019

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