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Reducing clinic visits can support retention in HIV care, African studies show
Keith Alcorn, 2016-07-26 17:50:00

Interventions which reduce the need for people to attend clinics are proving highly successful in retaining people in care and supporting adherence to HIV medication in southern Africa, the 21st International AIDS Conference (AIDS 2016) heard last week.

Measures to reduce the burden of seeking health care are also critical to improving the capacity of health systems to manage growing numbers of patients, numerous presenters at the conference confirmed. The new wave of interventions – described as 'differentiated care' in guidelines – are intended to reduce clinic visits, waiting times and monitoring requirements.

The benefits for patients include less time spent waiting in clinics and travelling to clinics, fewer out-of-pocket travel expenses and less time off work due to clinic attendance, and more support in the community for adherence to medication.

The benefits for health services come in the form of increased capacity to deal with growing patient numbers, more time to concentrate on patients with complex needs, and better retention of patients in care due to the use of community health workers and other community-level mechanisms for supporting treatment.

In new guidance issued ahead of the 21st International AIDS Conference, the World Heath Organization urged national treatment programmes to begin thinking in terms of delivering treatment to four different groups of patients, and tailoring services for each group accordingly. The four groups of patients are:

  • People presenting when well: new patients who will need adherence and retention support as they start treatment, and monitoring during the early months of treatment.
  • People with advanced disease: new patients who present with symptomatic HIV disease or CD4 counts below 200, or who develop TB, who will need fast-track clinical care and more intensive follow up.
  • Stable patients: people on treatment for at least one year with undetectable viral load, not pregnant or breastfeeding.
  • Unstable patients: people on treatment with detectable viral load, who need adherence support, possible second or third-line switches, monitoring for HIV drug resistance.

People can be expected to transition from one group to another; in the majority of cases from the `Presenting when well` to the `Stable` category.

“A one size fits all approach to care is no longer suitable, said Gottfried Hirnschall, director of the WHO HIV/AIDS programme, introducing the guidance.

A new, differentiated approach to care is needed, said Anna Grimsrud of the International AIDS Society. “We’re not getting the retention in care that we need, so something is wrong for patients. We need to treat all, so we will need to treat more people, and in order to reach the 90-90-90 targets, we need to speed up,” she told a pre-conference satellite meeting on differentiated care.

Differentiated care involves not only the shifting of tasks to new cadres in the health system, such as community health workers, but the assumption of responsibility for managing elements of their own care by largely self-organised patient groups. These mechanisms include the distribution of medication by patient groups, which may require changes in rules in many countries.

“One of the biggest barriers to differentiated care is regulatory – rules that say this person cannot do this,” said Carlos del Rio of Emory University.

The conference heard findings on a number of models for differentiated care including six-monthly appointments, adherence clubs and community ART refill groups.

But Dr Eric Goemaere of MSF warned that community services like adherence clubs are an extra cost. “Clinics still need to run,” he said, pointing out adherence clubs need to be understood as a mechanism to expand the volume of patients treated, not as a cost-saving mechanism.