Out-of-facility individual

Out-of-facility individual models vary according to where in the community the services are provided, as well as what services are delivered and by whom. They can be divided into three categories: fixed community points, mobile outreach ART delivery, and home delivery.

Promising results have been found in models using fixed community points. Evidence has come from the community drug distribution point (CDDP) model in Uganda, the community ART distribution points (PODI) in the Democratic Republic of the Congo (DRC), external pick-up points in South Africa, community pick-up points in Zambia and community private pharmacy collection in Nigeria.

In Uganda, cross-sectional outcomes for clients initiating ART from 2004 to 2009 (median time on ART: 5.7 years; interquartile range, IQR: 4.1-7.2 years) in the CDDP model were that 69% were retained in care, 17% had died, 6% were transferred out and 9% were lost to follow up (LTFU). Among CDDP clients, viral load suppression (<1,000 copies/mL) was 93% (median time on ART: 7.0 years; IQR; 5.0-8.0) (1). In a subsequent conference abstract, LTFU was reported as 16.5% in the facility arm and 4.28% in the CDDP arm (p<0.0001) (2). A costing comparison study in Uganda put the model from The AIDS Support Organization (TASO), including TASO-run clinics for new initiations and the CDDP model for stable clients, at US$74/visit and $332/client/year compared with a mobile ART delivery model utilizing expert clients to dispense ART (US$45/visit; $404/client/year) and a facility-based nurse-led model (US$38/visit; $257/client/year) (3). In the DRC, a retrospective cohort analysis found LTFU and death among PODI clients to be at 2.2% and 0.1% at six months,4.8% and 0.2% (at 12 months) and 9% and 0.3% (at 24 months), respectively, with overall crude attrition of 5.66/100 person years with little variation over time (4).

In South Africa, external pick-up points were endorsed as one of its three differentiated ART delivery models. This model allows clients to choose a non-facility based venue for ART refill collection. These include fixed community points and private pharmacies. National retention and viral load suppression outcomes were evaluated in a 2019 study comparing 24 intervention and control facilities.  External pick-up point patients had lower 12-month retention (81.5% versus 87.2%, aRD: −5.9%; CI: −12.5% to 0.8%) and comparable sustained viral suppression (<400 copies/mL any time ≤ 18 months) (77.2% versus 74.3%, aRD: −1.0%; CI: −12.2% to 10.1%). Interestingly, the study reported increased viral suppression among men (RD: 11.1%; 95% CI: −3.4% to 25.5%) (5).

In Zambia, clinically stable clients were able to select community pick-up points for ART refill collection. ART refills were pre-packed by a central dispensing unit. 6 participating clinic enrolled 6303 clients to collect from 19 community pick-up points (rural markets, shopping malls and some at clinics) with a 96% retention rate, 94% ART refill pick-up compliance rate and 93% viral suppression rate (<50 copies/ml) (6).

Nigeria is expanding an out-of-facility model where community private pharmacies are linked with public health facilities and clients can elect to collect two-month ART refills from these pharmacies. An early evaluation reported a 100% prescription refill rate and 99.7% retention in care (7).

There is limited published evidence of utilizing mobile outreach services to distribute ART refills outside of the health facility. Two conference abstracts report on outcomes. In Swaziland, health facilities were offered a choice of three ART delivery models for implementation. One health centre and one clinic implemented an outreach service to support remote communities; one health centre chose to implement ART adherence clubs (ACs); and 12 clinics implemented community ART groups (CAGs). Twelve-month retention was 77% for the outreach service model (n=102), 96% in ACs (n=289) and 81% in CAGs (n=336) (8). In South Africa, comprehensive ART services (including ART refills) were provided by mobile outreach on South African-Zimbabwean border farms to vulnerable, highly mobile Zimbabwean migrant farm workers and their families (9). The intervention piloted a travel package, including a 3-month ART refill. Viral suppression was 91.2%, and of those clients who indicated planned travel to Zimbabwe, only 2% did not return within three months of their planned return date. 

There are three cluster randomized controlled trials from Kenya and Uganda reporting outcomes from home ART delivery models. In Uganda, there was no difference between the virological failure rates for home versus for facility care (rate ratio, RR, 1.04, 0.78-1.40; equivalence shown) (10). Mortality rates were also similar between the groups (0.95, 0.71-1.28). Health services and patient cost year were less for home delivery compared with facility refill (US$793 vs. $838 for health services and $18 vs. $54 for patient). In Kenya, no significant intervention-control differences were found with regard to detectable viral load, mean CD4 count, change in ART regimen, new opportunistic infections or pregnancy rates. Intervention clients made half as many clinic visits as did controls (11). In Lusaka, Zambia, within the PopART study, clients in two study arms were offered a choice for collecting a three-month ART refill i) clinic-based care or home delivery ii) clinic-based care or community-based AC. 18-month retention was high for both those selecting ACs (93.6%) and those selecting home delivery (84.9%).  Primary outcomes are still to be published (12). 

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2. Mpima D, Birungi J, Makabayi R, Kanters S, Luzze C. Community Antiretroviral Therapy (ART) delivery models for high patient retention and sustaining good adherence: The AIDS Support Organisation (TASO) operational reseach findings, CDC/PEPFAR funded project in Uganda. 7th IAS Conference on HIV pathogenesis, treatment and Prevention, Kuala Lumpur, 30 June-3 July 2013.
3. Vu L, Waliggo S, Zieman B, Jani N, Buzaalirwa L, Okoboi S, et al. Annual cost of antiretroviral therapy among three service delivery models in Uganda. Journal of the International AIDS Society. 2016;19(5Suppl 4)
4. Vogt F, Kalenga L, Lukela J, Salumu F, Diallo I, Nico E, et al. Decentralizing ART supply for stable HIV patients to community-based distribution centres: Programme outcomes from an urban context in Kinshasa, DRC. JAIDS Journal of Acquired Immune Deficiency Syndromes. 2016
5. Fox MP, Pascoe S, Huber AN, Murphy J, Phokojoe M, Gorgens M, Rosen S, Wilson D, Pillay Y, Fraser-Hurt N. Adherence clubs and decentralized medication delivery to support patient retention and sustained viral suppression in care: Results from a cluster-randomized evaluation of differentiated ART delivery models in South Africa. PLoS medicine. 2019 Jul;16(7).
6. Hendriksz F, Dube T, Strydom B, Banoo S, Centralized dispensing and alternative pick up points increases access to ARVs in Zambia, poster presented at the 10th Conference on HIV Science (IAS 2019), 21-24 July 2019, Mexico City, Mexico
7. Avong YK, Kayode GA, Jatau B, Avong EB, Adekanmbi V, Abimiku A, Mensah CO, Dakum P. Providing antiretroviral therapy outside the hospital in a low-resource setting: a pilot study. The Lancet Global Health. 2018 Mar 1;6:S3.
8. Pasipamire L, Kerschberger B, I. Zabsonre I, Ndlovu S, Sibanda G, Mamba S, et al. Implementation of combination ART refills models in rural Swaziland. International AIDS Conference, Durban, 18-22 July 2016
9. Matambo T, Hildebrand K, C M, Wilkinson L, Van Cutsem G, Bauernfeind A, et al. Targeted adherence strategies for provision of cross border antiretroviral therapy (ART) to migrant farm workers in Musina, South Africa. 19th International AIDS Conference, Washington, 22-27 July 2012.
10. Jaffar S, Amuron B, Foster S, Birungi J, Levin J, Namara G, et al. Rates of virological failure in patients treated in a home-based versus a facility-based HIV-care model in Jinja, southeast Uganda: a cluster-randomised equivalence trial. The Lancet. 2010;374(9707):2080.
11. Selke HM, Kimaiyo S, Sidle JE, Vedanthan R, Tierney WM, Shen C, et al. Task-shifting of antiretroviral delivery from health care workers to persons living with HIV/AIDS: clinical outcomes of a community-based program in Kenya. Journal of Acquired Immune Deficiency Syndromes. 2010;55(4):483-90.
12. Limbada M, Macleod D, Fidler S, Schaap A, Shibwela O, Chiti B, Nzara D, Situmbeko V, Hayes R, Ayles H, on behalf of the HPTN 071(PopART) study team, Retention in non-facility-based ART delivery models among stable ART patients in Lusaka, Zambia – Findings from the HPTN 071 (PopART) trial, poster presented at 10th Conference on HIV Science (IAS 2019), 21-24 July 2019, Mexico City, Mexico.