Community based adherence clubs have higher drop-out rates than those based in clinics

Antiretroviral treatment adherence club drop-out rates were significantly higher for people attending community-based clubs compared to clinic-based clubs, reveals a study from South Africa. Overall, loss from adherence clubs was high at 47%, but clinic-based clubs had less loss to follow-up, at 43% compared to 52% in the community.

In this randomised control trial, patients living with HIV at the Witkoppen Health and Welfare Centre in Johannesburg, South Africa who had been virally suppressed for at least 12 months were assigned to an adherence club based either in-clinic or in the community.

Adherence clubs were designed as a task-shifting initiative to relieve the burden on clinicians. Patients who are stable on their ART meet with lower skilled healthcare workers in groups in order to allow clinicians to handle more complex patients such as those newly starting ART.

From February 2014 to May 2015, 775 eligible adults were put into 12 pairs of clubs—376 (49%) into clinic-based clubs and 399 (51%) into community-based clubs. The median age across both groups was 38 years old, 65% were female, and the median CD4 count was 506 cells/mm.

Adherence clubs were held every other month. These included 25 to 30 people and consisted of an hour-long discussion around an adherence-related topic that was led by a lay counsellor. Attendees collected their two-monthly supply of ART, were weighed and screened for signs of TB and other conditions. At the six-month interval, a nurse would collect blood for viral load and rescript medicine where necessary. Patients could pre-select a buddy to pick-up their medication for them, and on a limited basis could pick up medication five days after the session on days they could not attend.

Clinic-based clubs were held at a meeting space separate from where clinical exam rooms were located at the Witkoppen clinic. Community-based clubs were held at community venues within the pre-selected area of residence, including community-based organisation facilities, churches, and community centres.

The primary outcome was loss from club-based care. Participants were referred back to regular clinical consultations instead of club-based care, if they met any of the following conditions: two consecutive buddy pickups in a row (where a friend picks up their medication), two consecutive late medication pickups, three late pickups in 12 months, missing a medication pickup entirely, becoming pregnant, TB diagnosis, requiring treatment for another condition, ART regimen change for any reason, and viral rebound.

After adjusting for sex, age, nationality, time on ART, baseline CD4 count, and employment status, those in the community arm were 1.38 times more likely to be loss to follow-up compared to clinic-based care. Among those lost to care, the most common reason was missing a club visit and ART pickup. This was insignificantly higher in the community arm.

Among those who were lost to care, 72% did re-engage after three months, the authors note, “Such poor adherence club retention, where nearly half of those receiving the intervention were referred back into routine clinic-based care, cannot be considered a success, particularly given that de-congesting busy clinics and streamlining patient care are the primary goals of adherence clubs.”

Adherence clubs are designed to keep people living with HIV engaged in their HIV care and sticking to their drug-taking regime. In low-resourced contexts, they help lessen the burden on clinics and healthcare workers, as people responding well to their treatment and going to adherence clubs only need to attend an annual clinical health check.

Community-based initiatives are recommended by the World Health Organization (WHO) as an innovative care model, but until now it was unknown whether community or clinic-based adherence clubs offer comparable effectiveness in terms of retention in care and viral suppression, or if they are acceptable to patients.

“We urge caution in assuming that the effectiveness of clinic-based interventions will carry over to the community setting, without a better understanding of patient-level factors associated with loss from care,” remarked the investigators in their conclusion, “examining the outcome of loss from club-based care rather than just loss from ART care is essential to understanding the value of these and future interventions designed to provide differentiated care to people living with HIV.”