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The impact of home-based compared with facility-based HIV-care on virologic failure and mortality: a cluster randomised trial
Presented by Shabbar Jaffar (United Kingdom).
S. Jaffar1, B. Amuron2, J. Levin2, J. Birungi3, G. Namara2, C. Nabiryo3, A. Coutinho4, H. Grosskurth2,5
1London School Hygiene and Tropical Medicine, Epidemiology and Population Health, London, United Kingdom, 2MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda, 3The AIDS Support Organisation (TASO), Kampala, Uganda, 4Infectious Diseases Institute, Makerere University, Kampala, Uganda, 5London School Hygiene and Tropical Medicine, London, United Kingdom
Background: Because of health system constraints, identifying ways to increase access to antiretroviral therapy (ART) in Africa is an urgent priority. We conducted a cluster-randomised trial to compare home-based care (HBC) with facility-based (FBC).
Methods: Trial was conducted at The AIDS Support Organisation (TASO) clinic in Jinja, Uganda under normal health service conditions. ART was initiated at the clinic. 44 clusters were randomised to HBC or FBC. In HBC, support, monitoring and drug delivery was done monthly in the home by lay workers and patients attended clinic 6-monthly for routine evaluation. In FBC, patients attended clinic monthly to collect drugs and were evaluated routinely 3-monthly. Evaluations were done mostly by junior clinicians and experienced counsellors. Standard regimens were used. Analyses adjusted for CD4 count and clustering. Virologic failure was defined as RNA>500 copies /ml.
Results: 859 patients (22 clusters) were randomised to HBC and 594 (22 clusters) to FBC. Enrolment started February 2005 and follow-up ended January 2009. 24(2%) refused to enrol (21 HBC, 3 FBC), 119 (8%) withdrew (60 HBC, 59 FBC) and 34 (2%) were lost-to-follow-up (20 HBC, 14 FBC). Baseline CD4 count was < 100 cells /µl in 431 (50%) HBC and 245 (41%) in FBC. Mean number of clinic visits per patient was 8 in HBC and 26 in FBC. Mortality (95% CI) /100 person years was 6.28 (5.24, 7.53) in HBC and 6.48 (5.20, 8.07) in FBC: adjusted rate ratio (aRR) 0.96 (0.71, 1.28). 117 (13.6%) in HBC compared with 80 (13.5%) in FBC had virologic failure (aRR 0.96, 95% CI 0.71, 1.28). At final visit, 943 (65%) were followed-up with undetectable plasma RNA (HBC 66%, FBC 64%).
Conclusions: Excellent outcomes were achieved in both facility and home-based HIV care. Complex treatments in Africa can be delivered effectively nearer to patients' homes without frequent support from clinical staff.
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