Home Assessment and Initiation of Antiretroviral Therapy for HIV in Malawi

Not Applicable

Completed

Interventions: Other: Home assessment and initiation of ART
Other: Clinic-based ART assessment and initiation

Brief Summary: Despite increasing availability of antiretroviral therapy (ART) for HIV in high prevalence countries, the majority of people with HIV infection still initiate treatment at an advanced stage of disease. This leads to a high risk of death soon after HIV diagnosis. Prompt HIV diagnosis is, therefore, necessary for both individual and public health benefit and is being strongly promoted as international and national policy in Malawi. However timely HIV diagnosis may not in itself be sufficient to ensure ART initiation: this is reflected by the relatively high proportion of individuals who defer treatment-seeking for months or years following diagnosis of HIV.

Here the researchers investigate the extent to which home assessment and initiation of ART adds to the effectiveness of a home-based HIV testing and counseling strategy, using entry to, adherence with, and retention in HIV care as the outcome of interest.

Recruitment & Eligibility

Inclusion Criteria

Usual resident of an eligible cluster
Has had a positive HIV test (regardless of source) and requests facilitated access to HIV care from the resident community counsellor
Confirmatory HIV test is positive
No previous ART treatment, or less than one month's treatment in the past (including PMTCT interventions) and not currently receiving HIV care
No contraindications to receiving ART (as defined by Integrated Management of Adult Illnesses, HIV Department, WHO)
No acute danger signs requiring hospital referral
Aged 18 years or older
Written or witnessed informed consent to participate in the study

Exclusion Criteria

Not a usual resident of an eligible cluster
No previous HIV test, or HIV infection not confirmed by home-based ART nurse
Already receiving ART, or has had more than 1 month's treatment in the past
Known contraindication to firstline ART (known hypersensitivity, renal failure, chronic liver disease)
Acute danger sign present (as defined by Integrated Management of Adult Illnesses, HIV Department, WHO)
Age younger than 18 years
Not willing to accept home-based ART initiation
Suspected or confirmed TB disease will not be an exclusion criteria, but will be an indication for deferral, until completion of the screening algorithm, with initiation of TB treatment if indicated.

Arm && Interventions

Group	Intervention	Description
Home assessment and initiation of ART	Home assessment and initiation of ART	Participants with a positive home-based HIV test result will receive a home visit from a study nurse who will complete the following on the first home visit: * Confirmatory fingerprick HIV testing * TB symptom screening * ART eligibility assessment (Word Health Organization clinical staging, sampling of blood for measurement of CD4 count and treatment education) At a second home visit (within 5 days), participants who are ART eligible (as defined in National ART guidelines) will be initiated onto ART (using National Treatment Programme ART regimens). Following home initiation of ART, participants in the intervention arm will receive detailed counselling from the study nurse about the need to attend their first 2-week follow-up appointment at the primary health care clinic that serves their household's residence. They will receive a referral slip detailing the date, time and place of their appointment.
Clinic-based ART assessment and initiation	Clinic-based ART assessment and initiation	Participants who meet eligibility criteria and reside in a cluster that has been allocated to the control arm of this study will receive supported access to ART care through the primary care system for confirmation of HIV status and entry into HIV following disclosure to the resident community counsellor. HIV care, including ART, will be started from the primary care clinic.

Primary Outcome Measures

Name	Time	Method
ART Initiation	First six months following introduction of home-based HIV testing	Comparison between study arms of the proportion of all resident adults (per capita, and irrespective of HIV status or participation in home-based HIV testing intervention) who initiate ART during the first 6 months of the home-based HIV-testing intervention.

Secondary Outcome Measures

Name	Time	Method
Adult Mortality	The first 6-months following availability of home-based HIV testing	Comparison between study arms of non-traumatic and HIV-related adult (15-49) mortality rates during the first 6 months of the HIV-testing intervention
Uptake of Home-based HIV Testing	The first 6-months following home assessment and initiation of ART being made available	Comparison between study arms of the proportion of all resident adults who request HIV testing (either as standard HTC or as supervised HIV self-testing) from the resident community counsellor during the first year of the study.
Reporting of HIV-positive Results	The first 6-months following availability of home-based HIV testing	Comparison of the proportion of all cluster adults confiding HIV-positive results to the resident community counsellor between study arms during the 1-year study period
Loss to Retention	The first 6-months following availability of home-based HIV testing	Comparison between study arms of the proportion of participants who initiate ART during the first 6-months of the HIV-testing intervention who are lost to retention within 6 months after initiating ART 6-months
Adherence to ART	First 6-months following availability of home-based HIV testing	Comparison between study arms of the proportion of HIV-positive participants who are adherent to ART during the 1-year study period

Locations (1): Malawi-Liverpool-Wellcome Trust Clinical Research Programme
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Blantyre, Chichiri, Malawi