Developing and Assessing a Community Based Model of Antiretroviral Care

Universal Access to ART: Since 2003 there has been a concerted international effort to increase access to ART for HIV-infected individuals living in low and middle income countries.[1-6] Despite the substantial increase in the number of people receiving ART in SSA, by the end of 2010 only 49% of the 10,400,000 persons in need of ART were receiving treatment.[7-8] This is far short of the universal ART access goal of ≥80% of those in need of treatment.[2] Given that SSA commands only 3% of the world's health care providers and contributes to only 1% of the global health care expenditures, a significant barrier to meeting this goal is the profound shortage of infrastructure resources, most specifically, trained medical personnel.[9-10] With regard to Kenya, WHO estimates that the country will only be able to provide 25% of the 240,000 physicians needed to serve the country's population by 2015.[11] New initiatives under consideration such as "Test and Treat", Option B+ (ART for all pregnant women with lifelong maintenance) and treatment of index partners within HIV-discordant relationships will further tax the already strained health care work force.[12-22] As such, unless new care models can be developed that require fewer health care provider resources while maintaining optimal patient outcomes, the goal of universal access is unachievable.

Retention in Care: The high program attrition rates in SSA make achieving universal access even more complex. A meta-analysis of HIV-care programs in resource-constrained settings estimated one and two-year attrition rates (defined as death or lost to follow up (LTFU)) to be 22.6% (range 7-45%) and 25% (11-32%), respectively.[23] Of these approximately 41% were confirmed dead and 59% were LTFU. Patients LTFU represent heterogeneous outcomes including death, in care elsewhere, and disengaged from care.[24] Patients disengaged from care are at high risk of morbidity, mortality and transmitting HIV.[25-29] Despite the desirability of providing outreach to all patients LTFU, the cost of such programs frequently comes at the expense of expanding ART access. Geographic accessibility (distance to clinic and transportation costs) and shortages in health care personnel (excessive clinic waiting times) are documented barriers to retention.[24-25,30-35] As such, the optimal ART care model in resource constrained settings should minimize LTFU through reductions in transport time and costs as well as reducing clinic waiting time.

Task Shifting: In response to the severe shortage of health care workers in SSA, WHO and other organizations have advocated task shifting to lower cadre health care workers and lay individuals, including persons living with HIV (PLWHIV), in order to maximize patients' access to ART.[36-39] Such strategies decrease physician resource requirements, allow for decentralized ART delivery, and improve patient retention.[26,40-50] Médecins Sans Frontières (MSF) has developed a model of care which allows PLWHIV to become active participants in their own care and the care of other community members.[49]They successfully formed Community ART Groups (CAGs) to facilitate ART distribution, promote adherence, provide social support and monitor clinical status. During monthly group meetings a CAG member was chosen to represent each group at the clinic where each member's status was discussed and the group's monthly ART supply was picked up. Retention was exceptionally high with 97.5% patients remaining in care for a median follow-up period of 12.9 months (range 8.5-14 months).

Cost Effectiveness: Site-level cost studies of HIV care services have shown that human resource costs are a major determination of treatment scale-up costs and, as such, support the recommendations for task-shifting.[51-53] Despite this, only a few cost and cost-effectiveness studies have assessed alternative ART-delivery models.[54-59]

Justification for study: