Effects of community-based antiretroviral therapy initiation models on HIV treatment outcomes: A systematic review and meta-analysis

Background

Antiretroviral therapy (ART) initiation in the community and outside of a traditional health facility has the potential to improve linkage to ART, decongest health facilities, and minimize structural barriers to attending HIV services among people living with HIV (PLWH). We conducted a systematic review and meta-analysis to determine the effect of offering ART initiation in the community on HIV treatment outcomes.

Methods and findings

We searched databases between 1 January 2013 and 22 February 2021 to identify randomized controlled trials (RCTs) and observational studies that compared offering ART initiation in a community setting to offering ART initiation in a traditional health facility or alternative community setting. We assessed risk of bias, reporting of implementation outcomes, and real-world relevance and used Mantel–Haenszel methods to generate pooled risk ratios (RRs) and risk differences (RDs) with 95% confidence intervals. We evaluated heterogeneity qualitatively and quantitatively and used GRADE to evaluate overall evidence certainty. Searches yielded 4,035 records, resulting in 8 included studies—4 RCTs and 4 observational studies—conducted in Lesotho, South Africa, Nigeria, Uganda, Malawi, Tanzania, and Haiti—a total of 11,196 PLWH. Five studies were conducted in general HIV populations, 2 in key populations, and 1 in adolescents. Community ART initiation strategies included community-based HIV testing coupled with ART initiation at home or at community venues; 5 studies maintained ART refills in the community, and 4 provided refills at the health facility. All studies were pragmatic, but in most cases provided additional resources. Few studies reported on implementation outcomes. All studies showed higher ART uptake in community initiation arms compared to facility initiation and refill arms (standard of care) (RR 1.73, 95% CI 1.22 to 2.45; RD 30%, 95% CI 10% to 50%; 5 studies). Retention (RR 1.43, 95% CI 1.32 to 1.54; RD 19%, 95% CI 11% to 28%; 4 studies) and viral suppression (RR 1.31, 95% CI 1.15 to 1.49; RD 15%, 95% CI 10% to 21%; 3 studies) at 12 months were also higher in the community-based ART initiation arms. Improved uptake, retention, and viral suppression with community ART initiation were seen across population subgroups—including men, adolescents, and key populations. One study reported no difference in retention and viral suppression at 2 years. There were limited data on adherence and mortality. Social harms and adverse events appeared to be minimal and similar between community ART initiation and standard of care. One study compared ART refill strategies following community ART initiation (community versus facility refills) and found no difference in viral suppression (RD −7%, 95% CI −19% to 6%) or retention at 12 months (RD −12%, 95% CI −23% to 0.3%). This systematic review was limited by few studies for inclusion, poor-quality observational data, and short-term outcomes.

Conclusions

Based on data from a limited set of studies, community ART initiation appears to result in higher ART uptake, retention, and viral suppression at 1 year compared to facility-based ART initiation. Implementation on a wider scale necessitates broader exploration of costs, logistics, and acceptability by providers and PLWH to ensure that these effects are reproducible when delivered at scale, in different contexts, and over time.

Author summary

Why was this study done?

Over the last decade HIV services have increasingly moved out of the health facility and into the community through the provision of decentralized and differentiated HIV care.

It remains unclear however whether initiating ART in a community setting will result in treatment and safety outcomes that are comparable to facility-based ART initiation.

What did the researchers do and find?

We conducted a systematic review to identify studies where ART was initiated at community locations, including homes, mobile vans, or other community venues.

We identified 8 studies (including 11,196 HIV-positive people), 7 of which were conducted in sub-Saharan Africa; 4 were randomized controlled trials and 4 were cohort studies.

The methodological quality of the randomized controlled trials was high, but cohort data were of poorer quality. Studies were generally pragmatic in design, but implementation outcomes were infrequently reported.

Based on meta-analysis of this limited dataset, it appeared that ART initiation in the community resulted in higher ART uptake, higher retention, and greater viral suppression at 1 year compared to facility-based ART initiation and refill, among HIV-positive people offered ART. These findings were consistent across population subgroups and various implementation strategies.

There were insufficient data on serious adverse events or mortality to draw firm conclusions on these outcomes.

What do these findings mean?

Community ART initiation may result in better outcomes than ART initiation in traditional health facilities.

To increase the robustness of these findings, high-quality implementation research conducted in diverse settings, exploring optimum combinations of community ART initiation and ART refill strategies over longer time periods, will be critical.