Community-based HIV treatment increases viral suppression rates in men by 20%

02 October 2020

Rates of viral suppression among men significantly increase – and approach that of women – when services are provided in the community instead of in-clinic.

Men at a market stall in Africa

A study in South Africa and Uganda that compared community-based with clinic-based antiretroviral treatment (ART) services found community-based services led to significantly more people, particularly men, becoming virally suppressed.

The study in KwaZulu-Natal, South Africa and Sheema District, Uganda found that around two-thirds (73%) of men receiving community-based treatment became virally suppressed after 12 months, compared to 54% of men who received clinic-based care.

Not only is this rate similar to that of women receiving community-based care in the trial (75%), it also meets UNAIDS’ viral suppression target of 73%, something many ART programmes fail to do.

Researchers conducted community-based testing then enrolled 1,315 people in the trial between 2016 and 2019.

Participants in the trial were assigned to one of three groups. The first began community-based treatment on the same day as diagnosis, after which they received their quarterly monitoring and medication refills from a mobile van. The van was staffed by trained nurses and lay counsellors and was available on evenings and weekends as well as during the week.

The second group began treatment at a clinic, although not necessarily on the same day as diagnosis, they then received quarterly monitoring and refills at a mobile van (the hybrid approach).

Participants in both of these groups were sent appointment reminders by text message. They were also able to text to reschedule visits, request extra medication if travelling, and nominate someone else to collect their drugs. In addition to this, they each received individual adherence support.

Participants in the third group got standard of care, with clinic-based ART initiation, monitoring and refills.

After 12 months, 74% of people receiving community-based treatment were virally suppressed, compared to 63% of people in clinic-based care and 68% in the hybrid group.

The community-based approach resulted in 73% of men being virally suppressed, compared to 54% in the clinic-based group and 66% in the hybrid group.

A similar proportion of women became virally suppressed regardless of whether they were receiving community-based (75%) or clinic-based treatment (73%). This suggests the benefits of community-based ART are particularly significant for men.

Across the three groups, rates of bad events, such as poor health outcomes, were low, suggesting that community-based ART is as safe as clinic-based treatment.

In South Africa, the yearly cost per person virally suppressed was US$402–422 in the clinic group and US$325–390 in the community-based group. In Uganda, this cost was US$214 in the clinic-based group and $275 in the community-based group. But it is possible that the higher cost of community-based ART found in Uganda would be offset by the health gains of viral suppression over time.

These findings show that offering monitoring and ART refills at more convenient locations and times, and being flexible to meet travel or other needs, can significantly increase the number of people – particularly men – reaching viral suppression.

But it is important to note that around one in four people in the community-based group remained virally unsuppressed. More tailored services are needed to reach these people or risk them being left behind.

Written by Hester Phillips