Decentralised antiretroviral treatment delivery in an urban setting – a Kinshasa success
The first ever study evaluating the decentralising of HIV care through antiretroviral treatment (ART) distribution centres shows low rates of patient loss in the city.
Community-based antiretroviral treatment (ART) refill centres could help reduce the amount of patients dropping out of care in low-resource settings where access to the traditional medical facility is a challenge.
In a ‘Brief Report’ in the Journal of Acquired Immune Deficiency Syndrome (JAIDS), a case was described for decentralised ART supply via community-based distribution centres in Kinshasa, Democratic Republic of the Congo.
Low attrition rates were recorded in the decentralisation programme. After six months, 2.2% of patients were lost to follow-up (LTFU) and 0.1% had died. At 12 months, 4.8% were LTFU with 0.2% deaths; at 24 months, the figures showed 9% LTFU and 0.3% deaths.
In 2010, Kabinda Hospital in Kinshasa had more than 6,500 HIV patients enrolled in its Médecins Sans Frontières (MSF)-run HIV project. This centralised system of care delivery led to overcrowding and long waiting hours. Many patients also had to travel an average of three hours to the clinic due to poor infrastructure and traffic in Kinshasa – a city of 11 million people.
Only 25% of people living with HIV are on treatment in Kinshasa – much lower than the sub-Saharan Africa average. To combat high attrition rates, decentralised community centres were set up – known as poste de distribution communautaire (PODI) – where people living with HIV in good or stable health could pick up their HIV treatment outside of the hospital.
Every three months, patients would visit the PODI, have their adherence assessed and pick up their medication in a process which would normally take less than 15 minutes. They would also have annual appointments with a doctor and were referred by community workers to the hospital if medical support was needed.
Around 2,600 patients were eligible for decentralisation, with 2,259 patients included in the study. Most of the patients were female (76%) and had secondary education (67%). They found no demographic variables associated with attrition, but all clinical variables were. The risk of attrition fell if patients were on the drug Nevirapine, were not receiving stavudine, had a CD4 count of more than 500 cells/mm3, had a higher BMI and had already been on ART for more than three years.
Despite the positive attrition rates, a limit of the findings is that there was no control group where decentralised and centralised clinical variables were recorded. However, the PODI model is still a success, and has been included in their 2014-2017 National Strategic Plan against HIV by the Ministry of Health in the Democratic Republic of the Congo.