Dispensing and monitoring ART via community efforts may be feasible

Patients with HIV in Kenya may benefit from a treatment model that uses other patients with HIV as caregivers, according to results of a recent study.

The researchers created a model of care that utilized patients with HIV as community care coordinators. The coordinators cared for other clinically stable patients with HIV with the assistance of preprogrammed personal digital assistants.

In the model, rather than patients coming to the clinic for monthly visits, patients visited the clinic every three months and were visited by community care coordinators in the interim two months.

The site of the study was the Kosirai Division of western Kenya, which is comprised of 24 sub-locations. Eight of those locations were randomly assigned to employ the program model, and the rest were used as controls.

Kara Wools-Kaloustian, MD, associate professor of medicine at the Indiana University School of Medicine and co-field director of Research IU-Kenya Partnership, was involved in the study. "If we are going to effectively roll out ART to the majority of individuals that need it in resource-poor settings, we are going to have to develop models of health care and delivery that are not dependent on the traditional physician and nurse model," she said. "Human resources in sub-Saharan Africa are inadequate to ever sustain the western medical model for HIV care."

Study design

The community care coordinators participated in intensive training and mentoring in a number of areas related to HIV assessment and support. The personal digital assistants were programmed and prepared to handle situations or questions that fell outside the parameters of the training of the community care coordinators.

"This study opens up the potential for physicians to explore the use of lay partners to assist in providing HIV care and support," Wools-Kaloustian said.

Upon successful completion of training, all eight of the community care coordinators entered the field and actively participated in the program for two years. During year one, 89% of their summary scores were documented as superior. During year two, that number increased to 94%.

The coordinators were evaluated in six performance areas and were analyzed continuously based on ongoing feedback and quality improvement measures.

Impressionistic analysis from year one resulted in six associated themes:

• Confidentiality and ‘community disclosure’
• Roles and responsibilities
• Logistics
• Clinical care partnership
• ART adherence
• Personal digital assistant issues

Final analysis demonstrated that 64% of patients who participated in the intervention group and 52% of patients in the control group were willing to continue the same treatment program (P=.26).

Interpretation and applicability

Wools-Kaloustian commented on the potential universal applicability of the results.

"These results may not have a significant impact on the practices of clinicians providing care in resource-replete environments where patients are both culturally adapted to receiving care in traditional medical setting and have sufficient resources to travel to the clinic on a regular basis," she said. "However, for clinicians practicing in inner cities, this may provide a model of care that can be used for populations that are difficult to access and retain in care, such as immigrants, minority ethnic groups and substance users." She said that the model could work in other resource-poor areas if adapted to the geography and the culture of the area.

Wools-Kaloustian said that there has been little motivation to explore alternative models of care in resource-rich settings. She said that it was only after the researchers proved that they could deliver HIV care in a traditional model in resource constrained settings that they started feeling comfortable with adapting the model to the environment.

Regarding whether such a program could work in the United States or other developed countries, Wools-Kaloustian said that it could depend on pharmacy dispensing laws, especially in terms of bringing ART to patients. "If health care providers in a particular country or region feel strongly about adopting such models, it may require a challenge to the laws governing pharmaceuticals," she said.

"This model could lead to a paradigm shift in HIV care in resource constrained settings," she said. "Also, it has the potential to lead to a shift in the structure of HIV care in under-resourced urban settings in the United States and Europe. However, it remains to be seen whether such a model could impact the structure of HIV practice for American and European providers caring for populations with adequate resources."

Wools-Kaloustian KK et al. J Intl AIDS Soc. 2009;12:22.