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Starting ART at home improves HIV care in Africa
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BOSTON — Offering same-day, at-home ART initiation improves testing and treatment outcomes compared with standard-of-care in patients who undergo home-based HIV testing, according to study findings presented at CROI and published in JAMA.
In a first-of-its kind trial, Niklaus D. Labhardt, MD, MIH, deputy senior physician at the University Hospital of Basel, Switzerland, and research project leader at the Swiss Tropical and Public Health Institute, and colleagues randomly assigned patients who tested positive at home to either start at-home ART on the same day or be referred to a clinic for preparatory counseling and ART beginning after two or more pre-ART clinic visits, which is standard-of-care.
Not only did significantly more patients in the intervention arm seek care having received an initial 30-day supply of ART drugs, they were much more likely to have a suppressed viral load after 1 year. The study was conducted in rural Lesotho, southern Africa, but Labhardt expects that the results would be comparable in other countries.
“I’m convinced that in similar settings — meaning rural, high-prevalence Africa — this is quite generalizable,” he said during a press conference here.
Home-based testing is frequently used in sub-Saharan Africa to increase awareness of HIV status, but using standard referral, only a low percentage of patients who test positive are subsequently linked to care and start ART, Labhardt said.
“The problem is that to get universal testing so that everybody knows his or her HIV status, home-based testing has to be done. One cannot wait at the clinic for people to come and get tested,” he said. “However, we also know that if people get tested at home, only one out of three engages in care and starts ART, which makes home-based HIV testing fairly inefficient.”
In the CASCADE trial, if a patient tested positive and was in the intervention arm, a study team already at the house would explain ART and leave one bottle with enough drugs for 30 days. After that, the patient had to go to the clinic to receive medication like everyone else, Labhardt said.
A total of 274 ART-naive adults aged 18 years or older were enrolled evenly in the study from February to July 2016. The median age of the patients was 39 years, and their median CD4 cell count was 378 cells/μL. Most — 65.7% — were female and 78.1% were clinically asymptomatic.
In the intervention arm, 68.6% of patients were linked to care within 90 days and 50.4% had a suppressed viral load after 1 year, compared with just 43.1% of patients who were linked to care within 90 days and 34.3% who were virally suppressed after 1 year in the control arm.
Ninety days after a positive HIV test, 68.6% of patients in the intervention arm had initiated ART compared with just 31.4% of patients in standard care. Retention in care was also higher among patients who started same-day ART compared with the other patients, 64.2% vs. 49.6%.
“This easy addition to the current practice of home-based testing has the potential to improve practice in sub-Saharan African as part of future guidelines and policies,” Labhardt said. – by Gerard Gallagher
References:
Labhardt N, et al. Abstract 94. Presented at: Conference on Retroviruses and Opportunistic Infections; March 4-7, 2018; Boston.
Labhardt ND, et al. JAMA. 2018;doi:10.1001/jama.2018.1818.
Disclosure: Labhardt reports no relevant financial disclosures.
Perspective
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Carlos del Rio, MD
The idea of adding ART initiation to home-based testing is a paradigm shift, and the CASCADE study nicely showed that not only was this feasible, but it also improved linkage and retention in care as well as virologic suppression. In other words, by moving ART initiation from the clinic to the home, the care continuum was optimized. The data are quite encouraging and suggest that this can be done in other communities, including here in the United States, where retention in care is not optimal. Unfortunately, in this country, there are multiple bureaucratic barriers that would need to be addressed to make this possible.
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