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Abstract and Introduction
Abstract
Objectives: African health services have shortages of clinical staff. We showed previously, in a cluster-randomized trial, that a home-based strategy using trained lay-workers is as effective as a clinic-based strategy. It is not known whether home-based care is suitable for patients with advanced HIV disease.
Methods: The trial was conducted in Jinja, Uganda. One thousand, four hundred and fifty-three adults initiating ART between February 2005 and January 2009 were randomized to receive either home-based care or routine clinic-based care, and followed up for about 3 years. Trained lay workers, supervised by clinical staff based in a clinic, delivered the home-based care. In this sub-analysis, we compared survival between the two strategies for those who presented with CD4 cell count less than 50 cells/μl and those who presented with higher CD4 cell counts. We used Kaplan–Meier methods and Poisson regression.
Results: Four hundred and forty four of 1453 (31%) participants had baseline CD4 cell count less than 50 cells/μl. Overall, 110 (25%) deaths occurred among participants with baseline CD4 cell count less than 50 cells/μl and 87 (9%) in those with higher CD4 cell count. Among participants with CD4 cell count less than 50 cells/μl, mortality rates were similar for the home and facility-based arms; adjusted mortality rate ratio 0.80 [95% confidence interval (CI) 0.53–1.18] compared with 1.22 (95% CI 0.78–1.89) for those who presented with higher CD4 cell count.
Conclusion: HIV home-based care, with lay workers playing a major role in the delivery of care including providing monthly adherence support, leads to similar survival rates as clinic-based care even among patients who present with very low CD4 cell count. This emphasises the critical role of adherence to antiretroviral therapy.
Introduction
Over 7.5 million people are on combination antiretroviral therapy (ART) in Africa, which is just over half of those in need according to current guidelines. It is the largest and most rapid scale-up of a chronic care programme on the continent. A major challenge for sustaining and increasing the scale-up further is the shortage of clinically qualified staff, particularly doctors. In many countries in Africa there are less than 10 doctors per 100 000 people. Delivery of HIV services, which rely less on clinically qualified staff, are needed but the evidence-base on such models of care remains limited.
In a cluster-randomised trial in Jinja, Uganda, we have shown previously that HIV home-based care, with trained lay-workers delivering care and support in the home, was as effective as a standard clinic-based model using qualified clinical staff to manage patients. The lay-workers were monitored and supervised by clinical staff based at the clinic. The home-based care strategy was marginally cheaper for the health service through reduced contact time with doctors and nurses, and was cost saving for patients.
Various studies have shown that mortality is high just prior to initiating ART and in the first few weeks and months after initiating therapy; this high death rate is associated strongly with late presentation as indicated by low CD4 cell count. It is not known whether an HIV home-based care model which incorporates use of lay-workers is appropriate for people who present with advanced disease (i.e. with low CD4 cell count) or whether such patients should be managed by clinical staff in health facilities. Using data from the Jinja trial, we have examined mortality rates between the HIV home-based care and facility-based care trial arms for people who presented with low CD4 cell counts (<50 cells/μl) and those who presented with higher CD4 cell counts.
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