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The impact of decentralized 'out-of-facility individual delivery models' in improving retention and viral suppression of people living with HIV in northeast India

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BACKGROUND: Mizoram, Nagaland, and Manipur are three northeastern Indian states with the highest estimated adult HIV prevalence of 2.4%, 1.4%, and 1.2% respectively. These three states cater to approximately 32,000 People Living with HIV (PLHIV) through 24 antiretroviral therapy (ART) centres. The treatment retention rates vary between 74% to 80% in these states. Common reasons cited for treatment interruption include long-distance travel, transportation costs, difficult terrain, and loss of wages to visit the ART centre. Differentiated Service Delivery Models, such as decentralized out-of-facility strategies, are critical to prevent treatment interruption.
DESCRIPTION: The out-of-facility individual models are established outside of the usual ART centres and provide ART refills to PLHIV either directly at their home by community health workers or through the collection by the PLHIV at specific locations. Seventeen decentralized out-of-facility individual delivery facilities were established between March 2020 and December 2021. Stable PLHIV with CD4>350 cells/mm3 without known opportunistic infections and on ART for more than 6 months were linked to these decentralized models. We assessed the overall retention rate, viral load testing access, and viral load suppression (<1000 copies/ml) rates.
LESSONS LEARNED: We linked 773 of 18774 stable PLHIV including key populations to these facilities. Of these, 98% (761) PLHIV remain engaged in care through December 2021; 92% (699) were retained in the out-of-facility individual model and 8% (62) were retained in the respective ART centres. During the follow-up period, 2% (12) PLHIV died. Of the 588 PLHIV who were due for a viral load test, 59% (346) have undergone the test and out of this 92% (318) were virally suppressed.
CONCLUSIONS: Enabling access through community engagement are pivotal to retention. The differentiated out-of-facility individual delivery model improves engagement in care and ART adherence (viral suppression) among PLHIV. The coverage of viral load testing in these remote geographies remains a challenge due to difficult terrain for access and specimen transport, however, the establishment of the decentralized service sites will allow for future viral load testing through dried blood spots in such remote settings.