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How soon should patients be eligible for differentiated service delivery models for antiretroviral treatment?

Title
How soon should patients be eligible for differentiated service delivery models for antiretroviral treatment?
Presenter
Sydney Rosen
Authors
L. Jamieson (1,2), S. Rosen * (3,1), B. Phiri (4), A. Grimsrud (5), M. Mwansa (6), H. Shakwelele (4), P. Haimbe (4), M.M. Mwenechanya (7), P. Lumano-Mulenga (6), I. Chiboma (6), B.E. Nichols (3,2,1)
Institutions
(1) University of Witwatersrand, Health Economics and Epidemiology Research Office, Johannesburg, South Africa, (2) Amsterdam University Medical Centre, Department of Medical Microbiology, Amsterdam, Netherlands, the, (3) Boston University School of Public Health, Department of Global Health, Boston, United States, (4) Clinton Health Access Initiative, Lusaka, Zambia, (5) International AIDS Society, Cape Town, South Africa, (6) Ministry of Health, Lusaka, Zambia, (7) The Centre for Infectious Disease Research in Zambia, Lusaka, Zambia

BACKGROUND: Attrition from HIV treatment (ART) is highest during patients' first 6 months after initiation. Although '¥6 months on ART is an eligibility criterion for most differentiated service delivery (DSD) model guidelines, some patients enroll earlier. We used routinely-collected data on DSD models in Zambia to evaluate loss to follow-up (LTFU) comparing patients enrolling in DSD models early vs those who did so later (>6 months).
METHODS: We extracted data from electronic medical records for adults ('¥15 years) initiated on ART between 01/01/2019 and 31/12/2019 and evaluated LTFU (>90 days late for last scheduled medication pickup) at 18 months for 'early enrollers' (DSD enrolment within <6 months on ART) and 'established enrollers' (DSD enrolment with >6 months on ART). We used a log-binomial model to compare LTFU risk between groups, adjusting for age, sex, urban/rural status, ART refill intervals and DSD model.
RESULTS: For 6,340 early enrollers and 25,857 established enrollers, there were no important differences between the groups by sex (61% female), age (median 37 years), or setting (65% urban). ART refill intervals were longer for established vs early enrollers (72% vs 55% were given 4-6 month refills). LTFU at 18 months was 3% (192/6,340) for early enrollers and 5% (24,646/25,857) for established enrollers. Early enrollers were 41% less likely to be LTFU than established patients (adjusted risk ratio [95% confidence interval] 0.59[0.50-0.68]).


CONCLUSIONS: Patients enrolled early after ART initiation in DSD models in Zambia were more likely to be retained in care than patients referred after they were established on ART. A limitation of the analysis is that early enrollers may have been selected for DSD participation due to providers' and patients' expectations about future retention. Offering DSD model entry to at least some ART patients <6 months after ART initiation may help address high attrition during the early treatment period.