Mutasa-Apollo Tsitsi, Ford Nathan, Wiens Matthew, Socias Maria Eugenia, Negussie Eyerusalem, Wu Ping, Popoff Evan, Park Jay, Mills Edward J, Kanters Steve
College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe.
AIDS and TB Unit, Ministry of Health and Child Care, Harare, Zimbabwe.
J Int AIDS Soc. 2017 Jul 21;20(Suppl 4):21647. doi: 10.7448/IAS.20.5.21647.
Expanding and sustaining antiretroviral therapy (ART) coverage may require simplified HIV service delivery strategies that concomitantly reduce the burden of care on the health system and patients while ensuring optimal outcomes. We conducted a systematic review to assess the impact of reduced frequency of clinic visits and drug dispensing on patient outcomes.
As part of the development process of the World Health Organization antiretroviral (ARV) guidelines, we systematically searched medical literature databases for publications up to 30 August 2016. Information was extracted on trial characteristics, patient characteristics and the following outcomes: mortality, morbidity, treatment adherence, retention, patient and provider acceptability, cost and patients exiting the programme. When feasible, conventional pairwise meta-analyses were conducted. Of 6443 identified citations, 21 papers, pertaining to 16 studies, were included in this review, with 11 studies contributing to analyses. Although analyses were feasible, they were limited by the sparse evidence base, despite the importance of the research area, and relatively low quality. Comparative analyses of eight studies reporting on frequency of clinic visits showed that less frequent clinic visits led to higher odds of being retained in care (odds ratio [OR]: 1.90; 95% CI: 1.21-2.99). No differences were found with respect to viral failure, morbidity or mortality; however, most estimates were favourable to reduced clinic visits. Reduced frequency of ARVs pick-ups showed a trend towards better retention (OR: 1.93; 95% CI: 0.62-6.04). Strategies using community support tended to have better outcomes; however, their implementation varied, particularly by location. External validity may be questionable.
Our systematic review suggests that reduction of clinical visits (and likely ARVs pick-ups) may improve clinical outcomes, and that they are a viable option to relieve health systems and reduce burden of care for PLHIV. Strategies aimed at reducing clinic visits or drug refill services should focus on stable patients who are virally suppressed, tolerant to their drug regimen and fully adherent. These strategies may be critical to the current changes taking place in HIV treatment policy; thus, due to the data limitations, further high quality research is needed to inform policy and programmatic interventions.
扩大并维持抗逆转录病毒疗法（ART）的覆盖范围可能需要简化的HIV服务提供策略，这些策略要在确保最佳治疗效果的同时，减轻卫生系统和患者的护理负担。我们进行了一项系统评价，以评估减少门诊就诊频率和药物发放频率对患者治疗效果的影响。
作为世界卫生组织抗逆转录病毒（ARV）指南制定过程的一部分，我们系统检索了医学文献数据库，查找截至2016年8月30日的相关出版物。提取了有关试验特征、患者特征以及以下治疗效果的信息：死亡率、发病率、治疗依从性、留存率、患者和医疗服务提供者的接受度、成本以及退出该项目的患者情况。在可行的情况下，进行了传统的成对荟萃分析。在6443条检索到的文献中，本评价纳入了21篇论文，涉及16项研究，其中11项研究纳入分析。尽管分析可行，但受证据基础薄弱的限制，尽管该研究领域很重要，但证据质量相对较低。对8项报告门诊就诊频率的研究进行的比较分析表明，门诊就诊频率较低会增加继续接受治疗的几率（优势比[OR]：1.90；95%置信区间：1.21 - 2.99）。在病毒学失败、发病率或死亡率方面未发现差异；然而，大多数评估结果有利于减少门诊就诊次数。抗逆转录病毒药物取药频率降低显示出更好的留存趋势（OR：1.93；95%置信区间：0.62 - 6.04）。利用社区支持的策略往往有更好的治疗效果；然而，其实施情况各不相同，尤其是因地点而异。外部效度可能存在疑问。
我们的系统评价表明，减少门诊就诊次数（可能还包括抗逆转录病毒药物取药次数）可能会改善临床治疗效果，并且它们是减轻卫生系统负担和降低艾滋病毒感染者护理负担的可行选择。旨在减少门诊就诊或药物 refill 服务的策略应侧重于病毒得到抑制、对药物治疗方案耐受且完全依从的稳定患者。这些策略对于当前艾滋病毒治疗政策的变化可能至关重要；因此，由于数据限制，需要进一步开展高质量研究，为政策和项目干预提供依据。
