Songo John, Whitehead Hannah S, Nichols Brooke E, Makwaya Amos, Njala Joseph, Phiri Sam, Hoffman Risa M, Dovel Kathryn, Phiri Khumbo, van Oosterhout Joep J
Partners in Hope, Lilongwe, Malawi.
Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, California, United States of America.
PLOS Glob Public Health. 2023 Sep 28;3(9):e0002081. doi: 10.1371/journal.pgph.0002081. eCollection 2023.
Outcomes of community antiretroviral therapy (ART) distribution (CAD), in which provider-led ART teams deliver integrated HIV services at health posts in communities, have been mixed in sub-Saharan African countries. CAD outcomes and costs relative to facility-based care have not been reported from Malawi.
We performed a retrospective cohort study in two Malawian districts (Lilongwe and Chikwawa districts), comparing CAD with facility-based ART care. We selected an equal number of clients in CAD and facility-based care who were aged >13 years, had an undetectable viral load (VL) result in the last year and were stable on first-line ART for ≥1 year. We compared retention in care (alive and no period of ≥60 days without ART) using Kaplan-Meier survival analysis and Cox regression and maintenance of VL suppression (<1,000 copies/mL) during follow-up using logistic regression. We also compared costs (in US$) from the health system and client perspectives for the two models of care. Data were collected in October and November 2020.
700 ART clients (350 CAD, 350 facility-based) were included. The median age was 43 years (IQR 36-51), median duration on ART was 7 years (IQR 4-9), and 75% were female. Retention in care did not differ significantly between clients in CAD (89.4% retained) and facility-based care (89.3%), p = 0.95. No significant difference in maintenance of VL suppression were observed between CAD and facility-based care (aOR: 1.24, 95% CI: 0.47-3.20, p = 0.70). CAD resulted in slightly higher health system costs than facility-based care: $118/year vs. $108/year per person accessing care; and $133/year vs. $122/year per person retained in care. CAD decreased individual client costs compared to facility-based care: $3.20/year vs. $11.40/year per person accessing care; and $3.60/year vs. $12.90/year per person retained in care.
Clients in provider-led CAD care in Malawi had very good retention in care and VL suppression outcomes, similar to clients receiving facility-based care. While health system costs were somewhat higher with CAD, costs for clients were reduced substantially. More research is needed to understand the impact of other differentiated service delivery models on costs for the health system and clients.
在撒哈拉以南非洲国家，由医护人员主导的抗逆转录病毒治疗（ART）团队在社区卫生站提供综合HIV服务的社区抗逆转录病毒治疗（CAD）的效果参差不齐。马拉维尚未报告CAD相对于机构治疗的效果和成本。
我们在马拉维的两个地区（利隆圭和奇夸瓦区）进行了一项回顾性队列研究，将CAD与机构ART治疗进行比较。我们在CAD组和机构治疗组中选择了数量相等的年龄大于13岁、去年病毒载量（VL）检测不到且一线ART治疗稳定≥1年的患者。我们使用Kaplan-Meier生存分析和Cox回归比较治疗留存率（存活且无≥60天未接受ART治疗的时间段），并使用逻辑回归比较随访期间VL抑制的维持情况（<1000拷贝/毫升）。我们还从卫生系统和患者角度比较了两种治疗模式的成本（以美元计）。数据于2020年10月和11月收集。
纳入了700名ART患者（350名CAD组，350名机构治疗组）。中位年龄为43岁（四分位间距36 - 51岁），ART治疗的中位时长为7年（四分位间距4 - 9年），75%为女性。CAD组患者（留存率89.4%）和机构治疗组患者（留存率89.3%）的治疗留存率无显著差异，p = 0.95。CAD组和机构治疗组在VL抑制维持方面未观察到显著差异（调整后比值比：1.24，95%置信区间：0.47 - 3.20，p = 0.70）。CAD导致的卫生系统成本略高于机构治疗：每人每年接受治疗的成本分别为118美元和108美元；每人每年留存治疗的成本分别为133美元和122美元。与机构治疗相比，CAD降低了个体患者成本：每人每年接受治疗的成本分别为3.20美元和11.40美元；每人每年留存治疗的成本分别为3.60美元和12.90美元。
在马拉维，由医护人员主导的CAD治疗中的患者具有非常好的治疗留存率和VL抑制效果，与接受机构治疗的患者相似。虽然CAD的卫生系统成本略高，但患者成本大幅降低。需要更多研究来了解其他差异化服务提供模式对卫生系统和患者成本的影响。
