MD Program, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606-30100, Eldoret, Kenya.
BMC Health Serv Res. 2023 Nov 30;23(1):1331. doi: 10.1186/s12913-023-10215-1.
BACKGROUND: Street-connected individuals (SCI) in Kenya experience barriers to accessing HIV care. This pilot study provides proof-of-concept for Enabling Adherence to Treatment (EAT), a combination intervention providing modified directly observed therapy (mDOT), daily meals, and peer navigation services to SCI living with HIV or requiring therapy for other conditions (e.g. tuberculosis). The goal of the EAT intervention was to improve engagement in HIV care and viral suppression among SCI living with HIV in an urban setting in Kenya. METHODS: This pilot study used a single group, pre/post-test design, and enrolled a convenience sample of self-identified SCI of any age. Participants were able to access free hot meals, peer navigation services, and mDOT 6 days per week. We carried out descriptive statistics to characterize participants' engagement in EAT and HIV treatment outcomes. We used McNemar's chi-square test to calculate unadjusted differences in HIV outcomes pre- and post-intervention among participants enrolled in HIV care prior to EAT. We compared unadjusted time to initiation of antiretroviral therapy (ART) and first episode of viral load (VL) suppression among participants enrolled in HIV care prior to EAT vs. concurrently with EAT using the Wilcoxon rank sum test. Statistical significance was defined as p < 0.05. We calculated total, fixed, and variable costs of the intervention. RESULTS: Between July 2018 and February 2020, EAT enrolled 87 participants: 46 (53%) female and 75 (86%) living with HIV. At baseline, 60 out of 75 participants living with HIV (80%) had previously enrolled in HIV care. Out of 60, 56 (93%) had initiated ART, 44 (73%) were active in care, and 25 (42%) were virally suppressed (VL < 1000 copies/mL) at their last VL measure in the 19 months before EAT. After 19 months of follow-up, all 75 participants living with HIV had enrolled in HIV care and initiated ART, 65 (87%) were active in care, and 44 (59%) were virally suppressed at their last VL measure. Among the participants who were enrolled in HIV care before EAT, there was a significant increase in the proportion who were active in HIV care and virally suppressed at their last VL measure during EAT enrollment compared to before EAT enrollment. Participants who enrolled in HIV care concurrently with EAT had a significantly shorter time to initiation of ART and first episode of viral suppression compared to participants who enrolled in HIV care prior to EAT. The total cost of the intervention over 19 months was USD $57,448.64. Fixed costs were USD $3623.04 and variable costs were USD $63.75/month/participant. CONCLUSIONS: This pilot study provided proof of concept that EAT, a combination intervention providing mDOT, food, and peer navigation services, was feasible to implement and may support engagement in HIV care and achievement of viral suppression among SCI living with HIV in an urban setting in Kenya. Future work should focus on controlled trials of EAT, assessments of feasibility in other contexts, and cost-effectiveness studies.
背景：肯尼亚街头流浪者在获取艾滋病毒护理方面存在障碍。这项试点研究为“促进治疗依从性”（EAT）提供了概念验证，这是一种综合干预措施，为感染艾滋病毒或需要治疗其他疾病（如结核病）的流浪艾滋病毒感染者提供改良的直接观察治疗（mDOT）、每日膳食和同伴导航服务。EAT 干预的目标是改善肯尼亚城市环境中感染艾滋病毒的流浪人群参与艾滋病毒护理和病毒抑制的情况。
方法：这项试点研究采用单组、前后测试设计，招募了任何年龄的自我认定的流浪人员。参与者可以每周 6 天获得免费热餐、同伴导航服务和 mDOT。我们进行了描述性统计，以描述参与者参与 EAT 和艾滋病毒治疗结果的情况。我们使用 McNemar 卡方检验计算了在 EAT 干预前已经参加艾滋病毒护理的参与者在干预前后艾滋病毒结果方面的未调整差异。我们使用 Wilcoxon 秩和检验比较了在 EAT 干预前已经参加艾滋病毒护理的参与者和同时参加 EAT 的参与者开始接受抗逆转录病毒治疗（ART）和首次出现病毒载量（VL）抑制的未调整时间。统计学意义定义为 p < 0.05。我们计算了干预措施的总、固定和可变成本。
结果：2018 年 7 月至 2020 年 2 月，EAT 共招募了 87 名参与者：46 名（53%）女性和 75 名（86%）感染艾滋病毒。在基线时，75 名感染艾滋病毒的参与者中有 60 名（80%）之前已经参加了艾滋病毒护理。在这 60 名参与者中，有 56 名（93%）已经开始接受 ART，44 名（73%）在护理中活跃，25 名（42%）在接受 EAT 前的 19 个月内最后一次 VL 测量时病毒载量得到抑制（VL < 1000 拷贝/ml）。在 19 个月的随访后，所有 75 名感染艾滋病毒的参与者都已经参加了艾滋病毒护理并开始接受 ART，65 名（87%）在护理中活跃，44 名（59%）在最后一次 VL 测量时病毒载量得到抑制。在 EAT 干预前已经参加艾滋病毒护理的参与者中，与 EAT 干预前相比，在 EAT 干预期间，积极参加艾滋病毒护理和病毒载量得到抑制的参与者比例显著增加。与在 EAT 干预前参加艾滋病毒护理的参与者相比，同时参加 EAT 干预的参与者开始接受 ART 和首次出现病毒抑制的时间明显缩短。19 个月的干预总成本为 57448.64 美元。固定成本为 3623.04 美元，可变成本为每个参与者每月 63.75 美元。
结论：这项试点研究提供了概念验证，即 EAT，一种提供 mDOT、食物和同伴导航服务的综合干预措施，在肯尼亚城市环境中实施是可行的，可能有助于感染艾滋病毒的流浪人群参与艾滋病毒护理和实现病毒抑制。未来的工作应集中在 EAT 的对照试验、其他环境下的可行性评估以及成本效益研究上。
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