Rory Leisegang
Stellenbosch University, Uppsala University
Objectives: Establishing evidence for interventions that may improve patient care, using data routinely available in electronic healthcare records (EHR), is important. Delivery of chronic medication by courier to a patient’s home (home refill) is an emerging intervention and should be considered within differentiated service delivery (DSD) models [1] and may improve adherence. Home-based antiretroviral therapy (ART), which included clinical management, laboratory monitoring, and antiretroviral (ARV) delivery has been shown to be effective in a systematic review [2]; only one study has looked purely at ARV delivery and found improved outcomes, but numbers were limited and the study was conducted in a high-income country setting only [3]. In this analyses, we compared various outcomes in patients from a large cohort in South Africa, who either collected ARV refills at their local pharmacy (self-refill) or received ARV refills at home via courier (home-refill) during the course of the study.
Methods: We conducted a retrospective cohort analysis of ART naïve HIV-infected adults in AFA who initiated first line NNRTI based ART regimen between January 2002 and July 2013. The primary endpoint was all-cause mortality; secondary endpoints included viral load (VL) suppression, CD4+ cell (CD4) response (cells/μl), and hospitalization events. Statistical analyses included nonlinear mixed-effects models, survival analyses, baseline (propensity-score) models, and time-updated (marginal structural) models (MSM).
Results: 40,939 patients, contributing over 66,000 years of follow-up were evaluated. group. Home-refill (versus self-refill) was associated with improved survival (adjusted hazard ratio = 0.90 [95% CI: 0.84-0.96], p-value for log-rank test < 0.001) after adjusting for baseline differences; CD4 response and VL suppression rates were also superior for home-refill. Moreover, in patients who switched from self-refill to home refill ARVs during the course of their treatment (either routinely or on request), CD4 response and VL suppression rates all improved after switching together with survival (after adjusting for time-updated differences up to the point of switching). Finally, patients doing worse (lower CD4, higher VL) on self-refill were more likely to switch to home refill and this impacted comparison of hospitalization rates between the group and established the need for MSMs to evaluate the true impact on survival.
Conclusions: Using routinely-collected real-world data, we established evidence for home refill chronic ARVs (via courier) being associated with improved clinical, immunological, and virologic outcomes compared to self-refill in patients with HIV. Home refill offers a promising additional option to the growing chronic disease models and should facilitate the UNAIDS 90-90-90 targets [4] for HIV in resource-poor and resource-rich settings alike, where barriers to care impact ARV adherence.
References:
[1] Macdonald, V., A. Verster, and R. Baggaley, A call for differentiated approaches to delivering HIV services to key populations. J Int AIDS Soc, 2017. 20(Suppl 4): p. 21658.
[2] Mdege, N.D. and S. Chindove, Bringing antiretroviral therapy (ART) closer to the end-user through mobile clinics and home-based ART: systematic review shows more evidence on the effectiveness and cost effectiveness is needed. Int J Health Plann Manage, 2014. 29(1): p. e31-e47.
[3] Harte, D., et al., Evaluation of a home-delivery service for HIV-infected patients attending an inner London HIV treatment centre. Int J STD AIDS, 2008. 19(8): p. 533-5
[4] 90-90-90: Treatment for all. http://www.unaids.org/en/resources/909090 (accessed 1 Mar 2019)
Reference: PAGE 28 (2019) Abstr 9186 [www.page-meeting.org/?abstract=9186]
Poster: Clinical Applications