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Abstract Background: The numbers of women initiating lifelong antiretroviral therapy (ART) during pregnancy and postpartum is increasing rapidly, presenting a burden on health systems and an urgent need for scalable [...]

Introduction: Community‐based models of antiretroviral therapy (ART) delivery have been recommended to support ART expansion and retention in resource‐limited settings. However, the evidence base for community‐based models of care is limited. We describe the implementation of community‐based adherence clubs (CACs) at a large, public‐sector facility in peri‐urban Cape Town, South Africa. Methods: Starting in May 2012, stable ART patients were down‐referred from the primary care community health centre (CHC) to CACs. Eligibility was based on self‐reported adherence, >12 months on ART and viral suppression. CACs were facilitated by four community health workers and met every eight weeks for group counselling, a brief symptom screen and distribution of pre‐packed ART. The CACs met in community venues for all visits including annual blood collection and clinical consultations. CAC patients could send a patient‐nominated treatment supporter (“buddy”) to collect their ART at alternate CAC visits. Patient outcomes [mortality, loss to follow‐up and viral rebound (>1000 copies/ml)] during the first 18 months of the programme are described using Kaplan–Meier methods. Results and Discussion: From June 2012 to December 2013, 74 CACs were established, each with 25–30 patients, providing ART to 2133 patients. CAC patients were predominantly female (71%) and lived within 3 km of the facility (70%). During the analysis period, 9 patients in a CAC died ( Conclusions: Over a period of 18 months, a community‐based model of care was rapidly implemented decentralizing more than 2000 patients in a high‐prevalence, resource‐limited setting. The fundamental challenge for this out of facility model was ensuring that patients receiving ART within a CAC were viewed as an extension of the facility and part of the responsibility of CHC staff. Further research is needed to support down‐referral sooner after ART initiation and to describe patient experiences of community‐based ART delivery., Introduction Models of care for antiretroviral therapy (ART) delivery have evolved considerably over the past decade of ART provision in resource‐limited settings. Services have been decentralized from hospitals to primary [...]

Background: Community-based models of antiretroviral therapy (ART) delivery are widely discussed as a priority in the expansion of HIV treatment services, but data on their effectiveness are limited. We examined outcomes of ART patients decentralized to community-based adherence clubs (CACs) in Cape Town, South Africa and compared these to patients managed in the community health center., Methods: The analysis included 8150 adults initiating ART from 2002 to 2012 in a public sector service followed until the end of 2013. From June 2012, stable patients (on ART >12 months, suppressed viral load) were referred to CACs. Loss to follow-up (LTFU) was compared between services using proportional hazards models with time-varying covariates and inverse probability weights of CAC participation., Findings: Of the 2113 CAC patients (71% female, 7% youth ages ≤ 24 years), 94% were retained on ART after 12 months. Among CAC patients, LTFU [adjusted hazard ratio (aHR): 2.17, 95% confidence interval (CI): 1.26 to 3.73 ] and viral rebound (aHR 2.24, 95% CI: 1.00 to 5.04) were twice as likely in youth (16-24 years old) compared with older patients, but no difference in the risk of LTFU or viral rebound was observed by sex (P-values 0.613 and 0.278, respectively). CAC participation was associated with a 67% reduction in the risk of LTFU (aHR: 0.33, 95% CI: 0.27 to 0.40) compared with community health centre, and this association persisted when stratified by patient demographic and clinic characteristics., Interpretation: CACs are associated with reduced risk of LTFU compared with facility-based care. Community-based models represent an important development to facilitate ART delivery and possibly improve patient outcomes.