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Title
A “quick pick-up” differentiated model of ART delivery shows good retention in care
Presenter
Tali Cassidy
Authors
T. Cassidy1,2, R. O'Connell1, J. Euvrard3, S. Ndlovu1, L.T. Duran1, S.J. Steele4, J. Oba1, S. Daho1, A. Boulle3, R. Gerstenhaber4, T. Schulz5
Institutions
1Médecins Sans Frontières, Khayelitsha, Cape Town, South Africa, 2University of Cape Town, Division of Public Health Medicine, School of Public Health and Family Medicine, Cape Town, South Africa, 3University of Cape Town, CIDER, School of Public Health and Family Medicine, Cape Town, South Africa, 4Médecins Sans Frontières, Cape Town, South Africa, 5KESS, Western Cape Provincial Health Department, Cape Town, South Africa

Background: In the context of ART scale-up, Differentiated Models of Care (DMOC) are a key strategy to improve efficiency and cater to patient needs. Available to clinic patients after confirmed viral suppression, DMOCs include facility- or community-based counselor-led adherence clubs. Since October 2015, a quick pick-up model (QPUP) has been running in one clinic in Khayelitsha, a low-income area in Cape Town, South Africa, with high HIV prevalence. QPUP, also known as fast-lane, allows patients to collect ART directly from pharmacy, without counselor review. All three DMOC models require an annual clinical visit and viral load. We describe patient characteristics and retention in QPUP, other DMOCs and those not in any DMOC.
Methods: We used routine clinical data of patients starting ART before July 2017 in three Khayelitsha clinics. QPUP patients are stable on ART prior to referral to QPUP. For comparability in terms of time on ART and viral suppression we matched each QPUP patient to two non-DMOC ''clinic'' patients. Each QPUP patient was matched to two patients with the closest ART start date, from patients who were in care and virally suppressed at their last viral load when the QPUP patient joined QPUP. Follow-up time for both matched clinic patients began on the QPUP patient''s QPUP start date. To compare QPUP with other DMOCs, only patients that joined facility or community clubs after QPUP began were included.
Results: Those in QPUP were more likely to initiate ART at WHO Stage 1(Table 1). A larger proportion of clinic patients are male but age is similar across groups. DMOC patients have higher retention in care compared to clinic patients (see also Figure 1) but a notable proportion return to clinic. At 12-months 96% of QPUP patients are still in ART care, but 85% remain in QPUP.
Conclusions: QPUP outcomes suggest that reduced healthcare contact time is feasible for stable patients, although return to clinic care is not uncommon across all differentiated models. A limitation of this data is incomplete viral load capturing and self-selection of DMOC patients. We aim to further develop the QPUP model, adapting to patient needs and health facility resources.


Figure 1 Kaplan-Meier survival estimates of retention in any ART care of QPUP and Club patients compared to clinic controls
[Figure 1 Kaplan-Meier survival estimates of retention in any ART care of QPUP and Club patients compared to clinic controls]



 QPUP (N=976)Clinic (N=1852)Facility club (N=3138)Community Club (N=3431)
median age (IQR)37.3 (32.2-43)38.3 (32.1-45.8)36.3 (31-42.5)39.6 (34.3-45)
Number male (%)271 (28%)641 (33%)742 (24%)926 (27%)
N (%) WHO stage 1 at initiation451 (46%)668 (34%)1198 (38%)889 (26%)
Median baseline CD4 Count (IQR)208 (113-318)204 (120-315.5)224 (129-332)181 (100-268)
Median months on ART at DMOC start* (IQR)41.4 (21.6-70.4)41.3 (20.1-68.8)34.6 (18.1-63.2)57.5 (33-87.7)
12 Month Retention in ART care after first DMOC visit*96%85%93%96%
12 Month Retention in DMOC care85% 79%85%
Viral load within first year after first DMOC visit* % complete (%suppressed)33% (95%)36% (91%)43% (96%)77% (96%)
*in the case of clinic patients, DMOC start refers to the DMOC start date of the patient they were matched to
[Table 1: Baseline Characteristics and Outcomes of QPUP, Clinic and Club Patients]

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