Achieving the UNAIDS 90-90-90 target by 2020 in sub-Saharan Africa will require innovative solutions to meet the increasing demands placed on public health care facilities. With ART coverage in sub-Saharan Africa hovering around 50%, health systems face the dual challenge of increasing HIV testing and ART enrollment for those not yet in care and continuing to provide treatment to the millions of people already on ART. Community- based ART delivery is a potential strategy for maintaining long-term virologic suppression and retention in HIV care. South Africa?s new Central Chronic Medicine Dispensing and Distribution (CCMDD) program allows clinically stable patients to choose from a list of community pick-up points (e.g., private pharmacies, schools, churches) to access ART and therefore has the potential to offer more convenient services to patients and to decompress health facilities. The current proposal leverages this national policy change to assess the impact of this large scale service delivery intervention at the patient-, clinic-, and community-level over time in the high-density settlement of Umlazi in Durban, South Africa. Using a mixed-methods approach that incorporates the Practical, Robust Implementation and Sustainability Model (PRISM), we will comprehensively evaluate the impact of CCMDD at all 10 public sector clinics in Umlazi through the following specific aims: 1) To prospectively assess patient uptake of CCMDD and patient factors associated with favorable early clinical outcomes for CCMDD enrollees and to compare outcomes with non-enrollees; 2) To evaluate facilitators of and barriers to adoption of CCMDD by patients, clinic staff, and administrators using qualitative methods, and 3) To evaluate virologic suppression over time across all 10 public sector clinics in Umlazi using programmatic electronic health record data. This proposal is motivated by PA-17-182 to better understand system-level interventions using implementation science, which may increase the number of people consistently engaged in HIV care. We have played a major role for over a decade implementing and evaluating interventions along the HIV care continuum in South Africa and are well-positioned to evaluate the impact of this important policy change. Our results will inform clinical leaders and policymakers in high HIV prevalence settings developing community ART delivery systems that will enable life-long therapy for millions of people living with HIV. This research has the potential to change clinical practice throughout sub-Saharan Africa, where innovative and efficient approaches to long-term community-based HIV treatment delivery are urgently needed.

Public Health Relevance

Antiretroviral therapy has the potential to greatly increase life expectancy and prevent transmission of HIV; however many HIV-infected individuals who start antiretroviral therapy drop out of care, which results in poor health outcomes. We propose to evaluate a policy change in a high HIV prevalence community in South Africa that allows stable public sector patients on antiretroviral therapy to pick up medications at community venues with the expectation of improving long-term retention in care. Results of this study will help guide clinical leaders, policy makers, and governments to design flexible, community-level interventions for improving long- term engagement in HIV care.

National Institute of Health (NIH)
National Institute of Mental Health (NIMH)
Research Project (R01)
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Special Emphasis Panel (ZRG1)
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Gordon, Christopher M
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Massachusetts General Hospital
United States
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