Care buddies improve daily life but have no effect on retention and HIV progression among pre-ART persons

Impact of patient-selected care buddies on adherence to HIV care, disease progression and conduct of daily life among pre-antiretroviral HIV-infected patients in Rakai, Uganda: a randomized controlled trial.

Nakigozi G, Makumbi FE, Bwanika JB, Atuyambe L, Reynolds SJ, Kigozi G, Nalugoda F, Chang LW, Kiggundu V, Serwadda D, Wawer MJ, Gray RH, Kamya MR. J Acquir Immune Defic Syndr. 2015 Jun 1. [Epub ahead of print]

Background: Data are limited on effects of household or community support persons ("care buddies") on enrolment into and adherence to pre-antiretroviral HIV care. We assessed the impact of care buddies on adherence to HIV clinic appointments, HIV progression and conduct of daily life among pre-ART HIV-infected individuals in Rakai, Uganda.

Methods: 1209 HIV infected pre-ART patients aged ≥15 years were randomized to standard of care (SOC) (n = 604) or patient-selected care buddy (PSCB) (n= 605) and followed at 6 and 12 months. Outcomes were adherence to clinic visits; HIV disease progression and self-reported conduct of daily life. Incidence and prevalence rate ratios and 95% confidence intervals (95%CI) were used to assess outcomes in the intent-to-treat and as-treated analyses.

Results: Baseline characteristics were comparable. In the ITT analysis both arms were comparable with respect to adherence to CD4 monitoring visits (adjPRR 0.99, 95%CI 0.93-1.04, p=0.625), and ART eligibility (adjPRR=1.00, 95%CI 0.77-1.31, p=0.946). Good conduct of daily life was significantly higher in the PSCB than the SOC arm (adjPRR 1.08, 95%CI 1.03-1.13, p=0.001). More men (61%) compared to women (30%) selected spouses/partners as buddies (p<0.0001.) 22% of PSCB arm participants discontinued use of buddies.

Conclusion: In pre-ART persons, having care buddies improved the conduct of daily life of the HIV infected patients but had no effect on HIV disease progression and only limited effect on clinic appointment adherence.

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Editor’s notes: To maximise the impact of antiretroviral therapy (ART), people living with HIV should be diagnosed early, enrolled and retained in pre-ART care, initiated on ART promptly, and retained in ART care. Long-term adherence to achieve and maintain viral load suppression is the last step in the continuum of HIV care. Engagement along the complete HIV treatment cascade will determine the long-term success of the global response to HIV.

Like this one, the next article reports on the results of randomized trials evaluating programmes to improve enrolment and retention into pre-ART care .

The first randomized trial assessed the impact of trained patient-selected care buddies among people living with HIV not yet on ART. The outcomes were adherence to HIV clinic appointments, HIV progression, and conduct of daily life (participants’ perception of their general health, pain and ability to perform activities of daily living) over a 12-month period. The authors found that having care buddies improved the conduct of life but had no effect on retention in care or HIV disease progression. Their findings indicate that it is not necessary for HIV programmes to delay HIV care while waiting for a patient to identify a care buddy. They also found that 22% of the participants discontinued the use of a care buddy, possibly due to buddy exhaustion after an extended period of time, while 10% of the participants in the control arm utilized the services of trained buddies. This will have diluted the difference between the arms and contributed to the lack of effect seen in the intention to treat analysis.

Interestingly the authors also report that women were less likely to select their spouse as a care buddy, some 30% versus 61% among men, likely because disclosure of HIV often carries adverse consequences for women, including domestic violence, abandonment and divorce.

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