Patient support networks may improve long-term engagement in HIV care

Implementation and operational research: pulling the network together: quasiexperimental trial of a patient-defined support network intervention for promoting engagement in HIV care and medication adherence on Mfangano Island, Kenya.

Hickey MD, Salmen CR, Omollo D, Mattah B, Fiorella KJ, Geng EH, Bacchetti P, Blat C, Ouma GB, Zoughbie D, Tessler RA, Salmen MR, Campbell H, Gandhi M, Shade S, Njoroge B, Bukusi EA, Cohen CR. J Acquir Immune Defic Syndr. 2015 Aug 1;69(4):e127-34. doi: 10.1097/QAI.0000000000000664.

Background: Despite progress in the global scale-up of antiretroviral therapy, sustained engagement in HIV care remains challenging. Social capital is an important factor for sustained engagement, but interventions designed to harness this powerful social force are uncommon.

Methods: We conducted a quasiexperimental study evaluating the impact of the Microclinic Social Network intervention on engagement in HIV care and medication adherence on Mfangano Island, Kenya. The intervention was introduced into 1 of 4 similar communities served by this clinic; comparisons were made between communities using an intention-to-treat analysis. Microclinics, composed of patient-defined support networks, participated in 10 biweekly discussion sessions covering topics ranging from HIV biology to group support and group HIV status disclosure. Nevirapine concentrations in hair were measured before and after study.

Results: One hundred thirteen (74%) intervention community participants joined a microclinic group, 86% of whom participated in group HIV status disclosure. Over 22-month follow-up, intervention community participants experienced one-half the rate of ≥ 90-day clinic absence as those in control communities (adjusted hazard ratio: 0.48; 95% confidence interval: 0.25 to 0.92). Nevirapine hair levels declined in both study arms; in adjusted linear regression analysis, the decline was 6.7 ng/mg less severe in the intervention arm than control arm (95% confidence interval: -2.7 to 16.1).

Conclusions: The microclinic intervention is a promising and feasible community-based strategy to improve long-term engagement in HIV care and possibly medication adherence. Reducing treatment interruptions using a social network approach has important implications for individual patient virologic suppression, morbidity, and mortality and for broader community empowerment and engagement in healthcare.

Abstract access 

Editor’s notes: To maximise the impact of ART, people living with HIV should be diagnosed early, enrolled and retained in pre-ART care, initiated on ART 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 treatment cascade will determine the long-term success of the global response to HIV.

This article reports on the results of a quasi-experimental study that assessed whether a combined stigma reduction and social network empowerment programme resulted in improved HIV treatment outcomes. The programme consisted of an adaptation of a social network-based activity known as ‘microclinics’. ‘Microclinics’ are informal social networks empowered to support chronic disease management and prevention. ‘Microclinic’ groups consisted of five to ten close family, friends or other members of the patient’s social support system, irrespective of the member’s HIV status. ‘Microclinics’ were assigned a Community Health Worker coordinator and facilitator and were guided through a series of ten discussion sessions over a period of five months. During these sessions they received health education messages to promote knowledge of HIV prevention and treatment, and group support was promoted through discussion of confidentiality, HIV status disclosure, and encouragement of group support for adherence and clinic attendance. The programme was introduced into one of four similar communities served by the main study clinic, and comparisons were made between communities. The outcomes were engagement in HIV care and medication adherence. 

Three-quarters of participants in the programme community joined a ‘microclinic’. Participants in the programme community spent a larger proportion of time adherent to clinic schedules. On average, during a year of follow-up, compared to people in the control group, people in the ‘microclinics’ group returned to care three weeks sooner after a missed visit. Work by Ware et al. describes a pathway from missing a clinic visit to disengaging from care. The pathway includes as intermediate steps, developing a reluctance to return, and subsequent feelings of decreased connectedness to care. The authors of this study hypothesise that ‘microclinic’ participation prevented the development of ‘reluctance to return’ after a missed visit.

The authors conclude that there is empiric support for ‘microclinics’ as an effective model for chronic disease management. But, given the quasi-experimental design, other factors may have contributed to improved outcomes. Data from longer term follow up would be useful to determine the durability of the programme effect, since study participants were only followed up for 22 months. 

  • share