Home visits by community workers doubled retention in pre-ARV care

The effect of community support agents on retention of people living with HIV in pre-antiretroviral care - A randomized controlled trial in Eastern Uganda.

Lubega M, Tumwesigye MN, Kadobera D, Marrone G, Wabwire-Mangen F, Peterson S, Reynolds SJ, Ekstrom AM. J Acquir Immune Defic Syndr. 2015 Jun 12. [Epub ahead of print]

Introduction: Over 50% of people living with HIV (PLHIV) in sub-Saharan Africa are lost to follow-up between diagnosis and initiation of antiretroviral treatment during pre-ARV care. The effect of providing home counselling visits by community support agents on 2-year retention in pre-ARV care was evaluated through a randomized controlled trial in eastern Uganda.

Methods: 400 newly screened HIV-positive persons were randomly assigned to receive post test counselling alone (routine arm), or post test counselling and monthly home counselling visits by community support agents to encourage them go back for routine pre-ARV care (intervention arm). The outcome measure was the proportion of new PLHIV in either arm who attended their scheduled pre-ARV care visits for at least six out of the anticipated 8 visits in the first 24 months after HIV diagnosis. The difference between the two study arms was assessed using chi-square and T-tests. Mantel-Haenszel Risk Ratios (MHRR) and multivariate logistic models were used to assess the adjusted effect of the intervention on the outcome.

Findings: In all models generated, participants receiving monthly home counselling visits were 2.5 times more likely to be retained in pre-ARV compared to those in standard care over a period of 24 months (ARR 2.5, 95% CI 2.0-3.0).

Interpretation: Monthly follow-up home visits by community workers more than doubled the retention of PLHIV in pre-ARV care in rural Uganda and can be applicable in similar resource-poor settings.

Abstract access  [1]

Editor’s notes: In this second randomized trial, the impact of repeated home counselling visits by community support agents (CSAs) on retention among patients not yet on ART was assessed.

In contrast to the previous article [2], the authors found a large effect on retention. Some 82% were retained in the programme arm at two years after a positive HIV test compared to 34% in the control arm (standard of care: clinic-based post-test counselling alone). The authors suggest that the improved health seeking behaviour and retention in care, could be explained by the CSAs acting as primary care linkages as they encouraged participants to go to the nearest health centre for HIV care. They also suggest that the excellent two year retention rates can be explained by the persistent monthly visits by the CSAs to the people living with HIV. The linkage function of the CSAs, which was not a function of the care buddies described in the first article, might further explain the different findings on retention.

The authors also report that clients in the programme arm were twice as likely to disclose their HIV status compared to clients in the control arm.

They conclude that community programmes that encourage status acceptance and disclosure should be further reinforced. 

Africa [7]
Uganda [8]
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