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Home-based versus clinic-based care for patients starting antiretroviral therapy with low CD4⁺ cell counts: findings from a cluster-randomized trial.

Woodd SL, Grosskurth H, Levin J, Amuron B, Namara G, Birunghi J, Coutinho A, Jaffar S - AIDS (2014)

Bottom Line: In this sub-analysis, we compared survival between the two strategies for those who presented with CD4⁺ cell count less than 50 cells/μl and those who presented with higher CD4⁺ cell counts.Among participants with CD4 cell count less than 50  cells/μl, mortality rates were similar for the home and facility-based arms; adjusted mortality rate ratio 0.80 [95% confidence interval (CI) 0.53-1.18] compared with 1.22 (95% CI 0.78-1.89) for those who presented with higher CD4⁺ cell count.This emphasises the critical role of adherence to antiretroviral therapy.

View Article: PubMed Central - PubMed

Affiliation: aFaculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK bMRC/UVRI Research Unit on AIDS, Entebbe cThe AIDS Support Organisation dInfectious Disease Institute, Kampala, Uganda.

ABSTRACT

Objectives: African health services have shortages of clinical staff. We showed previously, in a cluster-randomized trial, that a home-based strategy using trained lay-workers is as effective as a clinic-based strategy. It is not known whether home-based care is suitable for patients with advanced HIV disease.

Methods: The trial was conducted in Jinja, Uganda. One thousand, four hundred and fifty-three adults initiating ART between February 2005 and January 2009 were randomized to receive either home-based care or routine clinic-based care, and followed up for about 3 years. Trained lay workers, supervised by clinical staff based in a clinic, delivered the home-based care. In this sub-analysis, we compared survival between the two strategies for those who presented with CD4⁺ cell count less than 50 cells/μl and those who presented with higher CD4⁺ cell counts. We used Kaplan-Meier methods and Poisson regression.

Results: Four hundred and forty four of 1453 (31%) participants had baseline CD4⁺ cell count less than 50 cells/μl. Overall, 110 (25%) deaths occurred among participants with baseline CD4⁺ cell count less than 50  cells/μl and 87 (9%) in those with higher CD4⁺ cell count. Among participants with CD4 cell count less than 50  cells/μl, mortality rates were similar for the home and facility-based arms; adjusted mortality rate ratio 0.80 [95% confidence interval (CI) 0.53-1.18] compared with 1.22 (95% CI 0.78-1.89) for those who presented with higher CD4⁺ cell count.

Conclusion: HIV home-based care, with lay workers playing a major role in the delivery of care including providing monthly adherence support, leads to similar survival rates as clinic-based care even among patients who present with very low CD4⁺ cell count. This emphasises the critical role of adherence to antiretroviral therapy.

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Related in: MedlinePlus

Kaplan–Meier survival curves showing the proportion surviving in the home and facility-based arms by baseline CD4+ cell count stratum.
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Figure 1: Kaplan–Meier survival curves showing the proportion surviving in the home and facility-based arms by baseline CD4+ cell count stratum.

Mentions: One hundred and ninety-seven participants died over a median follow-up time of 28 months (IQR 15–35) giving an overall mortality rate of 6.36 deaths per 100 person-years [95% confidence interval (CI) 5.53–7.32]. Kaplan–Meier survival curves by study arm for participants with a baseline CD4+ cell count less than 50 cells/μl and those who had higher counts are shown in Fig. 1. Overall, 110 (25%) deaths occurred among participants with baseline CD4+ cell count less than 50 cells/μl and 87 (9%) in those who had presented with higher CD4+ cell count. There was no evidence of a difference in the survival curves between study arms within either stratum of CD4+ cell count (CD4+ cell count less than 50 cells/μl P = 0.32, CD4+ cell count at least 50 cells/μl P = 0.39).


Home-based versus clinic-based care for patients starting antiretroviral therapy with low CD4⁺ cell counts: findings from a cluster-randomized trial.

Woodd SL, Grosskurth H, Levin J, Amuron B, Namara G, Birunghi J, Coutinho A, Jaffar S - AIDS (2014)

Kaplan–Meier survival curves showing the proportion surviving in the home and facility-based arms by baseline CD4+ cell count stratum.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3921227&req=5

Figure 1: Kaplan–Meier survival curves showing the proportion surviving in the home and facility-based arms by baseline CD4+ cell count stratum.
Mentions: One hundred and ninety-seven participants died over a median follow-up time of 28 months (IQR 15–35) giving an overall mortality rate of 6.36 deaths per 100 person-years [95% confidence interval (CI) 5.53–7.32]. Kaplan–Meier survival curves by study arm for participants with a baseline CD4+ cell count less than 50 cells/μl and those who had higher counts are shown in Fig. 1. Overall, 110 (25%) deaths occurred among participants with baseline CD4+ cell count less than 50 cells/μl and 87 (9%) in those who had presented with higher CD4+ cell count. There was no evidence of a difference in the survival curves between study arms within either stratum of CD4+ cell count (CD4+ cell count less than 50 cells/μl P = 0.32, CD4+ cell count at least 50 cells/μl P = 0.39).

Bottom Line: In this sub-analysis, we compared survival between the two strategies for those who presented with CD4⁺ cell count less than 50 cells/μl and those who presented with higher CD4⁺ cell counts.Among participants with CD4 cell count less than 50  cells/μl, mortality rates were similar for the home and facility-based arms; adjusted mortality rate ratio 0.80 [95% confidence interval (CI) 0.53-1.18] compared with 1.22 (95% CI 0.78-1.89) for those who presented with higher CD4⁺ cell count.This emphasises the critical role of adherence to antiretroviral therapy.

View Article: PubMed Central - PubMed

Affiliation: aFaculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK bMRC/UVRI Research Unit on AIDS, Entebbe cThe AIDS Support Organisation dInfectious Disease Institute, Kampala, Uganda.

ABSTRACT

Objectives: African health services have shortages of clinical staff. We showed previously, in a cluster-randomized trial, that a home-based strategy using trained lay-workers is as effective as a clinic-based strategy. It is not known whether home-based care is suitable for patients with advanced HIV disease.

Methods: The trial was conducted in Jinja, Uganda. One thousand, four hundred and fifty-three adults initiating ART between February 2005 and January 2009 were randomized to receive either home-based care or routine clinic-based care, and followed up for about 3 years. Trained lay workers, supervised by clinical staff based in a clinic, delivered the home-based care. In this sub-analysis, we compared survival between the two strategies for those who presented with CD4⁺ cell count less than 50 cells/μl and those who presented with higher CD4⁺ cell counts. We used Kaplan-Meier methods and Poisson regression.

Results: Four hundred and forty four of 1453 (31%) participants had baseline CD4⁺ cell count less than 50 cells/μl. Overall, 110 (25%) deaths occurred among participants with baseline CD4⁺ cell count less than 50  cells/μl and 87 (9%) in those with higher CD4⁺ cell count. Among participants with CD4 cell count less than 50  cells/μl, mortality rates were similar for the home and facility-based arms; adjusted mortality rate ratio 0.80 [95% confidence interval (CI) 0.53-1.18] compared with 1.22 (95% CI 0.78-1.89) for those who presented with higher CD4⁺ cell count.

Conclusion: HIV home-based care, with lay workers playing a major role in the delivery of care including providing monthly adherence support, leads to similar survival rates as clinic-based care even among patients who present with very low CD4⁺ cell count. This emphasises the critical role of adherence to antiretroviral therapy.

Show MeSH
Related in: MedlinePlus