title: Improved retention associated with community-based accompaniment for antiretroviral therapy delivery in rural Rwanda.
abstract: BACKGROUND
  Minimizing death and ensuring high retention and good adherence remain ongoing challenges for human immunodeficiency virus (HIV) treatment programs. We examined whether the addition of community-based accompaniment (characterized by daily home visits from a community health worker, directly observed treatment, nutritional support, transportation stipends, and other support as needed) to the Rwanda national model for antiretroviral therapy (ART) delivery would improve retention in care, viral load suppression, and change in CD4 count, relative to the national model alone.
  
  
  METHODS
  We conducted a prospective observational cohort study among 610 HIV-infected adults initiating ART in 1 of 2 programs in rural Rwanda. Psychosocial and clinical characteristics were recorded at ART initiation. Death, treatment retention, and plasma viral load were assessed at 1 year. CD4 count was evaluated at 6-month intervals. Multivariable regression models were used to adjust for baseline differences between the 2 populations.
  
  
  RESULTS
  Eighty-five percent and 79% of participants in the community-based and clinic-based programs, respectively, were retained with viral load suppression at 1 year. After adjusting for CD4 count, depression, physical health quality of life, and food insecurity, community-based accompaniment was protective against death or loss to follow-up during the first year of ART (hazard ratio, 0.17; 95% confidence interval [CI], .09-.35; P < .0001). In a second multivariable analysis, individuals receiving accompaniment were more likely to be retained with a suppressed viral load at 1 year (risk ratio: 1.15; 95% CI, 1.03-1.27; P = .01).
  
  
  CONCLUSIONS
  These findings indicate that community-based accompaniment is effective in improving retention, when added to a clinic-based program with fewer patient support mechanisms.
authors.affiliation: Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, 02115, USA. molly_franke@hms.harvard.edu
authors.forename: Molly F
authors.initials: MF
authors.lastname: Franke
authors.forename: Felix
authors.initials: F
authors.lastname: Kaigamba
authors.forename: Adrienne R
authors.initials: AR
authors.lastname: Socci
authors.forename: Massudi
authors.initials: M
authors.lastname: Hakizamungu
authors.forename: Anita
authors.initials: A
authors.lastname: Patel
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Bagiruwigize
authors.forename: Peter
authors.initials: P
authors.lastname: Niyigena
authors.forename: Kelly D C
authors.initials: KD
authors.lastname: Walker
authors.forename: Henry
authors.initials: H
authors.lastname: Epino
authors.forename: Agnes
authors.initials: A
authors.lastname: Binagwaho
authors.forename: Joia
authors.initials: J
authors.lastname: Mukherjee
authors.forename: Paul E
authors.initials: PE
authors.lastname: Farmer
authors.forename: Michael L
authors.initials: ML
authors.lastname: Rich
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D044966:Anti-Retroviral Agents / Q000008:administration & dosage*; D023241:Antiretroviral Therapy, Highly Active / Q000379:methods*; D018791:CD4 Lymphocyte Count; D015331:Cohort Studies; D005260:Female; D006678:HIV / Q000302:isolation & purification; D015658:HIV Infections / Q000188:drug therapy*; D006801:Humans; D008297:Male; D055118:Medication Adherence; D008875:Middle Aged; D011446:Prospective Studies; D012424:Rural Population; D012432:Rwanda; D012944:Social Support; D016896:Treatment Outcome; D019562:Viral Load; D055815:Young Adult
chemical_list: D044966:Anti-Retroviral Agents