title: Implementation and Operational Research: Community-Based Adherence Clubs for the Management of Stable Antiretroviral Therapy Patients in Cape Town, South Africa: A Cohort Study.
abstract: BACKGROUND
  Community-based models of antiretroviral therapy (ART) delivery are widely discussed as a priority in the expansion of HIV treatment services, but data on their effectiveness are limited. We examined outcomes of ART patients decentralized to community-based adherence clubs (CACs) in Cape Town, South Africa and compared these to patients managed in the community health center.
  
  
  METHODS
  The analysis included 8150 adults initiating ART from 2002 to 2012 in a public sector service followed until the end of 2013. From June 2012, stable patients (on ART >12 months, suppressed viral load) were referred to CACs. Loss to follow-up (LTFU) was compared between services using proportional hazards models with time-varying covariates and inverse probability weights of CAC participation.
  
  
  RESULTS
  Of the 2113 CAC patients (71% female, 7% youth ages ≤ 24 years), 94% were retained on ART after 12 months. Among CAC patients, LTFU [adjusted hazard ratio (aHR): 2.17, 95% confidence interval (CI): 1.26 to 3.73 ] and viral rebound (aHR 2.24, 95% CI: 1.00 to 5.04) were twice as likely in youth (16-24 years old) compared with older patients, but no difference in the risk of LTFU or viral rebound was observed by sex (P-values 0.613 and 0.278, respectively). CAC participation was associated with a 67% reduction in the risk of LTFU (aHR: 0.33, 95% CI: 0.27 to 0.40) compared with community health centre, and this association persisted when stratified by patient demographic and clinic characteristics.
  
  
  CONCLUSIONS
  CACs are associated with reduced risk of LTFU compared with facility-based care. Community-based models represent an important development to facilitate ART delivery and possibly improve patient outcomes.
authors.affiliation: *Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa;†Department of Medicine, University of Cape Town, Cape Town, South Africa;‡Gugulethu Community Health Centre, Provincial Government of the Western Cape, Cape Town, South Africa; and§The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
authors.forename: Anna
authors.initials: A
authors.lastname: Grimsrud
authors.forename: Maia
authors.initials: M
authors.lastname: Lesosky
authors.forename: Cathy
authors.initials: C
authors.lastname: Kalombo
authors.forename: Linda-Gail
authors.initials: LG
authors.lastname: Bekker
authors.forename: Landon
authors.initials: L
authors.lastname: Myer
mesh_terms: D000293:Adolescent; D000328:Adult; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active; D018791:CD4 Lymphocyte Count; D015331:Cohort Studies; D003153:Community Health Services / Q000458:organization & administration*; D003695:Delivery of Health Care / Q000458:organization & administration*; D005260:Female; D015658:HIV Infections / Q000188:drug therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009874:Operations Research; D016016:Proportional Hazards Models; D013019:South Africa; D019562:Viral Load; D055815:Young Adult; D016903:Drug Monitoring
chemical_list: D044966:Anti-Retroviral Agents