title: Community-based ART distribution system can effectively facilitate long-term program retention and low-rates of death and virologic failure in rural Uganda.
abstract: BACKGROUND
  Community-drug distribution point is a care model for stable patients in the community designed to make ART delivery more efficient for the health system and provide appropriate support to encourage long-term retention of patients. We examined program retention among ART program participants in rural Uganda, which has used a community-based distribution model of ART delivery since 2004.
  
  
  METHODS
  We analyzed data of all patients >18 years who initiated ART in Jinja, Ugandan site of The AIDS Support Organization between January 1, 2004 and July 31, 2009. Participants attended clinic or outreach visits every 2-3 months and had CD4 cell counts measured every 6 months. Retention to care was defined as any patient with at least one visit in the 6 months before June 1, 2013. We then identified participants with at least one visit in the 6 months before June 1, 2013 and examined associations with mortality and lost-to-follow-up (LTFU). Participants with >4 years of follow up during August, 2012 to May, 2013 had viral load conducted, since no routine viral load testing was available.
  
  
  RESULTS
  A total of 3345 participants began ART during 2004-2009. The median time on ART in June 2013 was 5.69 years. A total of 1335 (40 %) were residents of Jinja district and 2005 (60 %) resided in outlying districts. Of these, 2322 (69 %) were retained in care, 577 (17 %) died, 161 (5 %) transferred out and 285 (9 %) were LTFU. Factors associated with mortality or LTFU included male gender, [Adjusted Hazard Ratio (AHR) = 1.56; 95 % CI 1.28-1.9], CD4 cell count <50 cells/μL (AHR = 4.09; 95 % CI 3.13-5.36) or 50-199 cells/μL (AHR = 1.86; 95 % CI 1.46-2.37); ART initiation and WHO stages 3 (AHR = 1.35; 95 % CI 1.1-1.66) or 4 (AHR = 1.74; 95 % CI 1.23-2.45). Residence outside of Jinja district was not associated with mortality/LTFU (p value = 0.562). Of 870 participants who had VL tests, 756 (87 %) had VLs <50 copies/mL.
  
  
  CONCLUSIONS
  Community-based ART distribution systems can effectively mitigate the barriers to program retention and result in good rates of virologic suppression.
authors.affiliation: Mulago Hospital Complex, The AIDS Support Organization (TASO), P.O BOX 10443, Kampala, Uganda.
authors.forename: Stephen
authors.initials: S
authors.lastname: Okoboi
authors.affiliation: The BC Centre for Excellence in HIV/AIDS, Vancouver, Canada.
authors.forename: Erin
authors.initials: E
authors.lastname: Ding
authors.affiliation: Faculty of Medicine, University of British Columbia, Vancouver, Canada.
authors.forename: Steven
authors.initials: S
authors.lastname: Persuad
authors.affiliation: Mulago Hospital Complex, The AIDS Support Organization (TASO), P.O BOX 10443, Kampala, Uganda.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Wangisi
authors.affiliation: Mulago Hospital Complex, The AIDS Support Organization (TASO), P.O BOX 10443, Kampala, Uganda.
authors.forename: Josephine
authors.initials: J
authors.lastname: Birungi
authors.affiliation: The BC Centre for Excellence in HIV/AIDS, Vancouver, Canada.
authors.forename: Susan
authors.initials: S
authors.lastname: Shurgold
authors.affiliation: Mulago Hospital Complex, The AIDS Support Organization (TASO), P.O BOX 10443, Kampala, Uganda.
authors.forename: Darius
authors.initials: D
authors.lastname: Kato
authors.affiliation: Mulago Hospital Complex, The AIDS Support Organization (TASO), P.O BOX 10443, Kampala, Uganda.
authors.forename: Maureen
authors.initials: M
authors.lastname: Nyonyintono
authors.affiliation: Mulago Hospital Complex, The AIDS Support Organization (TASO), P.O BOX 10443, Kampala, Uganda.
authors.forename: Aggrey
authors.initials: A
authors.lastname: Egessa
authors.affiliation: Mulago Hospital Complex, The AIDS Support Organization (TASO), P.O BOX 10443, Kampala, Uganda.
authors.forename: Celestin
authors.initials: C
authors.lastname: Bakanda
authors.affiliation: MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda.
authors.forename: Paula
authors.initials: P
authors.lastname: Munderi
authors.affiliation: MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda.
authors.forename: Pontiano
authors.initials: P
authors.lastname: Kaleebu
authors.affiliation: The BC Centre for Excellence in HIV/AIDS, Vancouver, Canada ; Faculty of Medicine, University of British Columbia, Vancouver, Canada.
authors.forename: David M
authors.initials: DM
authors.lastname: Moore
keywords: Antiretroviral therapy; Lost-to-follow-up; mortality; Retention; Sub-Saharan Africa; Uganda; Virologic failure