Task-shifting of antiretroviral delivery from health care workers to persons living with HIV/AIDS: clinical outcomes of a community-based program in Kenya.
Selke HM, Kimaiyo S, Sidle JE, Vedanthan R, Tierney WM, Shen C, Denski CD, Katschke AR, Wools-Kaloustian K. J Acquir Immune Defic Syndr. 2010 Jul. [Epub ahead of print]
The objective of the study was to assess whether community-based care delivered by people living with HIV could replace clinic-based HIV care. This prospective cluster randomized controlled clinical trial was conducted in villages surrounding 1 rural clinic in western Kenya. HIV-infected adults clinically stable on antiretroviral therapy were enrolled. The intervention group received monthly Personal Digital Assistant supported home assessments by people living with HIV with clinic appointments every 3 months. The control group received standard of care monthly clinic visits. The main outcome measures were viral load, CD4 count, Karnofsky score, stability of antiretroviral therapy regimen, opportunistic infections, pregnancies, and number of clinic visits. After 1 year, there were no significant intervention-control differences with regard to detectable viral load, mean CD4 count, decline in Karnofsky score, change in antiretroviral therapy regimen, new opportunistic infection, or pregnancy rate. Intervention patients made half as many clinic visits as did controls (P <>. Community-based care by people living with HIV resulted in similar clinical outcomes as usual care but with half the number of clinic visits. This pilot study suggests that task-shifting and mobile technologies can deliver safe and effective community-based care to people living with HIV, expediting antiretroviral therapy rollout and increasing access to treatment while expanding the capacity of is the first randomised controlled trial to report results on the efficacy of home-based antiretroviral treatment monitoring by people living with HIV who have a secondary school education and are equipped with an electronic decision support tool. The combination of mobile health technologies with task shifting to community care coordinators proved a safe and effective approach to the challenge of human resource constraints in Eldoret, Kenya. The care coordinators assessed patients in their homes monthly using a personal digital assistant that was pre-programmed to collect information on symptoms, vital signs, adherence, food security, and domestic violence. If specific parameters were met, alerts were triggered for the care coordinator to return the next day, transport the patient to hospital, or call to consult the clinical officer. Although the small sample size (96 in intervention group and 112 in the control group) means the study had reduced power to find differences in clinical outcomes, the halving of clinic visits was statistically significant. In addition to rapid replication and evaluation of this approach in other contexts, cost-effectiveness studies are warranted to bring home to programme planners the wisdom of task-shifting that is ‘mobile’ in more than just the geographic sense.
No comments:
Post a Comment