Fewer clinic visits improve retention in HIV care in Zambia

People with HIV who attended their clinic once every six months were much less likely to miss their next clinic visit, miss medication pick up or become lost to follow-up than people expected to attend their clinic once a month, a large study of patient behaviour in Zambia has found.

The findings were presented at last month’s Conference on Retroviruses and Opportunistic Infections (CROI) in Seattle.

Poor co-ordination of clinic visits, resulting in the need to attend the clinic at one monthly visit to see a doctor, and on another monthly visit to collect medication, is often a cause of complaint among people with HIV. This lack of co-ordination is further aggravated by the distances that people must travel to attend the clinic, the amount of time spent waiting at the clinic, and the income foregone as a result of clinic visits. As a consequence, people become lost to follow-up – although they may come back to care later – and stop taking antiretrovirals resulting in viral load rebound.

Although it seems obvious that monthly visits are a burden to people with HIV and might affect retention in care, it is less clear how frequently people ought to be asked to attend a clinic. Is there a gap between appointments that is too long, resulting in disengagement from care altogether? How frequently are appointments for clinical follow-up and medication refills scheduled together?

To answer this question, researchers associated with the Centre for Infectious Disease Research in Zambia and the University of California San Francisco looked at loss to follow-up, missed clinic visits and gaps in medication in 127,448 people with HIV attending 63 clinics in Zambia between January 2013 and July 2015. They compared these measures of retention in people attending their clinic monthly, or less frequently.

The analysis included all people who had been on antiretroviral therapy (ART) for at least six months and who had a CD4 cell count above 200 cells/mm³. Any clinic visit for clinical follow-up, pharmacy visits or adherence support was included in the analysis, except for visits where changes in ART regimen or tuberculosis (TB) diagnosis or treatment took place. A total of 1,113,211 visits were included in the analysis.

The majority of clinical follow-up appointments were scheduled at three-month intervals, but pharmacy refill intervals varied: around 40% of pharmacy refill visits were scheduled within 30 days of the previous visit, around 40% at 90-day intervals, and the remainder at anywhere from 14-day to six-monthly intervals. In contrast, the majority of clinical return visits were scheduled three months apart; only 8.6% were scheduled six months apart.

Of those attending six-monthly clinic visits, only 8.6% were also attending the pharmacy at six-monthly intervals to refill medication. Over two-thirds (69%) were attending the pharmacy every three months. People attending the clinic at shorter intervals were more likely to be attending the pharmacy at a similar interval: 82% of people on a three-monthly schedule were also refilling medication every three months, and 84% of those on a monthly schedule were refilling medication monthly.

Looking at the relationship between appointment frequency and retention, the researchers found a clear relationship between shorter intervals between appointments and poorer retention. Almost half of people on a monthly appointment schedule failed to turn up on the appointed day, and at least one in five were over 14 days late. In contrast, less than one in five of all people on a six-month schedule failed to turn up on the appointed day, and they were also less likely to miss visits than people on a three-month schedule.

People on six-monthly appointment schedules were also significantly less likely to have gaps in medication refills or to be lost to follow-up (defined as being more than 90 days late for their next clinic appointment). Six-monthly appointments reduced the risk of gaps in medication by 50% compared to monthly visits (adjusted odds ratio 0.50, 95% CI 0.43-0.57) and reduced the risk of loss to follow-up by 52% (aOR 0.48, 95% CI 0.40-0.59).

The lack of integration between pharmacy visits and clinic visits may be a consequence of supply chain problems. Clinics often lack the space to store six months worth of medication to dispense to a patient, and supply chains may lack the capacity to deliver this quantity of medication. At the national level, ordering systems, demand forecasting and purchasing systems may need to be improved in order to shift the vast majority of patients to six-monthly medication refills.

Nevertheless, the researchers conclude that further research is warranted to investigate even longer clinic return intervals, such as one year, as well as investigating whether patients missing appointments on current schedules might benefit from longer appointment intervals.

In some countries medication refills are managed through community adherence clubs, run by people living with HIV, in which members take it in turns to collect medication for the group, reducing the number of clinic visits required by each member but also permitting clinics to manage supplies without becoming overwhelmed.