Background: Despite progress with ART scale up, 10.8% of HIV patients on treatment do not achieve virological suppression in Zambia. While most differentiated service delivery (DSD) models are tailored to fit the need of stable patients, unstable (i.e. viremic) patients receiving the standard of care face increased clinic visit frequency and longer wait times. This constitute a barrier to patient engagement in care and, ultimately, viral load (VL) suppression. We developed a novel viremic patient DSD model offering combined community- and clinic-based services including:
1) inviting them to join a routine CAG;
2) close clinical follow up in a dedicated “Viral Load” clinic.
We conducted a retrospective cohort study to test the hypothesis that our model would help viremic patients achieve viral suppression.
Methods: We implemented our DSD model at one first-level hospital in Lusaka to accommodate patients with viral load >1,000 copies/ml. To assess uptake of viremic DSD services and the proportion of beneficiaries who re-suppress, we reviewed all patient records for patients who received the intervention from the model''s inception, October 2017, to November 2018. We calculated descriptive statistics for baseline clinical & demographic variables and describe the care continuum for viremic patients in the model.
Results: We approached 386 patients to join the model who had a routine monitoring VL >1,000 copies/ml. Table 1 presents clinical and demographic characteristics of patients approached. All 386 (100%) patients accepted to attend the high VL clinic day and 346 (89.6%) accepted to join both CAG and high VL clinic. Of those accepting, 119/386 (30.8%) have completed Enhanced Adherence Counselling (EAC) and had their VL test repeated. Of 119 samples collected, 97 (81.5%) VL results were received, of which 27 (27.8%) suppressed (VL< 1000).
Conclusions: Introducing a dedicated DSD for viremic patients is a feasible intervention in urban Zambia and results in high patient uptake of services, particularly “fast track” clinical care in a dedicate clinic. Despite high uptake, only 27% of viremic patients with a documented repeat VL result achieved virologic suppression. Further research, including genotype testing and adherence monitoring, is needed to understand reasons for failed re-suppression after DSD model enrolment.