For Ugandans whose access to HIV care is compromised by poverty or lack of transportation, receiving HIV treatment at home may be a viable alternative to visiting a facility for services.1 In a four-year trial conducted in southeastern Uganda, the mortality rate among patients who received home-based care was the same as that among patients who received standard clinic care (14%), and about two-thirds of patients in each group had undetectable plasma viral loads at the end of the trial. Moreover, home-based care resulted in lower costs for patients (mostly due to reduced transportation and child-care costs) and for the health service.
Because the number of qualified medical staff in Uganda and some other parts of Africa is insufficient to serve the HIV-positive population, especially in poor areas, and because previously studied off-site care programs relied on nurses or clinic staff, researchers conducted a trial comparing an HIV clinic's services with a home-based treatment program that used fieldworkers who underwent a month of training in providing antiretroviral therapy. The researchers divided the area served by the clinic into nine strata and 44 clusters according to HIV prevalence, proportion of urban residents and distance from the clinic, and in each stratum the clusters were randomly assigned to home-based care or clinic-based care.
Patients were eligible for the trial if they were 18 or older, had stage 3 or 4 HIV (according to World Health Organization criteria) or a CD4 cell count below 200 cells per ml (the threshold for an AIDS diagnosis) and had started antiretroviral treatment at the clinic between February 2005 and December 2006. Eligible patients who declined to participate, or who withdrew after the trial started, received facility-based care. The final sample consisted of 594 persons with HIV in the clinic-based care group and 859 in the home-based treatment group. In both groups, the majority of patients were women (68–73%) and nearly two-thirds were widowed, divorced or separated (62–64%). Almost all were at an advanced clinical stage (the median baseline CD4 count was about 100 cells per ml) and needed transportation to visit the clinic (95–96%).
Each month, field officers brought medication to patients in the home-care group and used checklists to assess their condition; nurses saw patients in the clinic-care group when they came for medication. In both groups, patients received antiretroviral therapy and were referred to a clinic doctor as needed; all patients could visit the clinic any time they felt ill or after they missed a home visit or clinic appointment. In addition, two months after the start of therapy and at least once every six months thereafter, patients visited the clinic for a medical evaluation, including CD4 cell count, and were interviewed about their adherence to their medication. The trial ended in January 2009.
Patient outcomes for the two treatment programs were essentially equivalent. For example, among patients with undetectable viral loads at six months who remained in the trial beyond a year, the proportion who had an elevated plasma viral RNA load (more than 500 copies per ml) was statistically identical in the two groups (16–17%), as were the proportions who died (14%) or were admitted to a hospital at least once (11–13%) by the end of the trial; 11% of patients in each group died within the first year. At their final follow-up, eight in 10 patients had CD4 cell counts above 200 cells per ml and 63–66% had undetectable plasma viral loads. Adherence to assigned treatment programs was high in both groups: At scheduled follow-up visits, 91–94% of patients said they had followed their medication regimen completely during the past month.
The investigators used clinic records and patient questionnaires to assess the costs of treatment (in 2008 US$) to patients (including transportation fees, lost work time and child-care costs) and the health service (including staff time, transportation, lab fees, medication and administrative overhead). The home-based care program saved the clinic $45 per patient annually: The average cost was $793, compared with $838 for clinic-based care. Patients had similar savings: The average annual cost of home-based care was $18, compared with $54 for clinic-based care.
Overall, the findings attest to the efficacy of home-based treatment, the researchers conclude, noting that mortality and virological failure rates in both treatment groups were comparable to those in similar studies conducted elsewhere in Africa. Moreover, they suggest that in addition to saving considerable time and money, home-based care programs "could enable improved and equitable access to HIV treatment" by increasing continuity of care, reducing HIV stigma and establishing "trust … between patients and the community."
1. Jaffar S et al., Rates of virological failure in patients treated in a home-based versus a facility-based HIV-care model in Jinja, southeast Uganda: a cluster-randomised equivalence trial, Lancet, 2009, 374(9707):2080–2089.