London School of Hygiene & Tropical Medicine

Trained lay workers delivering anti-retroviral therapy (ART) to HIV-affected people in their homes are just as effective as doctors and nurses based in clinics, according to research findings announced today at the International AIDS conference in Cape Town, South Africa.

The findings could have major implications for reducing the devastating effect of the epidemic in poor settings such as sub-Saharan Africa, where urban hospitals, which currently provide the bulk of HIV care, are under severe pressure due to shortages of trained medical staff and the inability of patients to attend for follow-up support because of the high cost and limited availability of transport.

Over 20 million people are affected by HIV in sub-Saharan Africa. Antiretroviral therapy (ART), which is currently being taken by about 2 million HIV-infected African people (about 40% of those who need it) can transform lives but the treatment needs to be taken daily, for life. Drug side-effects are common, and the drugs can quickly fail if patients do not adhere closely to treatment programmes.

Shabbar Jaffar, Reader in Epidemiology at the London School of Hygiene & Tropical Medicine (LSHTM), and Christine Nabiryo, Deputy Director of The AIDS Support Organisation, Uganda, will announce the findings of a large, collaborative trial designed to assess whether trained field officers without medical qualifications, travelling on motorbikes, could deliver ART to the homes of patients, monitor them for drug side-effects or disease progression and give adherence support. Patients were invited for periodic clinical review by a doctor at a clinic, and asked to attend any time they felt sick. The home-based strategy was compared with a more standard model in which care (including the dispensing of drugs) was delivered from a clinic using mostly doctors and nurses. Allocation to the model of care was done randomly.

The trial collaborators were theMRC/UVRI Uganda Research Unit on AIDS, LSHTM, the AIDS Support Organisation (TASO), the Center for Disease Control and Prevention (CDC) in Uganda and the Ministry of Health of Uganda. The trial was coordinated from the TASO clinic in Jinja, South East Uganda, with patients cared for by TASO staff and patient management carried out according to national guidelines. Patients starting on ART were invited to join the trial; 1,453 subjects were enrolled, 859 on home-based care and 594 on the clinic-based model.

Home-based care with trained lay-workers was found to be as effective as nurse- and doctor-led clinic-based care, with outcomes as good as or better than those reported in most other African cohorts. Delivery of ART through the home-based care model was no more expensive than centralised clinic-based delivery, and was actually a few dollars cheaper per patient each month (US$66 compared to US$70). The costs to the patient of accessing ART were considerably less for those receiving home-based care, with mean annual costs totalling US$6 compared to US$30 for those attending the clinic.

Shabbar Jaffar comments: ‘This trial has shown that trained lay-workers can play a major role in delivering HIV services cost-effectively, and without compromising patient safety. More research is now needed both to inform how to provide community-based care on a larger scale, to determine how families, rather than individuals, might be targeted and to investigate the feasibility of combining HIV care with that of other conditions requiring long-term care, such as tuberculosis and cardiovascular disease’.