Antiretroviral therapy (ART) has provided a lifesaving advance for people with HIV. The medication is thought to have prevented almost 10 million deaths associated with HIV worldwide. Daily ART pill regimens must be taken consistently for the best effect, and unfortunately, there are barriers to routinely accessing and using this medication in many places. In a study funded by the National Institute of Mental Health and recently published in The Lancet HIV, researchers investigated whether home delivery of ART for a modest fee could help improve ART access and use, finding it resulted in increased viral suppression in participants compared with clinic-based medication distribution.
South Africa has one of the highest numbers of people with HIV of any country in the world. Although 72% of people with HIV in South Africa take ART, only 66% show viral suppression, and men show notably lower rates of viral suppression compared to women (58% vs. 72%). This may be due, in part, to barriers men experience when accessing medical care and ART. In many rural areas, ART is not readily available. Men often report that barriers to ART use include the time it takes to travel to distant clinics, as well as bottlenecks at the clinics themselves. While medication delivery to non-clinic pick-up points in community settings is rising, drop-off locations at non-clinics are primarily limited to urban areas.
In the current study, Ruanne Barnabas, Ph.D., of Massachusetts General Hospital, and colleagues were interested in whether a fee-based home delivery service for ART medication could help remove barriers to ART access and increase medication uptake and viral suppression. The study was conducted in rural and semi-urban areas of KwaZulu-Natal, South Africa. The population prevalence of HIV in these areas is high (36%). These communities also experience high unemployment, low per-capita income, and substantial income inequality, with many people making less than 2 U.S. dollars a day in income.
Participants were randomly assigned to receive ART initiation, monitoring, and resupply through a fee-based delivery service (81 participants) or to receive these same services in a standard clinic setting (74 participants). The one-time cost for the fee-based service was tiered based on income and equivalent to about 2, 4, or 6 U.S. Dollars. There was no charge for the participants assigned to standard clinic-based services. At the end of the 12-month study period, participants’ HIV plasma viral load was assessed. Participants were also asked about their experiences accessing care, including the acceptability of fee-based delivery or barriers to visiting the clinic locations.
The researchers found that ART home delivery resulted in increased viral suppression compared to clinic-based ART access among men (84% vs. 64%) and women (92% vs. 84%).
The difference in viral suppression was statistically significant for men but not women. All the participants who took part in the fee-based delivery service reported that they felt the fee was reasonable and would be willing to continue to pay for such a service. Additionally, they said that they felt the service helped them remember to take their medication, and they would recommend the service to others.
The researchers note that the study was conducted in a high-HIV prevalence setting, and the findings may not transfer to settings where virus prevalence is low. Future directions of this research include additional studies to better understand the impact of fee-based delivery services on women with HIV, studies to investigate the cost-effectiveness of ART delivery services, and studies testing the impact of fee-based delivery services on children and adolescents with HIV—a priority group for treatment.
While fee-based delivery service resulted in almost 90% of participants achieving viral suppression, more work still needs to be done to tackle barriers to care for those who still experience challenges accessing and maintaining care treatment.
Barnabas, R. V., Szpiro, A. A., Ntinga, X., Mugambi, M. L., van Rooyen, H., Bruce, A., Joseph, P., Ngubane, T., Krows, M. L., Schaafsma, T. T., Zhao, T., Tanser, F., Baeten, J. M., Celum, C., van Heerden, A., & Deliver Health Study Team (2022). Fee for home delivery and monitoring of antiretroviral therapy for HIV infection compared with standard clinic-based services in South Africa: A randomised controlled trial. The Lancet. HIV, 9 (12), e848–e856. https://doi.org/10.1016/S2352-3018(22)00254-5