1. World Health Organization
9 May 2018
Frequency of clinic visits and drug refills for antiretroviral therapy A systematic review and meta-analysis
Tsitsi Appollo,1,2, Nathan Ford,3 Eugenua Socias,4 Matthew Weins,4 Edward J Mills,4,5 Steve Kanters4,6
1. College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
2. AIDS and TB Unit, Ministry of Health and Child Care, Harare, Zimbabwe
3. Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
4. Global Evaluative Sciences, Vancouver, British Columbia, Canada
5. College of Medicine & Health Sciences, University of Rwanda, Kigali, Rwanda
6. School of Population and Public Health, University of British Columbia, Vancouver, Canada

3. Half of the 15 million people on ART people were started >5 years ago

4. Retention in care gender Clinical stage CD4 count Age
41 countries. WHO-IeDEA collaboration, 2015

5. Barriers to care Distance Waiting times Competing priorities
Govindasawmy, AIDS 2012; Mills Plos Med 2006

6. World Health Organization
Systematic review
9 May 2018
6 databases searched
01/2000 – 06/2015
Clinic visits & dispensing frequency
Mortality, morbidity, adherence, retention, viral suppression, cost

7. Strategies Reduced frequency could either be changed
Without any other changes, typically within centralized care
In combination with non-clinical services within a decentralized care model
Five studies reduced frequency of clinic visits and/or pharmacy re-fills without any further changes
Five studies reduced clinic visit frequency with decentralization of care

8. Study characteristics (1)

9. Study characteristics (2)

10. Less frequent clinic visits
Mortality
Morbidity

11. Less frequent clinic visits
Retention
Adherence

12. Less frequent clinic visits
Viral failure

13. Less frequent clinic visits
Other outcomes
Cost: Three studies pointed towards reduced cost per patient with reduced clinical visits
$520 USD vs. $655 USD in Babigumira et al, 2011
$58 USD vs. $109 USD in Adherence Clubs in South Africa
$793 USD vs. $838 USD in the Jinja trial
Acceptability (Direct): reported by one study (Selke et al, 2010)
Comparable
Acceptability (Indirect) : At 12 months follow-up 521 (13.6%) of patients in the 6-monthly group had returned to SOC in the Malawi study

14. Less frequent drug refills: retention

15. Reduced clinic visit frequency Reduced drug refill frequency
Summary
Reduced clinic visit frequency
No difference in mortality
Less morbidity
Significantly better retention
Possibly better adherence
Possibly better viral suppression
Reduced drug refill frequency
Possibly better retention
Possibly better adherence
Possibly better viral suppression

16. WHO Recommendations 2015
Less frequent clinical visits (3-6 months) are recommended for people stable on ART
Less frequent medication pickups (3-6 months) are recommended for people stable on ART

17. Acknowledgements Systematic review Team World Health Organization
Tsitsi Appollo, Eugenua Socias, Matthew Weins, Edward Mills, Steve Kanters,
World Health Organization
Meg Doherty, Rachel Beanland, Eyerusalem Negussie
Guidelines Development Group
MSF
Tom Decroo, Marielle Bemelmens, Saar Baert, Eric Goemaere, Marc Biot, Gilles van Cutsem, Lynne Wilkinson