Table 6 Summary of systematic reviews on community-based care for HIV
Review | Date of search, number of included studies | Participants | Intervention | Comparison | Outcomes | Summary of key findings |
|---|---|---|---|---|---|---|
Decroo 2013 [84] | Feb 2013. 18 studies: 2 cluster RCTs, 11 prospective/ retrospective cohort studies, 2 qualitative studies, 1 cost-effectiveness study, 1 activity report from an NGO, 1 abstract. | PLWHA | -Home-based ART delivery by CHWs. -Home-based ART delivery by volunteers. -Home-based ART by peer CHWs. -Patient-led community ART dispensing. | Facility based ART | -Attrition on ART. -Virological rebound on ART. -Cost –health service costs, patient costs. -Social. | -Increase adherence and accessibility to AR. -Cost effective -Positive social outcomes |
Kredo 2013 [5] | March 2013. 16 studies: 2 RCTs, 14 cohort. | HIV-infected patients at point of initiating treatment and patients already on treatment requiring maintenance and follow-up. | Any form of decentralised care delivery model for initiation or continuation of treatment, or both. | Care delivered at centralised site (usually a hospital or health facility) | -Attrition (composite of loss to follow up or death). -Loss to follow up at set time points after intervention. -Death. -Time to starting ART. -Patients diagnosed with TB after entry into HIV care. -Virologic response to ART (viral load). -Immunological response to ART (CD4+). -Occurrence of new AIDS-defining illness. -Patient satisfaction with care. -Cost to provider. -Cost to patient and family. -Any negative impact on other programme and health care delivery. | -Lower attrition in partial decentralisation models (ART started in hospital and continued at health centre). -No difference in attrition in full decentralisation models (ART started and continued at peripheral health centre) but fewer patients lost to care. -No difference in outcomes detected for ART provided at home by trained volunteers compared to facility-based care. |
Mwai 2013 [85] | December 2012. 21 studies: 5 qualitative, 7 cohort, 6 mixed method, 3 RCTs. | PLWH | CHWs in HIV | Facility based HIV care | Patient related: -Knowledge and literacy of HIV -Behaviour change -Uptake of HIV and other services. -Adherence to ART. -Retention in care. -Viral suppression. -Mortality. -Socio-economic status and quality of life. -Palliative care. Health system: -Service organisation and delivery -Data collection, surveillance and reporting -Service cost | CHWs perform a variety of roles in HIV including counselling, testing, home-based care, education, adherence support, livelihood support, screening, referral and surveillance activities, retention in care. No evidence that patient outcomes and quality of care are compromised. CHWs may also have positive impacts on HIV service organisation, delivery and cost. But to be sustainable, need to be better integrated into wider health systems. |
Nachega 2016 [86] | January 2016. 22 studies: 11 RCTs, 11 cohort. | HIV-infected individuals initiated on ART. | Community-based ART delivery. | Health-care facility (e.g. hospital or clinic) | -Proportion of PLWHA with optimal ART adherence levels (> 80%). -Proportion of PLWH with virologic suppression at 12 and/or 24 months after ART initiation. -Engagement (proportion of patients retained in care at 12 and/or 24 months post-ART initiation). -All-cause mortality. -Reported stigma. -Cost to patient and provider and cost effectiveness. | -No significant difference in optimal ART adherence, virological suppression, all-cause mortality and loss to follow-up between 2 groups when analysis was restricted to RCTs. -Pooled analysis from both RCTs and cohort studies showed higher rates of retention in care in community-based ART group than facility-based group. -Only 2 eligible studies reported on cost or cost-effectiveness outcomes. These suggest that community-based ART services may be more cost-effective in the long run but more research using economic outcomes is needed. |
Rachlis 2013 [87] | December 2011, updated February 2012. 21 CBC programs | Urban /rural populations including PLWHA, their family members, orphans, vulnerable children. | Community-based care (CBC) programmes | Â | -Region -Vision -Characteristics of target population -Program scope (services provided) -Program operations -Funding models -Human resources -Sustainability -Monitoring and evaluation. | 9 key categories useful for describing and organising CBC HIV/AIDS programs in resource limited settings. Suggest can be used to inform potential logic models to enhance overall program performance and to develop evidence based tools for sustainable HIV/AIDS service delivery. |
Wouters 2012 [9] | December 2011. 30 studies: 9 descriptive, 4 quasi-experiments, 5 retrospective/observational cohort studies, 2 qualitative, 6 (cluster/nested) RCTs. | PLWHA | 9 types community support providers: -CHWs (non-professional healthworkers who undertake short course training, work in own communities to support services provided by other health workers) -Peer health workers (CHWs who are HIV positive). -Field officers -Health extension workers -HIV/AIDS lay counsellors -DOT for ART -Adherence supporters -HBC volunteers | Health facility based care | ART programme outcomes: -Access and increasing coverage of ART programmes -Adherence -Virological/ immunological -Patient retention -Survival rates Contributory role of community program: -Integration of ART services into general health system. -Providing psychosocial care. -Empowered ART patients towards self-management. -Defaulter tracing. -Community as a resource. | Community support can positively impact ART programme delivery and outcomes in resource-limited settings. Potential strategy to address shortage of health workers/ broaden care to accommodate needs associated with chronic HIV/AIDS. More research needed to understand which tasks performed by community support initiatives contribute to long-lasting ART success and limits to which lay health workers can assume multiple roles. |