Effect of frequency of clinic visits and medication pick-up on antiretroviral treatment outcomes: a systematic literature review and meta-analysis

Abstract

Introduction: Expanding and sustaining antiretroviral therapy (ART) coverage may require simplified HIV service delivery strategies that concomitantly reduce the burden of care on the health system and patients while ensuring optimal outcomes. We conducted a systematic review to assess the impact of reduced frequency of clinic visits and drug dispensing on patient outcomes.

Methods: As part of the development process of the World Health Organization antiretroviral (ARV) guidelines, we systematically searched medical literature databases for publications up to 30 August 2016. Information was extracted on trial characteristics, patient characteristics and the following outcomes: mortality, morbidity, treatment adherence, retention, patient and provider acceptability, cost and patients exiting the programme. When feasible, conventional pairwise meta-analyses were conducted. Results and discussion Of 6443 identified citations, 21 papers, pertaining to 16 studies, were included in this review, with 11 studies contributing to analyses. Although analyses were feasible, they were limited by the sparse evidence base, despite the importance of the research area, and relatively low quality. Comparative analyses of eight studies reporting on frequency of clinic visits showed that less frequent clinic visits led to higher odds of being retained in care (odds ratio [OR]: 1.90; 95% CI: 1.21-2.99). No differences were found with respect to viral failure, morbidity or mortality; however, most estimates were favourable to reduced clinic visits. Reduced frequency of ARVs pick-ups showed a trend towards better retention (OR: 1.93; 95% CI: 0.62-6.04). Strategies using community support tended to have better outcomes; however, their implementation varied, particularly by location. External validity may be questionable.

Conclusions: Our systematic review suggests that reduction of clinical visits (and likely ARVs pick-ups) may improve clinical outcomes, and that they are a viable option to relieve health systems and reduce burden of care for PLHIV. Strategies aimed at reducing clinic visits or drug refill services should focus on stable patients who are virally suppressed, tolerant to their drug regimen and fully adherent. These strategies may be critical to the current changes taking place in HIV treatment policy; thus, due to the data limitations, further high quality research is needed to inform policy and programmatic interventions.

Keywords: HIV Services; clinical visit frequency; antiretroviral therapy HIV/AIDS; systematic literature review; meta-analysis.

Figure 1

Flow chart of study screening. Note: The McGuire et al. study is included in both the clinic and drug refill frequency analyses. Therefore, 11 studies were included in the quantitative analyses.

Figure 2

Meta‐analysis results comparing less frequent to more frequent clinic visits. Events for mortality were all cause; morbidity events were defined as developing a WHO Stage III–IV defining illness or opportunistic infection; retention events were persons completing a study period without discontinuation; adherence events were patients meeting the study defined adherence (>95% of pills taken, say); viral failure events was defined as a patient having detectable viral load after being suppressed.

Figure 3

Meta‐analysis comparing retention among patients with less frequent drug refills and more frequent drug refills. Note: Odds ratios of more than one favour less frequent visits (experimental) and odds ratios below one favour more frequent visits (control).