![[Uganda] Augustine Kishangaki visits Elly Tumusine, a nurse and HIV+ activist who just recently started on ARVs after being very ill.](https://assets.thenewhumanitarian.org/s3fs-public/styles/responsive_large_2x/public/images/200412106.jpg.webp?itok=diQGFd4D "Ugandan Augustine Kishangaki visits Elly Tumusine, a nurse and HIV-positive activist who just recently started on ARVs after being very ill")
A new Ugandan study adds to a growing body of evidence that providing home-based antiretroviral (ARV) care in low-income settings can be as effective as facility-based interventions.
The study, run by The AIDS Support Organisation (TASO), a national NGO, recorded the progress of 859 patients receiving home-based care in the district of Jinja in southeastern Uganda, and 594 receiving care at clinics in the town of Jinja, from Feb 2005 till Jan 2009.
"In terms of patient survival, patient retention and virological failure [an increase in viral load after taking ARVs], the patients in both arms of the study had very similar results," lead author Dr Shabbar Jaffar, from the London School of Hygiene and Tropical Medicine's department of epidemiology and population health, told IRIN/PlusNews.
In home-based care, 16 percent of patients had virological failure, compared with 17 percent in facility care; 11 percent of patients in both arms of the study died during the course of the research; one percent of patients receiving home care were lost to follow-up, and two percent of those receiving clinical care.
"We also found that for patients, the cost of home-based care was significantly lower because they did not have to make as many clinic visits. Costs incurred by the healthcare service were also slightly less for home-based care, but not by much," Jaffar said. Overall, the median cost of a clinic visit was US$2·30, about 13 percent of the reported monthly cash income for men, and 20 percent for women.
Task-shifting
Trained field officers on motorcycles visited patients in the home-care group every month to deliver drugs and provide adherence support; patients in the facility-based group obtained drugs from the clinic each month and had routine reviews with a medical officer and counsellor every three months.
"The main significance of this study is that it shows that programmes can successfully roll out care, using non-clinical workers," Jaffar said. "The need to rely on clinical staff is not as great as previously thought."
According to the UN World Health Organization, Uganda has only one doctor for every 22,000 patients, and an overall health worker deficit of up to 80 percent. Other African countries are not much better off: Tanzania has just 2.3 doctors per 100,000 people, while Malawi has 1.1 doctors for a similar population.
"Systems like South Africa's, where HIV service delivery is so highly medicalized, are not necessary, and can in fact inhibit wider access to these vital services," Jaffar noted.
Several southern African countries - Malawi, Mozambique, Lesotho - have allowed nurses to initiate and manage ARVs, but South Africa, where the doctor-patient ratio is better than many African countries - 69.2 doctors for every 100,000 people - still largely relies on doctors to manage HIV treatment.
Experts estimate that if this country is to reach its target of providing ARV coverage to 80 percent of people in urgent need of the drugs, it would have to more than double the number of people currently starting treatment annually.
Uganda's home-based care research programme also allowed health workers to provide HIV counselling and testing to other family members, which would not have been possible in the clinical setting, where a patient is usually seen alone. Jaffar said the additional services were very well received.
"Another thing we thought we might find was stigma; we had been warned that we would find that homes that were visited by these workers would be stigmatized by the community, but this is not what happened at all," he said. "In the Ugandan case, TASO had a good relationship with the community prior to our arrival; in a different setting, stigma could be an issue."
A need for training
The field officers used in the study had degree qualifications or college diplomas, and received four weeks of intensive training at the start of the study, with subsequent yearly refresher courses in the principles of ARV therapy and adherence support.
A recent Ugandan study found that many clinical officers, nurses and midwives were prescribing ARVs without sufficient training.
"Rolling out home-based care would mean providing staff with training and support mechanisms; effectively you are creating a new cadre of health worker, one that is easy to get hold of, easy to train and easy to retain," Jaffar said.
The researchers are exploring the possibility of expanding the same model of home-based care to other chronic health conditions such as tuberculosis and cardiovascular disease.
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The study, run by The AIDS Support Organisation (TASO), a national NGO, recorded the progress of 859 patients receiving home-based care in the district of Jinja in southeastern Uganda, and 594 receiving care at clinics in the town of Jinja, from Feb 2005 till Jan 2009.
"In terms of patient survival, patient retention and virological failure [an increase in viral load after taking ARVs], the patients in both arms of the study had very similar results," lead author Dr Shabbar Jaffar, from the London School of Hygiene and Tropical Medicine's department of epidemiology and population health, told IRIN/PlusNews.
In home-based care, 16 percent of patients had virological failure, compared with 17 percent in facility care; 11 percent of patients in both arms of the study died during the course of the research; one percent of patients receiving home care were lost to follow-up, and two percent of those receiving clinical care.
"We also found that for patients, the cost of home-based care was significantly lower because they did not have to make as many clinic visits. Costs incurred by the healthcare service were also slightly less for home-based care, but not by much," Jaffar said. Overall, the median cost of a clinic visit was US$2·30, about 13 percent of the reported monthly cash income for men, and 20 percent for women.
Task-shifting
Trained field officers on motorcycles visited patients in the home-care group every month to deliver drugs and provide adherence support; patients in the facility-based group obtained drugs from the clinic each month and had routine reviews with a medical officer and counsellor every three months.
"The main significance of this study is that it shows that programmes can successfully roll out care, using non-clinical workers," Jaffar said. "The need to rely on clinical staff is not as great as previously thought."
According to the UN World Health Organization, Uganda has only one doctor for every 22,000 patients, and an overall health worker deficit of up to 80 percent. Other African countries are not much better off: Tanzania has just 2.3 doctors per 100,000 people, while Malawi has 1.1 doctors for a similar population.
"Systems like South Africa's, where HIV service delivery is so highly medicalized, are not necessary, and can in fact inhibit wider access to these vital services," Jaffar noted.
Several southern African countries - Malawi, Mozambique, Lesotho - have allowed nurses to initiate and manage ARVs, but South Africa, where the doctor-patient ratio is better than many African countries - 69.2 doctors for every 100,000 people - still largely relies on doctors to manage HIV treatment.
Experts estimate that if this country is to reach its target of providing ARV coverage to 80 percent of people in urgent need of the drugs, it would have to more than double the number of people currently starting treatment annually.
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"Another thing we thought we might find was stigma; we had been warned that we would find that homes that were visited by these workers would be stigmatized by the community, but this is not what happened at all," he said. "In the Ugandan case, TASO had a good relationship with the community prior to our arrival; in a different setting, stigma could be an issue."
A need for training
The field officers used in the study had degree qualifications or college diplomas, and received four weeks of intensive training at the start of the study, with subsequent yearly refresher courses in the principles of ARV therapy and adherence support.
A recent Ugandan study found that many clinical officers, nurses and midwives were prescribing ARVs without sufficient training.
"Rolling out home-based care would mean providing staff with training and support mechanisms; effectively you are creating a new cadre of health worker, one that is easy to get hold of, easy to train and easy to retain," Jaffar said.
The researchers are exploring the possibility of expanding the same model of home-based care to other chronic health conditions such as tuberculosis and cardiovascular disease.
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