Fee for home delivery and monitoring of art raises viral suppression in south africa

ABSTRACT

Background: Home delivery and monitoring of antiretroviral therapy (ART) is convenient, overcomes logistic barriers, and could increase ART adherence and viral suppression particularly among men who engage less in clinic-based HIV care than women. If clients pay for this service and the benefits are sufficient, it could be a scalable strategy. Methods: We conducted a randomized trial, the Deliver Health Study, of a fee for home delivery and monitoring of ART compared to clinic ART delivery in Pietermaritzburg, KwaZulu Natal, South Africa. People living with HIV on ART or willing to initiate ART in the community were recruited through communitybased testing or from facilities and randomized to 1) fee for home delivery and monitoring of ART;or 2) clinic-based ART (standard of care). The one-time fee for home delivery was tiered based on participant income (ZAR 30, 60, and 90;equivalent to $2, 4, 6). The outcomes were payment of the fee for home delivery;acceptability of the delivery service;and viral suppression, assessed using loglinear regression adjusting for gender and age. Results: From October 2019-January 2020, 400 persons were screened;of the 180 persons living with HIV, 162 were enrolled - 82 randomized to the fee for home delivery group and 80 to the standard of care group. Overall, 87 participants (54%) were men, 22% were <30 years, 101 (62%) were on ART, and 98 (60%) were unemployed. Among participants in the fee for home delivery group, 40 (49%), 32 (40%), and 9 (11%) were in the ZAR 30, 60, and 90 fee groups, respectively. Median follow-up was 47 weeks (IQR 43-50 weeks) spanning COVID-19 restrictions. Retention at exit was 96%. In the fee payment group, 98% of participants paid the full user fee and acceptability was high with 100% reporting willingness to continue to pay a fee. Compared to standard clinic care, in the intent-to-treat analysis, fee for home delivery of ART significantly increased viral suppression from 74% to 88% (RR=1.21, 95% CI 1.02-1.42) with a RR of 1.31 among men;fee group (84%, RR=1.31, 95% CI 1.01-1.71) compared to standard of care (64%). Conclusion: Among South African adults living with HIV on ART or initiating ART, a fee for home delivery and monitoring of ART significantly increased viral suppression compared to clinic-based ART. Client payment of a fee for home delivery and monitoring of ART was highly acceptable in the context of low income and high unemployment, and improved health outcomes as a result.