Apondi R, Bunnell R, Awor A, Wamai N, Bikaako-Kajura W, Solberg P, Stall RD, Coutinho A, Mermin J. Home-Based Antiretroviral Care is Associated with Positive Social Outcomes in a Prospective Cohort in Uganda. J Acquir Immune Defic Syndr. 2007 Jan 1;44(1):71-6.
To assess the social outcomes, both positive and negative, of a home-based ART program.
This analysis is from a trial of ART monitoring regimens (Home-Based AIDS Care or HBAC Trial). The data presented here are from all three arms of the trial (clinical monitoring only, clinical monitoring plus CD4 counts, and clinical monitoring plus CD4 counts plus plasma viral load) and are combined across the arms. As such, the study design for this particular analysis is pre/post-test evaluation of an intervention. Data presented are from enrollment and three-month follow-up.
The study took place in rural Uganda between May 2004 and May 2005.
Eligible participants were HIV-infected clients of a non-governmental AIDS care organization, aged 18 or older, and had a CD4 count <250 cells/µL or symptomatic HIV infection.
All participants initiated ART and were monitored for response through a home-based mechanism.
Positive social outcomes included family emotional support, community emotional support, and strengthening relationship between spouse/partner. Negative social outcomes included break-up of marriage, discrimination by community, and alienation by family. One outcome was assessed among women only: physical abuse by spouse/sexual partner.
There were 654 eligible participants available at baseline and 598 at three-month follow-up. Seventy-two percent of the participants were female, and the medial CD4 cell count was 123 cells/µL. Controlling for gender, age group, education level, marital status, income group, religion, and lifetime social events at three months compared to baseline, participants were significantly more likely to report all positive social outcomes. Eighty-four percent of participants attributed these positive experiences to the HBAC program. None of the negative social outcomes were significantly more likely at follow-up. Three (1%) of 459 women at baseline (117 married) reported partner abuse within the three months prior to enrollment; this increased to nine (2%) of 436 at three-month follow-up [OR: 3.20, 95% CI: 0.94, 10.9]. Five of the nine women ascribed the abuse to program participation, but all five had prior histories of domestic violence.
The authors conclude that in rural Uganda, participation in a home-based HIV/AIDS care program was associated with multiple positive social outcomes for almost all participants.
There is no quality rating system for pre/post-intervention evaluations. When compared to other experimental methods, however, they have multiple problems, including lack of control group, which makes assignment of an intervention effect (as opposed to secular trends) difficult. Nonetheless, in this study, where adverse effects of home-based ART care are being examined, the design is a reasonable choice. Because these data are analyzed like cohort studies, loss-to-follow-up rates are important. The authors report that 9% of participants were lost between baseline and three months, which could have introduced error into their conclusions.
Home-based AIDS care can remove barriers (such as transportation) to care, and can provide the opportunity for care to multiple family members, improving overall access to care for persons living with HIV while remaining cost-effective. (1,2) However, issues of stigma and individual rights remain, as does the potential that home-based care could be associated with harmful outcomes.(3) This study indicates that in this population the response to home-based care has been overwhelmingly positive, with few instances of domestic violence to married or cohabiting women.
While the potential for harmful social outcomes does merit further study, based on these data it should not impede expansion of home-based HIV/AIDS care programs. It is important, however, that a counseling and support component be part of these programs to reduce any potential for negative outcomes. While the potential for harmful social outcomes does merit further study, based on these data it should not impede expansion of home-based HIV/AIDS care programs. It is important, however, that a counseling and support component be part of these programs to reduce any potential for negative outcomes.
- Sweat M, Gregorich S, Sangiwa G, et al. Cost-effectiveness of voluntary HIV-1 counseling and testing in reducing sexual transmission of HIV-1 in Kenya and Tanzania. Lancet 2000 Jul 8;356(9224):113-21.
- Moalosi G, Floyd K, Phatshwane J, et al. Cost-effectiveness of home-based care versus hospital care for chronically ill tuberculosis patients. Int J Tuberc Lung Dis 2003 Sep;7(9 Suppl 1):S80-5.
- Temmerman M, Ndinya-Achola J, Ambani J, Piot P. The right not to know HIV test results. Lancet 1995 Apr 15;345(8955):969-70.