Home delivery costs and monitoring of antiretroviral therapy for HIV infection compared to standard clinical services in South Africa: a randomized controlled trial
Home administration and monitoring of antiretroviral therapy (ART) is convenient, overcomes logistical barriers, and may increase individual adherence to ART and viral suppression. With client payment and sufficient health benefits, this strategy could be scalable. The aim of the Deliver Health study was to test the acceptability and effectiveness of user fees for home ART monitoring and delivery.
From October 7, 2019 to January 30, 2020, 162 participants were registered; 82 were randomly assigned to the paid-for-homebirth group and 80 to the clinic group, with similar characteristics at baseline. Overall, 87 (54%) participants were men, 101 (62%) were on ART and 98 (60%) were unemployed. In the home delivery group, 40 (49%), 33 (40%) and nine (11%) participants qualified for the ZAR 30, 60 and 90 fee, respectively. The median follow-up was 47 weeks (IQR 43–50) with 96% retention. 80 (98%) participants paid user fees, with high acceptability and willingness to pay. In the modified intention-to-treat analysis of 155 (96%) participants who completed follow-up, charges for home birth and monitoring statistically significantly increased viral suppression from 74% to 88% in the together (RR 1 21, 95% CI 1 02–1 42); and 64% to 84% in men (1 31, 1 01–1 71).
Among South African adults living with HIV, fees for home birth and ART follow-up significantly increased viral suppression compared to clinic-based ART. Clients paying fees for home delivery and follow-up of ART was quite acceptable in a low-income, high-unemployment setting, and improved health outcomes accordingly. Home-based ART delivery and monitoring, possibly with user fees to offset costs, should be evaluated as a differentiated service delivery strategy to increase access to care.
National Institutes of Mental Health.