Community-Based Accompaniment and the Impact of Distance for HIV Patients Newly Initiated on Antiretroviral Therapy: Early Outcomes and Clinic Visit Adherence in Rural Rwanda

  • Fabien Munyaneza
  • Joseph Ntaganira
  • Laetitia Nyirazinyoye
  • Ermyas Birru
  • Marie Paul Nisingizwe
  • Neil Gupta
  • Cheryl L. Amoroso
  • Guillaine Neza
  • Lisa R. Hirschhorn
  • Bethany L. Hedt-Gauthier
Original Paper

Abstract

Community-based accompaniment (CBA) has been associated with improved antiretroviral therapy (ART) patient outcomes in Rwanda. In contrast, distance has generally been associated with poor outcomes. However, impact of distance on outcomes under the CBA model is unknown. This retrospective cohort study included 537 adults initiated on ART in 2012 in two rural districts in Rwanda. The primary outcomes at 6 months after ART initiation included overall program status, missed a visit and missed three consecutive visits. The associations between cost surface distance (straight-line distance adjusted for surface features) and outcomes were assessed using logistic regression, controlling for potential confounders. Died/lost-to-follow-up and missed three consecutive visits were not associated with distance. Patients within 0–1 km cost surface distance were significantly more likely to miss a visit, potentially due to stigma of attending clinic within one’s community. These results suggest that CBA may mediate the impact of long distances on outcomes.

Keywords

Antiretroviral therapy Visit adherence Treatment outcomes Cost surface distance 

Resumen

El Acompañamiento Basado en la Comunidad (ABC) se ha asociado con mejores resultados para pacientes en Ruanda con tratamiento antirretroviral (TARGA). En contraste, la distancia entre una aldea y la clínica donde buscan tratamiento los pacientes generalmente se ha asociado con resultados no favorables. Sin embargo, el impacto que tiene la distancia sobre el resultado de tratamiento bajo el modelo ABC es desconocido. Este estudio retrospectivo de cohorte incluyó a 537 adultos que iniciaron tratamiento TARGA en 2012 en dos distritos rurales de Ruanda. Los indicadores primarios a los seis meses después del inicio de tratamiento TARGA incluyen estado general en el programa: perdida de una visita o perdida de tres visitas consecutivas. Las asociaciones entre la distancia del recorrido del camino (la distancia de una línea recta ajustada por características de la superficie) y resultados de tratamiento se evaluaron mediante regresión logística, controlando los posibles factores de confusión. Factores como fallecido, inubicable y perdida de tres visitas consecutivas no se asociaron con la distancia. Pacientes dentro de 0-1km de distancia del recorrido del camino tenían mayor probabilidad de perder una visita, posiblemente debido al estigma de asistir a la clínica dentro de su comunidad. Estos resultados sugieren que el ABC podría minimizar el impacto que tienen las distancias largas sobre los resultados de tratamiento.

Palabras claves

Tratamiento Antiretroviral de Gran Actividad Adherencia a visitas Resultados de tratamiento Distancia del recorrido del camino 

Notes

Acknowledgement

We gratefully acknowledge the financial support from the Doris Duke Charitable Foundation’s African Health Initiative, through PHIT Partnership funding for implementation of this study and for a Master’s degree scholarship at the University of Rwanda, College of Medicine and Health Sciences, School of Public Health. We would like to thank PIH/IMB and the RMoH leadership of Rwinkwavu and Kirehe Hospital affiliated Hospitals for technical and administrative support. BHG received support from the Global Health Research Core at Harvard Medical School. We thank Dr. Felix Rwabukwisi Cyanamatare, Peter Niyigena, and Jean Paul Umugisha who provided ideas on the methods, and Jackline Odhiambo who provided support in editing the manuscript.

Funding

This work was supported by the Doris Duke Charitable Foundation, Grant Number 2009057. BHG received support from the Global Health Research Core at Harvard Medical School.

Compliance with Ethical Standards

Conflict of interests

All authors declare that they have no competing interests.

Ethical approval

This study was reviewed and approved by the institutional review board of the University of Rwanda, College of Medicine and Health Sciences, School of Public Health in Kigali, Rwanda (007/UR/CMHS/SPH/2014), and the Institutional Review Board at Brigham and Women’s Hospital in Boston, Massachusetts (2012P000249/BWH). Patients’ names and their program identifiers were not extracted from the EMR system to ensure confidentiality.

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Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Fabien Munyaneza
    • 1
    • 2
  • Joseph Ntaganira
    • 2
  • Laetitia Nyirazinyoye
    • 2
  • Ermyas Birru
    • 3
  • Marie Paul Nisingizwe
    • 1
  • Neil Gupta
    • 1
    • 4
  • Cheryl L. Amoroso
    • 1
  • Guillaine Neza
    • 1
  • Lisa R. Hirschhorn
    • 3
    • 5
    • 6
  • Bethany L. Hedt-Gauthier
    • 1
    • 2
    • 5
  1. 1.Partners In Health/Inshuti Mu BuzimaRwinkwavuRwanda
  2. 2.School of Public Health, College of Medicine and Health SciencesUniversity of RwandaKigaliRwanda
  3. 3.Partners In HealthBostonUSA
  4. 4.Brigham and Women’s HospitalBostonUSA
  5. 5.Department of Global Health and Social MedicineHarvard Medical SchoolBostonUSA
  6. 6.Northwestern University Feinberg School of MedicineChicagoUSA

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