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South Africans living with HIV who paid to have antiretroviral therapy (ART) delivered had higher rates of viral suppression than those who got their medication at a clinic, a researcher said.

In a randomized trial of 162 people living with HIV, 88% of those randomized to home delivery of ART experienced viral suppression (defined as viral loads less than 100 copies/ml) versus 74% of those randomized to clinic visits (RR 1.21, 95% CI 1.02-1.42), reported Ruanne Barnabas, MBChB, DPhil, of the University of Washington in Seattle.

Moreover, these differences in viral suppression were more pronounced among South African men (64% in clinic group vs 84% in home group, RR 1.31, 95% CI 1.01-1.71), she said in a late-breaking presentation at the virtual Conference on Retroviruses and Opportunistic Infections (CROI).

Barnabas noted how gaps in viral suppression exist with standard, clinic-based ART, particularly among men and priority populations. Home ART delivery and monitoring can overcome logistic barriers and increase treatment intention.

"If a client pays for the service, and the benefits are sufficient, this could become a scalable strategy," Barnabas said.

She added how this strategy could even help increase viral suppression overall, helping to achieve UNAIDS viral suppression targets for South Africa of 86%.

Barnabas described the home delivery as an Amazon Prime-type service, where clients paid a one-time fee, depending on income level, for delivery of ART and monitoring. In fact, Barnabas' group used an Amazon algorithm to discover the most efficient delivery route, and in areas without addresses, they used GPS locators.

The study conducted enrollment from October 2019 to January 2020, with follow-up occurring during the COVID-19 pandemic, which included adapting to phone follow-up and non-contact ART delivery, an approach Barnabas described as "robust to COVID-19 disruptions."

At a CROI press conference, session moderator Sharon Hillier, PhD, of University of Pittsburgh, described the study as "super innovative."

Barnabas and colleagues conducted the study in an area of the country with 27% HIV prevalence. Only 64% of people living with HIV are virally suppressed, and that number is lower in men (58%).

The primary objective was to test client payment of a fee and the acceptability of the service, with viral suppression as a secondary objective. Participants living with HIV were recruited from the community and local clinics and randomized to either the home delivery group or the clinic group.

In the clinic group, participants continued ART at the clinic and were monitored at the clinic, while the home group was monitored at home. The home group received quarterly medication delivery and clinical monitoring, including point-of-care creatinine tests and plasma collected for viral load testing.

Primary outcomes were actual payment of fee and acceptability of the home delivery model, while viral suppression was a secondary outcome. A total of 162 participants were randomized with 80 to the clinic group and 82 to the home delivery group. Participants were followed up for a median of 47 weeks, spanning COVID-19 restrictions.

They were a median age of 36, and 54% were men. About 60% were on ART at the time of the study. Importantly, this was a lower income group, with 19% reporting their occupation as laborer or semi-skilled, and 60% unemployed.

The home intervention was well-received, with 98% of participants paying the fee, and 100% saying they thought the fee was reasonable, that it reminded them to take their medications, and that they would continue to pay it if delivery was available.

Barnabas said the next steps include figuring out whether the model is financially sustainable if scaled up.

"The main benefit is not whether the client benefit can compensate for the costs of service, but whether the benefits in health outweigh the cost of service," she noted.

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