Reducing facility appointment frequency to improve retention in care among clinically stable, HIV positive patients: A systematic review and meta-analysis

BACKGROUND: Global HIV treatment programs have sought to lengthen the interval between clinical encounters for stable patients to reduce the burden of seeking care, but the overall effect of reduced frequencies on retention is unknown. We conducted a systematic review and meta-analysis to evaluate the interventions that reduce the frequency of clinic visits, including clinical assessments and/or ART collection at the facility, for stable patients living with HIV.
METHODS: We searched seven databasesâ?? and reference lists through April 2019. Eligible studies included HIV+ patients in low- and middle-income countries who were stable on ART (ex. â?¥3 months on ART, 95% adherence). We extracted data from studies that reported on retention in care and viral suppression, and assessed risk of bias using the Cochrane tool in randomized controlled trials (RCT) and the Newcastle-Ottawa Scale in cohort studies. For each outcome, we conducted pairwise meta-analyses comparing the reduced frequency strategy to standard of care (1-2 monthly clinic visits), using random-effect models and cluster adjusted estimates for cluster RCTs.
RESULTS: Eligible studies included 18 comparative trials (4 RCTs and 14 observational studies), and 6 single arm studies. Among the comparative trials that reported retention in care, reduced frequency of clinic appointments (>2 months vs 1-2 months) was associated with increased retention on ART and in care compared to the standard of care with a relative risk (RR) of 1.18 (95% CI 1.06-1.31). Appointments from >2 months as compared to 1-2 months increased viral suppression (RR 1.23, 95% CI: 0.97-1.54).
CONCLUSIONS: Despite heterogeneity in effect size, reducing appointment frequency for stable patients on ART improved the attendance at the health care facility and likely improves viral suppression. Additional research on optimal interval should be conducted, but programs that have not offered quarterly (or longer) appointment intervals for stable patients should do so.

N. Le Tourneau * (1), R. Thompson (2,3), A. Germann (3), I. Eshun-Wilson (4), E.H. Geng (5,4)
(1) University of California, Division of HIV, Infectious Diseases & Global Medicine, School of Medicine, San Francisco, United States, (2) University of California, Proctor Foundation, San Francisco, United States, (3) Johns Hopkins University, School of Public Health, Baltimore, United States, (4) Washington University at St. Louis, Division of Infectious Diseases, School of Medicine, St. Louis, United States, (5) Washington University at St. Louis, Center for Dissemination and Implementation, Institute for Public Health, St. Louis, United States