Background: Delivering antiretroviral therapy (ART) to patients'' homes using community health workers (CHWs) could reduce patient volumes at healthcare facilities, improve ART adherence and retention, and decrease patients'' out-of-pocket health expenditures. This study uses baseline data from a randomized health systems trial in Dar es Salaam to ascertain the acceptability and logistical feasibility of CHW-led ART home-delivery in Dar es Salaam.
Methods: We randomized 48 healthcare facilities in Dar es Salaam to either the standard of care (facility-based ART care) or CHW-led ART home-delivery. The CHW cadre is a long-standing public sector cadre in Dar es Salaam, called home-based carers. Patients had to be clinically stable on ART to be eligible for ART home-delivery. We present data from three questionnaires administered between March 1st 2016 and January 15th 2017: i) an enrolment questionnaire (n=1,572), ii) a patient exit questionnaire administered to a random sample of patients at the end of a HIV care visit (n=718), and iii) a healthcare provider questionnaire administerd to clinical personnel at the study healthcare facilities (n=102). In addition, we conducted semi-structured qualitative interviews with eight participants who were offered ART home-delivery but refused.
Results: Regarding acceptability, 14% (46/334) of participants who were offered ART home-delivery opted for standard facility-based care instead. The main reason for opting against ART home-delivery appeared to be confidentiality concerns, as suggested by both questionnaire and qualitative data. Regarding logistical feasibility, CHWs had conducted a total of 533 ART home-delivery visits by September 30th 2016 and there had not been any reports of a CHW being unable to locate a participant. Eight participants complained to the study team that their ART had not been delivered on time.
Conclusions: The home-delivery of ART by CHWs appears to be logistically feasible in Dar es Salaam and socially acceptable to a majority of patients who are stable on ART. In general, programs that deliver ART to patients'' homes while minimizing the perceived risk of unintentional HIV-status disclosure would likely achieve the highest social acceptability in urban sub-Saharan Africa.

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