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Background: Adherence clubs, where groups of 25-30 patients stable on antiretroviral therapy (ART) meet for counselling and medication pick-up, is an innovative model to retain patients in care and facilitate task-shifting. Adherence clubs can be organized at a clinic or community venue. We performed a randomized controlled trial to compare club retention between community and clinic-based adherence clubs.
Methods: Stable patients with undetectable viral load at Witkoppen Clinic in Johannesburg, South Africa, were randomized to a clinic- or community-based adherence club. Clubs were held every other month. All club participants received annual viral load monitoring and medical exam at the clinic. Patients were referred back to standard clinic-based care if they missed a club visit without ART pickup within 5 days, had two consecutive late ART pickups, developed a comorbidity requiring closer monitoring, or had viral rebound. We assessed the proportion referred back to routine care by 24 months following randomization.
Results: From February 2014-May 2015, we randomized 775 adults into 12 pairs of clubs?376 (49%) clinic-based, and 399 (51%) community-based. Characteristics were similar by arm: 65% female, 89% on fixed-dose combination ART, and median CD4 count of 506 cells/mm3. The proportion referred back to standard clinic-based care was greater among community-based (47%, n=191) compared to clinic-based clubs (37%, n=140, p=0.003) (Figure).

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Adjusted for age, gender, employment and baseline CD4 count, community-based club participants had an increased risk of loss from club (aHR 1.43, 95% CI:1.15-1.79, p=0.001). Main reasons for return to clinic-based care were missing ART pickup (59%, n=198) or pregnancy (11%, n=36), and were similar by arm. Among those referred to standard care, 63% and 80% made a visit within 60 and 90 days respectively of their last club visit.
Conclusions: By two years, drop-out from adherence club participation was high (43%) and higher among community-based compared to clinic-based clubs.