The Retain6 Project

With the advent of universal treatment eligibility (“treat all”) and same-day and community-based antiretroviral therapy (ART) initiation, retention in care after a patient has started ART remains the main challenge to achieving optimal outcomes in HIV treatment programs. Consistently across both time and geography, the highest risk for loss from care is during a patient’s first six months after ART initiation, with about quarter of all patients not retained by the end of Month 6.

One of the reasons for the high attrition from care in this early retention period is that the model of care offered to most newly-initiating and re-initiating patients has barely evolved from its original outlines. Patients in their first six months on ART are generally not eligible for lower-intensity “differentiated service delivery” models that make remaining in care easier for experienced patients. Instead, most early patients must still make multiple clinic visits that include clinical consultations with providers, and most can receive only 1-2 month supplies of medications at a time. Reconsideration of how best to deliver ART during the first six months is overdue.

The Retain6 project focuses on optimizing the delivery of ART in the first six months after treatment initiation for both naïve and re-initiating patients. Retain6 hypothesizes that 1) a majority of early patients will flourish with a simple, low intensity service delivery model, while a minority will need and/or want a more intense model; 2) both retention in care and resource allocation can be improved based on this premise; and 3) naïve and non-naïve initiators will have different needs that may require different models of care. The 3+ year project aims to answer research questions such as:

  • Is a routine clinical consultation required between ART initiation and month 6, and for whom?
  • What are the main reasons for unscheduled visits in this period?
  • How much and what kind of non-clinical interaction (e.g. social support, HIV education, treatment literacy) with professional and/or lay healthcare providers is optimal?
  • Are there specific additional services or approaches that would help patients establish behaviors and long-term habits in support of ART adherence?
  • Is it realistic to design a system that offers one standard, low-intensity model to the large majority of patients who have minimal needs and several differentiated models for patients with additional needs?

Answering these questions includes 1) analysis of existing data; 2) enrollment of a prospective cohort of ART initiators to evaluate preferences, needs, and triaging potential; 3) consultation with patients and providers to develop one or more new models of care; and 4) a pragmatic evaluation of the effectiveness and cost-effectiveness of the new model(s) in improving early retention rates. Focus countries are South Africa and Zambia. The project is a collaboration among Boston University’s Department of Global Health, the Health Economics and Epidemiology Research Office (HE2RO) in South Africa, and the Clinton Health Access Initiative (CHAI) in Zambia.