DISCUSSION
PWH, HIV viral suppression, viral suppression, viremia
VIREMIA
A patient-centered HIV care intervention for mobile PWH did not increase viral suppression compared with standard care over 48 weeks but did increase retention in HIV care and ART possession among individuals with or at risk for HIV viral nonsuppression in Kenya and Uganda. Intervention effects on retention in care and ART possession were greatest among PWH who were unsuppressed at trial baseline and those with high mobility or alcohol use—key groups at increased risk of loss to follow-up and poor HIV treatment outcomes. These findings provide insights into which groups of mobile PWH are most likely to benefit from our patient-centered approach for mobile PWH and merit further evaluation. Exploring adherence challenges and addressing these through patient-centered treatment plans may be a next step in further improving HIV viral suppression rates among mobile PWH who are engaged in care but remain nonsuppressed.We did not observe a difference in viral suppression between participants who received the patient-centered intervention for mobile PWH versus standard care despite demonstrating a greater increase in viral suppression in the intervention compared with the control group from baseline to week 48 visit (5% increase from 80% to 85% vs. a 1% increase from 85% to 86%, respectively). We suspect that this finding may have been due to several factors. First, both groups started off at higher than anticipated HIV viral suppression rates (80%–85%), despite almost half (45%) having viral nonsuppression in the year before enrollment and three quarters having missed multiple HIV clinic appointments. High baseline viral suppression may have been a consequence of patients switching from non-nucleoside reverse transcriptase inhibitor (NNRTI)-based to dolutegravir (DTG)-based ART in the year or 2 before study start. Compared with NNRTIs, DTG is a more potent antiretroviral with a higher barrier to drug resistance. Multiple studies have shown that the transition from NNRTI to DTG-based ART has resulted in high levels of suppression among PWH retained in care, presumably in the context of varying adherence levels, and may explain the similar levels of viral suppression in both arms of our trial, despite significant differences in ART possession.Our patient-centered HIV care intervention for mobile PWH increased retention in HIV care and ART possession compared with standard care, with the greatest intervention effects observed among subgroups who have previously been shown to be at increased risk of poor HIV outcomes,Although viral suppression among participants was relatively high overall (85%) by the end of the trial, 15% of participants remained unsuppressed despite intensive adherence counseling in both arms, differentiated care (with multimonth dispensing in both trial arms), and high retention in care and ART possession in the intervention arm. We suspect that several factors contributed to this finding. First, ART adherence likely remained a challenge for participants who were unsuppressed at 48 weeks. Our findings suggest that there is an ongoing need for adherence interventions to supplement approaches for mobile PWH that improve HIV care engagement. Second, there may be multiple barriers hampering adherence such as intimate partner violence and food insecurity that highly mobile individuals face, in addition to the distinct challenges to care engagement that arise with high mobility.We observed high intervention uptake, with all intervention participants selecting at least 1 aspect of mobile PWH-centered care over 48 weeks. We offered choice of intervention options that could vary over time (ie, dynamic choice). Our findings demonstrate that need for intervention components was indeed variable, consistent with other studies that have identified care delivery that is responsive to patient preferences as a key element of patient-centered care.Our study has limitations. First, our duration of follow-up may have limited our ability to capture longer-term benefits expected with improved retention in care and ART possession over time, such as sustained viral suppression and avoidance of episodic viremia and the development of drug resistance. We also measured viral load twice—at baseline and trial endline—and could have missed periods of viremia that participants experienced in the interim period. Our participants had higher baseline viral load suppression than we anticipated which may have resulted in our inability to detect a difference in the primary outcome. We did not measure participant satisfaction or perceptions of the intervention in this analysis; however, qualitative interviews were conducted and will be shared in a future publication. Although we were able to measure travel pack refills (suggesting use of components such as the 14-day emergency supply of ART), we did not measure use of all intervention component options selected. Finally, we are unable to rule out contamination between the 2 arms because patients attending a clinic are likely to know and interact with each other and may have shared ideas about the intervention. To minimize this, we used mobility coordinators who only interacted with intervention group participants to deliver the intervention rather than HIV clinicians who interacted with both control and intervention participants.In conclusion, our mobile PWH-centered intervention designed to overcome barriers to HIV care and viral suppression among mobile PWH significantly improved retention in care and ART possession, which may confer long-term benefit despite not showing a difference in viral suppression at 48 weeks. This intervention should be considered for specific high-risk mobile populations, such as persons with viral nonsuppression and high mobility, to improve retention in care and sustain viral suppression over time.