The goal of this clinical trial is to learn if the DSD model (SUSTAIN-DSD) is effective in improving participants HIV treatment adherence. The main questions it aims to answer are:
* Does the SUSTAIN-DSD intervention significantly improve participants' treatment adherence and increase rates of viral suppression? * Does the SUSTAIN-DSD intervention help retain people in care? * Does SUSTAIN-DSD intervention help reduce the length of treatment interruptions? * for 24 months, Participants will either receive the SUSTAIN-DSD intervention (i.e. be enrolled in an adherence club where the participants will pick up 6-months of ART medication and have the option to use peer support and additional counseling), and or enhanced standard of care (i.e. visit the clinic for treatment and participate in optional counseling sessions).
Blood will be drawn from the participants at the adherence club visits for viral load tests at baseline and every 12 months.
\- Participants will take part in interviews to discuss the participants' experience with the SUSTAIN-DSD intervention.
Adults (≥18 years or age)
Living with HIV
On a dolutegravir-based first-line ART regimen
Evidence of a care gap (>28 days late for appointment) or having a raised viral load (≥50 copies/ml) in the preceding year, either from SUSTAIN study data or from clinic records.
Clinical conditions as assessed by the ART clinicians as requiring clinic-based follow-up e.g. tuberculosis or epilepsy.
Pregnant at enrollment and requiring care in the antenatal clinic system.
Sustained retention in care (no gaps of >28days) and viral suppression in the preceding year.
Plans to leave Cape Town permanently within the next 24 months.
Parallel
SUSTAIN-DSD
BehavioralParticipants randomized to SUSTAIN-DSD will be enrolled into an Adherence Club and will have 6 months of ART dispensed through a pre-packed dispensing service. Participants may choose to use the decentralized pick-up point solely for medication retrieval or may opt into the peer-support aspect of the Clubs by attending the group session of up to 30 PWH, who will meet once every 6 months in a safe space (e.g., clinic meeting room, church, or local library). At 6 months, 12 months, and every 12 months thereafter, a visiting nurse will draw a blood specimen for viral load. Optional process uptake will be recorded. Participants with a raised viral load will be called and offered enhanced adherence counselling; then recalled for a repeat viral load in 3 months.
Enhanced (guideline-driven) Standard of Care (E-SoC)
Other interventionAs per current SA ART guidelines, all patients who are \>28 days late for a scheduled visit are offered enhanced adherence counselling (EAC) at reengagement and restarted on ART. Patients who are \>90 days late also have blood drawn for a CD4 count to test for advanced HIV disease. Individual clinic visits occur every 3 months, with 3-month ART dispensing. VL testing is repeated 3 months after restart, then at 12 months and annually there-after, if suppressed. These visits will be managed by clinic staff (nurse or doctor). EAC is a single counselling session delivered by a lay counsellor. The study team will ensure all SoC processes are complete as per the guidelines; and reported to the COCT team as appropriate.
Viral suppression (Viral load <50 c/ml)
Viral suppression (Viral load c/ml) will be measured at 24 months post-enrollment.
Viral suppression (Viral load <50 c/ml) at 12 months
Viral suppression (Viral load \<50 c/ml) will be measured at 12 months post-enrollment.
Viremia
% Plasma VL 50-999 / ≥1000 copies/mL (dichotomous) \| Blood Draw and/or NHLS database at 12 and 24 months
Retention in care at study clinics
Retention in care at study clinics (and in care at any other clinic) will be measured at 12 and 24 months (measured by proportion attending club or clinic visits at months 12 and 24).
Treatment interruptions
Treatment interruptions will be measured using pharmacy refill data.
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