Off the beaten track east of Uganda's capital, Kampala, a four-wheel-drive vehicle is taking a nurse, a community health worker and a cooler full of life-saving medication to Gayaza village, where they will call on homes affected by HIV/AIDS.
Although more Ugandans than ever are on antiretroviral (ARV) therapy, many HIV-positive people in remote areas still struggle to get the life-prolonging drugs: health professionals are scarce (about one doctor per 12,500 people) and community health centres are few and far between. Most villagers, mainly subsistence farmers, cannot afford to travel long distances to reach them.
A study conducted in Uganda and published this month in the UK medical journal, The Lancet, has found that home-based ARV therapy provided by trained lay counsellors could be the best option for HIV-infected people living in remote, rural areas.
Mortality dropped more than 90 percent among HIV-positive participants and their families receiving home-based care. Instead of routine clinic visits, lay counsellors visited patients in their homes to deliver medication, support them in adhering to their drugs, collect blood samples, and refer those with symptoms to the nearest clinic. The home-based ARV programme also eased the burden on over-stretched local health centres.
Mortality among the dependants of HIV-positive participants decreased, as parents who were well cared for by the home-based services were in turn better able to care for their children, and the children were less likely to be orphaned.
Conducted between 2001 and 2005 by the United States Centres for Disease Control (CDC), with funding from the US President's Emergency Plan for AIDS Relief and support from Uganda's government, the study involved 1,373 HIV-infected participants and 4,601 of their uninfected family members referred by a branch of The AIDS Support Organisation (TASO), a local non-governmental organisation, in Tororo district in eastern Uganda.
Dr Frank Kaharuza, a CDC researcher, said Tororo was chosen because of its existing infrastructure, high rate of opportunistic infections and the need to find a distribution method for newly available ARVs.
Although most participants lacked post-primary education and lived in homes without electricity or running water, between 89 and 97 percent of them reported taking at least 95 percent of their ARVs - a better rate than many clinics are able to achieve.
"Adherence was surprisingly good," said Kaharuza, who noted that less than two percent of the patients had to be switched from first-line to second-line ARVs, which was usually necessitated by drug resistance developing due to poor adherence.
Scaling up home-based care
In Gayaza, the TASO team visits Deborah Namuwaya, 52, who has been on tuberculosis treatment for six weeks. The frail woman, feet tucked into her black and yellow gomesi (traditional dress), lies on a foam mattress on the concrete floor of her two-room home, coughing uncontrollably.
"We have fuel and transport, so we must assist them," said Florence Natukunda, the TASO nurse. She provides medical treatment and other small measures that make a significant difference to patients with compromised immune systems, monitors hygiene and use of mosquito nets.
Robert Nakidumba, public relations officer for TASO, said the organisation planned to scale up its home-based care programme after the Tororo study findings.
As of June 2007, 14 percent of the 106,000 Ugandans on ARV therapy were already receiving their medication through home- or community-based care, mostly through monthly home visits by TASO staff. Researchers now plan to test the efficacy and cost-effectiveness of home-based ARV programmes in longer and larger studies in other locations.
There are more than 20 million people infected with HIV in sub-Saharan Africa, and many of them live in remote villages with poor access to health services.
The Lancet article on the Tororo study noted that finding a way to scale up the provision of ARV therapy and care, "irrespective of geographic or socioeconomic background", could significantly reduce mortality among people with HIV, improve the health of their children, and reduce the level of orphanhood.