Impact of community dispensation of ART on retention in care and viral suppression rates among persons living with HIV in Zambézia Province, Mozambique

Introduction : In Mozambique, where the HIV burden remains high, community antiretroviral therapy dispensation by health care providers (cARTd) was introduced during the COVID-19 public health emergency to mitigate service disruptions and reduce lost to follow-up (LTFU). The strategy was subsequently expanded to support ART continuity amid seasonal flooding and other structural barriers. Trained staff delivered ART and adherence counseling through targeted home visits to individuals missing scheduled appointments, facilitating return to facility-based care. We applied the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to evaluate cARTd’s impact on reintegration, retention, and viral load suppression in Zambézia Province. Methods : We retrospectively analysed individual-level data from 68 health facilities (June 2021–September 2023), comparing cARTd recipients to facility-based ART dispensation (hfARTd) recipients. Outcomes included cARTd coverage, time to ART dispensation, time to health facility return, LTFU (> 59 days late), retention on ART (< 60 days late), and viral load suppression (< 1,000 copies/ml). Mixed-effects models adjusted for sex, locale, and age were fitted. Results : All 68 facilities implemented cARTd. Among 223,911 eligible patients (mean age 33.3 years, 65.9% female), cARTd coverage was 55.6%. Twelve months prior to cARTd eligibility, LTFU was higher among cARTd recipients (30.8%) than hfARTd recipients (21.2%). Recipients of cARTd received ART sooner (median of 13 vs. 16 days; adjusted hazard ratio [aHR] = 1.08 [95% confidence interval (CI):1.07–1.09], p < 0.001) and returned to the facility faster (median of 3 vs. 0 days before scheduled visit; aHR = 1.30 [95%CI:1.28–1.33], p < 0.001) than hfARTd recipients. At 12 months post-return, LTFU was 24.4% among cARTd recipients compared with 23.3% among hfARTd recipients, while 12-month retention rates were higher among cARTd recipients (81.6% vs. 75.9%; adjusted odds ratio [aOR] = 1.44 [95%CI:1.35–1.54], p < 0.001). Conversely, proportion of viral suppression was lower among cARTd recipients (92.9% vs. 95.0%; aOR = 0.66 [95%CI:0.60–0.72], p < 0.001). Conclusions : Compared to facility-based recipients, community ART dispensation effectively reached individuals at higher risk of LTFU and improved continuum of care outcomes, including faster return to facility-based care, and more favorable retention. Community-based ART delivery shows promise for sustaining HIV care during public health crises in resource-constrained settings.