scholarly journals Differentiated antiretroviral therapy delivery in rural Zimbabwe: availability, needs and challenges

2020 ◽  
Author(s):  
Benedikt Christ ◽  
Janneke van Dijk ◽  
Marie Ballif ◽  
Talent Nyandoro ◽  
Martina L. Reichmuth ◽  
...  
Keyword(s):  
Antiretroviral Therapy ◽  
Rural Areas ◽  
Fast Track ◽  
Care Delivery ◽  
Waiting Times ◽  
Hiv Care ◽  
People Living With Hiv ◽  
Linear Regression Models ◽  
Travel Costs ◽  
Art Delivery

Introduction: The traditional “one-size-fits-all” model of HIV care whereby people living with HIV (PLWH) have regular individual clinical visits does not reflect the various preferences and needs of PLWH and stretches the capacity of health facilities (HFs). Little is known about the availability and the experience of differentiated HIV care delivery in the rural areas of Zimbabwe.Methods: We used a mixed-method approach to collect data from clients and providers at 26 HFs in Zimbabwe in 2019. We collected quantitative data about antiretroviral therapy (ART) delivery and time spent at the HF during a visit from one representative healthcare providers (HCP) and a stratified sample of PLWH at each HF. We performed semi-structured interviews among HCPs and focus group discussions (FGDs) among PLWH to collect information about the implementation of differentiated ART delivery (DART) models and their experience. We performed linear regression models to assess factors associated with the time spent in the HFs. We analyzed the interviews using an inductive approach. Transcripts were coded and constricted down to themes significant to the research objectives.Results: The majority (77%) of participating HFs offered at least one of the five DART models recommended in Zimbabwe: 13 (50%) offered community ART refill group (CARG), 1 (4%) club refill, 6 (23%) family refill, and 8 (31%) fast-track refill models. Mobile outreach was not available at any participating HF. In an unadjusted linear model, PLWH enrolled in the fast-track refill model spent 0.40 (95% confidence interval (CI): 0.15-0.56) less time at the HF than PLWH on routine care, whereas PLWH in the family refill model and delegated to go to the HF spent 2.63 (95% CI 1.42-4.88) more time at the HF during visit. Confidentiality and disclosure concerns were highlighted as the major barriers affecting the implementation of DART models, together with travel costs and waiting times. HCPs reported on the challenge of excessive workloads. Fast-track refill was perceived as the most adapted DART model to meet clients’ needs, followed by CARG and family refill.Conclusions: Confidentiality, travel costs and waiting times are key elements to consider in the implementation of differentiated care in rural Zimbabwe. More implementation research is needed to support the roll-out of differentiated HIV services in that region, especially DART models addressing the needs of PLWH. Our study supports the call for personalized care at ART programs in rural Africa.

scholarly journals Patient and nurse perspectives of a nurse-led community-based model of HIV care delivery in Malawi: a qualitative study

2020 ◽  
Author(s):  
Odala Sande ◽  
Doris Burtscher ◽  
Daneck Kathumba ◽  
Hannock Tweya ◽  
Sam Phiri ◽  
...  
Keyword(s):  
Care Delivery ◽  
Quality Care ◽  
Waiting Times ◽  
Physical Structure ◽  
Models Of Care ◽  
Hiv Care ◽  
People Living With Hiv ◽  
Care Providers ◽  
Health Care Information ◽  
Community Based

Abstract Background Differentiated models of care (DMOC) are used to make antiretroviral therapy (ART) accessible to people living with HIV (PLHIV). In Malawi, Lighthouse Trust has piloted various DMOCs aimed at providing quality care while reducing personal and logistical barriers when accessing clinic-based healthcare. One of the approaches was community-based provision of ART by nurses to stable patients. Methods To explore how the nurse-led community ART programme (NCAP) is perceived, we interviewed eighteen purposively selected patients receiving ART through NCAP and the four nurses providing the community-based health care. Information obtained from them was complemented with observations by the study team. Interviews were recorded and transcribed. Data was analysed using manual coding and thematic analysis. Results Through the NCAP, patients were able to save money on transportation and the time it took them to travel to a health facility. Caseloads and waiting times were also reduced, which made patients more comfortable and gave nurses the time to conduct thorough consultations. Closer relationships were built between patients and care providers, creating a space for more open conversations (although this required care providers to set clear boundaries and stick to schedule). Patients’ nutritional needs and concerns related to stigma remain a concern, while operational issues affect the quality of the services provided in the community. Considerations for community-led healthcare programmes include the provision of transportation for care providers; the physical structure of community sites (in regard to private spaces); the timely consolidation of data collected in the field to a central database; and the need for care providers to cover multiple facility-based staff roles. Conclusions The patients interviewed in this study preferred the NCAP approach to the facility-based model of care because it saved them money on transport, reduced waiting-times, and allowed for a more thorough consultation, while continuing to provide quality HIV care. However, when considering a community-level DMOC approach, certain factors – including staff transportation and workload – must be taken into consideration and purposefully planned.

scholarly journals Patient and nurse perspectives of a nurse-led community-based model of HIV care delivery in Malawi: a qualitative study

2020 ◽  
Author(s):  
Odala Sande ◽  
Doris Burtscher ◽  
Daneck Kathumba ◽  
Hannock Tweya ◽  
Sam Phiri ◽  
...  
Keyword(s):  
Care Delivery ◽  
Quality Care ◽  
Waiting Times ◽  
Physical Structure ◽  
Models Of Care ◽  
Hiv Care ◽  
People Living With Hiv ◽  
Care Providers ◽  
Health Care Information ◽  
Community Based

Abstract Background Differentiated models of care (DMOC) are used to make antiretroviral therapy (ART) accessible to people living with HIV (PLHIV). In Malawi, Lighthouse Trust has piloted various DMOCs aimed at providing quality care while reducing personal and logistical barriers when accessing clinic-based healthcare. One of the approaches was community-based provision of ART by nurses to stable patients. Methods To explore how the nurse-led community ART programme (NCAP) is perceived, we interviewed eighteen purposively selected patients receiving ART through NCAP and the four nurses providing the community-based health care. Information obtained from them was complemented with observations by the study team. Interviews were recorded and transcribed. Data was analysed using manual coding and thematic analysis. Results Through the NCAP, patients were able to save money on transportation and the time it took them to travel to a health facility. Caseloads and waiting times were also reduced, which made patients more comfortable and gave nurses the time to conduct thorough consultations. Closer relationships were built between patients and care providers, creating a space for more open conversations (although this required care providers to set clear boundaries and stick to schedule). Patients’ nutritional needs and concerns related to stigma remain a concern, while operational issues affect the quality of the services provided in the community. Considerations for community-led healthcare programmes include the provision of transportation for care providers; the physical structure of community sites (in regard to private spaces); the timely consolidation of data collected in the field to a central database; and the need for care providers to cover multiple facility-based staff roles. Conclusions The patients interviewed in this study preferred the NCAP approach to the facility-based model of care because it saved them money on transport, reduced waiting-times, and allowed for a more thorough consultation, while continuing to provide quality HIV care. However, when considering a community-level DMOC approach, certain factors – including staff transportation and workload – must be taken into consideration and purposefully planned.

scholarly journals Community-based model for the delivery of antiretroviral therapy in Cambodia: a quasi-experimental study protocol

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Sovannary Tuot ◽  
Alvin Kuo Jing Teo ◽  
Kiesha Prem ◽  
Pheak Chhoun ◽  
Chamroen Pall ◽  
...  
Keyword(s):  
Experimental Study ◽  
Antiretroviral Therapy ◽  
Scale Up ◽  
Economic Evaluations ◽  
People Living With Hiv ◽  
Cad Model ◽  
Community Based ◽  
Quasi Experimental ◽  
Living With Hiv ◽  
Art Delivery

Abstract Background Multi-month dispensing (MMD) is the mainstay mechanism for clinically stable people living with HIV in Cambodia to refill antiretroviral therapy (ART) every 3-6 months. However, less frequent ART dispensing through the community-based ART delivery (CAD) model could further reduce the clients’ and health facilities’ burden. While community-based services have been recognized as an integral component of HIV response in Cambodia, their role and effectiveness in ART delivery have yet to be systematically assessed. This study aims to evaluate the CAD model’s effectiveness on the continuum of care and treatment outcomes for stable people living with HIV in Cambodia. Methods We will conduct this quasi-experimental study in 20 ART clinics across the capital city and nine provinces between May 2021 and April 2023. Study sites were purposively selected based on the availability of implementing partners, the number of people living with HIV each clinic serves, and the accessibility of the clinics. In the intervention arm, approximately 2000 stable people living with HIV will receive ART and services from the CAD model. Another 2000 stable people living with HIV in the control arm will receive MMD—a standard care model for stable people living with HIV. The primary outcomes will be retention in care, viral load suppression, and adherence to ART. The secondary endpoints will include health providers’ work burden, the model’s cost-effectiveness, quality of life, mental health, social support, stigma, and discrimination. We will compare the outcome indicators within each arm at baseline, midline, and endline using descriptive and inferential statistics. We will evaluate the differences between the intervention and control arms using the difference-in-differences method. We will perform economic evaluations to determine if the intervention is cost-effective. Discussion This study will build the evidence base for future implementation and scale-up of CAD model in Cambodia and other similar settings. Furthermore, it will strengthen engagements with community stakeholders and further improve community mobilization, a vital pillar of the Cambodian HIV response. Trial registration ClinicalTrials.gov, NCT04766710. Registered 23 February 2021, Version 1.

scholarly journals Extending access to care across the rural US south: Preliminary results from the Alabama eHealth programme

2018 ◽  
Vol 25 (5) ◽  
pp. 301-309
Author(s):  
Kriti M Jain ◽  
Prashanth Bhat ◽  
Cathy Maulsby ◽  
Alexandria Andersen ◽  
Tomas Soto ◽  
...  
Keyword(s):  
Missing Data ◽  
Antiretroviral Therapy ◽  
Rural Areas ◽  
Formative Evaluation ◽  
Social Innovation ◽  
People Living With Hiv ◽  
Viral Loads ◽  
Innovation Fund ◽  
Set Up ◽  
Hiv Continuum Of Care

Purpose Using a mixed-methods formative evaluation, the purpose of this study was to provide a broad overview of the Alabama eHealth programme set-up and initial patient outcomes. The Alabama eHealth programme uses telemedicine to provide medical care to people living with HIV in rural Alabama. It was led by a community-based organisation, Medical Advocacy and Outreach (MAO), and supported by AIDS United and the Corporation for National Community Service’s Social Innovation Fund with matching support from non-federal donors. Methods We conducted and transcribed in-depth interviews with Alabama eHealth staff and then performed directed content analysis. We also tracked patients’ ( n = 240) appointment attendance, CD4 counts, and viral loads. Findings Staff described the steps taken to establish the programme, associated challenges (e.g., costly, inadequate broadband in rural areas), and technology enabling this programme (electronic medical records, telemedicine equipment). Of all enrolled patients, 76% were retained in care, 88% had antiretroviral therapy and 75% had a suppressed viral load. Among patients without missing data, 96% were retained in care, 97% used antiretroviral therapy and 93% had suppressed viral loads. There were no statistically significant demographic differences between those with and without missing data. Conclusions Patients enrolled in a telemedicine programme evaluation successfully moved through the HIV continuum of care.

scholarly journals Implementing TB preventive treatment within differentiated HIV service delivery models in global programs

2020 ◽  
Vol 10 (3) ◽  
pp. 104-110
Author(s):  
A. T. Boyd ◽  
B. Moore ◽  
M. Shah ◽  
C. Tran ◽  
H. Kirking ◽  
...  
Keyword(s):  
Service Delivery ◽  
Care Delivery ◽  
Scale Up ◽  
Preventive Treatment ◽  
Hiv Care ◽  
People Living With Hiv ◽  
Emergency Plan ◽  
The Us ◽  
Living With Hiv ◽  
Delivery Models

Global HIV program stakeholders, including the US President’s Emergency Plan for AIDS Relief (PEPFAR), are undertaking efforts to ensure that eligible people living with HIV (PLHIV) receiving antiretroviral treatment (ART) receive a course of TB preventive treatment (TPT). In PEPFAR programming, this effort may require providing TPT not only to newly diagnosed PLHIV as part of HIV care initiation, but also to treatment-experienced PLHIV stable on ART who may not have been previously offered TPT. TPT scale-up is occurring at the same time as a trend to provide more person-centered HIV care through differentiated service delivery (DSD). In DSD, PLHIV stable on ART may receive less frequent clinical follow-up or receive care outside the traditional clinic-based model. The misalignment between traditional delivery of TPT and care delivery in innovative DSD may require adaptations to TPT delivery practices for PLHIV. Adaptations include components of planning and operationalization of TPT in DSD, such as determination of TPT eligibility and TPT initiation, and clinical management of PLHIV while on TPT. A key adaptation is alignment of timing and location for TPT and ART prescribing, monitoring, and dispensing. Conceptual examples of TPT delivery in DSD may help program managers operationalize TPT in HIV care.

scholarly journals A Systematic Review and Meta-Analysis on Depression and Associated Factors among Adult HIV/AIDS-Positive Patients Attending ART Clinics of Ethiopia: 2021

2021 ◽  
Vol 2021 ◽  
pp. 1-9
Author(s):  
Bitew Tefera Zewudie ◽  
Shegaw Geze ◽  
Yibeltal Mesfin ◽  
Muche Argaw ◽  
Haimanot Abebe ◽  
...  
Keyword(s):  
Mental Health ◽  
Antiretroviral Therapy ◽  
Random Effect ◽  
Hiv Care ◽  
Hiv Positive ◽  
People Living With Hiv ◽  
Negative Consequences ◽  
Aids Patients ◽  
Depression Prevalence ◽  
Hiv Aids

Introduction. Depression is the most common mental health problem in people living with the human immune virus. It ranges from 11% to 63% in low- and middle-income countries. Depression was high in people living with HIV/AIDS in developing countries, especially in the Ethiopian context. Even though depression has negative consequences on HIV-positive patients, the care given for depression in resource-limited countries like Ethiopia is below the standard in their HIV care programs. Method. International databases (Google Scholar, PubMed, Hinari, Embase, and Scopus) and Ethiopian university repository online have been covered in this review. Data were extracted using Microsoft Excel and analyzed by using the Stata version 14 software program. We detected the heterogeneity between studies using the I 2 test. We checked publication bias using a funnel plot test. Results. The overall pooled depression prevalence among adult HIV/AIDS patients attending antiretroviral therapy in Ethiopia was 36.3% (95% CI: 28.4%, 44.2%) based on the random effect analysis. Adult HIV/AIDS patients having CD4 count < 200 ( AOR = 5.1 ; 95% CI: 2.89, 8.99), widowed marital status ( AOR = 3.7 ; 95% CI: 2.394, 5.789), medication nonadherence ( AOR = 2.3 ; 95% CI: 1.63, 3.15), poor social support (2.986) (95% CI: 2.139, 4.169), perceived social stigma (2.938) (2.305, 3.743), opportunistic infections (3.010) (2.182, 4.151), and adverse drug reactions (4.013) (1.971, 8.167) were significantly associated with depression among adult HIV/AIDS patients on antiretroviral therapy, in Ethiopia. Conclusion and Recommendation. The pooled depression prevalence among adult HIV/AIDS patients attending antiretroviral therapy in Ethiopia was higher than the general population and is alarming for the government to take special consideration for HIV-positive patients. Depression assessment for all HIV-positive patients and integrating with mental health should be incorporated to ensure early detection, prevention, and treatment. Community-based and longitudinal study designs mainly focusing on the incidence and determinants of depression among adult HIV/AIDS patients should be done in the future.

scholarly journals Assessing the Content Validity of a New Patient-Reported Measure of Barriers to Antiretroviral Therapy Adherence for Electronic Administration in Routine HIV Care: Proposal for a Web-Based Delphi Study (Preprint)

2018 ◽  
Author(s):  
Kim Engler ◽  
Sara Ahmed ◽  
David Lessard ◽  
Serge Vicente ◽  
Bertrand Lebouché
Keyword(s):  
Antiretroviral Therapy ◽  
Hiv Care ◽  
People Living With Hiv ◽  
Free Text ◽  
Art Adherence ◽  
Web Based ◽  
Specific Patient ◽  
Patient Reported ◽  
Electronic Administration ◽  
Oriented Research

BACKGROUND Adherence to lifesaving antiretroviral therapy (ART) for HIV infection remains a challenge for many patients. Routine screening for barriers to ART adherence could help make HIV care more patient-centered and prevent virologic rebound or failure. Our team is currently developing a new HIV-specific patient-reported outcome measure (PROM) of these barriers for use in Canada and France along with a digital app for its electronic administration. In our previous work, we developed the PROM’s multidimensional conceptual framework and generated 100 English items, which have been translated to French. OBJECTIVE This study aims to use a Web-based Delphi to help validate and select the content of this new HIV-specific PROM, based on the perspective of anglophone and francophone patients and providers in Canada and France. Here, we present the proposal for this Delphi. METHODS This modified Delphi will involve a diverse panel of patients (n=32) and providers (n=52) recruited especially from the 9 sites of the PROM development study (site locations in Canada: Montreal, Toronto, Vancouver; in France: Paris, Nantes, Clermont-Ferrand, Saint-Martin, Cayenne). Overall, 2 rounds of Web-based questionnaires will be conducted. The threshold for consensus is set at 60% and will determine which items are carried forward to the second round. Per item, 3 aspects will be rated: importance as a barrier to ART adherence, relevance for HIV care, and clarity. In both rounds, space will be available for free text comments. Overall comprehensiveness will be assessed in the second round. RESULTS This study has undergone a methodological review by experts in patient-oriented research. It has received approval from a research ethics board of the McGill University Health Centre. It is financially supported, in part, by the Canadian Institutes of Health Research’s Strategy for Patient-Oriented Research-Quebec Support Unit (M006). As of May 21, 2019, 15 people living with HIV and 25 providers completed the first round of the Delphi (24 from Canada and 16 from France). CONCLUSIONS To our knowledge, this is the first Delphi to seek consensus on the most relevant and clinically actionable barriers to ART adherence, collecting opinions on an extensive list of barriers. Drawing on a relatively large and diverse panel of HIV patients and providers, it essentially engages key stakeholders in decision making about the PROM’s final content, helping to ensure its utility and adoption. INTERNATIONAL REGISTERED REPOR PRR1-10.2196/12836

scholarly journals Factors Affecting the Implementation of Electronic Antiretroviral Therapy Adherence Monitoring and Associated Interventions for Routine HIV Care in Uganda: Qualitative Study

10.2196/18038 ◽  
2020 ◽  
Vol 22 (9) ◽  
pp. e18038
Author(s):  
Jessica E Haberer ◽  
Lindsey Garrison ◽  
John Bosco Tumuhairwe ◽  
Robert Baijuka ◽  
Edna Tindimwebwa ◽  
...  
Keyword(s):  
Health Care ◽  
Antiretroviral Therapy ◽  
Clinical Outcomes ◽  
Care Delivery ◽  
Low Cost ◽  
Clinical Care ◽  
Hiv Care ◽  
Health Care Administrators ◽  
Adherence Monitoring ◽  
Data Informed

Background High, sustained adherence to HIV antiretroviral therapy (ART) is critical for achieving viral suppression, which in turn leads to important individual health benefits and reduced secondary viral transmission. Electronic adherence monitors record a date-and-time stamp with each opening as a proxy for pill-taking behavior. These monitors can be combined with interventions (eg, data-informed adherence counseling, SMS-based adherence support, and/or alarms) and have been shown to improve adherence in multiple settings. Their use, however, has largely been limited to the research context. Objective The goal of the research was to use the Consolidated Framework for Implementation Research (CFIR) to understand factors relevant for implementing a low-cost electronic adherence monitor and associated interventions for routine HIV clinical care in Uganda. Methods We conducted in-depth qualitative interviews with health care administrators, clinicians, and ART clients about likes and dislikes of the features and functions of electronic adherence monitors and associated interventions, their potential to influence HIV care, suggestions on how to measure their value, and recommendations for their use in routine care. We used an inductive, content analysis approach to understand participant perspectives, identifying aspects of CFIR most relevant to technology implementation in this setting. Results We interviewed 34 health care administrators/clinicians and 15 ART clients. Participants largely saw the monitors and associated interventions as favorable and beneficial for supporting adherence and improving clinical outcomes through efficient, differentiated care. Relevant outside factors included structural determinants of health, international norms around supporting adherence, and limited funding that necessitates careful assessment of costs and benefits. Within the clinic, the adherence data were felt likely to improve the quality of counseling and thereby morale, as well as increase the efficiency of care delivery. Existing infrastructure and care expenditures and the need for proper training were other noted considerations. At the individual level, the desire for good health and a welcomed pressure to adhere favored uptake of the monitors, although some participants were concerned with clients not using the monitors as planned and the influence of poverty, stigma, and need for privacy. Finally, participants felt that decisions around the implementation process would have to come from the Ministry of Health and other funders and would be influenced by sustainability of the technology and the target population for its use. Coordination across the health care system would be important for implementation. Conclusions Low-cost electronic adherence monitoring combined with data-informed counseling, SMS-based support, and/or alarms have potential for use in routine HIV care in Uganda. Key metrics of successful implementation will include their impact on efficiency of care delivery and clinical outcomes with careful attention paid to factors such as stigma and cost. Further theory-driven implementation science efforts will be needed to move promising technology from research into clinical care. Trial Registration ClinicalTrials.gov NCT03825952; https://clinicaltrials.gov/ct2/show/NCT03825952

scholarly journals Tuberculosis preventive treatment opportunities at antiretroviral therapy initiation and follow-up visits

2020 ◽  
Vol 10 (2) ◽  
pp. 64-69
Author(s):  
T. Agizew ◽  
D. Surie ◽  
J.E. Oeltmann ◽  
M. Letebele ◽  
S. Pals ◽  
...  
Keyword(s):  
Antiretroviral Therapy ◽  
Preventive Treatment ◽  
Evaluation Study ◽  
Hiv Care ◽  
People Living With Hiv ◽  
Control Effort ◽  
Missed Opportunities ◽  
Art Initiation ◽  
A Prospective Study

Setting: Twenty-two clinics providing HIV care and treatment in Botswana where tuberculosis (TB) and HIV comorbidity is as high as 49%.Objectives: To assess eligibility of TB preventive treatment (TPT) at antiretroviral therapy (ART) initiation and at four follow-up visits (FUVs), and to describe the TB prevalence and associated factors at baseline and yield of TB diagnoses at each FUV.Design: A prospective study of routinely collected data on people living with HIV (PLHIV) enrolled into care for the Xpert® MTB/RIF Package Rollout Evaluation Study between 2012 and 2015.Results: Of 6041 PLHIV initiating ART, eligibility for TPT was 69% (4177/6041) at baseline and 93% (5408/5815); 95% (5234/5514); 96% (4869/5079); and 97% (3925/4055) at FUV1, FUV2, FUV3, and FUV4, respectively. TB prevalence at baseline was 11% and 2%, 3%, 3% and 6% at each subsequent FUV. At baseline, independent risk factors for prevalent TB were CD4 <200 cells/mm3 (aOR = 1.4, P = 0.030); anemia (aOR = 2.39, P < 0.001); cough (aOR = 11.21, P < 0.001); fever (aOR = 2.15, P = 0.001); and weight loss (aOR = 2.60, P = 0.002).Conclusion: Eligibility for TPT initiation is higher at visits post-ART initiation, while most cases of active TB were identified at ART initiation. Missed opportunities for TB further compromises TB control effort among PLHIV in Botswana.

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