Effect and implementation experience of intensive adherence counseling in a public HIV care center in Uganda: a mixed-methods study

Background Intensive adherence counseling (IAC) is an intervention recommended by the World Health Organization to improve anti-retroviral therapy (ART) adherence among people living with HIV on ART with unsuppressed viral load; and in 2016, the intervention was implemented in Uganda. This study evaluated the effect and experiences of providing IAC in an urban HIV care center in Kampala, Uganda. Methods This was a sequential explanatory mixed-method study that compared viral load suppression during IAC implementation (intervention) to the period before IAC at Kisenyi Health centre IV. Data were abstracted from patient files and viral load register. The effect of IAC on viral load suppression and associated factors were analyzed using modified Poisson regression with robust standard errors. Using in-depth interviews and an inductive analysis approach in Atlas-ti 8. We also explored experiences of providing IAC among healthcare workers. Results A total of 500 records were sampled: 249 (49.8%) in the intervention period and 251 (51.2%) in the pre-intervention period. The mean age was lower during the intervention period 33.1 (± 12.0) than 36.5 (± 13.4) in the pre- intervention period, p = 0.002. More clients were currently on Protease-based regimen in the pre-intervention period 179 (71.3%) than 135 (54.2%) in the intervention period, p ≤ 0.001. In the intervention period, all eligible clients received IAC [249/249 (100.0%)]. Overall, 325 (65.0%) received IAC and of these, 143 (44.1%) achieved viral load suppression compared to 46 (26.3%) who received regular counseling. Receiving IAC significantly increased viral load suppression by 22% (aPR 1.22, 95% CI 1.01–1.47). Clients on Protease-based regimen were less likely to suppress than those on Efavirenz or Nevirapine-based regimens (aPR 0.11, 95% CI 0.08–0.15). All the interviewed healthcare workers lauded IAC for improving ART adherence. However, patient and health care system related factors hindered adherence during IAC. Conclusions The full potential of IAC in achieving viral load suppression in this setting has not been reached due to a combination of the patient and health care system related factors. Provision of adequate IAC necessities and use of patient centered approach should be emphasized to obtain the maximum benefit of the intervention.

Factors influencing antihypertensive medication adherence among hypertensive patients: A cross-sectional study in two selected Eritrean hospitals

Objective: Hypertension is a major modifiable cause of cardiovascular and cerebrovascular disease affecting more than one billion individuals worldwide. Adherence to recommended antihypertensive medications is central to control hypertension. The purpose of this study was to assess medication adherence and its influencing factors among hypertensive patients in Halibet and Hazhaz Hospitals in Asmara, Eritrea. Methods: Hospital-based cross-sectional study was conducted among 360 hypertensive patients in Halibet and Hazhaz Hospitals of Asmara from February through May 2018. A convenience sampling was used to select study participants. Data related to medication adherence were collected using a structured 8-item Morisky Medication Adherence Scale. Data were analyzed using SPSS version 22. A bivariate and multivariate analysis was done to determine independent predictors of medication adherence among hypertensive patients. Adjusted odds ratio (at 95% CI) and p value < 0.05 was used to assert the effect of the independent variables. Results: Out of 360 patients enrolled in the study, two hundred forty nine (69.2%) had good medication adherence and the remaining 30.8% had poor adherence. The study found that Being female (AOR (95% CI): 1.8 (0.63, 4.85), p<0.05), having Monthly income ≥ 1000 nakfa (AOR (95% CI): 2.85 (0.76, 5.61), , p<0.05), having comorbid disease (AOR (95% CI): 2.7 (0.98, 4.23), p<0.05), family history of hypertension (AOR (95% CI): 2.12 (0.78, 5.76), p <0.05), longer duration of hypertension (AOR (95% CI): 1.32 (0.65, 4.89), p< 0.05), BP < 140/90 mmHg (AOR (95% CI): 2.4 (1.41, 8.73), P<0.05), and taking only one pill per day (AOR (95% CI): 2.7 (0.97, 6.84),P<0.05) were factors significantly influenced good medication adherence. Conclusion: Medication adherence among hypertensive patients was relatively high in this study. Increasing adherence counseling and patient education about the disease and its treatment are important measures to scale-up adherence status of patients.

Factors affecting adherence to antiretroviral therapy among children and adolescents living with HIV in the Mbita Sub County Hospital, Homa Bay- Kenya

Background: Adequate adherence to antiretroviral therapy (ART) is key to the successful treatment of children and adoles- cents living with HIV. Continuous ART Adherence is the key factor for virologic suppression and stability of the immune system and prevents the occurrence of opportunistic infections. Children and adolescents struggle with adherence to ART for various reasons, including a poor psychosocial support system and clinic attendance. Objectives: To describe the uptake of HIV treatment services among children and adolescents in the Mbita Sub-County Hospital, Homa Bay and determine how schooling, clinic attendance, and type of pill/regimen affect adherence to ART and viral suppression. Methods: This retrospective study was conducted at the Mbita Sub-County Hospital. Medical chart data was abstracted from the hospital files of children and adolescents between the ages of 0-19 years on antiretroviral therapy, between the periods of October 2016 and September, 2017. Data was analyzed using measures of central tendency, and cross-tabulations were done to compare schooling, clinic attendance, type of pill/regimen and viral suppression. Univariate and multivariate logistic regression analyses were conducted to determine associations between groups. Results: According to patient files reviewed, majority of patients, 244(91.4%) were enrolled into care within 2 weeks of HIV diagnosis according to guidelines, and 193(73.1 %) remained enrolled in care at end of study period. An overall viral suppression of 74.2 %( 132) was recorded. Of all the files reviewed, 121(74.7%) of patients attending school suppressed against 11(68.8 %) out of school, p=0.280. Suppression among Day and boarding reported at 78.6 %( 11) and 74.8 %( 113) of those out of school, respectively, p=0.533. Participants in primary school, 17(85.0%) suppressed better than those in secondary school, 102(73.4%), p=0.263. Keeping clinic appointments among eligible patient files reviewed decreased from 83.1% at 3 months, p=0.016, to 76.6%, p=0.526 at 6 months and to 52.9% at 12 months, p=0.278. Only 3- month clinic appointment return rates and Enhanced Adherence Counseling (EAC) were significant predictors of viral supression χ2 (2) = 0.280, p = 0.869 (> 0.05). Conclusion: The clinic attendance rate within the first 3 months, and Enhanced Adherence Counseling (EAC) were signif- icant predictors of viral suppression, and therefore adherence to antiretroviral therapy. Keywords: Adherence; clinic attendance; antiretroviral therapy; HIV; virologic suppression.

Factors affecting adherence to antiretroviral therapy among children and adolescents living with HIV in the Mbita Sub County Hospital, Homa Bay- Kenya

Background: Adequate adherence to antiretroviral therapy (ART) is key to the successful treatment of children and adoles- cents living with HIV. Continuous ART Adherence is the key factor for virologic suppression and stability of the immune system and prevents the occurrence of opportunistic infections. Children and adolescents struggle with adherence to ART for various reasons, including a poor psychosocial support system and clinic attendance. Objectives: To describe the uptake of HIV treatment services among children and adolescents in the Mbita Sub-County Hospital, Homa Bay and determine how schooling, clinic attendance, and type of pill/regimen affect adherence to ART and viral suppression. Methods: This retrospective study was conducted at the Mbita Sub-County Hospital. Medical chart data was abstracted from the hospital files of children and adolescents between the ages of 0-19 years on antiretroviral therapy, between the periods of October 2016 and September, 2017. Data was analyzed using measures of central tendency, and cross-tabulations were done to compare schooling, clinic attendance, type of pill/regimen and viral suppression. Univariate and multivariate logistic regression analyses were conducted to determine associations between groups. Results: According to patient files reviewed, majority of patients, 244(91.4%) were enrolled into care within 2 weeks of HIV diagnosis according to guidelines, and 193(73.1 %) remained enrolled in care at end of study period. An overall viral suppression of 74.2 %( 132) was recorded. Of all the files reviewed, 121(74.7%) of patients attending school suppressed against 11(68.8 %) out of school, p=0.280. Suppression among Day and boarding reported at 78.6 %( 11) and 74.8 %( 113) of those out of school, respectively, p=0.533. Participants in primary school, 17(85.0%) suppressed better than those in secondary school, 102(73.4%), p=0.263. Keeping clinic appointments among eligible patient files reviewed decreased from 83.1% at 3 months, p=0.016, to 76.6%, p=0.526 at 6 months and to 52.9% at 12 months, p=0.278. Only 3- month clinic appointment return rates and Enhanced Adherence Counseling (EAC) were significant predictors of viral supression χ2 (2) = 0.280, p = 0.869 (> 0.05). Conclusion: The clinic attendance rate within the first 3 months, and Enhanced Adherence Counseling (EAC) were signif- icant predictors of viral suppression, and therefore adherence to antiretroviral therapy. Keywords: Adherence; clinic attendance; antiretroviral therapy; HIV; virologic suppression.

Staff Perceptions of Preimplementation Barriers and Facilitators to a Mobile Health Antiretroviral Therapy Adherence Counseling Intervention in South Africa: Qualitative Study

Background South Africa adopted a universal test and treatment program for HIV infection in 2015. The standard of care that people living with HIV receive consists of 3 sessions of readiness counseling delivered by lay counselors (LCs). In the largest antiretroviral therapy (ART) program worldwide, effective and early HIV and ART education and support are key for ensuring ART adoption, adherence, and retention in care. Having LCs to deliver readiness counseling allows for the wide task-sharing of this critical activity but carries the risks of loss of standardization, incomplete content delivery, and inadequate monitoring and supervision. Systems for ensuring that a minimum standard of readiness counseling is delivered to the growing number of people living with HIV are essential in the care cascade. In resource-constrained, high-burden settings, mobile health (mHealth) apps may potentially offer solutions to these treatment gaps by providing content structure and delivery records. Objective This study aims to explore, at a large Cape Town–based nonprofit HIV care organization, the staff’s perceived preimplementation barriers and facilitators of an mHealth intervention (Masivukeni) developed as a structured app for ART readiness counseling. Methods Masivukeni is a laptop-based app that incorporates written content, graphics, short video materials, and participant activities. In total, 20 participants were included in this study. To explore how an mHealth intervention might be adopted across different staff levels within the organization, we conducted 7 semistructured interviews (participants: 7/20, 35%) and 3 focus groups (participants in 2 focus groups: 4/20, 20%; participants in 1 focus group: 3/20, 15%) among LCs, supervisors, and their managers. In total, 20 participants were included in this study. Interviews lasted approximately 60 minutes, and focus groups ranged from 90 to 120 minutes. The Consolidated Framework for Implementation Research was used to explore the perceived implementation barriers and facilitators of the Masivukeni mHealth intervention. Results Several potential facilitators of Masivukeni were identified. Multimedia and visual elements were generally regarded as aids in content delivery. The interactive learning components were notably helpful, whereas facilitated updates to the adherence curriculum were important to facilitators and managers. The potential to capture administrative information regarding LC delivery and client logging was regarded as an attractive feature. Barriers to implementation included security risks and equipment costs, the high volume of clients to be counseled, and variable computer literacy among LCs. There was uncertainty about the app’s appeal to older clients. Conclusions mHealth apps, such as Masivukeni, were perceived as being well placed to address some of the needs of those who deliver ART adherence counseling in South Africa. However, the successful implementation of mHealth apps appeared to be dependent on overcoming certain barriers in this setting.

Evaluation of a multidisciplinary lipid clinic to improve the care of individuals with severe lipid conditions: a RE-AIM framework analysis

Background Individuals with complex dyslipidemia, or those with medication intolerance, are often difficult to manage in primary care. They require the additional attention, expertise, and adherence counseling that occurs in multidisciplinary lipid clinics (MDLCs). We conducted a program evaluation of the first year of a newly implemented MDLC utilizing the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework to provide empirical data not only on program effectiveness, but also on components important to local sustainability and future generalizability. Methods The purpose of the MDLC is to increase the uptake of guideline-based care for lipid conditions. Established in 2019, the MDLC provides care via a centralized clinic location within the healthcare system. Primary care providers and cardiologists were invited to refer individuals with lipid conditions. Using a pre/post-study design, we evaluated the implementation outcomes from the MDLC using the RE-AIM framework. Results In 2019, 420 referrals were made to the MDLC (reach). Referrals were made by 19% (148) of the 796 active cardiology and primary care providers, with an average of 35 patient referrals per month in 2019 (SD 12) (adoption). The MDLC saw 83 patients in 2019 (reach). Additionally, 50% (41/82) had at least one follow-up MDLC visit, and 12% (10/82) had two or more follow-up visits in 2019 (implementation). In patients seen by the MDLC, we found an improved diagnosis of specific lipid conditions (FH (familial hypercholesterolemia), hypertriglyceridemia, and dyslipidemia), increased prescribing of evidence-based therapies, high rates of medication prior authorization approvals, and significant reductions in lipid levels by lipid condition subgroup (effectiveness). Over time, the operations team decided to transition from in-person follow-up to telehealth appointments to increase capacity and sustain the clinic (maintenance). Conclusions Despite limited reach and adoption of the MDLC, we found a large intervention effect that included improved diagnosis, increased prescribing of guideline-recommended treatments, and clinically significant reduction of lipid levels. Attention to factors including solutions to decrease the large burden of unseen referrals, discussion of the appropriate number and duration of visits, and sustainability of the clinic model could aid in enhancing the success of the MDLC and improving outcomes for more patients throughout the system.

Virologic Outcomes Following Enhanced Adherence Counselling among Treatment Experienced HIV Positive Patients at University College Hospital, Ibadan, Nigeria

Aims: To explore the impact of enhanced adherence counseling (EAC) in achieving viral suppression among our patients unsuppressed viral load in a large Anti-retroviral therapy (ART) program in South West Nigeria. Study Design: This study was a descriptive cross-sectional review of patients’ records. Place and Duration of Study: The study was conducted in human immunodeficiency virus (HIV) Program located in Infectious Disease Institute, College of Medicine, University of Ibadan, Nigeria involving review of data of patients with unsuppressed viral loads between 1st March 2017 – 30th September 2018. Methodology: We described the viral loads (VL) outcomes of patients with VLs >1 000 copies/ml after at least 6 months on ART and a comprehensive 3 monthly EAC support programme. We calculated adherence using pharmacy refill data. Patients with one VL measurement after the EAC sessions were eligible for analysis. Results: Out of 400 patients with VL >1 000 copies/ml reviewed during the study period, only 204(51.0%) were virally suppressed at the end of the 3 EAC sessions. Those with initial VLs between 1000-5000cp/ml had the highest adherence rate (73.0%) and VL suppression rate (68%). The youngest age group (16-30 years) had the least adherence (55.2%) and the least viral suppression (44.8%) while the oldest age groups (61-80years) were the most adherent (69.0%) and the most virally suppressed (55.2%). The proportion of patients on second line regimen were significantly more virally suppressed than those on the first line regimen (P <0.002). Conclusion: This study showed the role EAC in accomplishing VL suppression and the need to intensify adherence counseling at commencement of highly active anti-retroviral therapy (HAART) to strengthen adherence in people living with HIV (PLHIV) and consequently preventing raised VL at the next laboratory testing of viral load. We strongly advocate for better measurement of adherence to antiretroviral therapy that will be accessible and reliable as this was a limitation of this study.

Evaluation of a multidisciplinary lipid clinic to improve the care of individuals with severe lipid conditions: a RE-AIM Framework Analysis

Background. Individuals with complex dyslipidemia, or those with medication intolerance, are often difficult to manage in primary care. They require the additional attention, expertise, and adherence counseling that occurs in multidisciplinary lipid clinics (MDLCs). We conducted a program evaluation of the first year of a newly implemented MDLC utilizing the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework to provide empirical data not only on program effectiveness, but also on components important to local sustainability and future generalizability.Methods. The purpose of the MDLC is to increase uptake of guideline-based care for lipid conditions. Established in 2019, the MDLC provides care via a centralized clinic location within the healthcare system. Primary care providers and cardiologists were invited to refer individuals with lipid conditions. Using a pre/post study design, we evaluated implementation outcomes from the MDLC using the RE-AIM framework. Results. In 2019, 420 referrals were made to the MDLC (reach). Referrals were made by 19% (148) of the 796 active cardiology and primary care providers; with an average of 35 patient referrals per month in 2019 (SD 12) (adoption). The MDLC saw 83 patients in 2019 (reach). Additionally, 50% (41/82) had at least one follow-up MDLC visit and 12% (10/82) had two or more follow-up visits in 2019 (implementation). In patients seen by the MDLC, we found improved diagnosis of specific lipid conditions (FH, hypertriglyceridemia, and dyslipidemia), increased prescribing of evidence-based therapies, high rates of medication prior authorization approvals, and significant reductions in lipid levels by lipid condition subgroup (effectiveness). Over time, the operations team decided to transition from in-person follow-up to telehealth appointments to increase capacity and sustain the clinic (maintenance).Conclusions. Despite limited reach and adoption of the MDLC, we found a large intervention effect that included improved diagnosis, increased prescribing of guideline-recommended treatments, and clinically significant reduction of lipid levels. Attention to factors including solutions to decrease the large burden of unseen referrals, discussion of the appropriate number and duration of visits, and sustainability of the clinic model could aid in enhancing the success of the MDLC and improving outcomes for more patients throughout the system.