Outcome assessment of decentralization of antiretroviral therapy provision in a rural district of Malawi using an integrated primary care model

Scaling-up access to antiretroviral therapy for children: a cohort study evaluating care and treatment at mobile and hospital-affiliated HIV clinics in rural Zambia

Background

Travel time and distance are barriers to care for HIV-infected children in rural sub-Saharan Africa. Decentralization of care is one strategy to scale-up access to antiretroviral therapy (ART), but few programs have been evaluated. We compared outcomes for children receiving care in mobile and hospital-affiliated HIV clinics in rural Zambia.

Methods

Outcomes were measured within an ongoing cohort study of HIV-infected children seeking care at Macha Hospital, Zambia from 2007 to 2012. Children in the outreach clinic group received care from the Macha HIV clinic and transferred to one of three outreach clinics. Children in the hospital-affiliated clinic group received care at Macha HIV clinic and reported Macha Hospital as the nearest healthcare facility.

Results

Seventy-seven children transferred to the outreach clinics and were included in the analysis. Travel time to the outreach clinics was significantly shorter and fewer caretakers used public transportation, resulting in lower transportation costs and fewer obstacles accessing the clinic. Some caretakers and health care providers reported inferior quality of service provision at the outreach clinics. Sixty-eight children received ART at the outreach clinics and were compared to 41 children in the hospital-affiliated clinic group. At ART initiation, median age, weight-for-age z-scores (WAZ) and CD4⁺ T-cell percentages were similar for children in the hospital-affiliated and outreach clinic groups. Children in both groups experienced similar increases in WAZ and CD4⁺ T-cell percentages.

Conclusions

HIV care and treatment can be effectively delivered to HIV-infected children at rural health centers through mobile ART teams, removing potential barriers to uptake and retention. Outreach teams should be supported to increase access to HIV care and treatment in rural areas.

Follow-Up Visit Patterns in an Antiretroviral Therapy (ART) programme in Zomba, Malawi

Background

Identifying follow-up (FU) visit patterns, and exploring which factors influence them are likely to be useful in determining which patients on antiretroviral therapy (ART) may become Lost to Follow-Up (LTFU). Using an operation and implementation research approach, we sought 1) to describe the timing of FU visits amongst patients who have been on ART for shorter and longer periods of time; and 2) to determine the median time to late visits, and 3) to identify specific factors that may be associated with these patterns in Zomba, Malawi.

Methods and Findings

Using routinely collected programme monitoring data from Zomba District, we performed descriptive analyses on all ART visits among patients who initiated ART between Jan. 1, 2007–June 30, 2010. Based on an expected FU date, each FU visit was classified as early (≥4 day before an expected FU date), on time (3 days before an expected FU date/up to 6 days after an expected FU date), or late (≥7 days after an expected FU date). In total, 7,815 patients with 76417 FU visits were included. Ninety-two percent of patients had ≥2 FU visits. At the majority of visits, patients were either on time or late. The median time to a first late visit among those with 2 or more visits was 216 days (IQR: 128–359). Various patient- and visit-level factors differed significantly across Early, On Time, and Late visit groups including ART adherence and frequency of, and type of side effects.

Discussion

The majority of patients do not demonstrate consistent FU visit patterns. Individuals were generally on ART for at least 6 months before experiencing their first late visit. Our findings have implications for the development of effective interventions that meet patient needs when they present early and can reduce patient losses to follow-up when they are late. In particular, time-varying visit characteristics need further research.

Treatment outcomes in a decentralized antiretroviral therapy program: a comparison of two levels of care in north central Nigeria

Background. Decentralization of antiretroviral therapy (ART) services is a key strategy to achieving universal access to treatment for people living with HIV/AIDS. Our objective was to assess clinical and laboratory outcomes within a decentralized program in Nigeria. Methods. Using a tiered hub-and-spoke model to decentralize services, a tertiary hospital scaled down services to 13 secondary-level hospitals using national and program guidelines. We obtained sociodemographic, clinical, and immunovirologic data on previously antiretroviral drug naïve patients aged ≥15 years that received HAART for at least 6 months and compared treatment outcomes between the prime and satellite sites. Results. Out of 7,747 patients, 3729 (48.1%) were enrolled at the satellites while on HAART, prime site patients achieved better immune reconstitution based on CD4+ cell counts at 12 (P < 0.001) and 24 weeks (P < 0.001) with similar responses at 48 weeks (P = 0.11) and higher rates of viral suppression (<400 c/mL) at 12 (P < 0.001) and 48 weeks (P = 0.03), but similar responses at 24 weeks (P = 0.21). Mortality was 2.3% versus 5.0% (P < 0.001) at prime and satellite sites, while transfer rate was 8.7% versus 5.5% (P = 0.001) at prime and satellites. Conclusion. ART decentralization is feasible in resource-limited settings, but efforts have to be intensified to maintain good quality of care.

Scaling up antiretroviral treatment and improving patient retention in care: lessons from Ethiopia, 2005-2013

Background

Antiretroviral treatment (ART) was provided to more than nine million people by the end of 2012. Although ART programs in resource-limited settings have expanded treatment, inadequate retention in care has been a challenge. Ethiopia has been scaling up ART and improving retention (defined as continuous engagement of patients in care) in care. We aimed to analyze the ART program in Ethiopia.

Methods

A mix of quantitative and qualitative methods was used. Routine ART program data was used to study ART scale up and patient retention in care. In-depth interviews and focus group discussions were conducted with program managers.

Results

The number of people receiving ART in Ethiopia increased from less than 9,000 in 2005 to more than 439, 000 in 2013. Initially, the public health approach, health system strengthening, community mobilization and provision of care and support services allowed scaling up of ART services. While ART was being scaled up, retention was recognized to be insufficient. To improve retention, a second wave of interventions, related to programmatic, structural, socio-cultural, and patient information systems, have been implemented. Retention rate increased from 77% in 2004/5 to 92% in 2012/13.

Conclusion

Ethiopia has been able to scale up ART and improve retention in care in spite of its limited resources. This has been possible due to interventions by the ART program, supported by health systems strengthening, community-based organizations and the communities themselves. ART programs in resource-limited settings need to put in place similar measures to scale up ART and retain patients in care.

Supporting middle-cadre health care workers in Malawi: lessons learned during implementation of the PALM PLUS package

BACKGROUND

The government of Malawi is committed to the broad rollout of antiretroviral treatment in Malawi in the public health sector; however one of the primary challenges has been the shortage of trained health care workers. The Practical Approach to Lung Health Plus HIV/AIDS in Malawi (PALM PLUS) package is an innovative guideline and training intervention that supports primary care middle-cadre health care workers to provide front-line integrated primary care. The purpose of this paper is to describe the lessons learned in implementing the PALM PLUS package.

METHODS

A clinical tool, based on algorithm- and symptom-based guidelines was adapted to the Malawian context. An accompanying training program based on educational outreach principles was developed and a cascade training approach was used for implementation of the PALM PLUS package in 30 health centres, targeting clinical officers, medical assistants, and nurses. Lessons learned were identified during program implementation through engagement with collaborating partners and program participants and review of program evaluation findings.

RESULTS

Key lessons learned for successful program implementation of the PALM PLUS package include the importance of building networks for peer-based support, ensuring adequate training capacity, making linkages with continuing professional development accreditation and providing modest in-service training budgets. The main limiting factors to implementation were turnover of staff and desire for financial training allowances.

CONCLUSIONS

The PALM PLUS approach is a potential model for supporting mid-level health care workers to provide front-line integrated primary care in low and middle income countries, and may be useful for future task-shifting initiatives.

Tuberculosis in developing countries: conditions for successful use of a decentralized approach in a rural health district

INTRODUCTION

This article reports the results and the lessons learned from implementing the decentralized approach to tuberculosis (TB) detection and treatment, embedded with Human Immunodeficiency Virus (HIV) co-infection in health district. The objective was to increase the TB screening indicators in the district using the common ways for offering care to patients in health district.

METHODS

Conducted from August 2006 to July 2007, this large-scale intervention using Non-experimental study Designs has implemented a decentralized approach for fighting against TB in Orodara Health District (OHD), Burkina Faso. Pretest-posttest design has been used for quantitative part using indicators in one hand, and postests-only design for the qualitative part in other hand. In the pretest-posttest design, the TB indicators from years before 2006 (from 2002 to 2005) were used as earlier measurement observations allowing examining changes over time. The decentralized approach was incorporated into the annual planning of the OHD. For the quantitative study design, indicators used were those from National TB Program in Burkina Faso: TB detection rate, incidence density of TB per 100,000 inhabitants per year, and HIV prevalence in incident TB cases with positive smears. Data entry and analysis employed Microsoft Access and Excel software. For the qualitative, in-depth interview was used in which a total of 16 persons have been interviewed. Discussions were tape-recorded and transcribed verbatim for analysis using the computer-based qualitative software program named QSR NVIVO.

RESULTS

There were a total of 99,259 outpatient visits during the study period: the7,345 patients (7.43%) presented with cough. Of the 7,345 patient having cough, 503 cases (6.8%) were declared chronic coughing. These 503 patients were screened for TB, including 35.59% whose coughing had lasted 10 to 15 days. We observed an increase in a measured variable was observed. The TB detection rate and incidence-density rate based on positive smears were 16.11% (11.00% in 2005) and 10.42 per 100,000 inhabitants per year (6.88 per 100,000 inhabitants in 2005), respectively. There were 29 patients positive for TB: 41.37% of these had cough lasting 10 to 15 days, 10.34% were also positive for HIV, and 68.97% were from rural areas. Health workers and patients reported satisfaction with the intervention. It was found that implementing a decentralized approach to TB prevention in rural areas is plausible and effective under some conditions: considering that health district system is functional; carefully designing the intervention for TB case management; setting up and implementing of decentralized approach including strong monitoring; and taking into account the all financing, community and volunteer involvement, evaluation of the cost savings from integrating specific donor funding, and being supported by regional and central levels including National TB program.

CONCLUSION

The study has shown that TB detection rate can be increased by implementing a decentralized approach to primary care. When carefully implemented, a decentralized approach is a suitable approach to TB and HIV prevention in rural and inaccessible settings.

Patient retention, clinical outcomes and attrition-associated factors of HIV-infected patients enrolled in Zimbabwe's National Antiretroviral Therapy Programme, 2007-2010

Background

Since establishment of Zimbabwe's National Antiretroviral Therapy (ART) Programme in 2004, ART provision has expanded from <5,000 to 369,431 adults by 2011. However, patient outcomes are unexplored.

Objective

To determine improvement in health status, retention and factors associated with attrition among HIV-infected patients on ART.

Methods

A retrospective review of abstracted patient records of adults ≥15 years who initiated ART from 2007 to 2009 was done. Frequencies and medians were calculated for rates of retention in care and changes in key health status outcomes at 6, 12, 24 and 36 months respectively. Cox proportional hazards models were used to determine factors associated with attrition.

Results

Of the 3,919 patients, 64% were female, 86% were either WHO clinical stage III or IV. Rates of patient retention at 6, 12, 24 and 36 months were 90.7%, 78.1%, 68.8% and 64.4%, respectively. After ART initiation, median weight gains at 6, 12, and 24 months were 3, 4.5, and 5.0 kgs whilst median CD4+ cell count gains at 6, 12 and 24 months were 122, 157 and 279 cells/µL respectively. Factors associated with an increased risk of attrition included male gender (AHR 1.2; 95% CI, 1.1–1.4), baseline WHO stage IV (AHR 1.7; 95% CI, 1.1–2.6), lower baseline body weight (AHR 2.0; 95% CI, 1.4–2. 8) and accessing care from higher level healthcare facilities (AHR 3.5; 95% 1.1–11.2).

Conclusions

Our findings with regard to retention as well as clinical and immunological improvements following uptake of ART, are similar to what has been found in other settings. Factors influencing attrition also mirror those found in other parts of sub-Saharan Africa. These findings suggest the need to strengthen earlier diagnosis and treatment to further improve treatment outcomes. Whilst decentralisation improves ART coverage it should be coupled with strategies aimed at improving patient retention.

Outcomes of antiretroviral treatment programmes in rural Lesotho: health centres and hospitals compared

Introduction

Lesotho was among the first countries to adopt decentralization of care from hospitals to nurse-led health centres (HCs) to scale up the provision of antiretroviral therapy (ART). We compared outcomes between patients who started ART at HCs and hospitals in two rural catchment areas in Lesotho.

Methods

The two catchment areas comprise two hospitals and 12 HCs. Patients ≥16 years starting ART at a hospital or HC between 2008 and 2011 were included. Loss to follow-up (LTFU) was defined as not returning to the facility for ≥180 days after the last visit, no follow-up (no FUP) as not returning after starting ART, and retention in care as alive and on ART at the facility. The data were analysed using logistic regression, competing risk regression and Kaplan-Meier methods. Multivariable analyses were adjusted for sex, age, CD4 cell count, World Health Organization stage, catchment area and type of ART. All analyses were stratified by gender.

Results

Of 3747 patients, 2042 (54.5%) started ART at HCs. Both women and men at hospitals had more advanced clinical and immunological stages of disease than those at HCs. Over 5445 patient-years, 420 died and 475 were LTFU. Kaplan-Meier estimates for three-year retention were 68.7 and 69.7% at HCs and hospitals, respectively, among women (p=0.81) and 68.8% at HCs versus 54.7% at hospitals among men (p<0.001). These findings persisted in adjusted analyses, with similar retention at HCs and hospitals among women (odds ratio (OR): 0.89, 95% confidence interval (CI): 0.73–1.09) and higher retention at HCs among men (OR: 1.53, 95% CI: 1.20–1.96). The latter result was mainly driven by a lower proportion of patients LTFU at HCs (OR: 0.68, 95% CI: 0.51–0.93).

Conclusions

In rural Lesotho, overall retention in care did not differ significantly between nurse-led HCs and hospitals. However, men seemed to benefit most from starting ART at HCs, as they were more likely to remain in care in these facilities compared to hospitals.

Integration of HIV care and treatment in primary health care centers and patient retention in central Mozambique: a retrospective cohort study

BACKGROUND

In 2004, the Mozambican Ministry of Health began a national scale-up of antiretroviral therapy (ART) using a vertical model of HIV clinics colocated within large urban hospitals. In 2006, the ministry expanded access by integrating ART into primary health care clinics.

METHODS

We conducted a retrospective cohort study including adult ART-naive patients initiating ART between January 2006 and June 2008 in public sector clinics in Manica and Sofala provinces. Cox proportional hazards models with robust variances were used to estimate the association between clinic model (vertical/integrated), clinic location (urban/rural), and clinic experience (first 6 months/post first 6 months) and attrition occurring in early patient follow-up (≤ 6 months) and attrition occurring in late patient follow-up (>6 months), while controlling for age, sex, education, pre-ART CD4 count, World Health Organization stage and pharmacy staff burden.

RESULTS

A total of 11,775 patients from 17 clinics were studied. The overall attrition rate was 37 per 100 person-years. Patients attending integrated clinics had a higher risk of attrition in late follow-up [hazard ratio (HR) = 1.75; 95% confidence interval (CI): 1.04 to 2.94], and patients attending urban clinics (HR = 0.57; 95% CI: 0.35 to 0.91) had a lower risk of attrition in late follow-up. Though not statistically significant, clinics open for longer than 6 months (HR = 0.71; 95% CI: 0.49 to 1.04) had a lower risk of attrition in early follow-up.

CONCLUSIONS

Patients attending vertical clinics had a lower risk of attrition. Utilizing primary health clinics to implement ART is necessary to reach higher levels of coverage; however, further implementation strategies should be developed to improve patient retention in these settings.

Decentralising HIV treatment in lower- and middle-income countries

BACKGROUND

Policy makers, health staff and communities recognise that health services in lower- and middle-income countries need to improve people's access to HIV treatment and retention to treatment programmes. One strategy is to move antiretroviral delivery from hospitals to more peripheral health facilities or even beyond health facilities. This could increase the number of people with access to care, improve health outcomes, and enhance retention in treatment programmes. On the other hand, providing care at less sophisticated levels in the health service or at community-level may decrease quality of care and result in worse health outcomes. To address these uncertainties, we summarised the research studies examining the risks and benefits of decentralising antiretroviral therapy service delivery.

OBJECTIVES

To assess the effects of various models that decentralised HIV treatment and care to more basic levels in the health system for initiating and maintaining antiretroviral therapy.

SEARCH METHODS

We conducted a comprehensive search to identify all relevant studies regardless of language or publication status (published, unpublished, in press, and in progress) from 1 January 1996 to 31 March 2013, and contacted relevant organisations and researchers. The search terms included 'decentralisation', 'down referral', 'delivery of health care', and 'health services accessibility'.

SELECTION CRITERIA

Our inclusion criteria were controlled trials (randomised and non-randomised), controlled-before and after studies, and cohorts (prospective and retrospective) in which HIV-infected people were either initiated on antiretroviral therapy or maintained on therapy in a decentralised setting in lower- and middle-income countries. We define decentralisation as providing treatment at a more basic level in the health system to the comparator.

DATA COLLECTION AND ANALYSIS

Two authors applied the inclusion criteria and extracted data independently. We designed a framework to describe different decentralisation strategies, and then grouped studies against these strategies. Data were pooled using random-effects meta-analysis. Because loss to follow up in HIV programmes is known to include some deaths, we used attrition as our primary outcome, defined as death plus loss to follow-up. We assessed evidence quality with GRADE methodology.

MAIN RESULTS

Sixteen studies met the inclusion criteria, all but one were from Africa, comprising two cluster randomised trials and 14 cohort studies. Antiretroviral therapy started at a hospital and maintained at a health centre (partial decentralisation) probably reduces attrition (RR 0.46, 95% CI 0.29 to 0.71, 4 studies, 39 090 patients, moderate quality evidence). There may be fewer patients lost to care with this model (RR 0.55, 95% CI 0.45 to 0.69, low quality evidence).We are uncertain whether there is a difference in attrition for antiretroviral therapy started and maintained at a health centre (full decentralisation) compared to a hospital at 12 months (RR 0.70, 95% CI 0.47 to 1.02; four studies, 56 360 patients, very low quality evidence), but there are probably fewer patients lost to care with this model (RR 0.3, 95% CI 0.17 to 0.54, moderate quality evidence).When antiretroviral maintenance therapy is delivered at home by trained volunteers, there is probably no difference in attrition at 12 months (RR 0.95, 95% CI 0.62 to 1.46, two trials, 1453 patients, moderate quality evidence).

AUTHORS' CONCLUSIONS

Decentralisation of HIV care aims to improve patient access and retention in care. Most data were from good quality cohort studies but confounding between site of treatment and outcomes cannot be excluded. Nevertheless, this review found that attrition appears to be lower in partial decentralisation models of treatment, where antiretrovirals were started at hospital and continued in the health centre; with antiretroviral drugs started and continued at health centres, no difference in attrition was detected, but there were fewer patients lost to care. For antiretroviral therapy provided at home by trained volunteers, no difference in outcomes were detected when compared to facility-based care.

Using concept mapping to explore why patients become lost to follow up from an antiretroviral therapy program in the Zomba District of Malawi

BACKGROUND

Retention in antiretroviral therapy (ART) programmes remains a challenge in many settings including Malawi, in part due to high numbers of losses to follow-up. Concept Mapping (CM), a mix-method participatory approach, was used to explore why patients on ART are lost to follow-up (LTFU) by identifying: 1) factors that influence patient losses to follow-up and 2) barriers to effective and efficient tracing in Zomba, Malawi.

METHODS

CM sessions (brainstorming, sorting and rating, interpretation) were conducted in urban and rural settings in Zomba, Malawi. Participants included ART patients, ART providers, Health Surveillance Assistants, and health managers from the Zomba District Health Office. In brainstorming, participants generated statements in response to "A specific reason why an individual on ART becomes lost to follow-up is…" Participants then sorted and rated the consolidated list of brainstormed items. Analysis included inductive qualitative methods for grouping of data and quantitative cluster identification to produce visual maps which were then interpreted by participants.

RESULTS

In total, 90 individuals brainstormed 371 statements, 64 consolidated statements were sorted (participant n = 46), and rated on importance and feasibility (participant n = 69). A nine-cluster concept map was generated and included both patient- and healthcare-related clusters such as: Stigma and Fears, Beliefs, Acceptance and Knowledge of ART, Access to ART, Poor Documentation, Social and Financial Support Issues, Health Worker Attitudes, Resources Needed for Effective Tracing, and Health Worker Issues Related to Tracing. Strategies to respond to the clusters were generated in Interpretation.

CONCLUSIONS

Multiple patient- and healthcare focused factors influence why patients become LTFU. Findings have implications particularly for programs with limited resources struggling with the retention of ART patients.

Integration of HIV Care with Primary Health Care Services: Effect on Patient Satisfaction and Stigma in Rural Kenya

HIV departments within Kenyan health facilities are usually better staffed and equipped than departments offering non-HIV services. Integration of HIV services into primary care may address this issue of skewed resource allocation. Between 2008 and 2010, we piloted a system of integrating HIV services into primary care in rural Kenya. Before integration, we conducted a survey among returning adults ≥18-year old attending the HIV clinic. We then integrated HIV and primary care services. Three and twelve months after integration, we administered the same questionnaires to a sample of returning adults attending the integrated clinic. Changes in patient responses were assessed using truncated linear regression and logistic regression. At 12 months after integration, respondents were more likely to be satisfied with reception services (adjusted odds ratio, aOR 2.71, 95% CI 1.32–5.56), HIV education (aOR 3.28, 95% CI 1.92–6.83), and wait time (aOR 1.97 95% CI 1.03–3.76). Men's comfort with receiving care at an integrated clinic did not change (aOR = 0.46 95% CI 0.06–3.86). Women were more likely to express discomfort after integration (aOR 3.37 95% CI 1.33–8.52). Integration of HIV services into primary care services was associated with significant increases in patient satisfaction in certain domains, with no negative effect on satisfaction.

Decentralization of pediatric HIV care and treatment in five sub-Saharan African countries

BACKGROUND

In resource-limited settings, decentralization of HIV care and treatment is a cornerstone of universal care and rapid scale-up. We compared trends in pediatric enrollment and outcomes at primary (PHFs) vs secondary/tertiary health facilities (SHFs).

METHODS

Using aggregate program data reported quarterly from 274 public facilities in Kenya, Lesotho, Mozambique, Rwanda, and Tanzania from January 2008 to March 2010, we examined trends in number of children younger than 15 years of age initiating antiretroviral treatment (ART) by facility type. We compared clinic-level lost to follow-up (LTFU) and mortality per 100 person-years (PYs) on ART during the period by facility type.

RESULTS

During the 2-year period, 17,155 children enrolled in HIV care and 8475 initiated ART in 182 (66%) PHFs and 92(34%) SHFs. PHFs increased from 56 to 182, whereas SHFs increased from 72 to 92 sites. SHFs accounted for 71% of children initiating ART; however, the proportion of children initiating ART each quarter at PHFs increased from 17% (129) to 44% (463) in conjunction with an increase in PHFs during observation period. The average LTFU and mortality rates for children on ART were 9.8/100 PYs and 5.2/100 PYs, respectively, at PHFs and 20.2/100 PYs and 6.0/100 PYs, respectively, at SHFs. Adjusted models show PHFs associated with lower LTFU (adjusted rate ratio = 0.55; P = 0.022) and lower mortality (adjusted rate ratio = 0.66; P = 0.028).

CONCLUSIONS

The expansion of pediatric services to PHFs has resulted in increased numbers of children on ART. Early findings suggest lower rates of LTFU and mortality at PHFs. Successful scale-up will require further expansion of pediatric services within PHFs.

Patient costs associated with accessing HIV/AIDS care in Malawi

INTRODUCTION

The decentralization of HIV services has been shown to improve equity in access to care for the rural poor of sub-Saharan Africa. This study aims to contribute to our understanding of the impact of decentralization on costs borne by patients. Such information is valuable for economic evaluations of anti-retroviral therapy programmes that take a societal perspective. We compared costs reported by patients who received care in an urban centralized programme to those in the same district who received care through rural decentralized care (DC).

METHODS

A cross-sectional survey on patient characteristics and costs associated with accessing HIV care was conducted, in May 2010, on 120 patients in centralized care (CC) at a tertiary referral hospital and 120 patients in DC at five rural health centres in Zomba District, Malawi. Differences in costs borne by each group were compared using χ2 and t-tests, and a regression model was developed to adjust for confounders, using bootstrapping to address skewed cost data.

RESULTS

There was no significant difference between the groups with respect to sex and age. However, there were significant differences in socio-economic status, with higher educational attainment (p<0.001), personal income (p=0.007) and household income per person (p=0.005) in CC. Travel times were similar (p=0.65), as was time waiting at the clinic (p=0.63) and total time spent seeking care (p=0.65). There was a significant difference in travel-related expenses (p<0.001) related to the type of travel participants noted that they used. In CC, 60% of participants reported using a mini-bus to reach the clinic; in DC only 4% reported using a mini-bus, and the remainder reported travelling on foot or by bicycle. There were no significant differences between the groups in the amount of lost income reported or other out-of-pocket costs. Approximately 91 Malawi Kwacha (95% confidence intervals: 1-182 MKW) or US$0.59 represents the adjusted difference in total costs per visit between CC and DC.

CONCLUSIONS

Even within a system of HIV/AIDS care where patients do not pay to see clinicians or for most medications, they still incur costs. We found that most costs are travel related. This has important implications for poorer patients who live at a distance from health facilities for whom these costs may be significant.

Current strategies for improving access and adherence to antiretroviral therapies in resource-limited settings

The rollout of antiretroviral therapy (ART) significantly reduced human immunodeficiency virus (HIV)-related morbidity and mortality, but good clinical outcomes depend on access and adherence to treatment. In resource-limited settings, where over 90% of the world's HIV-infected population resides, data on barriers to treatment are emerging that contribute to low rates of uptake in HIV testing, linkage to and retention in HIV care systems, and suboptimal adherence rates to therapy. A review of the literature reveals limited evidence to inform strategies to improve access and adherence with the majority of studies from sub-Saharan Africa. Data from observational studies and randomized controlled trials support home-based, mobile and antenatal care HIV testing, task-shifting from doctor-based to nurse-based and lower level provider care, and adherence support through education, counseling and mobile phone messaging services. Strategies with more limited evidence include targeted HIV testing for couples and family members of ART patients, decentralization of HIV care, including through home- and community-based ART programs, and adherence promotion through peer health workers, treatment supporters, and directly observed therapy. There is little evidence for improving access and adherence among vulnerable groups such as women, children and adolescents, and other high-risk populations and for addressing major barriers. Overall, studies are few in number and suffer from methodological issues. Recommendations for further research include health information technology, social-level factors like HIV stigma, and new research directions in cost-effectiveness, operations, and implementation. Findings from this review make a compelling case for more data to guide strategies to improve access and adherence to treatment in resource-limited settings.

Toward an understanding of disengagement from HIV treatment and care in sub-Saharan Africa: a qualitative study

BACKGROUND

The rollout of antiretroviral therapy in sub-Saharan Africa has brought lifesaving treatment to millions of HIV-infected individuals. Treatment is lifelong, however, and to continue to benefit, patients must remain in care. Despite this, systematic investigations of retention have repeatedly documented high rates of loss to follow-up from HIV treatment programs. This paper introduces an explanation for missed clinic visits and subsequent disengagement among patients enrolled in HIV treatment and care programs in Africa.

METHODS AND FINDINGS

Eight-hundred-ninety patients enrolled in HIV treatment programs in Jos, Nigeria; Dar es Salaam, Tanzania; and Mbarara, Uganda who had extended absences from care were tracked for qualitative research interviews. Two-hundred-eighty-seven were located, and 91 took part in the study. Interview data were inductively analyzed to identify reasons for missed visits and to assemble them into a broader explanation of how missed visits may develop into disengagement. Findings reveal unintentional and intentional reasons for missing, along with reluctance to return to care following an absence. Disengagement is interpreted as a process through which missed visits and ensuing reluctance to return over time erode patients' subjective sense of connectedness to care.

CONCLUSIONS

Missed visits are inevitable over a lifelong course of HIV care. Efforts to prevent missed clinic visits combined with moves to minimize barriers to re-entry into care are more likely than either approach alone to keep missed visits from turning into long-term disengagement.

Short and long term retention in antiretroviral care in health facilities in rural Malawi and Zimbabwe

Background

Despite the successful scale-up of ART services over the past years, long term retention in ART care remains a major challenge, especially in high HIV prevalence and resource-limited settings. This study analysed the short (<12 months) and long (>12 months) term retention on ART in two ART programmes in Malawi (Thyolo district) and Zimbabwe (Buhera district).

Methods

Retention rates at six-month intervals are reported separately among (1) patients since ART initiation and (2) patients who had been on ART for at least 12 months, according to the site of ART initiation and follow-up, using the Kaplan Meier method. ‘Retention’ was defined as being alive on ART or transferred out, while ‘attrition’ was defined as dead, lost to follow-up or stopped ART.

Results

In Thyolo and Buhera, a total of 12,004 and 9,721 patients respectively were included in the analysis. The overall retention among the patients since ART initiation was 84%, 80% and 77% in Thyolo and 88%, 84% and 82% in Buhera at 6, 12 and 18 months, respectively. In both programmes the largest drop in ART retention was found during the initial 12 months on ART, mainly related to a high mortality rate in the health centres in Thyolo and a high loss to follow-up rate in the hospital in Buhera. Among the patients who had been on ART for at least 12 months, the retention rates leveled out, with 97%, 95% and 94% in both Thyolo and Buhera, at 18, 24 and 30 months respectively. Loss to follow-up was identified as the main contributor to attrition after 12 months on treatment in both programmes.

Conclusions

To better understand the reasons of attrition and adapt the ART delivery care models accordingly, it is advisable to analyse short and long term retention separately, in order to adapt intervention strategies accordingly. During the initial months on ART more medical follow-up, especially for symptomatic patients, is required to reduce mortality. Once stable on ART, however, the ART care delivery should focus on regular drug refill and adherence support to reduce loss to follow up. Hence, innovative life-long retention strategies, including use of new communication technologies, community based interventions and drug refill outside the health facilities are required.

Quantifying and addressing losses along the continuum of care for people living with HIV infection in sub-Saharan Africa: a systematic review

Introduction

Recent years have seen an increasing recognition of the need to improve access and retention in care for people living with HIV/AIDS. This review aims to quantify patients along the continuum of care in sub-Saharan Africa and review possible interventions.

Methods

We defined the different steps making up the care pathway and quantified losses at each step between acquisition of HIV infection and retention in care on antiretroviral therapy (ART). We conducted a systematic review of data from studies conducted in sub-Saharan Africa and published between 2000 and June 2011 for four of these steps and performed a meta-analysis when indicated; existing data syntheses were used for the remaining two steps.

Results

The World Health Organization estimates that only 39% of HIV-positive individuals are aware of their status. Among patients who know their HIV-positive status, just 57% (95% CI, 48 to 66%) completed assessment of ART eligibility. Of eight studies using an ART eligibility threshold of≤200 cells/µL, 41% of patients (95% CI, 27% to 55%) were eligible for treatment, while of six studies using an ART eligibility threshold of≤350 cells/µL, 57% of patients (95% CI, 50 to 63%) were eligible. Of those not yet eligible for ART, the median proportion remaining in pre-ART care was 45%. Of eligible individuals, just 66% (95% CI, 58 to 73%) started ART and the proportion remaining on therapy after three years has previously been estimated as 65%. However, recent studies highlight that this is not a simple linear pathway, as patients cycle in and out of care. Published studies of interventions have mainly focused on reducing losses at HIV testing and during ART care, whereas few have addressed linkage and retention during the pre-ART period.

Conclusions

Losses occur throughout the care pathway, especially prior to ART initiation, and for some patients this is a transient event, as they may re-engage in care at a later time. However, data regarding interventions to address this issue are scarce. Research is urgently needed to identify effective solutions so that a far greater proportion of infected individuals can benefit from long-term ART.

Management of Chronic Diseases in Sub-Saharan Africa: Cross-Fertilisation between HIV/AIDS and Diabetes Care

There is growing attention for chronic diseases in sub-Saharan Africa (SSA) and for bridges between the management of HIV/AIDS and other (noncommunicable) chronic diseases. This becomes more urgent with increasing numbers of people living with both HIV/AIDS and other chronic conditions. This paper discusses the commonalities between chronic diseases by reviewing models of care, focusing on the two most dominant ones, diabetes mellitus type 2 (DM2) and HIV/AIDS. We argue that in order to cope with care for HIV patients and diabetes patients, health systems in SSA need to adopt new strategies taking into account essential elements of chronic disease care. We developed a “chronic dimension framework,” which analyses the “disease dimension,” the “health provider dimension,” the patient or “person dimension,” and the “environment dimension” of chronic diseases. Applying this framework to HIV/AIDS and DM2 shows that it is useful to think about management of both in tandem, comparing care delivery platforms and self-management strategies. A literature review on care delivery models for diabetes and HIV/AIDS in SSA revealed potential elements for cross-fertilisation: rapid scale-up approaches through the public health approach by simplification and decentralisation; community involvement, peer support, and self-management strategies; and strengthening health services.

Risk factors, barriers and facilitators for linkage to antiretroviral therapy care: a systematic review

OBJECTIVE

To characterize patient and programmatic factors associated with retention in care during the pre-antiretroviral therapy (ART) period and linkage to ART care.

DESIGN

Systematic literature review.

METHODS

An electronic search was conducted on MEDLINE, Global Health, Google Scholar and conference databases to identify studies reporting on predictors, barriers and facilitators of retention in care in the pre-ART period, and linkage to care at three steps: ART-eligibility assessment, pre-ART care and ART initiation. Factors associated with attrition were then divided into areas for intervention.

RESULTS

Seven hundred and sixty-eight citations were identified. Forty-two studies from 12 countries were included for review, with the majority from South Africa (16). The most commonly cited category of factors was transport costs and distance. Stigma and fear of disclosure comprised the second most commonly cited category of factors followed by staff shortages, long waiting times, fear of drug side effects, male sex, younger age and the need to take time off work.

CONCLUSION

This review highlights the importance of investigating interventions that could reduce transport difficulties. Decentralization, task-shifting and integration of services need to be expedited to alleviate health system barriers. Patient support groups and strategic posttest counselling are essential to assist patients deal with stigma and disclosure. Moreover, well tolerated first-line drugs and treatment literacy programmes are needed to improve acceptance of ART. This review suggests a combination of interventions to retain specific groups at risk for attrition such as workplace programmes for employed patients, dedicated clinic and support programmes for men and younger individuals.

Successful clinical outcomes following decentralization of tertiary paediatric HIV care to a community-based paediatric antiretroviral treatment network, Chiangrai, Thailand, 2002 to 2008

INTRODUCTION

Most paediatric antiretroviral treatments (ARTs) in Thailand are limited to tertiary care hospitals. To decentralize paediatric HIV treatment and care, Chiangrai Prachanukroh Hospital (CRH) strengthened a provincial paediatric HIV care network by training community hospital (CH) care teams to receive referrals of children for community follow-up. In this study, we assessed factors associated with death and clinical outcomes of HIV-infected children who received care at CRH and CHs after implementation of a community-based paediatric HIV care network.

METHODS

Clinical records were abstracted for all children who initiated ART at CRH. Paired Wilcoxon signed rank tests were used to assess CD4% and virological change among all children. Cox proportional hazard models were used to assess factors associated with death. Treatment outcomes (CD4%, viral load (VL) and weight-for-age Z-score (WAZ)) were compared between CRH and CH children who met the criteria for analysis.

RESULTS

Between February 2002 and April 2008, 423 HIV-infected children initiated ART and 410 included in the cohort analysis. Median follow-up for the cohort was 28 months (interquartile range (IQR)=12 to 42); 169 (41%) children were referred for follow-up at CH. As of 31 March 2008, 42 (10%) children had died. Baseline WAZ (< -2 (p=0.001)) and baseline CD4% (<5% (p=0.015)) were independently associated with death. At 48 months, 86% of ART-naïve children in follow-up had VL<400 copies/ml. For sub-group analysis, 133 children at CRH and 154 at CHs were included for comparison. Median baseline WAZ was lower in CH children than in CRH children (p=0.001); in both groups, WAZ, CD4% and VL improved after ART with no difference in rate of WAZ and CD4% gain (p=0.421 and 0.207, respectively).

CONCLUSIONS

Children at CHs had more severe immunological suppression and low WAZ at baseline. Community- and tertiary care-based paediatric ART follow-ups result in equally beneficial outcomes with the strengthening of a provincial referral network between tertiary and community care. Nutrition interventions may benefit children in community-based HIV treatment and care.

Barriers to retention in care as perceived by persons living with HIV in rural Ethiopia: focus group results and recommended strategies

Inability to retain HIV-infected patients in care undermines the benefits of starting millions in low-income countries on antiretroviral therapy (ART). In a hospital HIV clinic in rural southern Ethiopia, we conducted focus groups of HIV-infected men and women to learn more about experiences with and barriers to attending clinic appointments. Respondents reported multiple barriers, including those that were patient related (eg, misunderstandings about ART, mistaken belief in AIDS cures, and drug/alcohol use), clinic related (eg, negative provider interactions, lack of familiarity with patients' medical situation, and overcrowding), medication related (eg, side effects), social (eg, stigma and discrimination and lack of support), and situational/resource related (eg, distance to clinic, lack of funds, competing domestic/work priorities, and lack of food). Based on the lessons learned from these focus groups, we implemented a community intervention to improve retention, using trained community support workers who provide patient education, counseling, social support, problem-solving assistance, needed referrals, and improved communication/linkage to the patients' HIV clinic.

Attrition among human immunodeficiency virus (HIV)- infected patients initiating antiretroviral therapy in China, 2003-2010

BACKGROUND

Mortality and morbidity from HIV have dramatically decreased in both high- and low-income countries. However, some patients may not benefit from combination antiretroviral therapy (cART) because of inadequate access to HIV care, including attrition after care initiation.

METHODOLOGY/PRINCIPAL FINDINGS

The study population included all HIV-infected patients receiving cART through the Chinese National Free Antiretroviral Treatment Program from 1 January 2003 to 31 December 2010 (n = 106,542). We evaluated retention in HIV care and used multivariable Cox proportional hazard models to identify independent factors predictive of attrition. The cumulative probability of attrition from cART initiation was 9% at 12 months, 13% at 18 months, 16% at 24 months and 24% at 60 months. A number of factors were associated with attrition, including younger age, male gender, and being single or divorced. Patients with higher CD4 cell counts at cART initiation were more likely to drop out of HIV care. The proportion of patients remaining in HIV care increased in more recent calendar years and among patients who initiated modern cART regimens.

CONCLUSIONS/SIGNIFICANCE

Retention in HIV care is essential for optimizing individual and public health outcomes. Attrition, even the degree observed in our study, can lead to premature morbidity and mortality, and possibly affect further transmission of HIV and HIV resistant drug variants. Effective strategies to promote retention in HIV care programs are needed. In China these strategies may include focusing particularly on younger male patients and those with higher CD4 cell counts at therapy initiation.

Involving expert patients in antiretroviral treatment provision in a tertiary referral hospital HIV clinic in Malawi

Background

Current antiretroviral treatment (ART) models in Africa are labour intensive and require a high number of skilled staff. In the context of constraints in human resources for health, task shifting is considered a feasible alternative for ART service delivery. In 2006, Dignitas International in partnership with the Malawi Ministry of Health trained a cadre of expert patients at the HIV Clinic at a tertiary referral hospital in Zomba, Malawi. Expert patients were trained to assist with clinic tasks including measurement of vital signs, anthropometry and counseling.

Methods

A descriptive observational study using mixed methods was conducted two years after the start of program implementation. Semi-structured interviews were conducted with 20 patients, seven expert patients and six formal health care providers to explore perceptions towards the expert patients’ contributions in the clinic. Structured exit interviews with 81 patients, assessed whether essential ART information was conveyed during counseling sessions. Vital signs and anthropometry measurements performed by expert patients were repeated by a nurse to assess accuracy of measurements. Direct observations quantified the time spent with each patient.

Results

There were minor differences in measurement of patients’ weight, height and temperature between the expert patients and the nurse. The majority of patients exiting a counseling session reported, without prompting, at least three side effects of ART, correct actions to be taken on observing a side-effect, and correct consequences of non-adherence to ART. Expert patients carried out 368 hours of nurse tasks each month, saving two and a half full-time nurse equivalents per month. Formal health care workers and patients accept and value expert patients’ involvement in ART provision and care. Expert patients felt valued by patients for being a ‘role model’, or a ‘model of hope’, promoting positive living and adherence to ART.

Conclusions

Expert patients add value to the ART services at a tertiary referral HIV clinic in Malawi. Expert patients carry out shifted tasks acceptably, saving formal health staff time, and also act as ‘living testimonies’ of the benefits of ART and can be a means of achieving greater involvement of People Living with HIV in HIV treatment programs.

Loss to Followup in HIV-Infected Patients from Asia-Pacific Region: Results from TAHOD

This study examined characteristics of HIV-infected patients in the TREAT Asia HIV Observational Database who were lost to follow-up (LTFU) from treatment and care. Time from last clinic visit to 31 March 2009 was analysed to determine the interval that best classified LTFU. Patients defined as LTFU were then categorised into permanently LTFU (never returned) and temporary LTFU (re-entered later), and these groups compared. A total of 3626 patients were included (71% male). No clinic visits for 180 days was the best-performing LTFU definition (sensitivity 90.6%, specificity 92.3%). During 7697 person-years of follow-up, 1648 episodes of LFTU were recorded (21.4 per 100-person-years). Patients LFTU were younger (P = 0.002), had HIV viral load ≥500 copies/mL or missing (P = 0.021), had shorter history of HIV infection (P = 0.048), and received no, single- or double-antiretroviral therapy, or a triple-drug regimen containing a protease inhibitor (P < 0.001). 48% of patients LTFU never returned. These patients were more likely to have low or missing haemoglobin (P < 0.001), missing recent HIV viral load (P < 0.001), negative hepatitis C test (P = 0.025), and previous temporary LTFU episodes (P < 0.001). Our analyses suggest that patients not seen at a clinic for 180 days are at high risk of permanent LTFU, and should be aggressively traced.

Validation of a single-platform, volumetric, flow cytometry for CD4 T cell count monitoring in therapeutic mobile unit

Background

A mobile health unit may be useful to follow up adult and pediatric patients on antiretroviral treatment and living in remote areas devoid of laboratory facilities. The study evaluated the use of the simplified, robust, single-plateform, volumetric, pan-leucogating Auto40 flow cytometer (Apogee Flow Systems Ltd, Hemel Hempstead, UK) for CD4 T cell numeration in a mobile unit, compared against a reference flow cytometry method.

Methods

The therapeutic mobile unit of the Laboratoire National de Santé Hygiène Mobile, Yaoundé, Cameroon, was equipped with the Auto40. A FACSCalibur flow cytometer (Becton Dickinson Immuno-cytometry System, San Jose, CA, USA) was used as reference method. EDTA-blood samples from volunteers were first subjected to CD4 T cell count in the mobile unit, and an aliquot was sent within 4 hours to Centre International de Référence Chantal Biya, Yaoundé, for FACSCalibur assay.

Results

Two HIV screening campaigns with the mobile unit were organised in December 2009 and January 2010. The campaign in the suburb of Yaoundé which was 20 km from the reference laboratory included 188 volunteers comprising 93 children less than 5 years old. The campaign in Ambang Bikok (53 km far from Yaoundé) included 69 adult volunteers. In Yaoundé suburb, mean ± standard deviation (SD) CD4 T cell count was 996 ± 874 cells/μl by Auto40, and 989 ± 883 cells/μl by FACSCalibur; in Ambang Bikok, mean ± SD CD4 T cell count was 1041 ± 317 cells/μl by Auto40, and 1032 ± 294 cells/μl by FACSCalibur. Results by Auto40 and FACSCalibur were highly correlated in Yaoundé (r² = 0.982) as in Ambang Bikok (r² = 0.921). Bland-Altman analysis showed a close agreement between Auto40 and FACSCalibur results expressed in absolute count as in percentage in Yaoundé and Ambang Bikok. When pooling the 257 CD4 T cell count measurements, the Auto40 yielded a mean difference of +7.6 CD4 T cells/μl higher than by reference flow cytometry; and the sensitivity and specificity of Auto40 in enumerating absolute CD4 T cell counts of less than 200 cells/μl were 87% and 99%, respectively, and in enumerating absolute CD4 T cell counts of less than 350 cells/μl were 87% and 98%, respectively. The intrarun and interun precisions of the Auto40 assay assessed in the mobile unit were 5.5% and 7.9%, respectively.

Conclusions

The Auto40 flow cytometer installed in a therapeutic mobile unit and operated far from its reference laboratory gave a perfect correlation with the reference method, and could be useful in carrying out immunological monitoring of HIV-infected patients living in areas without access to laboratory facilities.

Low mortality risk but high loss to follow-up among patients in the Tanzanian national HIV care and treatment programme

OBJECTIVE To analyse survival and retention rates of the Tanzanian care and treatment programme.

METHODS

Routine patient-level data were available from 101 of 909 clinics. Kaplan-Meier probabilities of mortality and attrition after ART initiation were calculated. Mortality risks were corrected for biases from loss to follow-up using Egger's nomogram. Smoothed hazard rates showed mortality and attrition peaks. Cox regression identified factors associated with death and attrition. Median CD4 counts were calculated at 6 month intervals.

RESULTS

In 88,875 adults, 18% were lost to follow up 12 months after treatment initiation, and 36% after 36 months. Cumulative mortality reached 10% by 12 months (15% after correcting for loss to follow-up) and 14% by 36 months. Mortality and attrition rates both peaked within the first six months, and were higher among males, those under 45 kg and those with CD4 counts below 50 cells/μl at ART initiation. In the first year on ART, median CD4 count increased by 126 cells/μl, with similar changes in both sexes.

CONCLUSION

Earlier diagnoses through expanded HIV testing may reduce high mortality and attrition rates if combined with better patient tracing systems. Further research is needed to explore reasons for attrition.

Loss to follow-up of stable antiretroviral therapy patients in a decentralized down-referral model of care in Johannesburg, South Africa

A retrospective record review was conducted for patients down referred to primary health care facilities between 2007 and 2009 to assess the rate and reported reasons for loss to follow-up among stable antiretroviral patients in a down-referral model of care in Johannesburg, South Africa. Missing patients were traced telephonically. Of 3361 patients down referred, 4.11% were lost to follow-up. Most patients who were lost to follow-up were lost at the transfer stage between initiation and maintenance sites. Decentralization and nurse management of ART should be prioritized to increase access to and retention in HIV/AIDS care.

Interventions to increase antiretroviral adherence in sub-Saharan Africa: a systematic review of evaluation studies

The success of potent antiretroviral treatment for HIV infection is primarily determined by adherence. We systematically review the evidence of effectiveness of interventions to increase adherence to antiretroviral treatment in sub-Saharan Africa. We identified 27 relevant reports from 26 studies of behavioural, cognitive, biological, structural, and combination interventions done between 2003 and 2010. Despite study diversity and limitations, evidence suggests that treatment supporters, directly observed therapy, mobile-phone text messages, diary cards, and food rations can effectively increase adherence in sub-Saharan Africa. However, some interventions are unlikely to have large or lasting effects, and others are effective only in specific settings. These findings emphasise the need for more research, particularly for randomised controlled trials, to examine the effect of context and specific features of intervention content on effectiveness. Future work should assess intervention targeting and selection of interventions based on behavioural theories relevant to sub-Saharan Africa.

Anti-retroviral treatment outcomes among older adults in Zomba district, Malawi

BACKGROUND

There are approximately 3 million people aged 50 and older in sub-Saharan Africa who are HIV-positive. Despite this, little is known about the characteristics of older adults who are on treatment and their treatment outcomes.

METHODS

A retrospective cohort analysis was performed using routinely collected data with Malawi Ministry of Health monitoring tools from facilities providing antiretroviral therapy services in Zomba district. Patients aged 25 years and older initiated on treatment from July 2005 to June 2010 were included. Differences in survival, by age group, were determined using Kaplan-Meier survival plots and Cox proportional hazards regression models.

RESULTS

There were 10,888 patients aged 25 and older. Patients aged 50 and older (N = 1419) were more likely to be male (P<0.0001) and located in rural areas (P = 0.003) than those aged 25-49. Crude survival estimates among those aged 50-59 were not statistically different from those aged 25-49 (P = 0.925). However, survival among those aged 60 and older (N = 345) was worse (P = 0.019) than among those 25-59. In the proportional hazards model, after controlling for sex and stage at initiation, survival in those aged 50-59 did not differ significantly from those aged 25-49 (hazard ratio 1.00 (95% CI: 0.79 to 1.27; P = 0.998) but the hazard ratio was 1.46 (95% CI: 1.03 to 2.06; P = 0.032) for those aged 60 and older compared to those aged 25-49.

CONCLUSIONS

Treatment outcomes of those aged 50-59 are similar to those aged 25-49. A better understanding of how older adults present for and respond to treatment is critical to improving HIV services.

A study of patient attitudes towards decentralisation of HIV care in an urban clinic in South Africa

Background

In South Africa, limited human resources are a major constraint to achieving universal antiretroviral therapy (ART) coverage. Many of the public-sector HIV clinics operating within tertiary facilities, that were the first to provide ART in the country, have reached maximum patient capacity. Decentralization or "down-referral" (wherein ART patients deemed stable on therapy are referred to their closest Primary Health Clinics (PHCs) for treatment follow-up) is being used as a possible alternative of ART delivery care. This cross-sectional qualitative study investigates attitudes towards down-referral of ART delivery care among patients currently receiving care in a centralized tertiary HIV clinic.

Methods

Ten focus group discussions (FGDs) with 76 participants were conducted in early 2008 amongst ART patients initiated and receiving care for more than 3 months in the tertiary HIV clinic study site. Eligible individuals were invited to participate in FGDs involving 6-9 participants, and lasting approximately 1-2 hours. A trained moderator used a discussion topic guide to investigate the main issues of interest including: advantages and disadvantages of down-referral, potential motivating factors and challenges of down-referral, assistance needs from the transferring clinic as well as from PHCs.

Results

Advantages include closeness to patients' homes, transport and time savings. However, patients favour a centralized service for the following reasons: less stigma, patients established relationship with the centralized clinic, and availability of ancillary services. Most FGDs felt that for down-referral to occur there needed to be training of nurses in patient-provider communication.

Conclusion

Despite acknowledging the down-referral advantages of close proximity and lower transport costs, many participants expressed concerns about lack of trained HIV clinical staff, negative patient interactions with nurses, limited confidentiality and stigma. There was consensus that training of nurses and improved health systems at the local clinics were needed if successful down-referral was to take place.

Outcome assessment of a dedicated HIV positive health care worker clinic at a central hospital in Malawi: a retrospective observational study

Background

Malawi has one of the world's lowest densities of Health Care Workers (HCW) per capita. This study evaluates outcomes of a dedicated HCW HIV clinic in Malawi, created at Zomba Central Hospital in January 2007.

Methods and Findings

Retrospective cohort data was analyzed comparing HCW clinic patient baseline characteristics and treatment outcomes at 18 months after inception, against those attending the general HIV clinic. In-depth interviews and focus group discussions were conducted to explore perceptions of patients and caregivers regarding program value, level of awareness and barriers for uptake amongst HCW. 306 patients were enrolled on antiretroviral therapy (ART) in the HCW HIV clinic, 6784 in the general clinic. Significantly (p<0.01) more HCW clients were initiated on ART on the basis of CD4 as opposed to WHO Stage 3/4 (36% vs.23%). Significantly fewer HCW clients defaulted (6% vs.17%), and died (4% vs.12%). The dedicated HCW HIV clinic was perceived as important and convenient in terms of reduced waiting times, and prompt and high quality care. Improved confidentiality was an appreciated quality of the HCW clinic however barriers included fear of being recognized.

Conclusions/Significance

Outcomes at the HCW clinic appear better compared to the general HIV clinic. The strategy of dedicated clinics to care for health providers is a means of HIV impact mitigation within human resource constrained health systems in high prevalence settings.

Accurate CD4 T-cell enumeration and antiretroviral drug toxicity monitoring in primary healthcare clinics using point-of-care testing

OBJECTIVE

To evaluate the accuracy of point-of-care tests (POCTs) for CD4 cell, clinical chemistry and hemoglobin in primary healthcare clinics in Mozambique.

DESIGN AND METHODS

POCT and laboratory-based assays were conducted on adult HIV-positive patients enrolled consecutively at primary healthcare clinics in Mozambique. Patients were tested on-site with POCT CD4 (Pima), clinical chemistry (Reflotron) and hemoglobin (HemoCue) devices using finger prick blood. Results obtained on paired blood samples were used for agreement analysis (bias and limits of agreement). Repeatability analysis was also performed for POCT CD4 cell counting.

RESULTS

Primary health nurses operating the Pima, Reflotron and HemoCue POCT devices produced results with low levels of bias for CD4(+) T-cell counts (-52.8 cells/μl), alanine aminotransferase (-0.2 U/l), aspartate aminotransferase (-4.0 U/l) and hemoglobin (0.95 g/dl). CD4(+) T-cell counts in paired specimens of finger prick and venous blood tested on the POCT CD4 device were in close agreement (bias -9 cells/μl, coefficient of variation 10.6%). The repeatability of POCT CD4 cell counting was similar to that observed with laboratory instruments (bias -6.2 cells/μl, coefficient of variation 10.7% vs. bias -5.7 cells/μl, coefficient of variation 7.5%).

CONCLUSION

Primary health clinic nurses generated accurate results for CD4(+) T-cell counts, liver enzymes and hemoglobin using simple POC devices on finger prick samples at decentralized antiretroviral therapy (ART) clinics. POC diagnostics to monitor ART at primary healthcare level is technically feasible and should be utilized in efforts to decentralize HIV care and treatment.

Retention in care among HIV-infected patients in resource-limited settings: emerging insights and new directions

In resource-limited settings--where a massive scale-up of HIV services has occurred in the last 5 years--both understanding the extent of and improving retention in care presents special challenges. First, retention in care within the decentralizing network of services is likely higher than existing estimates that account only for retention in clinic, and therefore antiretroviral therapy services may be more effective than currently believed. Second, both magnitude and determinants of patient retention vary substantially and therefore encouraging the conduct of locally relevant epidemiology is needed to inform programmatic decisions. Third, socio-structural factors such as program characteristics, transportation, poverty, work/child care responsibilities, and social relations are the major determinants of retention in care, and therefore interventions to improve retention in care should focus on implementation strategies. Research to assess and improve retention in care for HIV-infected patients can be strengthened by incorporating novel methods such as sampling-based approaches and a causal analytic framework.