Patient retention and attrition on antiretroviral treatment at district level in rural Malawi

Barriers to longitudinal follow-up for hepatitis B treatment in rural Sierra Leone: A mixed methods study of retention in care

HBV disproportionately affects resource-limited settings, and retaining patients in longitudinal care remains challenging. We conducted a mixed methods investigation to understand the causes of losses to follow-up within an HBV clinic in rural Sierra Leone. We developed a multivariable logistic regression model of baseline clinical and sociodemographic factors predicting losses to follow-up, defined as failing to present for a follow-up visit within 14 months of enrollment. We included patients enrolled between April 30, 2019 and March 1, 2020, permitting 14 months of follow-up by April 30, 2021. We then developed a survey to solicit patient perspectives on the challenges surrounding retention. We interviewed randomly selected patients absent from HBV care for at least 6 months. Among 271 patients enrolled in the Kono HBV clinic, 176 (64.9%) did not have a follow-up visit within 14 months of the study end point. Incomplete baseline workup (aOR 2.9; 95% CI: 1.6-4.8), lack of treatment at baseline (aOR 5.0; 95% CI: 1.7-14.4), and having cirrhosis at baseline (aOR 3.3; 95% CI: 0.99-10.8) were independently associated with being lost to follow-up. For the patient survey, 21 patients completed the interview (median age 34 years [IQR: 25-38]). Travel-related factors were the most frequently reported barrier to retention (57%). Almost 30% suggested improved customer care might support retention in care; 24% requested to be given medication. In our setting, factors that might reduce losses to follow-up included expanded criteria for treatment initiation, overcoming transportation barriers, reducing wait times, ensuring against stockouts, and scaling up point-of-care testing services.

Agreement between maternal self-report of birth-related information and medical records in Brazil: A comparison study between public, mixed, and private hospitals

BACKGROUND

The study aims to assess agreement between data obtained from interviews with postpartum women and their health records about labor and birth characteristics, newborn care, and reasons for cesarean birth.

METHODS

The present study analyzes the Birth in Brazil study dataset, a nationwide hospital-based survey that included 23,894 postpartum women. Reliability was assessed using kappa coefficients and 95% confidence intervals. We also calculated the proportion of specific agreement: the observed proportion of positive agreement (Ppos) and the observed proportion of negative agreement (Pneg).

RESULTS

In terms of labor and birth characteristics, more significant discrepancies in prevalence were observed for fundal pressure (1.4%-42.6%), followed by amniotomy, and augmentation. All of these variables were reported more frequently by women. Reliability was nearly perfect only for mode of delivery (kappa 0.99-1.00, Ppos and Pneg >99.0%). Higher discrepancies in reasons for cesarean prevalence were observed for previous cesarean birth (CB) (3.9%-10.4%) and diabetes mellitus (0.5%-8.5%). Most kappa coefficients for CB reasons were moderate to substantial. Lower coefficients were seen for diabetes mellitus, induction failure, and prelabor rupture of membranes and Pneg was consistently higher than Ppos.

DISCUSSION

Our findings raise relevant questions about the quality of information shared with women during and after the process of care for labor and birth, as well as the information recorded in medical charts. Not having access to full information about their own health status at birth may impair women's health promotion behaviors or clear disclosure of risk factors in future interactions with the healthcare system.

Clinical outcomes among adolescents living with HIV in Kenya following initiation on antiretroviral treatment

In Kenya, HIV/AIDS remains a leading cause of morbidity and mortality among adolescents living with HIV (ALHIV). Our study evaluated associations between demographic and healthcare factors and HIV treatment outcomes among ALHIV in care in Kenya. This retrospective cohort study evaluated the clinical outcomes of newly diagnosed ALHIV enrolled in HIV care during January 2017-June 2018 at 32 healthcare facilities in Homabay and Kakamega Counties. Demographic and clinical data were abstracted from patient clinical records and registers during the follow up study period January 2017-through May 2019. ALHIV were stratified by age (10-14 versus 15-19 years). Categorical variables were summarized using descriptive statistics; continuous variables were analyzed using mean values. The latest available treatment and virological outcomes for ALHIV were assessed. 330 ALHIV were included in the study (mean age 15.9 years; 81.8% female, 63.0% receiving HIV care at lower-level healthcare facilities). Most (93.2%) were initiated on ART within 14 days of diagnosis; 91.4% initiated EFV-based regimens. Of those on ART, only 44.6% were active on care at the end of the study period. Of those eligible for viral load testing, 83.9% were tested with 84.4% viral suppression rate. Retention in care was higher at higher-level facilities (67.5%) compared to lower-level facilities (28.6%). Factors associated with higher retention in care were school attendance (aRR = 1.453), receipt of disclosure support (aRR = 13.315), and receiving care at a high-level health facility (aRR = 0.751). Factors associated with viral suppression included older age (15-19 years) (aRR = 1.249) and pre-ART clinical WHO stage I/II (RR = .668). Viral suppression was higher among older ALHIV. Studies are needed to evaluate effective interventions to improve outcomes among ALHIV in Kenya.

Long-Distance Travel for HIV-Related Care-Burden or Choice?: A Mixed Methods Study in Tanzania

Decentralization of HIV care across sub-Saharan Africa has increased access to anti-retroviral therapy (ART). Although traveling for care has traditionally been viewed as a barrier, some individuals may choose to travel for care due to stigma and fear of HIV status disclosure. We sought to understand the prevalence of traveling long distances for HIV care, as well as reasons for engaging in such travel. Using a concurrent embedded mixed-methods study design, individuals receiving care at two HIV care and treatment clinics in Tanzania completed a quantitative survey (n = 196), and a sub-set of participants reporting long-distance travel for care were interviewed (n = 31). Overall 58.2% of participants (n = 114/196) reported knowing of a closer clinic than the one they chose to attend. Having experienced enacted stigma was significantly associated with traveling for care (OR 2.31, 95% CI 1.12, 4.75, p = 0.02). Reasons for clinic choice centered on three main themes: clinic familiarity, quality of care, and stigma. Traveling for care was often viewed as an enabling strategy for remaining engaged in care by helping overcome other barriers, including stigma and suboptimal quality of care.

Incidence and predictors of attrition among patients receiving ART in eastern Zimbabwe before, and after the introduction of universal 'treat-all' policies: A competing risk analysis

As HIV treatment is expanded, attention is focused on minimizing attrition from care. We evaluated the impact of treat-all policies on the incidence and determinants of attrition amongst clients receiving ART in eastern Zimbabwe. Data were retrospectively collected from the medical records of adult patients (aged≥18 years) enrolled into care from July 2015 to June 2016-pre-treat-all era, and July 2016 to June 2017-treat-all era, selected from 12 purposively sampled health facilities. Attrition was defined as an absence from care >90 days following ART initiation. Survival-time methods were used to derive incidence rates (IRs), and competing risk regression used in bivariate and multivariable modelling. In total, 829 patients had newly initiated ART and were included in the analysis (pre-treat-all 30.6%; treat-all 69.4%). Incidence of attrition (per 1000 person-days) increased between the two time periods (pre-treat-all IR = 1.18 (95%CI: 0.90-1.56) versus treat-all period IR = 1.62 (95%CI: 1.37-1.91)). In crude analysis, patients at increased risk of attrition were those enrolled into care during the treat-all period, <34 years of age, WHO stage I at enrolment, and had initiated ART on the same day as HIV diagnosis. After accounting for mediating clinical characteristics, the difference in attrition between the pre-treat-all, and treat-all periods ceased to be statistically significant. In a full multivariable model, attrition was significantly higher amongst same-day ART initiates (aSHR = 1.47, 95%CI:1.05-2.06). Implementation of treat-all policies was associated with an increased incidence of ART attrition, driven largely by ART initiation on the same day as HIV diagnosis which increased significantly in the treat all period. Differentiated adherence counselling for patients at increased risk of attrition, and improved access to clinical monitoring may improve retention in care.

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

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.

The impact of an integrated depression and HIV treatment program on mental health and HIV care outcomes among people newly initiating antiretroviral therapy in Malawi

BACKGROUND

Depression is highly prevalent among patients newly starting antiretroviral treatment (ART) in Malawi and many other countries. Untreated depression at ART initiation can disrupt the HIV care continuum. Effective approaches for depression screening and treatment exist for low-resource settings, but they are rarely applied. Identifying effective implementation strategies are critical.

METHODS

A pilot program integrated depression screening and treatment into routine HIV care using existing staff at two public health clinics in Malawi in two phases; a screening-only "control" phase and an active "intervention" phase. During the intervention phase, providers prescribed antidepressants or referred patients for Friendship Bench problem-solving therapy. We evaluated the program's impact on retention in HIV care, viral suppression, and depression remission at 6 months using tabular comparisons and log-binomial models to estimate adjusted risk ratios and mean differences among the intervention group relative to the control group.

RESULTS

Nearly all consenting participants were screened for depression appropriately and 25% had mild to severe depressive symptoms. During the intervention phase, 86% of participants with mild depressive symptoms started Friendship Bench therapy and 96% of participants with moderate to severe depressive symptoms started antidepressants. Few participants in the intervention group received consistent depression treatment over their first 6 months in care. In the adjusted main analysis, program exposure did not demonstrably affect most HIV or mental health outcomes, though the probability of currently being on ART at 6 months was significantly lower among the intervention group than the control group [RR 0.6(95%CI: 0.4-0.9)].

CONCLUSIONS

While it is feasible to integrate depression screening and treatment initiation into ART initiation, providing ongoing depression treatment over time is challenging. Similar implementation science studies focused on maintaining depression management will be increasingly important as we strive to understand and test the best ways to implement evidence-based depression treatment within HIV care.

The effects of decentralising antiretroviral therapy care delivery on health outcomes for adolescents and young adults in low- and middle-income countries: a systematic review

Background: Decentralisation of antiretroviral therapy has been implemented to scale up HIV care provision for patients in resource-limited countries. Youth living with HIV demonstrate the poorest care outcomes, compared to other age groups. Objectives: To systematically evaluate evidence on the effects of decentralising facility-based HIV care on care outcomes for youth living with HIV in low- and middle-income countries. Methods: A systematic review was conducted through 12 electronic databases of peer-reviewed articles, conference abstracts, and grey literature; contacting relevant experts; and hand-searching references. Records were included if they were published after 1 January 1996 (advent of triple-drug ART) and reported health outcomes for decentralised and centralised care, separately, or evaluated the effect of decentralised care on care outcomes. Two authors independently screened search results. When age-disaggregated data (10-24 years old) were required for inclusion, we contacted study authors for data abstraction. Implementation fidelity of decentralisation, study quality, and risk of bias was assessed using the TIDieR checklist, CASP checklists, and ROBINS-I tool, respectively. Results: Of 11 potentially eligible studies, two studies from sub-Saharan Africa met inclusion criteria after data disaggregation by age. The studies and abstracted data were insufficiently homogenous in implementation and study design to justify meta-analysis. However, evidence suggests the potential for decentralised care to result in at least equivalent attrition-related outcomes (retention in care and mortality) for youth within decentralised HIV care. Limited sample size and significant selection and allocation bias confound clear, generalisable conclusions for youth living with HIV in resource-limited settings. Conclusions: There is a paucity of evidence for the effects of decentralising HIV care for youth living in resource-limited settings, particularly recent evidence reflective of the current HIV care landscape. Further work is required to rigorously analyse the effects of decentralising HIV care to inform policymakers and care providers, particularly as demand for HIV care in this population grows.

Differentiated Antiretroviral Therapy Distribution Models: Enablers and Barriers to Universal HIV Treatment in South Africa, Uganda, and Zimbabwe

Emerging HIV treatment distribution models across sub-Saharan Africa seek to overcome barriers to attaining antiretroviral therapy and to strengthen adherence in people living with HIV. We describe enablers, barriers, and benefits of differentiated treatment distribution models in South Africa, Uganda, and Zimbabwe. Data collection included semistructured interviews and focus group discussions with 163 stakeholders from policy, program, and patient levels. Four types of facility-based and 3 types of community-based models were identified. Enablers included policy, leadership, and guidance; functional information systems; strong care linkages; steady drug supply; patient education; and peer support. Barriers included insufficient drug supply, stigma, discrimination, and poor care linkages. Benefits included perceived improved adherence, peer support, reduced stigma and discrimination, increased time for providers to spend with complex patients, and travel and cost savings for patients. Differentiated treatment distribution models can enhance treatment access for patients who are clinically stable.

Retention in care and adherence to HIV and AIDS treatment in Anambra State Nigeria

Background

Retaining patients on antiretroviral treatment in care is critical to sustaining the 90:90:90 vision. Nigeria has made some progress in placing HIV-positive patients on treatment. In an effort to increase access to treatment, ART decentralization has been implemented in the country. This is aimed at strengthening lower level health facilities to provide comprehensive antiretroviral treatment. We determined the level of retention and adherence to treatment as well as the associated factors among private and public secondary level hospitals in Anambra State.

Method

We conducted a cross-sectional study among patients who had taken antiretroviral treatment for at least one complete year. A structured questionnaire and patient record review were used to extract information on patient adherence to treatment, and retention in care. Adherence to treatment was ascertained by patient self-report of missed pills in the 30 days prior to date of interview. Retention in care was ascertained using the 3-month visit constancy method reviewing the period spanning 12 months prior to the study.

Result

We found a comparable level of retention in care (private 81.1%; public 80.3%; p = 0.722). However, treatment adherence was significantly higher amongst participants in the private hospitals compared to those in the public hospitals (private: 95.3%; public: 90.7%; p = 0.001). Determinants of good retention in the private hospitals included disclosure of one’s HIV status (AOR: 1.94, 95% CI: 1.09–3.46), being on first-line regimen (AOR: 3.07, 95% CI: 1.27–7.41), whereas being on once-daily regimen (AOR: 0.58, 95% CI: 0.36–0.92), and being currently married (AOR: 0.54 95% CI: 0.32–0.91) determined poor retention. In the public hospitals, only disclosure (AOR: 3.12 95% CI: 1.81–5.56) determined good retention, whereas, spending less than N1000 on transport (AOR: 0.230 95% CI: 0.07–0.78) and residing in a rural area (AOR: 0.64 95% CI: 0.41–0.99) determined poor retention. None of the factors determined adherence.

Conclusion

Retention in care was high and comparable among the different hospital types and HIV disclosure status was an important factor relating to retention in care. The other factors that determined retention were however different at public and private hospitals. The HIV program manager should consider these variations in designing programs to improve patient retention in care and adherence to treatment.

The effectiveness of depression management for improving HIV care outcomes in Malawi: protocol for a quasi-experimental study

BACKGROUND

Depression, prevalent among people living with HIV (PLWH) in Malawi, is associated with negative HIV patient outcomes and likely affects HIV medical management. Despite the high prevalence of depression, its management has not been integrated into HIV care in Malawi or most low-income countries.

METHODS

This study employs a pre-post design in two HIV clinics in Lilongwe, Malawi, to evaluate the effect of integrating depression management into routine HIV care on both mental health and HIV outcomes. Using a multiple baseline design, this study is examining mental health and HIV outcome data of adult (≥18 years) patients newly initiating ART who also have depression, comparing those entering care before and after the integration of depression screening and treatment into HIV care. The study is also collecting cost information to estimate the cost-effectiveness of the program in improving rates of depression remission and HIV treatment engagement and success.

DISCUSSION

We anticipate that the study will generate evidence on the effect of depression management on HIV outcomes and the feasibility of integrating depression management into existing HIV care clinics. The results of the study will inform practice and policy decisions on integration of depression management in HIV care clinics in Malawi and related settings, and will help design a next-step strategy to scale-up integration to a larger scale.

TRIAL REGISTRATION

ClinicalTrials.gov ID [ NCT03555669 ]. Retrospectively registered on 13 June 2018.

Integrating depression management into HIV primary care in central Malawi: the implementation of a pilot capacity building program

BACKGROUND

In Malawi, early retention in HIV care remains challenging. Depression is strongly associated with reduced anti-retroviral therapy (ART) adherence and viral suppression. Appropriate depression care for people initiating ART is likely to be supportive of early and continued engagement in the HIV care continuum. This paper aims to provide an overview of a task-shifting program that integrates depression screening and treatment into HIV care and the strategy used to evaluate this program, describes the implementation process, and discusses key challenges and lessons learned in the first phase of program implementation.

METHODS

We are implementing a program integrating depression screening and treatment into HIV care initiation at two clinics in Lilongwe District, Malawi. The program's effect on patients' depression and HIV outcomes will be evaluated using a multiple baseline pre-post study. In this manuscript, we draw from our experiences as program implementers and some of the quantitative data to describe the process of implementation and key lessons learned.

RESULTS

We successfully implemented the screening phase of this program at both clinics; 88.3 and 93.2% of newly diagnosed patients have been screened for depression at each clinic respectively. 25% of enrolled patients reported symptoms of mild-to-severe depression and only 6% reported symptoms of moderate-to-severe depression. Key lessons learned from the process show the importance of utilizing existing processes and infrastructure and focusing on iterative and collaborative learning. We continued to face challenges around establishing a sense of program ownership among providers, developing capacity to diagnose and manage depression, and ensuring the availability of appropriate medication. Our efforts to address these challenges provide insight into the technical and managerial support needed to prepare for, roll out, and sustain integrated models of mental health and HIV care.

CONCLUSIONS

This activity demonstrates how a depression screening program can successfully be integrated into HIV care within the public health system in Malawi. While this program focuses on integrating depression management into HIV care, most of the lessons learned could apply to integration of mental health into any non-psychiatric specialist setting.

TRIAL REGISTRATION

ClinicalTrials.gov ID [ NCT03555669 ]. Retrospectively registered on 13 June 2018.

Review of differentiated approaches to antiretroviral therapy distribution

In response to global trends of maximizing the number of patients receiving antiretroviral therapy (ART), this review summarizes literature describing differentiated models of ART distribution at facility and community levels in order to highlight promising strategies and identify evidence gaps. Databases and gray literature were searched, yielding thirteen final articles on differentiated ART distribution models supporting stable adult patients. Of these, seven articles focused on distribution at facility level and six at community level. Findings suggest that differentiated models of ART distribution contribute to higher retention, lower attrition, and less loss to follow-up (LTFU). These models also reduced patient wait time, travel costs, and time lost from work for drug pick-up. Facility- and community-level ART distribution models have the potential to extend treatment availability, enable improved access and adherence among people living with HIV (PLHIV), and facilitate retention in treatment and care. Gaps remain in understanding the desirability of these models for PLHIV, and the need for more information the negative and positive impacts of stigma, and identifying models to reach traditionally marginalized groups such as key populations and youth. Replicating differentiated care so efforts can reach more PLHIV will be critical to scaling these approaches across varying contexts.

Retention in Differentiated Care: Multiple Measures Analysis for a Decentralized HIV Care and Treatment Program in North Central Nigeria

Objective

Differentiated care refers collectively to flexible service models designed to meet the differing needs of HIV-infected persons in resource-scarce settings. Decentralization is one such service model. Retention is a key indicator for monitoring the success of HIV treatment and care programs. We used multiple measures to compare retention in a cohort of patients receiving HIV care at “hub” (central) and “spoke” (decentralized) sites in a large public HIV treatment program in north central Nigeria.

Methods

This retrospective cohort study utilized longitudinal program data representing central and decentralized levels of care in the Plateau State Decentralization Initiative, north central Nigeria. We examined retention with patient- level (retention at fixed times, loss-to-follow-up [LTFU]) and visit-level (gaps-in-care, visit constancy) measures. Regression models with generalized estimating equations (GEE) were used to estimate the effect of decentralization on visit-level measures. Patient-level measures were examined using survival methods with Cox regression models, controlling for baseline variables.

Results

Of 15,650 patients, 43% were enrolled at the hub. Median time in care was 3.1 years. Hub patients were less likely to be LTFU (adjusted hazard ratio (AHR)=0.91, 95% CI: 0.85-0.97), compared to spoke patients. Visit constancy was lower at the hub (−4.5%, 95% CI: −3.5, −5.5), where gaps in care were also more likely to occur (adjusted odds ratio=1.95, 95% CI: 1.83-2.08).

Conclusion

Decentralized sites demonstrated better retention outcomes using visit-level measures, while the hub achieved better retention outcomes using patient-level measures. Retention estimates produced by incorporating multiple measures showed substantial variation, confirming the influence of measurement strategies on the results of retention research. Future studies of retention in HIV care in sub-Saharan Africa will be well-served by including multiple measures.

Identifying models of HIV care and treatment service delivery in Tanzania, Uganda, and Zambia using cluster analysis and Delphi survey

BACKGROUND

Organization of HIV care and treatment services, including clinic staffing and services, may shape clinical and financial outcomes, yet there has been little attempt to describe different models of HIV care in sub-Saharan Africa (SSA). Information about the relative benefits and drawbacks of different models could inform the scale-up of antiretroviral therapy (ART) and associated services in resource-limited settings (RLS), especially in light of expanded client populations with country adoption of WHO's test and treat recommendation.

METHODS

We characterized task-shifting/task-sharing practices in 19 diverse ART clinics in Tanzania, Uganda, and Zambia and used cluster analysis to identify unique models of service provision. We ran descriptive statistics to explore how the clusters varied by environmental factors and programmatic characteristics. Finally, we employed the Delphi Method to make systematic use of expert opinions to ensure that the cluster variables were meaningful in the context of actual task-shifting of ART services in SSA.

RESULTS

The cluster analysis identified three task-shifting/task-sharing models. The main differences across models were the availability of medical doctors, the scope of clinical responsibility assigned to nurses, and the use of lay health care workers. Patterns of healthcare staffing in HIV service delivery were associated with different environmental factors (e.g., health facility levels, urban vs. rural settings) and programme characteristics (e.g., community ART distribution or integrated tuberculosis treatment on-site).

CONCLUSIONS

Understanding the relative advantages and disadvantages of different models of care can help national programmes adapt to increased client load, select optimal adherence strategies within decentralized models of care, and identify differentiated models of care for clients to meet the growing needs of long-term ART patients who require more complicated treatment management.

Specification of implementation interventions to address the cascade of HIV care and treatment in resource-limited settings: a systematic review

Background

The global response to HIV has started over 18 million persons on life-saving antiretroviral therapy (ART)—the vast majority in low- and middle-income countries (LMIC)—yet substantial gaps remain: up to 40% of persons living with HIV (PLHIV) know their status, while another 30% of those who enter care are inadequately retained after starting treatment. Identifying strategies to enhance use of treatment is urgently needed, but the conceptualization and specification of implementation interventions is not always complete. We sought to assess the completeness of intervention reporting in research to advance uptake of treatment for HIV globally.

Methods

We carried out a systematic review to identify interventions targeting the adult HIV care cascade in LMIC dating from 1990 to 2017. We identified components of each intervention as “intervention types” to decompose interventions into common components. We grouped “intervention types” into a smaller number of more general “implementation approaches” to aid summarization.

We assessed the reporting of six intervention characteristics adapted from the implementation science literature: the actor, action, action dose, action temporality, action target, and behavioral target in each study.

Findings

In 157 unique studies, we identified 34 intervention “types,” which were empirically grouped into six generally understandable “approaches.” Overall, 42% of interventions defined the actor, 64% reported the action, 41% specified the intervention “dose,” 43% reported action temporality, 61% defined the action target, and 69% reported a target behavior. Average completeness of reporting varied across approaches from a low of 50% to a high of 72%. Dimensions that involved conceptualization of the practices themselves (e.g., actor, dose, temporality) were in general less well specified than consequences (e.g., action target and behavioral target).

Implications

The conceptualization and Reporting of implementation interventions to advance treatment for HIV in LMIC is not always complete. Dissemination of standards for reporting intervention characteristics can potentially promote transparency, reproducibility, and scientific accumulation in the area of implementation science to address HIV in low- and middle-income countries.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-017-0630-8) contains supplementary material, which is available to authorized users.

Impact of decentralisation of antiretroviral therapy services on HIV testing and care at a population level in Agago District in rural Northern Uganda: results from the Lablite population surveys

Background

We conducted unlinked cross-sectional population-based surveys in Northern Uganda before and after antiretroviral therapy (ART) provision (including Option B+ [lifelong ART for pregnant/breast-feeding women]) at a local primary care facility (Lira Kato Health Centre [HC]). Prior to decentralisation, people travelled 56-76 km round-trip for ART; we aimed to evaluate changes in uptake of HIV-testing, ART coverage and access to ART following decentralisation.

Methods

A total of 2124 adults in 1351 households in two parishes closest to Lira Kato HC were interviewed using questionnaires between March and April 2013 and 2123 adults in 1229 households between January and March 2015.

Results

Adults reporting HIV-testing in the last year increased from 1077/2124 (50.7%) to 1298/2123 (61.1%) between surveys (p<0.001). ART coverage increased from 74/136 (54.4%) self-reported HIV-positive adults in 2013 to 108/133 (81.2%) in 2015 (p<0.001). Post-decentralisation, 47/108 (43.5%) of those on ART were in care at Lira Kato HC (including 37 new initiations). Most of the remainder (47/61, 77%) started ART prior to any ART provision at Lira Kato HC; the most common reason given for not accessing ART locally was concern about drug-stock-outs (30/59, 51%).

Conclusions

HIV-testing and ART coverage increased after decentralisation combined with Option B+ roll-out. However, patients on ART before decentralisation were reluctant to transfer to their local facility.

Cost-effectiveness analysis of the national decentralization policy of antiretroviral treatment programme in Zambia

Background

In resource-limited settings with a high prevalence of human immunodeficiency virus (HIV) infection such as Zambia, decentralization of HIV/acquired immunodeficiency syndrome (HIV/AIDS) treatment and care with effective use of resources is a cornerstone of universal treatment and care.

Objectives

This research aims to analyse the cost effectiveness of the National Mobile Antiretroviral Therapy (ART) Services Programme in Zambia as a means of decentralizing ART services.

Methods

Cost-effectiveness analyses were performed using a decision analytic model and Markov model to compare the original ART programme, ‘Hospital-based ART’, with the intervention programme, Hospital-based plus ‘Mobile ART’, from the perspective of the district government health office in Zambia. The total cost of ART services, quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs) were examined.

Results

The mean annual per-patient costs were 1259.16 USD for the original programme and 2601.02 USD for the intervention programme, while the mean number of QALYs was 6.81 for the original and 7.27 for the intervention programme. The ICER of the intervention programme relative to the original programme was 2965.17 USD/QALY, which was much below the willingness-to-pay (WTP), or three times the GDP per capita (4224 USD), but still over the GDP per capita (1408 USD). In the sensitivity analysis, the ICER of the intervention programme did not substantially change.

Conclusion

The National Mobile ART Services Programme in Zambia could be a cost-effective approach to decentralizing ART services into rural areas in Zambia. This programme could be expanded to more districts where it has not yet been introduced to improve access to ART services and the health of people living with HIV (PLHIV) in rural areas.

Electronic supplementary material

The online version of this article (doi:10.1186/s12962-017-0065-8) contains supplementary material, which is available to authorized users.

Adolescent Linkage to Care After a Large-scale Transfer From a Hospital-based HIV Clinic to the Public Sector in South Africa

HIV clinics formerly supported by the President's Emergency Plan for AIDS Relief are transferring patients to public-sector clinics. We evaluated adolescent linkage to care after a large-scale transfer from a President's Emergency Plan for AIDS Relief-subsidized pediatric HIV clinic in Durban, South Africa. All adolescents (11-18 years) in care at a pediatric state-subsidized, hospital-based clinic (HBC) were transferred, from May to June 2012, to government sites [primary health care (PHC) clinic; community health center (CHC); and HBCs] or private clinics. Caregivers were surveyed 7-8 months after transfer to assess their adolescents' linkage to care and their reports were validated by clinic record audits in a subset of randomly selected clinics. Of the 309 (91%) caregivers reached, only 5 (2%) reported that their adolescent did not link. Of the 304 adolescents who linked, 105 (35%) were referred to a PHC, 73 (24%) to a CHC and 106 (35%) to a HBC. A total of 146 (48%) linked adolescents attended a different clinic than that assigned. Thirty-five (20%) of the 178 who linked and were assigned to a PHC or CHC ultimately attended a HBC. Based on clinic validation, the estimated transfer success was 88% (95% confidence interval: 77%-97%). The large majority of adolescents successfully transferred to a new HIV clinic, although nearly half attended a clinic other than that assigned.

Patient Experiences of Decentralized HIV Treatment and Care in Plateau State, North Central Nigeria: A Qualitative Study

Background. Decentralization of care and treatment for HIV infection in Africa makes services available in local health facilities. Decentralization has been associated with improved retention and comparable or superior treatment outcomes, but patient experiences are not well understood. Methods. We conducted a qualitative study of patient experiences in decentralized HIV care in Plateau State, north central Nigeria. Five decentralized care sites in the Plateau State Decentralization Initiative were purposefully selected. Ninety-three patients and 16 providers at these sites participated in individual interviews and focus groups. Data collection activities were audio-recorded and transcribed. Transcripts were inductively content analyzed to derive descriptive categories representing patient experiences of decentralized care. Results. Patient participants in this study experienced the transition to decentralized care as a series of “trade-offs.” Advantages cited included saving time and money on travel to clinic visits, avoiding dangers on the road, and the “family-like atmosphere” found in some decentralized clinics. Disadvantages were loss of access to ancillary services, reduced opportunities for interaction with providers, and increased risk of disclosure. Participants preferred decentralized services overall. Conclusion. Difficulty and cost of travel remain a fundamental barrier to accessing HIV care outside urban centers, suggesting increased availability of community-based services will be enthusiastically received.

Discontinuation from Antiretroviral Therapy: A Continuing Challenge among Adults in HIV Care in Ethiopia: A Systematic Review and Meta-Analysis

BACKGROUND

Discontinuation of antiretroviral therapy (ART) reduces the immunological benefit of treatment and increases complications related to human immune-deficiency virus (HIV). However, the risk factors for ART discontinuation are poorly understood in developing countries particularly in Ethiopia. This review aimed to assess the best available evidence regarding risk factors for ART discontinuation in Ethiopia.

METHODS

Quantitative studies conducted in Ethiopia between 2002 and 2015 that evaluated factors associated with ART discontinuation were sought across six major databases. Only English language articles were included. This review considered studies that included the following outcome: ART treatment discontinuation, i.e. 'lost to follow up', 'defaulting' and 'stopping medication'. Meta- analysis was performed with Mantel Haenszel method using Revman-5 software. Summary statistics were expressed as pooled odds ratio with 95% confidence intervals at a p-value of <0.05.

RESULTS

Nine (9) studies met the criteria of the search. Five (5) were retrospective studies, 3 were case control studies, and 1 was a prospective cohort study. The total sample size in the included studies was 62,156. Being rural dweller (OR = 2.1, 95%CI: 1.5-2.7, I2 = 60%), being illiterate (OR = 1.5, 95%CI: 1.1-2.1), being not married (OR = 1.4, 95%CI: 1.1-1.8), being alcohol drinker (OR = 2.9, 95%CI: 1.9-4.4, I2 = 39%), being tobacco smoker (OR = 2.6, 95%CI: 1.6-4.3, I2 = 74%), having mental illness (OR = 2.7, 95%CI: 1.6-4.6, I2 = 0%) and being bed ridden functional status (OR = 2.3, 95%CI: 1.5-3.4, I2 = 37%) were risk factors for ART discontinuation. Whereas, having HIV positive partner (OR = 0.4, 95%CI: 0.3-0.6, I2 = 69%) and being co-infected with Tb/HIV (OR = 0.6, 95%CI: 0.4-0.9, I2 = 0%) were protective factors.

CONCLUSION

Demographic, behavioral and clinical factors influenced ART treatment discontinuation. Hence, we recommend strengthening decentralization of HIV care services in remote areas, strengthening of ART task shifting, application of seek-test-treat-succeed model, and integration of smoking cession strategies and mental health care into the routine HIV care program.

Marked sex differences in all-cause mortality on antiretroviral therapy in low- and middle-income countries: a systematic review and meta-analysis

Introduction

While women and girls are disproportionately at risk of HIV acquisition, particularly in low- and middle-income countries (LMIC), globally men and women comprise similar proportions of people living with HIV who are eligible for antiretroviral therapy. However, men represent only approximately 41% of those receiving antiretroviral therapy globally. There has been limited study of men’s outcomes in treatment programmes, despite data suggesting that men living with HIV and engaged in treatment programmes have higher mortality rates. This systematic review (SR) and meta-analysis (MA) aims to assess differential all-cause mortality between men and women living with HIV and on antiretroviral therapy in LMIC.

Methods

A SR was conducted through searching PubMed, Ovid Global Health and EMBASE for peer-reviewed, published observational studies reporting differential outcomes by sex of adults (≥15 years) living with HIV, in treatment programmes and on antiretroviral medications in LMIC. For studies reporting hazard ratios (HRs) of mortality by sex, quality assessment using Newcastle–Ottawa Scale (cohort studies) and an MA using a random-effects model (Stata 14.0) were conducted.

Results

A total of 11,889 records were screened, and 6726 full-text articles were assessed for eligibility. There were 31 included studies in the final MA reporting 42 HRs, with a total sample size of 86,233 men and 117,719 women, and total time on antiretroviral therapy of 1555 months. The pooled hazard ratio (pHR) showed a 46% increased hazard of death for men while on antiretroviral treatment (1.35–1.59). Increased hazard was significant across geographic regions (sub-Saharan Africa: pHR 1.41 (1.28–1.56); Asia: 1.77 (1.42–2.21)) and persisted over time on treatment (≤12 months: 1.42 (1.21–1.67); 13–35 months: 1.48 (1.23–1.78); 36–59 months: 1.50 (1.18–1.91); 61 to 108 months: 1.49 (1.29–1.71)).

Conclusions

Men living with HIV have consistently and significantly greater hazards of all-cause mortality compared with women while on antiretroviral therapy in LMIC. This effect persists over time on treatment. The clinical and population-level prevention benefits of antiretroviral therapy will only be realized if programmes can improve male engagement, diagnosis, earlier initiation of therapy, clinical outcomes and can support long-term adherence and retention.

Comparison of survival in adult antiretroviral treatment naïve patients treated in primary health care centers versus those treated in hospitals: retrospective cohort study; Oromia region, Ethiopia

BACKGROUND

Antiretroviral treatment (ART) service scaling up has been practiced in the Ethiopia since 2006. Regardless of increasing number of primary health care centers providing the service, the existing hospitals are still overcrowded with ART service seeking patients may be because of the common belief that treatment outcome is better for hospital patients than those treated at the primary health centers. However, documented evidence comparing the treatment outcome for the two categories of health facilities is scarce in the study setting. The purpose of the current study was to compare major treatment outcomes among new patients treated at the two health facility categories.

METHOD

Retrospective cohort study was implemented using secondary data from medical records collected between October 2010 and January 2014 in the selected health facilities. All patients (1895) who started the treatment in the facilities during the period were included in the study. Univariate analyses were made using descriptive methods such as frequency distributions and measures of central tendency. Bivariate and multivariate analyses were made using Kaplan Meier and Cox regression models respectively to compare the mean survival time between the two facility categories. P-value less than 0.05 was considered as statistically significant.

RESULTS

A total of 1895 patient records were followed for 27,990 person-months. Risks of unwanted treatment outcomes (death and lose-to-follow-up) were the same for both categories of patients. The median survival probability was similar to the facility categories (P-value = 0.11). Baseline performance scale III/IV (AHR, 2.4; 95 % CI: 2.0, 3.0), baseline WHO clinical stages III/IV (AHR, 2.8; 95 % CI: 2.3, 3.4), and low adherence (<95 %) to ART drugs (AHR, 3.4; 95 % CI: 2.8, 5.2) were the independent predictors of the unwanted treatment outcomes.

CONCLUSION

Antiretroviral treatment service delivery at primary health care facilities did not compromise the treatment outcomes among adult ART naïve patients. This implies that, ART services decentralization can result in acceptable treatment outcome in less developed settings. Therefore, treatment requiring patients should be encouraged to start the treatment in either of the health facilities as early as possible.

Act local, think global: how the Malawi experience of scaling up antiretroviral treatment has informed global policy

The scale-up of antiretroviral therapy (ART) in Malawi was based on a public health approach adapted to its resource-poor setting, with principles and practices borrowed from the successful tuberculosis control framework. From 2004 to 2015, the number of new patients started on ART increased from about 3000 to over 820,000. Despite being a small country, Malawi has made a significant contribution to the 15 million people globally on ART and has also contributed policy and service delivery innovations that have supported international guidelines and scale up in other countries. The first set of global guidelines for scaling up ART released by the World Health Organization (WHO) in 2002 focused on providing clinical guidance. In Malawi, the ART guidelines adopted from the outset a more operational and programmatic approach with recommendations on health systems and services that were needed to deliver HIV treatment to affected populations. Seven years after the start of national scale-up, Malawi launched a new strategy offering all HIV-infected pregnant women lifelong ART regardless of the CD4-cell count, named Option B+. This strategy was subsequently incorporated into a WHO programmatic guide in 2012 and WHO ART guidelines in 2013, and has since then been adopted by the majority of countries worldwide. In conclusion, the Malawi experience of ART scale-up has become a blueprint for a public health response to HIV and has informed international efforts to end the AIDS epidemic by 2030.

Predictors of CD4 count over time among HIV patients initiated ART in Felege Hiwot Referral Hospital, northwest Ethiopia: multilevel analysis

Background

The response of HIV patients to antiretroviral therapy could be measured by its strong predictor, the CD4+ T cell (CD4) count for the initiation of antiretroviral therapy and proper management of disease progress. However, in addition to HIV, there are other factors which can influence the CD4 cell count. Patient’s socio-economic, demographic, and behavioral variables, accessibility, duration of treatment etc., can be used to predict CD4 count.

Methods

A retrospective cohort study was conducted to examine the predictors of CD4 count among ART users enrolled in the first 6 months of 2010 and followed upto mid 2014. The covariance components model was employed to determine the predictors of CD4 count over time.

Results

A total of 1196 ART attendants were used to analyze their data descriptively. Eight hundred sixty-one of the attendants had two or more CD4 count measurements and were used in modeling their data using the linear mixed method. Thus, the mean rates of incensement of CD4 counts for patients with ambulatory/bedridden and working baseline functional status were 17.4 and 30.6 cells/mm³ per year, respectively. After adjusting for other variables, for each additional baseline CD4 count, the gain in CD4 count during treatment was 0.818 cells/mm³ (p value <0.001). Patient’s age and baseline functional status were also statistically significantly associated with CD4 count.

Conclusion

In this study, higher baseline CD4 count, younger age, working functional status, and time in treatment contributed positively to the increment of the CD4 count. However, the observed increment at 4 year was unsatisfactory as the proportion of ART users who reached the normal range of CD4 count was very low. To see their long term treatment outcome, it requires further research with a sufficiently longer follow up data. In line with this, the local CD4 count for HIV negative persons should also be investigated for better comparison and proper disease management.

Disparities in the Magnitude of Human Immunodeficiency Virus-related Opportunistic Infections Between High and Low/Middle-income Countries: Is Highly Active Antiretroviral Therapy Changing the Trend?

Opportunistic infections (OIs) cause significant morbidity/mortality in human immunodeficiency virus (HIV)-infected individuals globally. Disparities between high-income countries (HICs) and low/middle-income countries (LMICs) in the magnitude of HIV-related OIs in pre-highly active antiretroviral therapy (HAART) populations was reviewed, and HAART-induced decline in OIs was further compared between the two settings. Studies published in English from onset of HIV epidemic up to December 2013 were searched in PubMed, Google, Google Scholar, and African Journal online. An article was included if (a) the study was conducted in HIC or LMIC, (b) the age of the participants was ≥12 years, (c) the HAART status of the participants was stated, and (d) various types of OIs were investigated. In predominantly pre-HAART populations, the incidence and prevalence of overall HIV-related OIs in HIC ranged from 5.5 to 50.0 per 100 person-years (PY) and 27.4-56.7%, respectively. In LMIC, the respective overall incidence and prevalence of OIs were 12.2-93.9 per 100 PY and 32.0-77.7%. Pneumocystis jirovecii pneumonia, candidiasis, Cytomegalovirus disease, Mycobacterium avium complex disease, and Kaposi's sarcoma were the most frequent OIs in HICs while tuberculosis, candidiasis, chronic diarrhea, and cryptococcosis were predominant in LMICs. The introduction of HAART led to substantial reduction in the incidence of OIs with more impressive percentage decline in HICs (43-97%) compared to 30-79% in LMICs. Disparities in the magnitude of HIV-related OIs between HICs and LMICs are evident both in the pre-HAART and post-HAART era. Efforts to optimize HAART-induced decline in HIV-related OIs should become a global health priority irrespective of prevailing socioeconomic circumstances.

Facilitators and barriers to treatment adherence within PMTCT programs in Malawi

In Malawi, an innovative prevention of mother-to-child transmission (PMTCT) of HIV program, Option B+, has greatly expanded access to antiretroviral treatment at no cost to women and their exposed infants. However, many women continue to experience social, cultural, and structural barriers impeding their ability to consistently access medical treatment. Understanding these women's perspectives may make programs more responsive to patients' needs. This qualitative study sought to explore factors influencing women's adherence within PMTCT programs in southern Malawi. Participants were current PMTCT patients (the first cohort following national implementation of Option B+), healthcare providers, community leaders, and patients who had dropped out of the program ("defaulters"). Qualitative interviews and focus groups were conducted to investigate barriers and facilitators to continued participation within PMTCT programs. Data were analyzed using content analysis. Barriers identified included fears of HIV disclosure to husbands, community-based HIV/AIDS stigma, and poor interactions with some health workers. Facilitators included the improved survival of PMTCT patients in recent years and the desire to remain healthy to care for one's children. This research highlights important sociocultural factors affecting adherence within HIV/AIDS treatment programs in Malawi. Recommendations to improve access to medical care for PMTCT patients include integrated services to increase attention to confidentiality and minimize stigma, shared HIV testing and counseling for couples to minimize conflict in gender-unequal relationships, and peer-led support groups to provide social support from other women with the shared experience of an HIV-positive serostatus.

Loss to Follow-Up within the Prevention of Mother-to-Child Transmission Care Cascade in a Large ART Program in Nigeria

BACKGROUND

The 2013 WHO guidelines incorporated simplified and more effective antiretroviral regimens for the purposes of preventing mother-to-child transmission of HIV. With ideal implementation of these recommendations, perinatal HIV transmission could be reduced to less than 2%. However, loss to follow-up (LTFU) has the potential to erode the success of programs and a number of studies report high rates of LTFU within the prevention of mother-to-child transmission (PMTCT) care cascade. We evaluated the timing and magnitude of LTFU in a large programmatic PMTCT cohort in Nigeria in order to focus future efforts to reduce loss in this high burden setting.

METHODS

From 2004-2014, the APIN/Harvard PEPFAR program supported antenatal HIV screening for nearly one million pregnant women and provided PMTCT care to over 30,000 women. The care cascade for women enrolling in the PMTCT program includes antenatal, delivery, and infant follow-up services through 12-18 months of life. In this retrospective cohort analysis, we examined data collected between 2004-2014 from 31 clinical sites in Nigeria and assessed the numbers of mothers and infants enrolled and LTFU at various points along the care cascade.

RESULTS

Among 31,504 women (median age 30, IQR: 27-34) entering PMTCT care during the antenatal period, 20,679 (66%) completed the entire cascade of services including antenatal, delivery, and at least one infant follow-up visit. The median gestational age at presentation for antenatal care services was 23 weeks (IQR: 17-29). The median infant age at last follow-up visit was 12 months (IQR: 5-18). The greatest loss in the PMTCT care cascade occurred prior to delivery care (21%), with a further 16% lost prior to first infant visit. Of the 38,223 women who entered at any point along the PMTCT cascade, an HIV DNA PCR was available for 20,202 (53%) of their infants. Among infants for whom DNA PCR results were available, the rate of HIV transmission for infants whose mothers received any antenatal and/or delivery care was 2.8% versus 20.0% if their mother received none.

CONCLUSION

In this large cohort analysis, the proportion of women LTFU in the PMTCT care cascade was lower than that reported in previous cohort analyses. Nevertheless, this proportion remains unacceptably high and inhibits the program from maximally achieving the goals of PMTCT care. We also provide the largest analysis to date on rates of perinatal HIV transmission, with low rates among women receiving NNRTI- or PI-based regimens, approaching that reported in clinical trials. However, among mothers who received any antenatal care, infant outcomes were unknown for 48%, and women presented later in pregnancy than that recommended by current guidelines. Implementation research to evaluate ways to improve integration of services, particularly transitions from antenatal to delivery and pediatric care, are critically needed to reduce LTFU within PMTCT programs and achieve the ultimate goal of eliminating pediatric HIV infection.

Tracing defaulters in HIV prevention of mother-to-child transmission programmes through community health workers: results from a rural setting in Zimbabwe

Introduction

High retention in care is paramount to reduce vertical human immunodeficiency virus (HIV) infections in prevention of mother-to-child transmission (PMTCT) programmes but remains low in many sub-Saharan African countries. We aimed to assess the effects of community health worker–based defaulter tracing (CHW-DT) on retention in care and mother-to-child HIV transmission, an innovative approach that has not been evaluated to date.

Methods

We analyzed patient records of 1878 HIV-positive pregnant women and their newborns in a rural PMTCT programme in the Tsholotsho district of Zimbabwe between 2010 and 2013 in a retrospective cohort study. Using binomial regression, we compared vertical HIV transmission rates at six weeks post-partum, and retention rates during the perinatal PMTCT period (at delivery, nevirapine [NVP] initiation at three days post-partum, cotrimoxazole (CTX) initiation at six weeks post-partum, and HIV testing at six weeks post-partum) before and after the introduction of CHW-DT in the project.

Results

Median maternal age was 27 years (inter-quartile range [IQR] 23 to 32) and median CD4 count was 394 cells/µL³ (IQR 257 to 563). The covariate-adjusted rate ratio (aRR) for perinatal HIV transmission was 0.72 (95% confidence intervals [95% CI] 0.27 to 1.96, p=0.504), comparing patient outcomes after and before the intervention. Among fully retained patients, 11 (1.9%) newborns tested HIV positive. ARRs for retention in care were 1.01 (95% CI 0.96 to 1.06, p=0.730) at delivery; 1.35 (95% CI 1.28 to 1.42, p<0.001) at NVP initiation; 1.78 (95% CI 1.58 to 2.01, p<0.001) at CTX initiation; and 2.54 (95% CI 2.20 to 2.93, p<0.001) at infant HIV testing. Cumulative retention after and before the intervention was 496 (85.7%) and 1083 (87.3%) until delivery; 480 (82.9%) and 1005 (81.0%) until NVP initiation; 303 (52.3%) and 517 (41.7%) until CTX initiation; 272 (47.0%) and 427 (34.4%) until infant HIV testing; and 172 (29.7%) and 405 (32.6%) until HIV test result collection.

Conclusions

The CHW-DT intervention did not reduce perinatal HIV transmission significantly. Retention improved moderately during the post-natal period, but cumulative retention decreased rapidly even after the intervention. We showed that transmission in resource-limited settings can be as low as in resource-rich countries if patients are fully retained in care. This requires structural changes to the regular PMTCT services, in which community health workers can, at best, play a complementary role.

Retention in Care of Adult HIV Patients Initiating Antiretroviral Therapy in Tigray, Ethiopia: A Prospective Observational Cohort Study

INTRODUCTION

Although Ethiopia has been scaling up the antiretroviral therapy (ART) services, low retention in care of patients remains one of the main obstacles to treatment success. We report data on retention in care and its associated determinants in Tigray, Ethiopia.

METHODS

We used data from the CASA project, a prospective observational and multi-site study of a cohort of HIV-infected patients who initiated ART for the first time in Tigray. Four participating health facilities (HFs) located in the South of Tigray were considered for this study. Patients were followed for one year after ART initiation. The main outcome measure was represented by the current retention in care, defined as the proportion of patients who were alive and receiving ART at the same HF one year after ART initiation. Patients who started ART between January 1, 2013 and December 31, 2013 were included in this analysis. Patients were followed for one year after ART initiation. The determinants of retention were analysed using univariate and multivariate Cox Proportional Hazards model with robust sandwich estimates to account for within HF correlation.

RESULTS

The four participating HFs in Tigray were able to retain overall 85.1% of their patients after one year from starting ART. Loss to follow-up (5.5%) and transfers to other HF (6.6) were the main determinant of attrition. A multivariate analysis shows that the factors significantly associated with retention were the type of HF, gender and active TB. Alamata health center was the HF with the highest attrition rate (HR 2.99, 95% CI: 2.77-3.23). Active TB (HR 1.72, 95% CI: 1.23-2.41) and gender (HR 1.64, 95% CI: 1.10-2.56) were also significantly associated with attrition.

CONCLUSIONS

Although Ethiopia has significantly improved access to the ART program, achieving and maintaining a satisfactory long-term retention rate is a future goal. This is difficult because of different retention rates among HFs. Moreover specific interventions should be directed to people of different sex to improve retention in care in male population.

Enhancing linkage and retention in HIV care: a review of interventions for highly resourced and resource-poor settings

Given the widespread availability of effective antiretroviral therapy, engagement of HIV-infected persons in care is a global priority. We reviewed 51 studies, published in the past decade, assessing strategies for improving linkage to and retention in HIV care. The review included studies from highly resourced settings (HRS) and resource-poor settings (RPS), specifically the USA and sub-Saharan Africa. In HRS, strength-based case management was best supported for improving linkage and retention in care; peer navigation and clinic-based health promotion were supported for improving retention. In RPS, point of care CD4 testing was best supported for improving linkage to care; decentralization, and task-shifting for improving retention. Novel interventions continue to emerge in HRS and RPS, yet many strategies have not been adequately evaluated. Further consideration should be given to analyses that identify which interventions, or combinations of interventions, are most effective, cost-effective, scalable, and aligned with patient preferences for HIV care.

Implementation and Operational Research: Evaluation of Swaziland's Hub-and-Spoke Model for Decentralizing Access to Antiretroviral Therapy Services

BACKGROUND

In 2007, Swaziland initiated a hub-and-spoke model for decentralizing antiretroviral therapy (ART) access. Decentralization was facilitated through (1) down-referral of stable ART patients from overburdened central facilities (hubs) to primary health care clinics (spokes) and (2) ART initiation at spokes (spoke initiation).

METHODS

We conducted a nationally representative retrospective cohort study among adult ART enrollees during 2004-2010 to assess the effect of down-referral and spoke-initiation on rates of loss to follow-up (LTFU), death, and attrition (death or LTFU). Sixteen of 31 hubs were randomly selected using probability-proportional-to-size sampling. Seven selected facilities had initiated the hub-and-spoke model by study start. At these facilities, 1149 of 24,782 hub-initiated and maintained and 878 of 7722 down-referred or spoke-initiated patient records were randomly selected and analyzed. At the 9 hub-only facilities, 483 of 6638 records were randomly selected and analyzed. Multivariable proportional hazards regression was used to assess effect of down-referral (a time-varying covariate) and spoke-initiation on outcomes.

RESULTS

At ART initiation, median age was 35, 65% were female, and median CD4 count was 147 cells per microliter. Controlling for known confounders, down-referral was strongly protective against LTFU [adjusted hazard ratio (AHR) 0.38; 95% confidence interval (CI): 0.29 to 0.50] and attrition (AHR = 0.50; 95% CI: 0.34 to 0.76) but not mortality. Compared with hub-initiated and maintained patients, spoke-initiated patients had lower LTFU (AHR 0.59; 95% CI: 0.45 to 0.77) and attrition rates (AHR 0.60; 95% CI: 0.47 to 0.77), but not mortality.

CONCLUSIONS

Down-referral and spoke-initiation within a hub-and-spoke ART decentralization model were protective against LTFU and overall attrition and could facilitate future ART program expansion.

Do loss to follow-up and death rates from ART care vary across primary health care facilities and hospitals in south Ethiopia? A retrospective follow-up study

Background

Decentralization and task shifting has significantly improved access to antiretroviral therapy (ART). Many studies conducted to determine the attrition rate in Ethiopia have not compared attrition rates between hospitals and health centers in a relatively recent cohort of patients. This study compared death and loss to follow-up (LTFU) rates among ART patients in hospitals and health centers in south Ethiopia.

Methods

Data routinely collected from patients aged older than 15 years who started ART between July 2011 and August 2012 in 20 selected health facilities (12 being hospitals) were analyzed. The outcomes of interest were LTFU and death. The data were entered, cleaned, and analyzed using Statistical Package for the Social Sciences version 20.0 and Stata version 12.0. Competing-risk regression models were used.

Results

The service years of the facilities were similar (median 8 and 7.5 for hospitals and health centers, respectively). The mean patient age was 33.7±9.6 years. The median baseline CD4 count was 179 (interquartile range 93–263) cells/mm³. A total of 2,356 person-years of observation were made with a median follow-up duration of 28 (interquartile range 22–31) months; 24.6% were either dead or LTFU, resulting in a retention rate of 75.4%. The death rates were 3.0 and 1.5 and the LTFU rate were 9.0 and 10.9 per 100 person-years of observation in health centers and hospitals, respectively. The competing-risk regression model showed that the gap between testing and initiation of ART, body mass index, World Health Organization clinical stage, isoniazid prophylaxis, age, facility type, and educational status were independently associated with LTFU. Moreover, baseline tuberculous disease, poor functional status, and follow-up at a health center were associated with an elevated probability of death.

Conclusion

We observed a higher death rate and a lower LTFU rate in health centers than in hospitals. Most of the associated variables were also previously documented. Higher LTFU was noticed for patients with a smaller gap between testing and initiation of treatment.

Decentralization of HIV care and treatment services in Central Province, Kenya

BACKGROUND

Since 2006, the government of Kenya began decentralizing HIV care from secondary health facilities (SHF) to an expanded network, including primary health facilities (PHF). We evaluated the impact of this strategy on enrollment, care, and outcomes among adult patients in Central Province, Kenya, from 2006 to 2010.

METHODS

We analyzed electronic patient-level data for 26,690 patients at 15 SHF and 22 PHF. Enrollment, patient, and facility characteristics and patterns in CD4 testing, World Health Organization staging, and antiretroviral treatment (ART) initiation were compared between SHF and PHF. Survival analysis was used to estimate cumulative death and loss to follow-up (LTF) rates in PHF and SHF. Multivariate competing risks regression and Cox proportional hazards models were constructed to identify correlates of LTF and death.

RESULTS

Enrollment in PHF increased mainly between 2007 and 2009, representing 5% and 25% of all new enrollments, respectively. CD4 test provision and World Health Organization staging, time to ART initiation, and CD4 count at ART initiation were for the most part similar between PHF and SHF. In multivariate analyses, pre-ART patients enrolled in PHF had a lower risk of LTF than those enrolled in SHF (SHR = 0.77, 95% confidence interval: 0.61 to 0.96). No differences in risk of death among pre-ART patients or in LTF or death among ART patients were observed.

CONCLUSIONS

Enrollment at PHF increased substantially during the period; death rates were comparable between PHF and SHF, whereas LTF among pre-ART patients was lower at PHF. This suggests that decentralization can be a successful strategy for expanding HIV care.

Antiretroviral treatment outcome in HIV-1-infected patients routinely followed up in capital cities and remote areas of Senegal, Mali and Guinea-Conakry

Introduction

Access to antiretroviral treatment (ART) becomes more and more effective in resource-limited settings (RLS). However, this global effort would be even more profitable if the access to laboratory services especially in decentralized settings was strengthened. We report the virological outcome and HIV-1 drug resistance in three West African countries using dried blood spots (DBS) samples.

Methods

We included HIV-1-infected adults on ART ≥6 months and followed up in capital cities and decentralized sites in Senegal, Mali and Guinea-Conakry. Patients were consecutively enrolled and DBS were collected in field conditions and kept at ambient temperature before transfer to the reference laboratory. Viral load (VL) was quantified using the NucliSENS EasyQ HIV-1 v1.2. Genotyping of HIV-1 pol gene was performed using in-house protocol.

Results

Of the 407 participants, 119, 152 and 136 were from Senegal, Mali and Guinea-Conakry, respectively. The median treatment duration was 36 months [IQR: 6–136]. Virological failure (VF) (VL≥3log₁₀ copies/mL) was observed in 26% (95% confidence interval (CI), 18–35; n=31), 11% (95% CI, 6–17; n=16) and 24% (95% CI, 17–32; n=33) of patients in Senegal, Mali and Guinea-Conakry, respectively (p=0.001). Of samples presenting VL≥3log₁₀ copies/mL (n=80), 70 were successfully genotyped. At least one drug resistance mutation (DRM) was detected in the following proportions: 70% (95% CI, 50–86; n=19), 93% (95% CI, 68–100; n=14) and 68% (95% CI, 48–84; n=19) in Senegal, Mali and Guinea-Conakry, respectively (p=0.22). Twenty-six per cent (26%; 95% CI, 16–38; n=18) of patients in VF harboured wild-type viruses, which is likely indicative of weak adherence. Phylogenetic analysis showed the predominance of CRF02_AG subtype (73%; 95% CI, 61–83; n=51).

Conclusions

We describe the ART outcome in capital and rural settings of Senegal, Mali and Guinea-Conakry. Our results in all of the three countries highlight the need to reinforce the ART adherence in order to minimize the occurrence of drug resistance. In addition, these findings provide additional evidence that the use of DBS as a sampling support could assist virological monitoring of patients on ART in remote areas.

The Linkage Outcomes of a Large-scale, Rapid Transfer of HIV-infected Patients From Hospital-based to Community-based Clinics in South Africa

BACKGROUND

President's Emergency Plan for AIDS Relief (PEPFAR) funding changes have resulted in human immunodeficiency virus (HIV) clinic closures. We evaluated linkage to care following a large-scale patient transfer from a PEPFAR-funded, hospital-based HIV clinic to government-funded, community-based clinics in Durban.

METHODS

All adults were transferred between March and June 2012. Subjects were surveyed 5-10 months post-transfer to assess self-reported linkage to the target clinic. We validated self-reports by auditing records at 8 clinics. Overall success of transfer was estimated using linkage to care data for both reached and unreached subjects, adjusted for validation results.

RESULTS

Of the 3913 transferred patients, 756 (19%) were assigned to validation clinics; 659 (87%) of those patients were reached. Among those reached, 468 (71%) had a validated clinic record visit. Of the 46 who self-reported attending a different validation clinic than originally assigned, 39 (85%) had a validated visit. Of the 97 patients not reached, 59 (61%) had a validated visit at their assigned clinic. Based on the validation rates for reached and unreached patients, the estimated success of transfer for the cohort overall was 82%.

CONCLUSIONS

Most patients reported successful transfer to a community-based clinic, though a quarter attended a different clinic than assigned. Validation of attendance highlights that nearly 20% of patients may not have linked to care and may have experienced a treatment interruption. Optimizing transfers of HIV care to community sites requires collaboration with receiving clinics to ensure successful linkage to care.

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.

Understanding factors, outcomes and reasons for loss to follow-up among women in Option B+ PMTCT programme in Lilongwe, Malawi

OBJECTIVE

To assess factors, outcomes and reasons for loss to follow-up (LTFU) among pregnant and breastfeeding women initiated on a lifelong antiretroviral therapy (ART) for PMTCT in a large antenatal clinic in Malawi.

METHODS

We identified all pregnant and breastfeeding women who were initiated on ART between September 2011 and September 2013 and had missed their clinic appointment by at least 3 weeks at Bwaila Hospital, the largest antenatal clinic in Malawi. These women were traced by phone or home visits. Their true status and reasons for ART discontinuation were documented during tracing.

RESULTS

A total of 2930 women started ART for PMTCT; 2458 (84%) pregnant and 472 (16%) breastfeeding, of which, 577 (20%) missed a scheduled clinic appointment. LTFU was associated with younger age, being pregnant, and earlier year of ART initiation. We successfully traced 229 (40%), of whom, 10 (4%) had died. Of the 219 women found alive, 118 (54%) had stopped taking ARV drugs, 67 (30%) had self-transferred to another ART clinic, 13 (6%) had collected drugs from other sources, 9 (4%) had treatment interruptions and 12 (5%) had other outcomes. Reasons cited for stopping ART were travel (38%), lack of transport money (16%), not understanding the initial ARV education session (10%), being too weak/sick (10%), ARV side effects (10%) and other reasons.

CONCLUSION

Approximately half of the women who were traced were taking ARVs. The study emphasises the need for enhanced post-test counselling strategies, ongoing psychosocial support, provision of incentives and further decentralisation efforts of PMTCT services.

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.

Impact of geographic and transportation-related barriers on HIV outcomes in sub-Saharan Africa: a systematic review

Difficulty obtaining reliable transportation to clinic is frequently cited as a barrier to HIV care in sub-Saharan Africa (SSA). Numerous studies have sought to characterize the impact of geographic and transportation-related barriers on HIV outcomes in SSA, but to date there has been no systematic attempt to summarize these findings. In this systematic review, we summarized this body of literature. We searched for studies conducted in SSA examining the following outcomes in the HIV care continuum: (1) voluntary counseling and testing, (2) pre-antiretroviral therapy (ART) linkage to care, (3) loss to follow-up and mortality, and (4) ART adherence and/or viral suppression. We identified 34 studies containing 52 unique estimates of association between a geographic or transportation-related barrier and an HIV outcome. There was an inverse effect in 23 estimates (44 %), a null association in 26 (50 %), and a paradoxical beneficial impact in 3 (6 %). We conclude that geographic and transportation-related barriers are associated with poor outcomes across the continuum of HIV care.

Tracing of patients lost to follow-up and HIV transmission: mathematical modeling study based on 2 large ART programs in Malawi

OBJECTIVE

Treatment as prevention depends on retaining HIV-infected patients in care. We investigated the effect on HIV transmission of bringing patients lost to follow-up (LTFU) back into care.

DESIGN

Mathematical model.

METHODS

Stochastic mathematical model of cohorts of 1000 HIV-infected patients on antiretroviral therapy, based on the data from 2 clinics in Lilongwe, Malawi. We calculated cohort viral load (sum of individual mean viral loads each year) and used a mathematical relationship between viral load and transmission probability to estimate the number of new HIV infections. We simulated 4 scenarios: "no LTFU" (all patients stay in care), "no tracing" (patients LTFU are not traced), "immediate tracing" (after missed clinic appointment), and "delayed tracing" (after 6 months).

RESULTS

About 440 of 1000 patients were LTFU over 5 years. Cohort viral loads (million copies/mL per 1000 patients) were 3.7 [95% prediction interval (PrI), 2.9-4.9] for no LTFU, 8.6 (95% PrI, 7.3-10.0) for no tracing, 7.7 (95% PrI, 6.2-9.1) for immediate, and 8.0 (95% PrI, 6.7-9.5) for delayed tracing. Comparing no LTFU with no tracing, the number of new infections increased from 33 (95% PrI, 29-38) to 54 (95% PrI, 47-60) per 1000 patients. Immediate tracing prevented 3.6 (95% PrI, -3.3 to 12.8) and delayed tracing 2.5 (95% PrI, -5.8 to 11.1) new infections per 1000. Immediate tracing was more efficient than delayed tracing: to 116 and 142 tracing efforts, respectively, were needed prevent 1 new infection.

CONCLUSIONS

Tracing of patients LTFU enhances the preventive effect of antiretroviral therapy, but the number of transmissions prevented is small.

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.

Patient guardians as an instrument for person centered care

Person-centered care involves keeping the person at the center of the care planning and decision-making process. While the theory behind person-centered care is commonly shared, its application in healthcare settings is more challenging. In a number of African countries, a lesson emerges involving the application of person-centered care through the use of patient guardians. Patient guardians, often family or close friends, act as an extension of the patient's hospital care team. Medical teams engage with these self-designated individuals who invest their time and efforts in the care of the patient. More importantly, the guardian continues this role and relationship when the patient is released from the hospital to return home. Healthcare workers view patient guardians as a valuable resource. In a structured manner, guardians become stewards of information regarding topics such as hand hygiene and infection control. The knowledge gained can help the recovering patient upon discharge and potentially spread the information to others in the community. Further study of this model may show clear applicability to help improve health literacy in underserved settings in both low-income and high-income countries.

Improving antiretroviral therapy scale-up and effectiveness through service integration and decentralization

BACKGROUND

Current service delivery systems do not reach all people in need of antiretroviral therapy (ART). In order to inform the operational and service delivery section of the WHO 2013 consolidated antiretroviral guidelines, our objective was to summarize systematic reviews on integrating ART delivery into maternal, newborn, and child health (MNCH) care settings in countries with generalized epidemics, tuberculosis (TB) treatment settings in which the burden of HIV and TB is high, and settings providing opiate substitution therapy (OST); and decentralizing ART into primary health facilities and communities.

DESIGN

A summary of systematic reviews.

METHODS

The reviewers searched PubMed, Embase, PsycINFO, Web of Science, CENTRAL, and the WHO Index Medicus databases. Randomized controlled trials and observational cohort studies were included if they compared ART coverage, retention in HIV care, and/or mortality in MNCH, TB, or OST facilities providing ART with MNCH, TB, or OST facilities providing ART services separately; or primary health facilities or communities providing ART with hospitals providing ART.

RESULTS

The reviewers identified 28 studies on integration and decentralization. Antiretroviral therapy integration into MNCH facilities improved ART coverage (relative risk [RR] 1.37, 95% confidence interval [CI] 1.05-1.79) and led to comparable retention in care. ART integration into TB treatment settings improved ART coverage (RR 1.83, 95% CI 1.48-2.23) and led to a nonsignificant reduction in mortality (RR 0.55, 95% CI 0.29-1.05). The limited data on ART integration into OST services indicated comparable rates of ART coverage, retention, and mortality. Partial decentralization into primary health facilities improved retention (RR 1.05, 95% CI 1.01-1.09) and reduced mortality (RR 0.34, 95% CI 0.13-0.87). Full decentralization improved retention (RR 1.12, 95% CI 1.08-1.17) and led to comparable mortality. Community-based ART led to comparable rates of retention and mortality.

CONCLUSION

Integrating ART into MNCH, TB, and OST services was often associated with improvements in ART coverage, and decentralization of ART into primary health facilities and communities was often associated with improved retention. Neither integration nor decentralization was associated with adverse outcomes. These data contributed to recommendations in the WHO 2013 consolidated antiretroviral guidelines to integrate ART delivery into MNCH, TB, and OST services and to decentralize ART.

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.

Nurse and manager perceptions of nurse initiated and managed antiretroviral therapy (NIMART) implementation in South Africa: a qualitative study

OBJECTIVE

To explore nurse and facility and programme manager perceptions of nurse initiated and managed antiretroviral therapy (NIMART) implementation in Gauteng, South Africa.

DESIGN

In this qualitative study, in-depth interviews and focus group discussions were conducted to gain insight into participants' experiences of NIMART implementation.

SETTING

Participants came from urban, peri-urban and rural primary healthcare clinics in two Gauteng Province municipalities.

PARTICIPANTS

25 nurses and 18 managers who were actively involved in NIMART implementation were purposively sampled.

RESULTS

The findings from this study reveal that, despite encountering numerous challenges including human resources, training and clinical mentoring and health systems issues, NIMART nurses and managers remained optimistic about their work. Study participants felt empowered by their expanded roles. Increased responsibilities associated with NIMART implementation encouraged better use of creative problem-solving and teamwork to facilitate integration of NIMART into existing clinic services. NIMART nurses perceived antiretroviral therapy (ART) patients to be more insightful about their illness, engaged in their HIV treatment and aware of the importance of adherence which enhanced nurse-patient relationships and increased their sense of job satisfaction.

CONCLUSIONS

Although the implementation of NIMART is complex, when NIMART is implemented well, ART access is increased and patient outcomes are improved. Supportive interventions which address the specific challenges faced by nurses providing NIMART now need to be implemented. Attempts should be made to replicate the positive aspects of NIMART implementation identified by participants as this may improve healthcare providers' experiences of task-shifting.

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.