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Hoffman R, Phiri K, Kalande P, Whitehead H, Moses A, Rockers PC, Tseng CH, Talama G, Banda JC, van Oosterhout JJ, Phiri S, Moucheraud C. Preferences for Hypertension Care in Malawi: A Discrete Choice Experiment Among People Living with Hypertension, With and Without HIV. AIDS Behav 2024:10.1007/s10461-024-04492-y. [PMID: 39269593 DOI: 10.1007/s10461-024-04492-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2024] [Indexed: 09/15/2024]
Abstract
Hypertension is the most common non-communicable disease diagnosed among people in sub-Saharan Africa. However, little is known about client preferences for hypertension care. We performed a discrete choice experiment in Malawi among people with hypertension, with and without HIV. Participants were asked to select between two care scenarios, each with six attributes: distance, waiting time, provider friendliness, individual or group care, antihypertensive medication supply, and antihypertensive medication dispensing frequency (three versus one month). Eight choice sets (each with two scenarios) were presented to each individual. Mixed effects logit models quantified preferences for each attribute. Estimated model coefficients were used to predict uptake of hypothetical models of care. Between July 2021 and April 2022 we enrolled 1003 adults from 14 facilities in Malawi; half were living with HIV and on ART for a median of 11 years. Median age of respondents was 57 years (IQR 49-63), 58.2% were female, and median duration on antihypertensive medications was 4 years (IQR 2-7). Participants strongly preferred seeing a provider alone versus in a group (OR 11.3, 95% CI 10.4-12.3), with stronger preference for individual care among those with HIV (OR 15.4 versus 8.6, p < 0.001). Three-month versus monthly dispensing was also strongly preferred (OR 4.2; 95% CI 3.9-4.5). 72% of respondents would choose group care if all other facility attributes were favorable, although PLHIV were less likely to make this trade-off (66% versus 77%). These findings have implications for the scale-up of hypertension care in Malawi and similar settings.
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Affiliation(s)
- Risa Hoffman
- David Geffen School of Medicine, Department of Medicine, Division of Infectious Diseases, University of California, Risa Hoffman, 911 Broxton Avenue Suite 301D, Los Angeles, CA, 90024, USA.
| | - Khumbo Phiri
- Partners in Hope Medical Center, Lilongwe, Malawi
| | | | - Hannah Whitehead
- David Geffen School of Medicine, Department of Medicine, Division of Infectious Diseases, University of California, Risa Hoffman, 911 Broxton Avenue Suite 301D, Los Angeles, CA, 90024, USA
| | - Agnes Moses
- Partners in Hope Medical Center, Lilongwe, Malawi
| | - Peter C Rockers
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Chi-Hong Tseng
- David Geffen School of Medicine, Department of Medicine, Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, CA, USA
| | | | | | - Joep J van Oosterhout
- David Geffen School of Medicine, Department of Medicine, Division of Infectious Diseases, University of California, Risa Hoffman, 911 Broxton Avenue Suite 301D, Los Angeles, CA, 90024, USA
- Partners in Hope Medical Center, Lilongwe, Malawi
| | - Sam Phiri
- Partners in Hope Medical Center, Lilongwe, Malawi
- School of Global and Public Health, Kamuzu University of Health Sciences, Lilongwe, Malawi
| | - Corrina Moucheraud
- Department of Public Health Policy and Management, New York University Global School of Public Health, New York, NY, USA
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Merid F, Guyo TG, Wagaye S, Mekuria M, Anbesie A, Toma TM. Uptake and associated factors of six multi-month scripting/appointment spacing differentiated service delivery model of care among stable clients on antiretroviral therapy in Southern Ethiopia. PLoS One 2024; 19:e0310400. [PMID: 39264931 PMCID: PMC11392334 DOI: 10.1371/journal.pone.0310400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Accepted: 08/30/2024] [Indexed: 09/14/2024] Open
Abstract
BACKGROUND Differentiated service delivery models have been developed to accommodate the rising number of stable antiretroviral therapy clients and to maintain improvements in health outcomes and care retention. Ethiopia adopted the appointment spacing model and has had notable successes in implementing it. However, with the implementation of the six multi-month scripting/appointment spacing model in Ethiopia, little is known about the uptake and its associated factors. Therefore, this study aimed to assess the uptake and associated factors of the six multi-month scripting/appointment spacing differentiated service delivery model of care among stable clients on antiretroviral therapy in Southern Ethiopia. METHODS A hospital-based cross-sectional study was conducted among 419 stable clients on antiretroviral therapy in southern Ethiopia from June 22 to September 29, 2023. A systematic sampling technique was used to select the study participants. Using a structured questionnaire, socio-demographic, health service delivery, behavioral, and clinical-related data were collected. The collected data were entered into Epi Data version 3.1 and analyzed using Stata version 14. Variables with a P-value <0.05 in the multivariable logistic analysis were considered statistically significant. Multicollinearity and model fitness were checked using the variance inflation factor and the Hosmer and Lemeshow goodness of fit tests, respectively. RESULTS The uptake of the six multi-month scripting/appointment spacing differentiated service delivery model of care was 63.25% (95% confidence interval (CI): 58.61%, 67.88%). Missed appointment (Adjusted Odds Ratio (AOR): 1.91 (95% CI: 1.13, 3.25)), distance to antiretroviral therapy facility (AOR: 2.90 (95% CI: 1.67, 5.04)), duration on antiretroviral therapy (AOR: 2.21 (95% CI: 1.34, 3.64)), and intermediate social support (AOR: 2.02 (95% CI: 1.29, 3.17)) and strong social support (AOR: 2.71 (95% CI: 1.23, 5.97)) were factors significantly associated with the uptake. CONCLUSION The uptake of six multi-month scripting/appointment spacing differentiated service delivery models of care was six out of ten clients on antiretroviral therapy. To further improve the uptake, a precise intervention on the identified associated factor is required.
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Affiliation(s)
- Fasika Merid
- Department of Public Health, Arba Minch College of Health Sciences, Arba Minch, Ethiopia
| | - Tamirat Gezahegn Guyo
- Department of Public Health, Arba Minch College of Health Sciences, Arba Minch, Ethiopia
| | - Simegn Wagaye
- Department of Public Health, Arba Minch College of Health Sciences, Arba Minch, Ethiopia
| | - Mesele Mekuria
- Department of Public Health, Arba Minch College of Health Sciences, Arba Minch, Ethiopia
| | - Abraham Anbesie
- Department of Public Health, Arba Minch College of Health Sciences, Arba Minch, Ethiopia
| | - Temesgen Mohammed Toma
- Department of Public Health Emergency Management, South Ethiopia Region Public Health Institute, Jinka, Ethiopia
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Whitehead HS, Phiri K, Kalande P, van Oosterhout JJ, Talama G, Phiri S, Moucheraud C, Moses A, Hoffman RM. High rate of uncontrolled hypertension among adults receiving integrated HIV and hypertension care with aligned multi-month dispensing in Malawi: results from a cross-sectional survey and retrospective chart review. J Int AIDS Soc 2024; 27:e26354. [PMID: 39295131 PMCID: PMC11410859 DOI: 10.1002/jia2.26354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 08/30/2024] [Indexed: 09/21/2024] Open
Abstract
INTRODUCTION People living with HIV have high rates of hypertension. Integrated HIV and hypertension care with aligned multi-month dispensing of medications (MMD) could decrease the burden of care for individuals and health systems. We sought to describe hypertension control and evaluate its association with different durations of MMD among Malawian adults receiving integrated care with aligned dispensing of antiretroviral therapy (ART) and antihypertensive medication. METHODS We conducted a cross-sectional survey and retrospective chart review of adults (≥18 years) receiving integrated HIV and hypertension care on medications for both conditions for at least 1 year, with aligned MMD at seven clinics in Malawi. Data were collected from July 2021 to April 2022 and included socio-demographics, clinical characteristics, antihypertensive medications and up to the three most recent blood pressure measurements. Bivariate analyses were used to characterize associations with hypertension control. Uncontrolled hypertension was defined as ≥2 measurements ≥140 and/or ≥90 mmHg. Chart reviews were conducted for a random subset of participants with uncontrolled hypertension to describe antihypertensive medication adjustments in the prior year. RESULTS We surveyed 459 adults receiving integrated care with aligned dispensing (58% female; median age 54 years). Individuals most commonly received a 3-month aligned dispensing of ART and antihypertensive medications (63%), followed by every 6 months (16%) and every 4 months (15%). Hypertension control was assessed in 359 respondents, of whom only 23% had controlled hypertension; 90% of individuals in this group reported high adherence to blood pressure medications (0-1 missed days/week). Control was more common among those with longer aligned medication dispensing intervals (20% among those with 1- to 3-month dispensing vs. 28% with 4-month dispensing vs. 40% with 6-month dispensing, p = 0.011). Chart reviews were conducted for 147 individuals with uncontrolled hypertension. Most had high self-reported adherence to blood pressure medications (89% missing 0-1 days/week); however, only 10% had their antihypertensive medication regimen changed in the prior year. CONCLUSIONS Uncontrolled hypertension was common among Malawian adults receiving integrated care with aligned MMD and was associated with shorter refill intervals and few antihypertensive medication escalations. Integrated care with aligned MMD is promising, but further work is needed to understand how to optimize hypertension outcomes.
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Affiliation(s)
- Hannah S Whitehead
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | | | | | - Joep J van Oosterhout
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Partners in Hope, Lilongwe, Malawi
| | | | - Sam Phiri
- Partners in Hope, Lilongwe, Malawi
- School of Global and Public Health, Kamuzu University of Health Sciences, Lilongwe, Malawi
| | - Corrina Moucheraud
- Department of Public Health Policy and Management, School of Global Public Health at NYU, New York City, New York, USA
| | | | - Risa M Hoffman
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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Ross J, Anastos K, Hill S, Remera E, Rwibasira GN, Ingabire C, Umwiza F, Munyaneza A, Muhoza B, Zhang C, Nash D, Yotebieng M, Murenzi G. Reducing time to differentiated service delivery for newly-diagnosed people living with HIV in Kigali, Rwanda: a pilot, unblinded, randomized controlled trial. BMC Health Serv Res 2024; 24:555. [PMID: 38693537 PMCID: PMC11062003 DOI: 10.1186/s12913-024-10950-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 04/04/2024] [Indexed: 05/03/2024] Open
Abstract
BACKGROUND Differentiated service delivery (DSD) programs for people living with HIV (PWH) limit eligibility to patients established on antiretroviral therapy (ART), yet uncertainty exists regarding the duration on ART necessary for newly-diagnosed PWH to be considered established. We aimed to determine the feasibility, acceptability, and preliminary impact of entry into DSD at six months after ART initiation for newly-diagnosed PWH. METHODS We conducted a pilot randomized controlled trial in three health facilities in Rwanda. Participants were randomized to: (1) entry into DSD at six months after ART initiation after one suppressed viral load (DSD-1VL); (2) entry into DSD at six months after ART initiation after two consecutive suppressed viral loads (DSD-2VL); (3) treatment as usual (TAU). We examined feasibility by examining the proportion of participants assigned to intervention arms who entered DSD, assessed acceptability through patient surveys and by examining instances when clinical staff overrode the study assignment, and evaluated preliminary effectiveness by comparing study arms with respect to 12-month viral suppression. RESULTS Among 90 participants, 31 were randomized to DSD-1VL, 31 to DSD-2VL, and 28 to TAU. Among 62 participants randomized to DSD-1VL or DSD-2VL, 37 (60%) entered DSD at 6 months while 21 (34%) did not enter DSD because they were not virally suppressed. Patient-level acceptability was high for both clinical (mean score: 3.8 out of 5) and non-clinical (mean score: 4.1) elements of care and did not differ significantly across study arms. Viral suppression at 12 months was 81%, 81% and 68% in DSD-1VL, DSD-2VL, and TAU, respectively (p = 0.41). CONCLUSIONS The majority of participants randomized to intervention arms entered DSD and had similar rates of viral suppression compared to TAU. Results suggest that early DSD at six months after ART initiation is feasible for newly-diagnosed PWH, and support current WHO guidelines on DSD. TRIAL REGISTRATION Clinicaltrials.gov NCT04567693; first registered on September 28, 2020.
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Affiliation(s)
- Jonathan Ross
- Albert Einstein College of Medicine, 3300 Kossuth Avenue, Bronx, NY, 10467, USA.
| | - Kathryn Anastos
- Albert Einstein College of Medicine, 3300 Kossuth Avenue, Bronx, NY, 10467, USA
| | - Sarah Hill
- Albert Einstein College of Medicine, 3300 Kossuth Avenue, Bronx, NY, 10467, USA
| | - Eric Remera
- Division of HIV, STIs and Viral Hepatitis, Rwanda Biomedical Center, Kigali, Rwanda
| | - Gallican N Rwibasira
- Division of HIV, STIs and Viral Hepatitis, Rwanda Biomedical Center, Kigali, Rwanda
| | | | | | | | | | - Chenshu Zhang
- Albert Einstein College of Medicine, 3300 Kossuth Avenue, Bronx, NY, 10467, USA
| | - Denis Nash
- Institute for Implementation Science in Population Health, City University of New York, New York, 10027, USA
| | - Marcel Yotebieng
- Albert Einstein College of Medicine, 3300 Kossuth Avenue, Bronx, NY, 10467, USA
| | - Gad Murenzi
- Research for Development (RD Rwanda), Kigali, Rwanda
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Hill SE, Zhang C, Remera E, Ingabire C, Umwiza F, Munyaneza A, Muhoza B, Rwibasira G, Yotebieng M, Anastos K, Murenzi G, Ross J. Association Between Clinical Encounter Frequency and HIV-Related Stigma Among Newly-Diagnosed People Living with HIV in Rwanda. AIDS Behav 2024; 28:1390-1400. [PMID: 38112826 PMCID: PMC10947825 DOI: 10.1007/s10461-023-04226-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2023] [Indexed: 12/21/2023]
Abstract
HIV-related stigma in healthcare settings remains a key barrier to engaging people living with HIV (PLHIV) in care. This study investigated the association between clinical encounter frequency and HIV-related anticipated, enacted, and internalized stigma among newly-diagnosed PLHIV in Rwanda. From October 2020 to May 2022, we collected data from adult PLHIV on antiretroviral therapy (ART) in Kigali, Rwanda who were participating in a randomized, controlled trial testing early entry into differentiated care at 6 months after ART initiation. We measured anticipated HIV stigma with five-point Likert HIV Stigma Framework measures, enacted stigma with the four-point Likert HIV/AIDS Stigma Instrument, and internalized stigma with the four-point Likert HIV/AIDS Stigma Instrument. We used multivariable linear regression to test the associations between clinical encounter frequency (average inter-visit interval ≥ 50 days vs. < 50 days) and change in mean anticipated, enacted and internalized HIV stigma over the first 12 months in care. Among 93 individuals enrolled, 76 had complete data on encounter frequency and stigma measurements and were included in the present analysis. Mean internalized stigma scores of all participants decreased over the first 12 months in care. Anticipated and enacted stigma scores were low and did not change significantly over time. There was no association between encounter frequency and change in internalized stigma. In this pilot study of newly-diagnosed Rwandan PLHIV with relatively low levels of HIV-related stigma, clinical encounter frequency was not associated with change in stigma. Additional research in diverse settings and with larger samples is necessary to further explore this relationship.
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Affiliation(s)
- Sarah E Hill
- Division of General Internal Medicine, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY, 10461, USA.
| | - Chenshu Zhang
- Division of General Internal Medicine, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY, 10461, USA
| | - Eric Remera
- HIV/AIDS and STIs Diseases Division, Rwanda Biomedical Center, Institute of HIV Disease Prevention and Control, Kigali, Rwanda
| | - Charles Ingabire
- Rwanda Military Hospital, Kigali, Rwanda
- Research for Development, Kigali, Rwanda
| | - Francine Umwiza
- Rwanda Military Hospital, Kigali, Rwanda
- Research for Development, Kigali, Rwanda
| | - Athanase Munyaneza
- Rwanda Military Hospital, Kigali, Rwanda
- Research for Development, Kigali, Rwanda
| | - Benjamin Muhoza
- Rwanda Military Hospital, Kigali, Rwanda
- Research for Development, Kigali, Rwanda
| | - Gallican Rwibasira
- HIV/AIDS and STIs Diseases Division, Rwanda Biomedical Center, Institute of HIV Disease Prevention and Control, Kigali, Rwanda
| | - Marcel Yotebieng
- Division of General Internal Medicine, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY, 10461, USA
| | - Kathryn Anastos
- Division of General Internal Medicine, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY, 10461, USA
| | - Gad Murenzi
- Rwanda Military Hospital, Kigali, Rwanda
- Research for Development, Kigali, Rwanda
| | - Jonathan Ross
- Division of General Internal Medicine, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY, 10461, USA
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Casalini C, Bateganya M, Akolo C, Sanwo O, Idemudia A, Nwaokoro P, Eyam F, Ogbechie MD, Obiora-Okafo C, Oduola A, Wilcher R, Mack N, Khamofu H, Pandey SR. Increasing multimonth dispensing of antiretrovirals and assessing the effect on viral load suppression among children and adolescents receiving HIV services in Nigeria. PLoS One 2023; 18:e0286303. [PMID: 37315075 PMCID: PMC10266651 DOI: 10.1371/journal.pone.0286303] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 05/15/2023] [Indexed: 06/16/2023] Open
Abstract
INTRODUCTION Multimonth dispensing (MMD) enables less frequent clinic visits and improved outcomes for people living with HIV, but few children and adolescents living with HIV (CALHIV) are on MMD. At the end of the October-December 2019 quarter, only 23% of CALHIV receiving antiretroviral therapy (ART) through SIDHAS project sites in Akwa Ibom and Cross River states, Nigeria, were receiving MMD. In March 2020, during COVID-19, the government expanded MMD eligibility to include children and recommended rapid implementation to minimize clinic visits. SIDHAS provided technical assistance to 36 "high-volume" facilities-≥5 CALHIV on treatment-in Akwa Ibom and Cross River to increase MMD and viral load suppression (VLS) among CALHIV, toward PEPFAR's 80% benchmark for people currently on ART. We present change in MMD, viral load (VL) testing coverage, VLS, optimized regimen coverage, and community-based ART group enrollment among CALHIV from the October-December 2019 quarter (baseline) to January-March 2021 (endline) based on retrospective analysis of routinely collected program data. MATERIALS AND METHODS We compared MMD coverage (primary objective), and optimized regimen coverage, community-based ART group enrollment, VL testing coverage, and VLS (secondary objectives), among CALHIV 18 years and younger pre-/post-intervention (baseline/endline) at the 36 facilities. We excluded children younger than two years, who are not recommended for or routinely offered MMD. The extracted data included age, sex, ART regimen, months of ART dispensed at last refill, most recent VL test results, and community ART group enrollment. Data on MMD-three or more months of ARVs dispensed at one time-were disaggregated into three to five months (3-5-MMD) vs. six or more months (6-MMD). VLS was defined as ≤1,000 copies. We documented MMD coverage by site, optimized regimen, and VL testing and suppression. Using descriptive statistics, we summarized the characteristics of CALHIV on MMD and non-MMD, number of CALHIV on optimized regimens, and proportion enrolled in differentiated service delivery models and community-based ART refill groups. For the intervention, SIDHAS technical assistance was data driven: weekly data analysis/review, site-prioritization scoring, provider mentoring, line listing eligible CALHIV, pediatric regimen calculator, child-optimized regimen transitioning, and community ART models. RESULTS The proportion of CALHIV ages 2-18 receiving MMD increased from 23% (620/2,647; baseline) to 88% (3,992/4,541; endline), while the proportion of sites reporting suboptimal MMD coverage among CALHIV (<80%) decreased (100% to 28%). In March 2021, 49% of CALHIV were receiving 3-5-MMD and 39% 6-MMD. In October-December 2019, 17%-28% of CALHIV were receiving MMD; by January-March 2021, 99% of those 15-18 years, 94% 10-14 years, 79% 5-9 years, and 71% 2-4 years were on MMD. VL testing coverage remained high (90%), while VLS increased (64% to 92%). The proportion on pediatric-optimized regimens increased (58% to 79%). CONCLUSIONS MMD was feasible among CALHIV without compromising VLS. Expanded eligibility criteria, line listing eligible children, monitoring pediatric antiretroviral stock, and data use contributed to positive results. Future efforts should address low 6-MMD uptake related to stock limitations and synchronize antiretroviral refill pickup with VL sample collection.
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Affiliation(s)
| | | | - Chris Akolo
- FHI 360, Washington, DC, United States of America
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Mantell JE, Zech JM, Masvawure TB, Assefa T, Molla M, Block L, Duguma D, Yirsaw Z, Rabkin M. Implementing six multi-month dispensing of antiretroviral therapy in Ethiopia: perspectives of clients and healthcare workers. BMC Health Serv Res 2023; 23:563. [PMID: 37259098 DOI: 10.1186/s12913-023-09549-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 05/14/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND Multi-month dispensing (MMD) of antiretroviral therapy (ART) is an integral component of differentiated HIV service delivery for people living with HIV (PLHIV). Although many countries have scaled up ART dispensing to 3-month intervals, Ethiopia was the first African country to implement six-month dispensing (6-MMD) at scale, introducing its Appointment Spacing Model (ASM) for people doing well on ART in 2017. As of June 2021, 51.4% (n = 215,101) of PLHIV on ART aged ≥ 15 years had enrolled in ASM. Since little is known about the benefits and challenges of ASM perceived by Ethiopian clients and their healthcare workers (HCWs), we explored how the ASM was being implemented in Ethiopia's Oromia region in September 2019. METHODS Using a parallel convergent mixed-methods study design, we conducted 6 focus groups with ASM-eligible enrolled clients, 6 with ASM-eligible non-enrolled clients, and 22 in-depth interviews with HCWs. Data were audio-recorded, transcribed and translated into English. We used thematic analysis, initially coding deductively, followed by inductive coding of themes that emerged from the data, and compared the perspectives of ASM-enrolled and non-enrolled clients and their HCWs. RESULTS Participants enrolled in ASM and HCWs perceived client-level ASM benefits to include time and cost-savings, fewer work disruptions, reduced stigma due to fewer clinic visits, better medication adherence and improved overall health. Perceived health system-level benefits included improved quality of care, decongested facilities, reduced provider workloads, and improved record-keeping. Although non-enrolled participants anticipated many of the same benefits, their reasons for non-enrollment included medication storage challenges, concerns over less frequent health monitoring, and increased stress due to the large quantities of medicines dispensed. Enrolled participants and HCWs identified similar challenges, including client misunderstandings about ASM and initial ART stock-outs. CONCLUSIONS ASM with 6-MMD was perceived to have marked benefits for clients and health systems. Clients enrolled in the ASM and their HCWs had positive experiences with the model, including perceived improvements in efficiency, quality and convenience of HIV treatment services. The concerns of non-ASM enrolled participants suggest the need for enhanced client education about the model and more discreet and efficiently packaged ART and highlight that ASM is not ideal for all clients.
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Affiliation(s)
- Joanne E Mantell
- New York State Psychiatric Institute and Department of Psychiatry, HIV Center for Clinical and Behavioral Studies, Gender, Sexuality and Health Area, Columbia University Irving Medical Center, New York, New York, United States of America.
| | - Jennifer M Zech
- ICAP at Columbia University, New York, NY, United States of America
| | - Tsitsi B Masvawure
- Health Studies Program, Center for Interdisciplinary Studies, College of the Holy Cross, Worcester, MA, United States of America
| | | | | | - Laura Block
- ICAP at Columbia University, New York, NY, United States of America
| | | | | | - Miriam Rabkin
- ICAP at Columbia University, New York, NY, United States of America
- Departments of Medicine and Epidemiology, Columbia University Irving Medical Center, New York, NY, United States of America
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Belay YA, Yitayal M, Atnafu A, Taye FA. Barriers and facilitators to the implementation and scale up of differentiated service delivery models for HIV treatment in Africa: a scoping review. BMC Health Serv Res 2022; 22:1431. [PMID: 36443853 PMCID: PMC9703668 DOI: 10.1186/s12913-022-08825-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 11/10/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND In the face of health-system constraints, local policymakers and decision-makers face difficult choices about how to implement, expand and institutionalize antiretroviral therapy (ART) services. This scoping review aimed to describe the barriers and facilitators to the implementation and scale up of differentiated service delivery (DSD) models for HIV treatment in Africa. METHODS PubMed, Web of Science, Embase, Scopus, CINAHL, Global Health, Google, and Google Scholar databases were searched. There was no start date thereby all references up until May 12, 2021, were included in this review. We included studies reported in the English language focusing on stable adult people living with human immune deficiency virus (HIV) on ART and the healthcare providers in Africa. Studies related to children, adolescents, pregnant and lactating women, and key populations (people who inject drugs, men having sex with men, transgender persons, sex workers, and prisoners), and studies about effectiveness, cost, cost-effectiveness, and pre or post-exposure prophylaxis were excluded. A descriptive analysis was done. RESULTS Fifty-seven articles fulfilled our eligibility criteria. Several factors influencing DSD implementation and scale-up emerged. There is variability in the reported factors across DSD models and studies, with the same element serving as a facilitator in one context but a barrier in another. Perceived reduction in costs of visit for patients, reduction in staff workload and overburdening of health facilities, and improved or maintained patients' adherence and retention were reported facilitators for implementing DSD models. Patients' fear of stigma and discrimination, patients' and providers' low literacy levels on the DSD model, ARV drug stock-outs, and supply chain inconsistencies were major barriers affecting DSD model implementation. Stigma, lack of model adoption from providers, and a lack of resources were reported as a bottleneck for the DSD model scale up. Leadership and governance were reported as both a facilitator and a barrier to scaling up the DSD model. CONCLUSIONS This review has important implications for policy, practice, and research as it increases understanding of the factors that influence DSD model implementation and scale up. Large-scale studies based on implementation and scale up theories, models, and frameworks focusing on each DSD model in each healthcare setting are needed.
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Affiliation(s)
- Yihalem Abebe Belay
- Department of Public Health, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
- Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Mezgebu Yitayal
- Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Asmamaw Atnafu
- Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Fitalew Agimass Taye
- Department of Accounting, Finance, and Economics, Griffith University, Brisbane, Australia
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Firth's Logistic Regression of Interruption in Treatment before and after the Onset of COVID-19 among People Living with HIV on ART in Two Provinces of DRC. Healthcare (Basel) 2022; 10:healthcare10081516. [PMID: 36011173 PMCID: PMC9407772 DOI: 10.3390/healthcare10081516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 08/03/2022] [Accepted: 08/05/2022] [Indexed: 11/17/2022] Open
Abstract
The impact of the COVID-19 pandemic extends beyond the immediate physical effects of the virus, including service adjustments for people living with the human immunodeficiency virus (PLHIV) on antiretroviral therapy (ART). Purpose: To compare treatment interruptions in the year immediately pre-COVID-19 and after the onset of COVID-19 (10 April 2020 to 30 March 2021). Methods: We analyze quantitative data covering 36,585 persons with HIV who initiated antiretroviral treatment (ART) between 1 April 2019 and 30 March 2021 at 313 HIV/AIDS care clinics in the Haut-Katanga and Kinshasa provinces of the Democratic Republic of Congo (DRC), using Firth’s logistic regression. Results: Treatment interruption occurs in 0.9% of clients and tuberculosis (TB) is detected in 1.1% of clients. The odds of treatment interruption are significantly higher (adjusted odds ratio: 12.5; 95% confidence interval, CI (8.5−18.3)) in the pre-COVID-19 period compared to during COVID-19. The odds of treatment interruption are also higher for clients with TB, those receiving ART at urban clinics, those younger than 15 years old, and female clients (p < 0.05). Conclusions: The clients receiving ART from HIV clinics in two provinces of DRC had a lower risk of treatment interruption during COVID-19 than the year before COVID-19, attributable to program adjustments.
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10
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Christ B, van Dijk JH, Nyandoro TY, Reichmuth ML, Kunzekwenyika C, Chammartin F, Egger M, Wringe A, Ballif M. Availability and experiences of differentiated antiretroviral therapy delivery at HIV care facilities in rural Zimbabwe: a mixed-method study. J Int AIDS Soc 2022; 25:e25944. [PMID: 36008925 PMCID: PMC9411726 DOI: 10.1002/jia2.25944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 05/20/2022] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Zimbabwe adopted differentiated HIV care policies in 2015 to promote client-centred care and relieve strain on health facilities. We examined the availability, experiences and perceptions of differentiated antiretroviral therapy (ART) delivery in rural Zimbabwe following the policy adoption. METHODS We undertook a cross-sectional mixed methods study in all the 26 facilities providing HIV care in a rural district in Zimbabwe. We collected quantitative data about ART delivery and visit durations from 31 healthcare providers and a purposive stratified sample of 378 clients obtaining ART either through routine care or differentiated ART delivery models. We performed 26 semi-structured interviews among healthcare providers and seven focus group discussions (FGDs) among clients to elicit their perceptions and experiences of ART delivery. Data were collected in 2019, with one follow-up FGD in 2021. We analysed the transcripts thematically, with inductive coding, to identify emerging themes. RESULTS Twenty facilities (77%) offered at least one differentiated ART delivery models, including community ART refill groups (CARGs; 13 facilities, 50%), fast-track refill (8, 31%), family refill (6, 23%) or club refill (1, 4%). Thirteen facilities (50%) offered only one model. The median visit duration was 28 minutes (interquartile range [IQR]: 16-62). Participants in fast-track had the shortest visit durations (18 minutes, IQR: 11-24). Confidentiality and disclosure of HIV status, travelling long distances, travel costs and waiting times were the main issues influencing clients' views on differentiated ART delivery. Fast-track refill was perceived as the preferred model of clients for its limited involuntary disclosure and efficiency. In contrast, group- and community-based refill models reduced travel costs but were felt to be associated with involuntary disclosure of HIV status, which could discourage clients. Healthcare providers also experienced an additional workload when offering facility-based group models, such as CARGs. CONCLUSIONS Differentiated ART delivery models were widely available in this rural setting, but most facilities did not offer a choice of models to address clients' diverse preferences. A minority offered fast-track refills, although this model was often mentioned as desirable. Confidentiality, travel expenses and client waiting times are key elements to consider when planning and rolling out differentiated HIV care.
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Affiliation(s)
- Benedikt Christ
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | | | | | - Martina L Reichmuth
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | | | | | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.,Centre for Infectious Disease Research and Epidemiology, University of Cape Town, Cape Town, South Africa.,Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Alison Wringe
- London School of Hygiene and Tropical Medicine, London, UK
| | - Marie Ballif
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
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11
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Acceptability of Community-Based Tuberculosis Preventive Treatment for People Living with HIV in Zimbabwe. Healthcare (Basel) 2022; 10:healthcare10010116. [PMID: 35052280 PMCID: PMC8775984 DOI: 10.3390/healthcare10010116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 01/03/2022] [Accepted: 01/04/2022] [Indexed: 11/17/2022] Open
Abstract
As Zimbabwe expands tuberculosis preventive treatment (TPT) for people living with HIV (PLHIV), the Ministry of Health and Child Care is considering making TPT more accessible to PLHIV via less-intensive differentiated service delivery models such as Community ART Refill Groups (CARGs). We designed a study to assess the feasibility and acceptability of integrating TPT into CARGs among key stakeholders, including CARG members, in Zimbabwe. We conducted 45 key informant interviews (KII) with policy makers, implementers, and CARG leaders; 16 focus group discussions (FGD) with 136 PLHIV in CARGs; and structured observations of 8 CARG meetings. KII and FGD were conducted in English and Shona. CARG observations were conducted using a structured checklist and time-motion data capture. Ninety six percent of participants supported TPT integration into CARGs and preferred multi-month TPT dispensing aligned with ART dispensing schedules. Participants noted that the existing CARG support systems could be used for TB symptom screening and TPT adherence monitoring/support. Other perceived advantages included convenience for PLHIV and decreased health facility provider workloads. Participants expressed concerns about possible medication stockouts and limited knowledge about TPT among CARG leaders but were confident that CARGs could effectively provide community-based TPT education, adherence monitoring/support, and TB symptom screening provided that CARG leaders received appropriate training and supervision. These results are consistent with findings from pilot projects in other African countries that are scaling up both differentiated service delivery for HIV and TPT and suggest that designing contextually appropriate approaches to integrating TPT into less-intensive HIV treatment models is an effective way to reach people who are established on ART but who may have missed out on access to TPT.
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12
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Lopes J, Grimwood A, Ngorima-Mabhena N, Tiam A, Tukei BB, Kasu T, Mahachi N, Mothibi E, Tukei V, Chasela C, Lombard C, Fatti G. Out-of-Facility Multimonth Dispensing of Antiretroviral Treatment: A Pooled Analysis Using Individual Patient Data From Cluster-Randomized Trials in Southern Africa. J Acquir Immune Defic Syndr 2021; 88:477-486. [PMID: 34506343 DOI: 10.1097/qai.0000000000002797] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 08/27/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Out-of-facility multi-month dispensing (MMD) is a differentiated service delivery model which provides antiretroviral treatment (ART) at intervals of up to 6 monthly in the community. Limited randomized evidence investigating out-of-facility MMD is available. We evaluated participant outcomes and compared out-of-facility MMD models using data from cluster-randomized trials in Southern Africa. SETTING Eight districts in Zimbabwe and Lesotho. METHODS Individual-level participant data from 2 cluster-randomized trials that included stable adults receiving ART at 60 facilities were pooled. Both trials had 3 arms: ART collected 3-monthly at healthcare facilities (3MF, control); ART provided three-monthly in community ART groups (CAGs) (3MC); and ART provided 6-monthly in either CAGs or on an individual provider-patient basis (6MC). Participant retention, viral suppression and incidence of unscheduled facility visits were compared. RESULTS Ten thousand one hundred thirty-six participants were included, 3817 (37.7%), 2893 (28.5%) and 3426 (33.8%) in arms 3MF, 3MC and 6MC, respectively. After 12 months, retention was non-inferior for 3MC (95.7%) vs. 3MF (95.0%) {adjusted risk difference (aRD) = 0.3 [95% confidence interval (CI): -0.8 to 1.4]}; and 6MC (95.1%) vs. 3MF [aRD = -0.2 (95% CI: -1.4 to 1.0)]. Retention was greater amongst intervention arm participants in CAGs versus 6MC participants not in CAGs, aRD = 1.5% (95% CI: 0.2% to 2.9%). Viral suppression was excellent (≥98%) and unscheduled facility visits were not increased in the intervention arms. CONCLUSIONS Three and 6-monthly out-of-facility MMD was non-inferior versus facility-based care for stable ART patients. Out-of-facility 6-monthly MMD should incorporate small group peer support whenever possible. CLINICALTRIAL REGISTRATION ClinicalTrials.gov NCT03238846 and NCT03438370.
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Affiliation(s)
- John Lopes
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | | | | | - Appolinaire Tiam
- Elizabeth Glaser Pediatric AIDS Foundation, Washington DC, United States
| | | | | | - Nyika Mahachi
- Zimbabwe College of Public Health Physicians, Harare, Zimbabwe
| | - Eula Mothibi
- Right to Care/EQUIP Health, Centurion, South Africa
| | - Vincent Tukei
- Elizabeth Glaser Pediatric AIDS Foundation, Maseru, Lesotho
| | - Charles Chasela
- Right to Care/EQUIP Health, Centurion, South Africa
- Department of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; and
| | - Carl Lombard
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Biostatistics Unit, South African Medical Research Council, Cape Town, South Africa
| | - Geoffrey Fatti
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Kheth'Impilo AIDS Free Living, Cape Town, South Africa
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13
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Tomescu S, Crompton T, Adebayo J, Kinge CW, Akpan F, Rennick M, Chasela C, Ondura E, Dauda DS, Pisa PT. Factors associated with an interruption in treatment of people living with HIV in USAID-supported states in Nigeria: a retrospective study from 2000-2020. BMC Public Health 2021; 21:2194. [PMID: 34847909 PMCID: PMC8638522 DOI: 10.1186/s12889-021-12264-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 11/16/2021] [Indexed: 12/04/2022] Open
Abstract
Background Patient interruption of antiretroviral therapy (ART) continues to limit HIV programs’ progress toward epidemic control. Multiple factors have been associated with client interruption in treatment (IIT)— including age, gender, CD4 count, and education level. In this paper, we explore the factors associated with IIT in people living with HIV (PLHIV) in United States Agency for International Development (USAID)-supported facilities under the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) program in Nigeria. Methods We conducted cross-sectional analyses on data obtained from Nigeria’s National Data Repository (NDR), representing a summarized record of 573 630 ART clients that received care at 484 PEPFAR/USAID-supported facilities in 16 states from 2000–2020. IIT was defined as no clinical contact for 28 days or more after the last expected clinical contact. Univariate and multivariate logistic regression models were computed to explore the factors associated with IIT. The variables included in the analysis were sex, age group, zone, facility level, regimen line, multi-month dispensing (MMD), and viral load category. Results Of the 573 630 clients analysed in this study, 32% have been recorded as having interrupted treatment. Of the clients investigated, 66% were female (32% had interrupted treatment), 39% were aged 25–34 at their last ART pick-up date (with 32% of them interrupted treatment), 59% received care at secondary level facilities (37% interrupted treatment) and 38% were last receiving between three- to five-month MMD (with 10% of these interrupted treatment). Those less likely to interrupt ART were males (aOR = 0.91), clients on six-month MMD (aOR = 0.01), adults on 2nd line regimen (aOR = 0.09), and paediatrics on salvage regimen (aOR = 0.02). Clients most likely to interrupt ART were located in the South West Zone (aOR = 1.99), received treatment at a tertiary level (aOR = 12.34) or secondary level facilities (aOR = 4.01), and had no viral load (VL) on record (aOR =10.02). Age group was not significantly associated with IIT. Conclusions Sex, zone, facility level, regimen line, MMD, and VL were significantly associated with IIT. MMD of three months and longer (especially six months) had better retention on ART than those on shorter MMD. Not having a VL on record was associated with a considerable risk of IIT.
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Affiliation(s)
| | | | | | | | | | | | - Charles Chasela
- Right to Care, Centurion, South Africa.,Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Pedro T Pisa
- Right to Care, Centurion, South Africa.,Department of Human Nutrition and Dietetics, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
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14
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Bailey LE, Siberry GK, Agaba P, Douglas M, Clinkscales JR, Godfrey C. The impact of COVID-19 on multi-month dispensing (MMD) policies for antiretroviral therapy (ART) and MMD uptake in 21 PEPFAR-supported countries: a multi-country analysis. J Int AIDS Soc 2021; 24 Suppl 6:e25794. [PMID: 34713578 PMCID: PMC8554217 DOI: 10.1002/jia2.25794] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 07/29/2021] [Indexed: 11/29/2022] Open
Abstract
Introduction Increasing access to multi‐month dispensing (MMD) of antiretroviral therapy (ART) supports treatment continuity and viral load suppression for people living with HIV (PLHIV) and reduces burden on health facilities. During the COVID‐19 response, PEPFAR worked with ministries of health to scale up MMD and expand eligibility to new groups of PLHIV, including children and pregnant/breastfeeding women. We analysed PEPFAR program data to understand the impact of the policy changes on actual practice. Methods We conducted a desk review in 21 PEPFAR‐supported countries to identify and collect official documentation released between March and June 2020 addressing changes to MMD guidance during the COVID‐19 response. MMD coverage, the proportion of all ART clients on MMD, was assessed in the calendar quarters preceding the COVID‐19 response (Q4 2019, October–December 2019; and Q1, January–March 2020) and the quarters following the start of the response (Q2 2020, April–June 2020; Q3 2020, July–September, 2020; Q4 2020, October–December 2020). We used the two‐proportion Z‐test to test for differences in MMD coverage pre‐COVID‐19 (Q4 2019) and during implementation of COVID‐19 policy adaptations (Q2 2020). Results and discussion As of June 2020, 16 of the 21 PEPFAR‐supported countries analysed adapted MMD policy or promoted intensified scale‐up of MMD in response to COVID‐19. MMD coverage for all clients on ART grew from 49% in Q4 2019 pre‐COVID‐19 to 72% in Q2 2020 during COVID‐19; among paediatric clients (< 15), MMD coverage increased from 27% to 51% in the same period. Adaptations to MMD policy were associated with a significantly accelerated growth in the proportion of clients on MMD (p < 0.001) for all populations, irrespective of age and dispensing interval. Conclusions Access to MMD markedly expanded during the COVID‐19 pandemic, supporting treatment continuity while mitigating exposure to COVID‐19 at health facilities. This model is beneficial in public health emergencies and during disruptions to the healthcare system. Outside emergency contexts, expanded MMD eligibility extends client‐centred care to previously excluded populations. The success in expanding MMD access during COVID‐19 should motivate countries to recommend broader MMD access as a new standard of care.
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Affiliation(s)
- Lauren E Bailey
- United States Agency for International Development, Office of HIV/AIDS, Washington, DC, USA
| | - George K Siberry
- United States Agency for International Development, Office of HIV/AIDS, Washington, DC, USA
| | - Patricia Agaba
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
| | - Meaghan Douglas
- United States Agency for International Development, Office of HIV/AIDS, Washington, DC, USA
| | - Jessica R Clinkscales
- United States Agency for International Development, Office of HIV/AIDS, Washington, DC, USA
| | - Catherine Godfrey
- U.S. Department of State, Office of the Global AIDS Coordinator, Washington, DC, USA
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15
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Zakumumpa H, Tumwine C, Milliam K, Spicer N. Dispensing antiretrovirals during Covid-19 lockdown: re-discovering community-based ART delivery models in Uganda. BMC Health Serv Res 2021; 21:692. [PMID: 34256756 PMCID: PMC8276217 DOI: 10.1186/s12913-021-06607-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 06/04/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The notion of health-system resilience has received little empirical attention in the current literature on the Covid-19 response. We set out to explore health-system resilience at the sub-national level in Uganda with regard to strategies for dispensing antiretrovirals during Covid-19 lockdown. METHODS We conducted a qualitative case-study of eight districts purposively selected from Eastern and Western Uganda. Between June and September 2020, we conducted qualitative interviews with district health team leaders (n = 9), ART clinic managers (n = 36), representatives of PEPFAR implementing organizations (n = 6).In addition, six focus group discussions were held with recipients of HIV care (48 participants). Qualitative data were analyzed using thematic approach. RESULTS Five broad strategies for distributing antiretrovirals during 'lockdown' emerged in our analysis: accelerating home-based delivery of antiretrovirals,; extending multi-month dispensing from three to six months for stable patients; leveraging the Community Drug Distribution Points (CDDPs) model for ART refill pick-ups at outreach sites in the community; increasing reliance on health information systems, including geospatial technologies, to support ART refill distribution in unmapped rural settings. District health teams reported leveraging Covid-19 outbreak response funding to deliver ART refills to homesteads in rural communities. CONCLUSION While Covid-19 'lockdown' restrictions undoubtedly impeded access to facility-based HIV services, they revived interest by providers and demand by patients for community-based ART delivery models in case-study districts in Uganda.
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Affiliation(s)
- Henry Zakumumpa
- Makerere University, School of Public Health, Kampala, Uganda.
| | | | - Kiconco Milliam
- Department of Sociology, Kyambogo University, Kampala, Uganda
| | - Neil Spicer
- London School of Hygiene and Tropical Medicine, London, UK
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16
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Huber A, Pascoe S, Nichols B, Long L, Kuchukhidze S, Phiri B, Tchereni T, Rosen S. Differentiated Service Delivery Models for HIV Treatment in Malawi, South Africa, and Zambia: A Landscape Analysis. GLOBAL HEALTH: SCIENCE AND PRACTICE 2021; 9:296-307. [PMID: 34234023 PMCID: PMC8324204 DOI: 10.9745/ghsp-d-20-00532] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 03/02/2021] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Many countries in Africa are scaling up differentiated service delivery (DSD) models for HIV treatment, but most existing data systems do not describe the models in use. We surveyed organizations that were supporting DSD models in 2019 in Malawi, South Africa, and Zambia to describe the diversity of DSD models being implemented at that time. METHODS We interviewed DSD model implementing organizations for descriptive information about each of the organization's models of care. We described the key characteristics of each model, including population of patients served, location of service delivery, frequency of interactions with patients, duration of dispensing, and cadre(s) of provider involved. To facilitate analysis, we refer to 1 organization supporting 1 model of care as an "organization-model." RESULTS The 34 respondents (8 in Malawi, 16 in South Africa, 10 in Zambia) interviewed described a total of 110 organization-models, which included 19 facility-based individual models, 21 out-of-facility-based individual models, 14 health care worker-led groups, and 3 client-led groups; jointly, these encompassed 12 specific service delivery strategies, such as multimonth dispensing, adherence clubs, home delivery, and changes to facility hours. Over two-thirds (n=78) of the organization-models were limited to clinically stable patients. Almost all organization-models (n=96) continued to provide clinical care at established health care facilities; medication pickup took place at facilities, external pickup points, and adherence clubs. Required numbers of provider interactions per year varied widely, from 2 to 12. Dispensing intervals were typically 3 or 6 months in Malawi and Zambia and 2 months in South Africa. Individual models relied more on clinical staff, while group models made greater use of lay personnel. CONCLUSIONS As of 2019, there was a large variety of differentiated service models being offered for HIV treatment in Malawi, South Africa, and Zambia, serving diverse patient populations.
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Affiliation(s)
- Amy Huber
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand Johannesburg, South Africa
| | - Sophie Pascoe
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand Johannesburg, South Africa
| | - Brooke Nichols
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand Johannesburg, South Africa.,Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Lawrence Long
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand Johannesburg, South Africa.,Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Salome Kuchukhidze
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Bevis Phiri
- Clinton Health Access Initiative, Lusaka, Zambia
| | | | - Sydney Rosen
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand Johannesburg, South Africa. .,Department of Global Health, Boston University School of Public Health, Boston, MA, USA
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Ross J, Murenzi G, Hill S, Remera E, Ingabire C, Umwiza F, Munyaneza A, Muhoza B, Habimana DS, Mugwaneza P, Zhang C, Yotebieng M, Anastos K. Reducing time to differentiated service delivery for newly diagnosed people living with HIV in Kigali, Rwanda: study protocol for a pilot, unblinded, randomised controlled study. BMJ Open 2021; 11:e047443. [PMID: 33895720 PMCID: PMC8074553 DOI: 10.1136/bmjopen-2020-047443] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Current HIV guidelines recommend differentiated service delivery (DSD) models that allow for fewer health centre visits for clinically stable people living with HIV (PLHIV). Newly diagnosed PLHIV may require more intensive care early in their treatment course, yet frequent appointments can be burdensome to patients and health systems. Determining the optimal parameters for defining clinical stability and transitioning to less frequent appointments could decrease patient burden and health system costs. The objectives of this pilot study are to explore the feasibility and acceptability of (1) reducing the time to DSD from 12 to 6 months after antiretroviral therapy (ART) initiation,and (2) reducing the number of suppressed viral loads required to enter DSD from two to one. METHODS AND ANALYSES The present study is a pilot, unblinded trial taking place in three health facilities in Kigali, Rwanda. Current Rwandan guidelines require PLHIV to be on ART for ≥12 months with two consecutive suppressed viral loads in order to transition to less frequent appointments. We will randomise 90 participants to one of three arms: entry into DSD at 6 months after one suppressed viral load (n=30), entry into DSD at 6 months after two suppressed viral loads (n=30) or current standard of care (n=30). We will measure feasibility and acceptability of this intervention; clinical outcomes include viral suppression at 12 months (primary outcome) and appointment attendance (secondary outcome). ETHICS AND DISSEMINATION This clinical trial was approved by the institutional review board of Albert Einstein College of Medicine and by the Rwanda National Ethics Committee. Findings will be disseminated through conferences and peer-reviewed publications, as well as meetings with stakeholders. TRIAL REGISTRATION NUMBER NCT04567693.
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Affiliation(s)
- Jonathan Ross
- Division of General Internal Medicine, Montefiore Health System, Bronx, New York, USA
- Division of General Internal Medicine, Yeshiva University Albert Einstein College of Medicine, Bronx, New York, USA
| | - Gad Murenzi
- Clinical Education and Research Division, Rwanda Military Hospital, Kigali, Kigali City, Rwanda
| | - Sarah Hill
- Division of General Internal Medicine, Yeshiva University Albert Einstein College of Medicine, Bronx, New York, USA
| | - Eric Remera
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda
| | - Charles Ingabire
- Clinical Education and Research Division, Rwanda Military Hospital, Kigali, Kigali City, Rwanda
| | - Francine Umwiza
- Clinical Education and Research Division, Rwanda Military Hospital, Kigali, Kigali City, Rwanda
| | - Athanase Munyaneza
- Clinical Education and Research Division, Rwanda Military Hospital, Kigali, Kigali City, Rwanda
| | - Benjamin Muhoza
- Clinical Education and Research Division, Rwanda Military Hospital, Kigali, Kigali City, Rwanda
| | | | - Placidie Mugwaneza
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda
| | - Chenshu Zhang
- Division of General Internal Medicine, Montefiore Health System, Bronx, New York, USA
- Division of General Internal Medicine, Yeshiva University Albert Einstein College of Medicine, Bronx, New York, USA
| | - Marcel Yotebieng
- Division of General Internal Medicine, Montefiore Health System, Bronx, New York, USA
- Division of General Internal Medicine, Yeshiva University Albert Einstein College of Medicine, Bronx, New York, USA
| | - Kathryn Anastos
- Division of General Internal Medicine, Montefiore Health System, Bronx, New York, USA
- Division of General Internal Medicine, Yeshiva University Albert Einstein College of Medicine, Bronx, New York, USA
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18
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Lujintanon S, Amatavete S, Sungsing T, Seekaew P, Peelay J, Mingkwanrungruang P, Chinbunchorn T, Teeratakulpisarn S, Methajittiphan P, Leenasirima P, Norchaiwong A, Nilmanat A, Phanuphak P, Ramautarsing RA, Phanuphak N. Client and provider preferences for HIV care: Implications for implementing differentiated service delivery in Thailand. J Int AIDS Soc 2021; 24:e25693. [PMID: 33792192 PMCID: PMC8013790 DOI: 10.1002/jia2.25693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 02/14/2021] [Accepted: 02/23/2021] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Differentiated service delivery (DSD) for antiretroviral therapy (ART) maintenance embodies the client-centred approach to tailor services to support people living with HIV in adhering to treatment and achieving viral suppression. We aimed to assess the preferences for HIV care and attitudes towards DSD for ART maintenance among ART clients and providers at healthcare facilities in Thailand. METHODS A cross-sectional study using self-administered questionnaires was conducted in September-November 2018 at five healthcare facilities in four high HIV burden provinces in Thailand. Eligible participants who were ART clients aged ≥18 years and ART providers were recruited by consecutive sampling. Descriptive statistics were used to summarize demographic characteristics, preferences for HIV services and expectations and concerns towards DSD for ART maintenance. RESULTS Five hundred clients and 52 providers completed the questionnaires. Their median ages (interquartile range; IQR) were 38.6 (29.8 to 45.5) and 37.3 (27.3 to 45.1); 48.5% and 78.9% were females, 16.8% and 1.9% were men who have sex with men, and 2.4% and 7.7% were transgender women, respectively. Most clients and providers agreed that ART maintenance tasks, including ART refill, viral load testing, HIV/sexually transmitted infection monitoring, and psychosocial support should be provided at ART clinics (85.2% to 90.8% vs. 76.9% to 84.6%), by physicians (77.0% to 94.6% vs. 71.2% to 100.0%), every three months (26.7% to 40.8% vs. 17.3% to 55.8%) or six months (33.0% to 56.7% vs. 28.9% to 80.8%). Clients agreed that DSD would encourage their autonomy (84.9%) and empower responsibility for their health (87.7%). Some clients and providers disagreed that DSD would lead to poor ART retention (54.0% vs. 40.4%), increased loss to follow-up (52.5% vs. 42.3%), and delayed detection of treatment failure (48.3% vs. 44.2%), whereas 31.4% to 50.0% of providers were unsure about these expectations and concerns. CONCLUSIONS Physician-led, facility-based clinical consultation visit spacing in combination with multi-month ART refill was identified as one promising DSD model in Thailand. However, low preference for decentralization and task shifting may prove challenging to implement other models, especially since many providers were unsure about DSD benefits. This calls for local implementation studies to prove feasibility and governmental and social support to legitimize and normalize DSD in order to gain acceptance among clients and providers.
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Affiliation(s)
| | | | | | - Pich Seekaew
- Institute of HIV Research and InnovationBangkokThailand
- Department of EpidemiologyColumbia University Mailman School of Public HealthNew YorkNYUSA
| | | | | | | | | | | | | | | | | | | | | | - Nittaya Phanuphak
- Institute of HIV Research and InnovationBangkokThailand
- Center of Excellence in Transgender HealthChulalongkorn UniversityBangkokThailand
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