Motivational Interviewing among HIV Health Care Providers: Challenges and Opportunities to Enhance Engagement and Retention in Care in Buenos Aires, Argentina

Factors influencing the transition from paediatric to adult HIV care in the Western Cape, South Africa: perspectives of health care providers

Transitioning to adult care for HIV-infected adolescents is a critical process in determining long-term health outcomes. Poor transitioning to adult care can lead to several adverse HIV-related outcomes for adolescents living with HIV, including disruption of care, non-adherence to ART and virological failure. In this qualitative study, we explore the barriers to and facilitators of the transition to adult care among HIV-infected youth from the perspectives of health care workers and allied staff. We enrolled 24 health care workers and allied staff from two infectious diseases clinics in the Western Cape of South Africa. Participants took part in a once-off, semi-structured interview that was conducted face-to-face at the respective clinics. Interviews were audio-recorded and transcribed verbatim for thematic analysis using ATLAS.ti. Two superordinate themes and seven subthemes emerged from the data. We found that barriers to the transition process were related to a lack of preparedness and readiness to transition at both an institutional level and at the level of the caregiver and adolescent. At the institutional level, a lack of a transition policy and limited time and resources available for the transition process were salient barriers. At the caregiver-adolescent level, adolescents' desire for normality and caregivers' reluctance to devolve responsibility of care to their children were important barriers to the transition process. Facilitators prepare adolescents and caregivers for transition from an early age. Our findings highlight the importance of considering both adolescent, caregiver and institutional factors when preparing for the transition process. Our findings also show that pressure on the health care system precludes the time required for this process. However, counselling for transition from an early age might be an important way to negate these issues.

A small cluster randomised clinical trial to improve health outcomes among Argentine patients disengaged from HIV care

Background

Patients disengaged from HIV care, e.g., missed medication pick-ups, not attending physician visits, account for ≥70% of new HIV infections. Re-engaging and sustaining engagement is essential to controlling the HIV pandemic. This study tested a physician-delivered evidence-based intervention, Motivational Interviewing (MI), to improve health outcomes, adherence to antiretroviral therapy (ART), HIV virologic suppression, CD4+ count, retention in HIV care, and self-efficacy among patients disengaged from care in Argentina.

Methods

Regional clinics (n = 6) were randomised to condition, MI Intervention or Enhanced Standard of Care (ESOC), and recruited N = 360 patients disengaged from HIV care. ART adherence, HIV RNA viral load, CD4+ count retention, and self-efficacy were assessed at baseline, 6, 12, 18, and 24-months. Indirect effects from condition to main outcomes were examined using patient-provider relationship as a mediator. The study was a cluster-randomised clinical trial entitled Conexiones y Opciones Positivas en la Argentina 2 (COPA2) and was registered at clinicaltrials.gov, NCT02846350.

Findings

Participants were an average age of 39·15 (SD = 10·96), 51% were women; intervention participants were older (p = ·019), and more ESOC participants were women (60% vs. 42%, p = 0·001). Using mixed models, the intervention had no effect on ART adherence over time by condition on HIV RNA viral load, CD4+ count retention, or self-efficacy. However, analysing mediated paths, there was an indirect effect of condition on ART adherence (B = 0·188, p = 0·009), HIV viral load (B = -0·095, P = 0·027), and self-efficacy (B = 0·063, P = 0·001), suggesting the intervention was associated with improved patient-provider relationships, which was in turn associated with increased ART adherence, lower HIV viral load, and higher self-efficacy.

Interpretation

These findings suggest that physician-delivered MI may enhance the patient-provider relationship, self-efficacy, and ART adherence, and reduced HIV viral load in patients disengaged from HIV care. However, these findings are preliminary due to the small number of clusters randomised, and replication is warranted.

Funding

National Institutes of Health.

Cyclical Engagement in HIV Care: A Qualitative Study of Clinic Transfers to Re-enter HIV Care in Cape Town, South Africa

Long-term patient engagement and retention in HIV care is an ongoing challenge in South Africa's strained health system. However, some patients thought to be "lost to follow-up" (LTFU) may have "transferred" clinics to receive care elsewhere. Through semi-structured interviews, we explored the relationship between clinic transfer and long-term patient engagement among 19 treatment-experienced people living with HIV (PLWH) who self-identified as having engaged in a clinic transfer at least once since starting antiretroviral therapy (ART) in Gugulethu, Cape Town. Our findings suggest that patient engagement is often fluid, as PLWH cycle in and out of care multiple times during their lifetime. The linear nature of the HIV care cascade model poorly describes the lived realities of PLWH on established treatment. Further research is needed to explore strategies for reducing unplanned clinic transfers and offer more supportive care to new and returning patients.

Behavioural insights (BI) for childhood development and effective public policies in Latin America: a survey and a randomised controlled trial

OBJECTIVES

We developed (a) a survey to investigate the knowledge of childhood health experts on public policies and behavioural insights (BI), as well as its use in Latin American and the Caribbean countries (LACs), and (b) an intervention (randomised controlled trial) to test the influence of nudges on the effect of a simulated public health programme communication.

PARTICIPANTS AND SETTINGS

A total of 2003 LACs childhood health professionals participated in the study through a Hispanic online platform.

PRIMARY AND SECONDARY OUTCOMES

We used regression models analysing expertise-related information, individual differences and location. We extracted several outcome variables related to (a) 'Public Policy Knowledge Index' based on the participants' degree of knowledge on childhood health public policies and (b) BI knowledge, perceived effectiveness and usefulness of a simulated public programme communication. We also analysed a 'Behavioural Insights Knowledge Index' (BIKI) based on participants' performance in BI questions.

RESULTS

In general, health professionals showed low BI knowledge (knowledge of the term BI: χ²=210.29, df=1 and p<0.001; BIKI: χ²=160.5, df=1 and p<0.001), and results were modulated by different factors (age, academic formation, public policy knowledge and location). The use of BI principles for the communication of the public programme revealed higher impact and clarity ratings from professionals than control messages.

CONCLUSIONS

Our findings provide relevant knowledge about BI in health professionals to inform governmental and non-governmental organisations' decision-making processes related with childhood public policies and BI designs.

Motivational Interviewing Training for HIV Care Physicians in Argentina: Uptake and Sustainability of an Effective Behavior Change Intervention

Motivational interviewing (MI) utilizes a patient-centered approach to address patient ambivalence about treatment and has been found to improve treatment ART adherence among patients living with HIV disengaged from care. This study examined MI training for clinicians, uptake, and sustainability over time. Clinics (n = 7) with N = 38 physicians were randomized to condition (MI, Enhanced Standard of Care). Physicians completed video- recorded patient consultations at baseline and 6, 12, and 18-month follow-up. MI condition physicians had greater relational and technical scores over time and were more likely to adhere to and sustain MI over time. Overall, physicians found the MI training highly acceptable and were able to sustain their skills. Results illustrate the feasibility of MI training, implementation, and sustainment over 18 months. Findings support previous research in Argentina in which trained physicians found MI useful with challenging patients. Broader implementation of MI among HIV care physicians in Argentina is merited.

Psychosocial support interventions for improved adherence and retention in ART care for young people living with HIV (10-24 years): a scoping review

Background

Mental health disorders such as high levels of anxiety, isolation, depression and suicide ideation reported among young people living with HIV (10–24 years;YPLHIV) contribute significantly to poor medication adherence and retention in care. While there is evidence supporting the role of psychosocial support interventions in promoting adherence and retention in antiretroviral treatment (ART) among adults living with HIV, there is little evidence on the role of psychosocial support on medication adherence among YPLHIV. This scoping review was designed to identify and classify the types and effects of psychosocial support interventions designed to improve adherence and retention in ART among YPLHIV globally.

Method

We searched six electronic databases (i.e., Scopus, Pubmed and EBSCOHost (Academic Search Premier, CINAHL, Psycarticles and Medline). Six relevant articles published between 2011 and 2019 met our inclusion criteria. We extracted information relevant to the nature and outcomes of the reported interventions using thematic content analysis informed by the Population, Intervention, comparison, outcome, and time (PICOT) framework.

Results

Four distinctive treatment modalities that focused on improving ART adherence and retention in care were identified: individual counselling, support groups, family-centered services, and treatment supporters.

Conclusion

There is a dearth of psychosocial support interventions to improve adherence and retention in ART amongst adolescents and young adults living with HIV. Future research and programming should seek to address psychosocial support interventions or approaches specifically designed to address the needs of YPLHIV.

Trial registration

PROSPERO: Registration CRD42018105057.

Training physicians in behavioural change counseling: A systematic review

BACKGROUND

Poor health behaviours (e.g., smoking, physical inactivity) represent major underlying causes of non-communicable chronic diseases (NCDs). Prescriptive behaviour change interventions employed by physicians show limited effectiveness. Physician training in evidence-based behaviour change counselling (BCC) may improve behavioural risk factor management, but the efficacy and feasibility of current programs remains unclear.

OBJECTIVE

(1) To systematically review the efficacy of BCC training programs for physicians, and (2) to describe program content, dose and structure, informing better design and dissemination.

METHODS

Using PRISMA guidelines, a database search up to January 2018, yielded 1889 unique articles, screened by 2 authors; 9 studies met inclusion criteria and were retained for analysis.

RESULTS

100% of studies reported significant improvements in BCC skills among physicians, most programs targeting provider-patient collaboration, supporting patient autonomy, and use of open questions to elicit "change-talk". Limitation included: poor reporting quality, high program heterogeneity, small sample sizes, 78% of studies having no comparison group, and less than 30% of skills taught being formally assessed.

CONCLUSION

Training programs were efficacious, but methodological weaknesses limit the ability to determine content and delivery. Caution is necessary when interpreting the results.

PRACTICE IMPLICATIONS

Further research emphasizing rigorous training program development and testing is warranted.

Physician-delivered motivational interviewing to improve adherence and retention in care among challenging HIV-infected patients in Argentina (COPA2): study protocol for a cluster randomized controlled trial

BACKGROUND

"Challenging" HIV-infected patients, those not retained in treatment, represent a critical focus for positive prevention, as linkage to care, early initiation of antiretroviral therapy, adherence and retention in treatment facilitate viral suppression, thus optimizing health and reducing HIV transmission. Argentina was one of the first Latin American countries to guarantee HIV prevention, diagnosis and comprehensive care services, including antiretroviral medication, which removed cost and access as barriers. Yet, dropout occurs at every stage of the HIV continuum. An estimated 110,000 individuals are HIV-infected in Argentina; of these, 70% have been diagnosed and 54% were linked to care. However, only 36% have achieved viral suppression and 31% of those diagnosed delayed entry to care. To achieve meaningful reductions in HIV infection at the community level, innovative strategies must be developed to re-engage patients. Motivational Interviewing (MI) is a patient-centered approach and has been used by therapists in Central and South America to enhance motivation and commitment in substance use and risk reduction. Our pilot feasibility study utilized culturally tailored MI in physicians to target patients not retained in treatment in public and private clinics in Buenos Aires, Argentina. Results demonstrated that a physician-based MI intervention was feasible and effective in enhanced and sustained patient adherence, viral suppression, and patient-physician communication and attitudes about treatment among these patients at 6 and 9 months post baseline.

METHODS/DESIGN

This clinical trial seeks to extend these findings in public and private clinics in four urban population centers in Argentina, in which clinics (n = 6 clinics, six MDs per clinic site) are randomized to experimental (physician MI Intervention) (n = 3) or control (physician Standard of Care) (n = 3) conditions in a 3:3 ratio. Using a cluster randomized clinical trial design, the study will test the effectiveness of a physician-based MI intervention to improve and sustain retention, adherence, persistence, and viral suppression among "challenging" patients (n = 420) over 24 months.

DISCUSSION

Results are anticipated to have significant public health implications for the implementation of MI to re-engage and retain patients in HIV treatment and care and improve viral suppression through high levels of medication adherence.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT02846350 . Registered on 1 July 2016.

Evaluations of training programs to improve human resource capacity for HIV, malaria, and TB control: a systematic scoping review of methods applied and outcomes assessed

BACKGROUND

Owing to the global health workforce crisis, more funding has been invested in strengthening human resources for health, particularly for HIV, tuberculosis, and malaria control; however, little is known about how these investments in training are evaluated. This paper examines how frequently HIV, malaria, and TB healthcare provider training programs have been scientifically evaluated, synthesizes information on the methods and outcome indicators used, and identifies evidence gaps for future evaluations to address.

METHODS

We conducted a systematic scoping review of publications evaluating postgraduate training programs, including in-service training programs, for HIV, tuberculosis, and malaria healthcare providers between 2000 and 2016. Using broad inclusion criteria, we searched three electronic databases and additional gray literature sources. After independent screening by two authors, data about the year, location, methodology, and outcomes assessed was extracted from eligible training program evaluation studies. Training outcomes evaluated were categorized into four levels (reaction, learning, behavior, and results) based on the Kirkpatrick model.

FINDINGS

Of 1473 unique publications identified, 87 were eligible for inclusion in the analysis. The number of published articles increased after 2006, with most (n = 57, 66%) conducted in African countries. The majority of training evaluations (n = 44, 51%) were based on HIV with fewer studies focused on malaria (n = 28, 32%) and TB (n = 23, 26%) related training. We found that quantitative survey of trainees was the most commonly used evaluation method (n = 29, 33%) and the most commonly assessed outcomes were knowledge acquisition (learning) of trainees (n = 44, 51%) and organizational impacts of the training programs (38, 44%). Behavior change and trainees' reaction to the training were evaluated less frequently and using less robust methods; costs of training were also rarely assessed.

CONCLUSIONS

Our study found that a limited number of robust evaluations had been conducted since 2000, even though the number of training programs has increased over this period to address the human resource shortage for HIV, malaria, and TB control. Specifically, we identified a lack evaluation studies on TB- and malaria-related healthcare provider training and very few studies assessing behavior change of trainees or costs of training. Developing frameworks and standardized evaluation methods may facilitate strengthening of the evidence base to inform policies on and investments in training programs.

Improving antiretroviral therapy adherence in resource-limited settings at scale: a discussion of interventions and recommendations

Introduction: Successful population-level antiretroviral therapy (ART) adherence will be necessary to realize both the clinical and prevention benefits of antiretroviral scale-up and, ultimately, the end of AIDS. Although many people living with HIV are adhering well, others struggle and most are likely to experience challenges in adherence that may threaten virologic suppression at some point during lifelong therapy. Despite the importance of ART adherence, supportive interventions have generally not been implemented at scale. The objective of this review is to summarize the recommendations of clinical, research, and public health experts for scalable ART adherence interventions in resource-limited settings. Methods: In July 2015, the Bill and Melinda Gates Foundation convened a meeting to discuss the most promising ART adherence interventions for use at scale in resource-limited settings. This article summarizes that discussion with recent updates. It is not a systematic review, but rather provides practical considerations for programme implementation based on evidence from individual studies, systematic reviews, meta-analyses, and the World Health Organization Consolidated Guidelines for HIV, which include evidence from randomized controlled trials in low- and middle-income countries. Interventions are categorized broadly as education and counselling; information and communication technology-enhanced solutions; healthcare delivery restructuring; and economic incentives and social protection interventions. Each category is discussed, including descriptions of interventions, current evidence for effectiveness, and what appears promising for the near future. Approaches to intervention implementation and impact assessment are then described. Results and discussion: The evidence base is promising for currently available, effective, and scalable ART adherence interventions for resource-limited settings. Numerous interventions build on existing health care infrastructure and leverage available resources. Those most widely studied and implemented to date involve peer counselling, adherence clubs, and short message service (SMS). Many additional interventions could have an important impact on ART adherence with further development, including standardized counselling through multi-media technology, electronic dose monitoring, decentralized and differentiated models of care, and livelihood interventions. Optimal targeting and tailoring of interventions will require improved adherence measurement. Conclusions: The opportunity exists today to address and resolve many of the challenges to effective ART adherence, so that they do not limit the potential of ART to help bring about the end of AIDS.

Implementation and uptake of the Conexiones y Opciones en la Argentina intervention: feasibility and acceptability

Challenging HIV-infected patients, those neither adherent nor actively engaged in care, represent an important opportunity for intervention if the HIV epidemic is to be contained. This pilot study assessed the feasibility and acceptability of an adapted patient adherence intervention and a motivational interview-based provider intervention in urban Buenos Aires, Argentina, in order to optimize health benefits in challenging HIV-infected patients. To maximize implementation and uptake of both strategies, interventions were adapted to the local setting. Qualitative data and a short quantitative assessment from patients, staff, fellows, residents and physicians (n = 84) were examined to establish the feasibility and acceptability of offering patient and provider evidence-based interventions in both public and private health-care settings. Results identified key themes on provision of information, use of specialized communication techniques and group support in the utilization of the interventions. Both providers (n = 12) and patients (n = 120) endorsed the acceptability and value of the interventions, and the feasibility of their delivery. Findings support the use of both intervention modalities with challenging patients in diverse urban health-care settings.