Understanding the dynamic interactions driving the sustainability of ART scale-up implementation in Uganda

Understanding Uganda's early adoption of novel differentiated HIV treatment services: a qualitative exploration of drivers of policy uptake

BACKGROUND

Although differentiated service delivery (DSD) for HIV treatment was endorsed by the WHO in its landmark 2016 guidelines to lessen patients' need to frequently visit clinics and hence to reduce unnecessary burdens on health systems, uptake has been uneven globally. This paper is prompted by the HIV Policy Lab's annual report of 2022 which reveals substantial variations in programmatic uptake of differentiated HIV treatment services across the globe. We use Uganda as a case study of an 'early adopter' to explore the drivers of programmatic uptake of novel differentiated HIV treatment services.

METHODS

We conducted a qualitative case-study in Uganda. In-depth interviews were held with national-level HIV program managers (n = 18), district health team members (n = 24), HIV clinic managers (n = 36) and five focus groups with recipients of HIV care (60 participants) supplemented with documentary reviews. Our thematic analysis of the qualitative data was guided by the Consolidated Framework for Implementation Research (CFIR)'s five domains (inner context, outer setting, individuals, process of implementation).

RESULTS

Our analysis reveals that drivers of Uganda's 'early adoption' of DSD include: having a decades-old HIV treatment intervention implementation history; receiving substantial external donor support in policy uptake; the imperatives of having a high HIV burden; accelerated uptake of select DSD models owing to Covid-19 'lockdown' restrictions; and Uganda's participation in clinical trials underpinning WHO guidance on DSD. The identified processes of implementation entailed policy adoption of DSD (such as the role of local Technical Working Groups in domesticating global guidelines, disseminating national DSD implementation guidelines) and implementation strategies (high-level health ministry buy-in, protracted patient engagement to enhance model uptake, devising metrics for measuring DSD uptake progress) for promoting programmatic adoption.

CONCLUSION

Our analysis suggests early adoption derives from Uganda's decades-old HIV intervention implementation experience, the imperative of having a high HIV burden which prompted innovations in HIV treatment delivery as well as outer context factors such as receiving substantial external assistance in policy uptake. Our case study of Uganda offers implementation research lessons on pragmatic strategies for promoting programmatic uptake of differentiated treatment HIV services in other countries with a high HIV burden.

Implementation, interrupted: Identifying and leveraging factors that sustain after a programme interruption

Many implementation efforts experience interruptions, especially in settings with developing health systems. Approaches for evaluating interruptions are needed to inform re-implementation strategies. We sought to devise an approach for evaluating interruptions by exploring the sustainability of a programme that implemented diabetes mellitus (DM) screening within tuberculosis clinics in Uganda in 2017. In 2019, we conducted nine interviews with clinic staff and observed clinic visits to determine their views and practices on providing integrated care. We mapped themes to a social ecological model with three levels derived from the Consolidated Framework for Implementation Research (CFIR): outer setting (i.e. community), inner setting (i.e. clinic), and individuals (i.e. clinicians). Respondents explained that DM screening ceased due to disruptions in the national supply chain for glucose test strips, which had cascading effects on clinics and clinicians. Lack of screening supplies in clinics limited clinicians' opportunities to perform DM screening, which contributed to diminished self-efficacy. However, culture, compatibility and clinicians' beliefs about DM screening sustained throughout the interruption. We propose an approach for evaluating interruptions using the CFIR and social ecological model; other programmes can adapt this approach to identify cascading effects of interruptions and target them for re-implementation.

Strategies to adapt and implement health system guidelines and recommendations: a scoping review

BACKGROUND

Evidence-based health system guidelines are pivotal tools to help outline the important financial, policy and service components recommended to achieve a sustainable and resilient health system. However, not all guidelines are readily translatable into practice and/or policy without effective and tailored implementation and adaptation techniques. This scoping review mapped the evidence related to the adaptation and implementation of health system guidelines in low- and middle-income countries.

METHODS

We conducted a scoping review following the Joanna Briggs Institute methodology for scoping reviews. A search strategy was implemented in MEDLINE (Ovid), Embase, CINAHL, LILACS (VHL Regional Portal), and Web of Science databases in late August 2020. We also searched sources of grey literature and reference lists of potentially relevant reviews. All findings were reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews.

RESULTS

A total of 41 studies were included in the final set of papers. Common strategies were identified for adapting and implementing health system guidelines, related barriers and enablers, and indicators of success. The most common types of implementation strategies included education, clinical supervision, training and the formation of advisory groups. A paucity of reported information was also identified related to adaptation initiatives. Barriers to and enablers of implementation and adaptation were reported across studies, including the need for financial sustainability. Common approaches to evaluation were identified and included outcomes of interest at both the patient and health system level.

CONCLUSIONS

The findings from this review suggest several themes in the literature and identify a need for future research to strengthen the evidence base for improving the implementation and adaptation of health system guidelines in low- and middle-income countries. The findings can serve as a future resource for researchers seeking to evaluate implementation and adaptation of health system guidelines. Our findings also suggest that more effort may be required across research, policy and practice sectors to support the adaptation and implementation of health system guidelines to local contexts and health system arrangements in low- and middle-income countries.

Transitioning health workers from PEPFAR contracts to the Uganda government payroll

Although increasing public spending on health worker (HW) recruitments could reduce workforce shortages in sub-Saharan Africa, effective strategies for achieving this are still unclear. We aimed to understand the process of transitioning HWs from President's Emergency Plan for AIDS Relief (PEPFAR) to Government of Uganda (GoU) payrolls and to explore the facilitators and barriers encountered in increasing domestic financial responsibility for absorbing this expanded workforce. We conducted a multiple case study of 10 (out of 87) districts in Uganda which received PEPFAR support between 2013 and 2015 to expand their health workforce. We purposively selected eight districts with the highest absorption rates ('high absorbers') and two with the lowest absorption rates ('low absorbers'). A total of 66 interviews were conducted with high-level officials in three Ministries of Finance, Health and Public Service (n = 14), representatives of PEPFAR-implementing organizations (n = 16), district health teams (n = 15) and facility managers (n = 22). Twelve focus groups were conducted with 87 HWs absorbed on GoU payrolls. We utilized the Consolidated Framework for Implementation Research to guide thematic analysis. At the sub-national level, facilitators of transition in 'high absorber' districts were identified as the presence of transition 'champions', prioritizing HWs in district wage bill commitments, host facilities providing 'bridge financing' to transition workforce during salary delays and receiving donor technical support in district wage bill analysis-attributes that were absent in 'low absorber' districts. At the national level, multi-sectoral engagements (incorporating the influential Ministry of Finance), developing a joint transition road map, aligning with GoU salary scales and recruitment processes emerged as facilitators of the transition process. Our case studies offer implementation research lessons on effective donor transition and insights into pragmatic strategies for increasing public spending on expanding the health workforce in a low-income setting.

The impact of loss of PEPFAR support on HIV services at health facilities in low-burden districts in Uganda

BACKGROUND

Although donor transitions from HIV programs are more frequent, little research exists seeking to understand the perceptions of patients and providers on this process. Between 2015 and 2017, PEPFAR implemented the ´geographic prioritization´ (GP) policy in Uganda whereby it shifted support from 734 'low-volume' facilities and 10 districts with low HIV burden and intensified support in select facilities in high-burden districts. Our analysis intends to explore patient and provider perspectives on the impact of loss of PEPFAR support on HIV services in transitioned health facilities in Uganda.

METHODS

We report qualitative findings from a larger mixed-methods evaluation. Six facilities were purposefully selected as case studies seeking to ensure diversity in facility ownership, size, and geographic location. Five out of the six selected facilities had experienced transition. A total of 62 in-depth interviews were conducted in June 2017 (round 1) and November 2017 (round 2) with facility in-charges (n = 13), ART clinic managers (n = 12), representatives of PEPFAR implementing organizations (n = 14), district health managers (n = 23) and 12 patient focus group discussions (n = 72) to elicit perceived effects of transition on HIV service delivery. Data were analyzed using thematic analysis.

RESULTS

While core HIV services, such as testing and treatment, offered by case-study facilities prior to transition were sustained, patients and providers reported changes in the range of HIV services offered and a decline in the quality of HIV services offered post-transition. Specifically, in some facilities we found that specialized pediatric HIV services ceased, free HIV testing services stopped, nutrition support to HIV clients ended and the 'mentor mother' ART adherence support mechanism was discontinued. Patients at three ART-providing facilities reported that HIV service provision had become less patient-centred compared to the pre-transition period. Patients at some facilities perceived waiting times at clinics to have become longer, stock-outs of anti-retroviral medicines to have been more frequent and out-of-pocket expenditure to have increased post-transition.

CONCLUSIONS

Participants perceived transition to have had the effect of narrowing the scope and quality of HIV services offered by case-study facilities due to a reduction in HIV funding as well as the loss of the additional personnel previously hired by the PEPFAR implementing organizations for HIV programming. Replacing the HIV programming gap left by PEPFAR in transition districts with Uganda government services is critical to the attainment of 90-90-90 targets in Uganda.

Reimagining the role of the nursing workforce in Uganda after more than a decade of ART scale-up

BACKGROUND

The expanding roles and increasing importance of the nursing workforce in health services delivery in resource-limited settings is not adequately documented and sufficiently recognized in the current literature. Drawing upon the theme of 2020 as the International Year of the Nurse and the Midwife, we set out to describe how the role of nurses expanded tremendously in health facilities in Uganda during the era of anti-retroviral therapy (ART) scale-up that commenced in June 2004.

METHODS

We employed a mixed-methods sequential explanatory research design. Phase I entailed a cross-sectional health facility survey (n = 195) to assess the extent to which human resource management strategies (such as task shifting) were common. Phase II entailed a qualitative multiple case study of 16 (of the 195) health facilities for an in-depth understanding of the strategies adopted (e.g. nurse-centred HIV care). Descriptive analyses were performed in STATA (v 13) while qualitative data were analysed by thematic approach.

RESULTS

We found that nurses were the most represented cadre of health workers involved in the overall leadership of HIV clinics across Uganda. Most nurse-led HIV clinics were based in rural settings; however, this trend was fairly even across setting (rural/urban/peri-urban). While 181 (93%) health facilities allowed non-physician cadre to prescribe ART, a number of health facilities (n = 36) or 18% deliberately adopted nurse-led HIV care models. Nurses were empowered to be multi-skilled with a wide range of competencies across the HIV care continuum right from HIV testing to mainstream clinical HIV disease management. In several facilities, nursing cadre were the backbone of ART service delivery. A select number of facilities devised differentiated models of task shifting from physicians to nurses in which the latter handled patients who were stable on ART.

CONCLUSION

Overall, our study reveals a wide expansion in the scope-of-practice of nurses during ART scale-up in Uganda. Nurses were thrust in roles of HIV disease management that were traditionally the preserve of physicians. Our study underscores the importance of reforming regulatory frameworks governing nursing workforce scope of practice such as the need for developing a policy on task shifting which is currently lacking in Uganda.

Understanding implementation barriers in the national scale-up of differentiated ART delivery in Uganda

BACKGROUND

Although Differentiated Service Delivery (DSD) for anti-retroviral therapy (ART) has been rolled-out nationally in several countries since World Health Organization (WHO)'s landmark 2016 guidelines, there is little research evaluating post-implementation outcomes. The objective of this study was to explore patients' and HIV service managers' perspectives on barriers to implementation of Differentiated ART service delivery in Uganda.

METHODS

We employed a qualitative descriptive design involving 124 participants. Between April and June 2019 we conducted 76 qualitative interviews with national-level HIV program managers (n = 18), District Health Team leaders (n = 24), representatives of PEPFAR implementing organizations (11), ART clinic in-charges (23) in six purposively selected Uganda districts with a high HIV burden (Kampala, Luwero, Wakiso, Mbale, Budadiri, Bulambuli). Six focus group discussions (48 participants) were held with patients enrolled in DSD models in case-study districts. Data were analyzed by thematic approach as guided by a multi-level analytical framework: Individual-level factors; Health-system factors; Community factors; and Context.

RESULTS

Our data shows that multiple barriers have been encountered in DSD implementation. Individual-level: Individualized stigma and a fear of detachment from health facilities by stable patients enrolled in community-based models were reported as bottlenecks. Socio-economic status was reported to have an influence on patient selection of DSD models. Health-system: Insufficient training of health workers in DSD delivery and supply chain barriers to multi-month ART dispensing were identified as constraints. Patients perceived current selection of DSD models to be provider-intensive and not sufficiently patient-centred. Community: Community-level stigma and insufficient funding to providers to fully operationalize community drug pick-up points were identified as limitations.

CONTEXT

Frequent changes in physical addresses among urban clients were reported to impede the running of patient groups of rotating ART refill pick-ups.

CONCLUSION

This is one of the first multi-stakeholder evaluations of national DSD implementation in Uganda since initial roll-out in 2017. Multi-level interventions are needed to accelerate further DSD implementation in Uganda from demand-side (addressing HIV-related stigma, community engagement) and supply-side dimensions (strengthening ART supply chain capacities, increasing funding for community models and further DSD program design to improve patient-centeredness).

Protocol for a randomized clinical trial exploring the effect of antimicrobial agents on the penile microbiota, immunology and HIV susceptibility of Ugandan men

Background

The foreskin is the main site of HIV acquisition in a heterosexual uncircumcised man, but many men in endemic countries are reluctant to undergo penile circumcision (PC). Observational studies suggest that proinflammatory anaerobic bacteria are enriched on the uncircumcised penis, where they may enhance HIV susceptibility through increased foreskin inflammatory cytokines and the recruitment of HIV-susceptible CD4⁺ target cells. This trial will examine the impact of systemic and topical antimicrobials on ex vivo foreskin HIV susceptibility.

Methods/design

This randomized, open-label clinical trial will randomize 125 HIV-negative Ugandan men requesting voluntary PC to one of five arms (n = 25 each). The control group will receive immediate PC, while the four intervention groups will defer PC for 1 month and be provided in the interim with either oral tinidazole, penile topical metronidazole, topical clindamycin, or topical hydrogen peroxide. The impact of these interventions on HIV entry into foreskin-derived CD4⁺ T cells will be quantified ex vivo at the time of PC using a clade A, R5 tropic HIV pseudovirus assay (primary endpoint); secondary endpoints include the impact of antimicrobials on immune parameters and the microbiota of the participant’s penis and of the vagina of their female partner (if applicable), assessed by multiplex enzyme-linked immunosorbent assay and 16S rRNA sequencing.

Discussion

There is a critical need to develop acceptable, simple, and effective means of HIV prevention in men unwilling to undergo PC. This trial will provide insight into the causative role of the foreskin microbiota on HIV susceptibility, and the impact of simple microbiota-focused clinical interventions. This may pave the way for future clinical trials using low-cost, nonsurgical intervention(s) to reduce HIV risk in uncircumcised heterosexual men.

Trial registration

ClinicalTrials.gov, NCT03412071. Retrospectively registered on 26 January 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3545-7) contains supplementary material, which is available to authorized users.

"The number of clients is increasing but the supplies are reducing": provider strategies for responding to chronic antiretroviral (ARV) medicines stock-outs in resource-limited settings: a qualitative study from Uganda

Background

Despite the increasing frequency of ARV medicines stock-outs in Sub-Saharan Africa, there is little research inquiring into the mitigation strategies devised by frontline health facilities. Many previous studies have focused on ‘upstream’ or national-level drivers of ARVs stock-outs with less empirical attention devoted ‘down-stream’ or at the facility-level. The objective of this study was to examine the strategies devised by health facilities in Uganda to respond to the chronic stock-outs of ARVs.

Methods

This was a qualitative research design nested within a larger mixed-methods study. We purposively selected 16 health facilities from across Uganda (to achieve diversity with regard to; level of care (primary/ tertiary), setting (rural/urban) and geographic sub-region (northern/ central/western). We conducted 76 Semi-structured interviews with ART clinic managers, clinicians and pharmacists in the selected health facilities supplemented by on-site observations and documentary reviews. Data were analyzed by coding and thematic analyses.

Results

Participants reported that facility-level contributors to stock-outs include untimely orders of drugs from suppliers and inaccurate quantification of ARV medicine needs due to a paucity of ART program data. Internal stock management solutions for mitigating stock-outs which emerged include the substitution of ARV medicines which were out of stock, overstocking selected medicines and the use of recently expired drugs. The external solutions for mitigating stock-outs which were identified include ‘borrowing’ of ARVs from peer-providers, re-distributing stock across regions and upward referrals of patients. Systemic drivers of stock-outs were identified. These include the supply of drugs with a short shelf life, oversupply and undersupply of ARV medicines and migration pressures on the available ARVs stock at case-study facilities.

Conclusion

Health facilities devised internal stock management strategies and relied on peer-provider networks for ARV medicines during stock-out events. Our study underscores the importance of devising interventions aimed at improving Uganda’s medicines supply chain systems in the quest to reduce the frequency of ARV medicines stock-outs at the front-line level of service delivery. Further research is recommended on the effect of substituting ARV medicines on patient outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4137-7) contains supplementary material, which is available to authorized users.

Assessing the level of institutionalization of donor-funded anti-retroviral therapy (ART) programs in health facilities in Uganda: implications for program sustainability

Background: In the context of declining international assistance for ART scale-up in Sub-Saharan Africa, the institutionalization of ART programs through integrating them in the organizational routines of health facilities is gaining importance as a program sustainability strategy.

Objective: The aims of this study were; (i) to compare the level of institutionalization of ART programs in health facilities in Uganda and (ii) to explore reasons for variations in the degree of program institutionalization.

Methods: In Phase One, we utilized Level of Institutionalization Scales developed by Goodman (1993) to measure the degree of institutionalization of ART interventions in 195 health facilities across Uganda. The 45-item questionnaire measured institutionalization based on four sub-systems (production, maintenance, supportive, managerial) theorized to make up an organization assessed against two levels of institutionalization; routines (lowest) niche saturation (highest). In Phase Two, four health facilities were purposively selected (2 with the highest and 2 with the lowest institutionalization scores) for a multiple case-study involving semi-structured interviews with ART clinic managers(n = 32), on-site observations and document review.

Results: The two highest scoring health facilities had a longer HIV intervention implementation history of between 8 and 11 years. The highest scoring cases associated intervention institutionalization with sustained workforce trainings in ART management, the retention of ART-trained personnel and generating in-house ART manuals. The turnover of ART-proficient staff was identified as a barrier to intervention institutionalization in the lowest-ranked cases. Significant differences in organizational contexts were identified. The two highest-ranked health facilities were well-established, higher-tier hospitals while the lowest scoring health facilities were lower-level health facilities.

Conclusions: The level of institutionalization of ART interventions appeared to be differentiated by level of care in the Ugandan health system. Interventions aimed at strengthening program institutionalization in lower-level health centers at the level of human resources for health could enhance ART scale-up sustainability.

Understanding the persistence of vertical (stand-alone) HIV clinics in the health system in Uganda: a qualitative synthesis of patient and provider perspectives

Background

Although there is mounting evidence and policy guidance urging the integration of HIV services into general health systems in countries with a high HIV burden, vertical (stand-alone) HIV clinics are still common in Uganda. We sought to describe the specific contexts underpinning the endurance of vertical HIV clinics in Uganda.

Methods

A qualitative research design was adopted. Semi-structured interviews were conducted with the heads of HIV clinics, clinicians and facility in-charges (n = 78), coupled with eight focus group discussions (64 participants) with patients from 16 health facilities purposively selected, from a nationally-representative sample of 195 health facilities across Uganda, because they run stand-alone HIV clinics. Data were analyzed by thematic approach as guided by the theory proposed by Shediac-Rizkallah & Bone (1998) which identifies; Intervention characteristics, organizational context, and broader environment factors as potentially influential on health programme sustainability.

Results

Intervention characteristics: Provider stigma was reported to have been widespread in the integrated care experience of participating health facilities which necessitated the establishment of stand-alone HIV clinics. HIV disease management was described as highly specialized which necessitated a dedicated workforce and vertical HIV infrastructure such as counselling rooms. Organizational context: Participating health facilities reported health-system capacity constraints in implementing integrated systems of care due to a shortage of ART-proficient personnel and physical space, a lack of laboratory capacity to concurrently conduct HIV and non-HIV tests and increased workloads associated with implementing integrated care. Broader environment factors: Escalating HIV client loads and external HIV funding architectures were perceived to have perpetuated verticalized HIV programming over the past decade.

Conclusion

Our study offers in-depth, contextualized insights into the factors contributing to the endurance of vertical HIV clinics in Uganda. Our analysis suggests that there is a complex interaction in supply-side constraints (shortage of ART-proficient personnel, increased workloads, laboratory capacity deficiencies) and demand-side factors (escalating demand for HIV services, psychosocial barriers to HIV care) as well as the specialized nature of HIV disease management which pose challenges to the integrated-health services agenda.