An exploration of group-based HIV/AIDS treatment and care models in Sub-Saharan Africa using a realist evaluation (Intervention-Context-Actor-Mechanism-Outcome) heuristic tool: a systematic review

Evaluation of differentiated service delivery models on HIV treatment retention among key populations in Nigeria: a prospective cohort analysis

INTRODUCTION

Differentiated Service Delivery models (DSD) that cater to the needs of key populations (KP) have shown promise in providing KP-sensitive and KP-tailored care and treatment services. We evaluated the effect of two DSD models on linkage to and retention in treatment in Nigeria.

METHODS

Between December 2017 and June 2018, newly-diagnosed men who have sex with men (MSM) and female sex workers (FSWs) were enrolled into treatment through two DSD models and followed prospectively for one year. Model 1 was a fully integrated one-stop-shop (OSS) while model 2 was a hybrid HIV prevention and treatment site (DIC). Retention was estimated from drug pick-up records and was defined as being on treatment within 90 days one-year post ART initiation. Cox regression was used to identify the independent effect of the DSD models on retention while probability of being retained in treatment at 1-year was estimated with Kaplan-Meier product limit.

RESULTS

A total of 605 newly-diagnosed clients were enrolled into the study (340 in OSS and 265 in DIC; 342 were FSWs, while 263 were MSM). Median age was 26 years for MSM and 30 years for FSWs. Among those linked to treatment, retention was higher in the OSS than in DIC (63% vs. 48%; p = 0.002). Among those not retained, mean days to be lost-to-follow up (LFTU) was 60 days. Controlling for educational level, population type and age, clients who received treatment in M2 were 6 times more likely not to be retained in treatment at the end of 1 year (Hazard ratio 5.89; 95% CI: 1.04-33.16). The Kaplan Meier estimates of the probability of being retained in 6 months, 9 months and 12 months was 0.97, 0.92, 0.80 for the DIC and 1.00, 0.96, 0.91 for the OSS.

CONCLUSION

Linkage to treatment was suboptimal across both models with less than 90% of newly-diagnosed positives initiated on treatment and suggests that facilitated linkage is required to achieve at least 95%. Though retention was higher in the OSS model, both models had an alarmingly short time frame for LTFU and thus intensive monitoring during this phase of treatment is recommended irrespective of the type of DSD. Addressing these gaps will improve service delivery by one stop shops for HIV care and treatment.

Mechanism-Based Middle-Range Theories: Using Realist Syntheses to Reconcile Specificity to Context and Generalizability

Realist synthesis is a recognized methodological approach to evidence synthesis to inform evidence-based health policy and practice. The implicit assumption behind research synthesis is that the evidence it generates should be generalizable--drawing broad inferences from specific observations. While this understanding is generally shared among social scientists, tensions exist between having generalizable evidence and how this evidence can be useful in specific contexts. This paper considers the role of mechanism-based middle-range theories obtained from realist synthesis in bridging specificity to context and generalizability. Retroductive theorizing in realist synthesis helps to identify ideas about mechanisms related to the phenomenon embedded in the social and organizational contexts that could, in principle, have a much broader application. Also, because mechanism-based middle-range theories are linked to contextual features, they capture contextual nuances to enhance evidence implementation. We conclude that middle-range mechanisms provide an opportunity to achieve generalizability and contextualization in implementation science.

Increasing the uptake of Intermittent Preventive Treatment of malaria in pregnancy using Sulfadoxine-Pyrimethamine (IPTp-SP) through seasonal malaria chemoprevention channel delivery: protocol of a multicenter cluster randomized implementation trial in Mali and Burkina Faso

BACKGROUND

The uptake of Intermittent Preventive Treatment of malaria in pregnancy using Sulfadoxine-Pyrimethamine (IPTp-SP) remains unacceptably low, with more than two-thirds of pregnant women in sub-Saharan Africa still not accessing the three or more doses recommended by the World Health Organisation (WHO). In contrast, the coverage of Seasonal Malaria Chemoprevention (SMC), a more recent strategy recommended by the WHO for malaria prevention in children under five years living in Sahelian countries with seasonal transmission, including Mali and Burkina-Faso, is high (up to 90%). We hypothesized that IPTp-SP delivery to pregnant women through SMC alongside antenatal care (ANC) will increase IPTp-SP coverage, boost ANC attendance, and increase public health impact. This protocol describes the approach to assess acceptability, feasibility, effectiveness, and cost-effectiveness of the integrated strategy.

METHODS AND ANALYSIS

This is a multicentre, cluster-randomized, implementation trial of IPTp-SP delivery through ANC + SMC vs ANC alone in 40 health facilities and their catchment populations (20 clusters per arm). The intervention will consist of monthly administration of IPTp-SP through four monthly rounds of SMC during the malaria transmission season (July to October), for two consecutive years. Effectiveness of the strategy to increase coverage of three or more doses of IPTp-SP (IPTp3 +) will be assessed using household surveys and ANC exit interviews. Statistical analysis of IPT3 + and four or more ANC uptake will use a generalized linear mixed model. Feasibility and acceptability will be assessed through in-depth interviews and focus group discussions with health workers, pregnant women, and women with a child < 12 months.

DISCUSSION

This multicentre cluster randomized implementation trial powered to detect a 45% and 22% increase in IPTp-SP3 + uptake in Mali and Burkina-Faso, respectively, will generate evidence on the feasibility, acceptability, effectiveness, and cost-effectiveness of IPTp-SP delivered through the ANC + SMC channel. The intervention is designed to facilitate scalability and translation into policy by leveraging existing resources, while strengthening local capacities in research, health, and community institutions. Findings will inform the local national malaria control policies.

TRIAL REGISTRATION

Retrospectively registered on August 11th, 2022; registration # PACTR202208844472053. Protocol v4.0 dated September 04, 2023. Trail sponsor: University of Sciences Techniques and Technologies of Bamako (USTTB), Mali.

HIV advocacy: knowledge translation and implementation at three diverse sites in sub-Saharan Africa

PURPOSE

To explore how the gap in knowledge translation around HIV and rehabilitation could be addressed using advocacy. This article describes and reflects on lessons learned from incorporating content on HIV and advocacy into the curricula at three diverse physiotherapy (PT) programs in sub-Saharan Africa.

METHODS

A realistic evaluation approach was followed. Three study sites were purposively chosen to reflect diverse settings with respect to pedagogical approach, university or college, degree or diploma programs, use of technology, and regional prevalence of HIV. A multi-faceted intervention was implemented that included three activities: (i) to develop three core components of a novel knowledge translation intervention designed to improve knowledge, attitudes, and self-efficacy in HIV and rehabilitation advocacy among PT students; (ii) to tailor and implement the knowledge translation intervention by local faculty according to the context and needs of their program and to implement this with a cohort of PT students at each of the three study sites; and (iii) to evaluate the adaptation and implementation of the intervention at each site.

RESULTS

Differences exist between the three-country programmes, specifically in the length of time the degree takes, the extent of HIV inclusion in the curriculum and years of the study included in the project.

CONCLUSIONS

This research adds to the call to shift the focus of HIV care from just test-and-treat, or on just keeping people alive, towards a broader approach that centres the whole person, that focuses not only on surviving but on thriving, and which commits to the goal of optimising functioning and living full, whole lives with HIV. Advocacy across the continuum of care plays a pivotal role in translating research findings into practice.Implications for rehabilitationResults are relevant for policymakers in government and at senior levels within universities whose mandates include informing, reviewing, and driving educational programs and curricula.The result from this project illuminates the role for rehabilitation and allows for incorporating HIV into curriculum and practice for physiotherapists and other related stakeholders so that they can advocate for and with patients.

The effectiveness of nurse-led group interventions on hypertension lifestyle management: A mixed method study

PURPOSE

Hypertension is prevalent in Uganda and achieving treatment goals remains a challenge. Our aim was to assess the impact of a bundled nurse-led intervention on hypertension physiologic measures and lifestyle modification, and to explore perceptions of the interventions to enhance sustainability.

DESIGN AND SETTING

We employed a sequential explanatory mixed-method design. The study was conducted at a large urban private hospital in Uganda from September 2018 to May 2019.

SAMPLE

Participants were clinic patients with hypertension currently under care. A total of 54 participants were enrolled in two study groups. Two focus groups with 16 participants and 2 nurse-educator interviews were conducted.

METHODS

Blood pressure and weight were measured at baseline, three, six, and nine months. The Self-Care of Hypertension Inventory was used to assess lifestyle modification. Monthly education and group-support with text-message follow-up were implemented. Two focus-groups and nurse-educator interviews were conducted to assess perceptions post-implementation. The analysis included descriptive statistic, multivariate analysis and qualitative analysis for themes and subthemes.

FINDINGS

Overall, participants had a mean weight loss of 7.7 kg (p = 0.001) and a mean reduction in systolic blood pressure (SBP) of 9.5 mm Hg (p = 0.001). Improvement in biometric outcomes was associated with lifestyle modification such as taking medicine as prescribed (p = 0.008), eat lots of fruit and vegetables (p = 0.043), and control your body weight (p = 0.015). Thematic analysis yielded the following themes: Knowledge and understanding, Attitude change, Adherence-a real struggle, and Adapting to what suits us. Participants found group support, shared learning, and knowledge reinforcement enhanced their knowledge and self-efficacy. Nurse educators were motivated by the patients' favorable responses to the Bundled Education and Support with Text (BEST) intervention.

CONCLUSION

Findings support the use of nurse-led interventions to enhance the achievement of hypertension treatment goals. To sustain the achieved lifestyle modification and blood pressure outcomes, participants expressed a desire for continued support, information access, and inclusion of patients as champions for knowledge dissemination. Future studies need to explore the provision of enabling structures to support nurse-led interventions in routine non-Communicable disease (NCD) care.

CLINICAL RELEVANCE

Hypertension knowledge-gaps exist among patients and may reflect missed opportunities for patient engagement and education for behavior change. Bundled nurse-led hypertension interventions can significantly improve lifestyle modification and enhance hypertension outcomes. Persons supported and empowered with knowledge can act as conduits to wider communities in championing knowledge dissemination.

How gender shapes interprofessional teamwork in the operating room: a qualitative secondary analysis

BACKGROUND

Despite substantial implications for healthcare provider practice and patient outcomes, gender has yet to be systematically explored with regard to interprofessional operating room (OR) teamwork. We aimed to explore and describe how gender and additional social identity factors shape experiences and perceptions of teamwork in the OR.

METHODS

This study was a qualitative secondary analysis of semi-structured interviews with OR team members conducted between November 2018 and July 2019. Participants were recruited across hospitals in Ontario, Canada. We conducted both purposive and snowball sampling until data saturation was reached. Transcripts were analyzed thematically by two independent research team members, moving from open to axial coding.

RESULTS

Sixty-six interviews of OR healthcare professionals were completed: anesthesia (n=17), nursing (n=19), perfusion (n=2), and surgery (n=26). Traditional gender roles, norms, and stereotypes were perceived and experienced by both women and men, but with different consequences. Both women and men participants described challenges that women face in the OR, such as being perceived negatively for displaying leadership behaviours. Participants also reported that interactions and behaviours vary depending on the team gender composition, and that other social identities, such as age and race, often interact with gender. Nevertheless, participants indicated a belief that the influence of gender in the OR may be modified.

CONCLUSIONS

The highly gendered reality of the OR creates an environment conducive to breakdowns in communuication and patient safety risks in addition to diminishing team morale, psychological safety, and provider well-being. Consequently, until teamwork interventions adequately account for gender, they are unlikely to be optimally effective or sustainable.

Incidence of cardiometabolic diseases in a Lesotho HIV cohort: Evidence for policy decision-making

Background

Antiretroviral treatment (ART) has been associated with the development of certain cardiometabolic diseases (CMDs). The burden of CMDs amongst ART-experienced patients in sub-Saharan Africa was unknown.

Objective

We quantified the burden of CMDs and identified the associated risk factors in a large treatment cohort on ART at a high-volume facility in Lesotho.

Methods

In this retrospective cohort study, we extracted data from the daily dispensing electronic system and routine clinical records of 785 adults on ART between 2011 and 2015 in Maseru, Lesotho. CMD was defined as a diagnosis of hypertension, diabetes mellitus or dyslipidaemia (singly or collectively). Descriptive statistics were used to describe the disease burden; Kaplan–Meier curves and cause-specific Cox proportional hazards models were fitted to examine the impact of the ART regimen and identify the risk factors associated with the occurrence of CMD.

Results

Of the 785 participants, 473 (60%) were women. The median age of the group was 42 years, interquartile range (IQR), 36–51 years. The overall incidence of CMD was 5.6 (95% confidence interval [CI] = 4.4–7.1) per 100 person-months of follow-up. The median time to onset of CMD was 16.6 months (IQR = 7.4–23.4). ART was not associated with the occurrence of CMD (cause-specific hazard ratio [CHR] = 1.55; 95% CI = 0.14–16.85; P = 0.72). Higher body mass index (BMI) was associated with the occurrence of diabetes mellitus (CHR = 1.19; 95% CI = 1.14–1.38; P = 0.026).

Conclusion

The incidence of CMD in this relatively young patient population is low yet noteworthy. We recommend that patients living with HIV and AIDS should be routinely screened for CMD. Higher BMI is generally associated with the occurrence of CMD.

Effect of community antiretroviral therapy on treatment outcomes among stable antiretroviral therapy patients in Nigeria: A quasi experimental study

OBJECTIVES

This study evaluates the effect of Community Anti-retroviral Groups on Immunologic, Virologic and clinical outcomes of stable Antiretroviral Therapy patients in Nigeria.

METHOD

A cohort of 251 eligible adults (≥18 years) on first-line ART for at least 6 months with CD4 counts >200 cells/mm3 and viral load <1000 c/ml were devolved from 10 healthcare facilities to 51 community antiretroviral therapy groups. Baseline immunologic, virologic and clinical parameters were collected and community antiretroviral therapy group patients were followed up for a year after which Human Immunodeficiency Virus treatment outcomes at the baseline and a year after follow-up were compared using paired sample t-test. All the analyses were performed in STATA version 14.

RESULT

Out of the 251 stable antiretroviral therapy adults enrolled, 186 (75.3%) were female, 52 (22.7%) had attained post-secondary education and the mean age of participants was 38 years (SD: 9.5). Also, 66 (27.9%) were employed while 125 (52.7%) were self-employed and 46(19.41%) unemployed. 246 (98.0%) of the participants were retained in care. While there was no statistically significant change in the CD4 counts (456cells/mm3 vs 481cells/mm3 P-0.489) and Log10 viral load (3.54c/ml vs 3.69c/ml P-0.359) after one year of devolvement into the community, we observed a significant increase in body weight (60.8 vs 65, P-0.01).

CONCLUSION

This study demonstrates that community antiretroviral therapy has a potential of maintaining optimum treatment outcomes while improving adherence and retention, and reducing the burden of HIV treatment on the health facility. This study provides baseline information for further research and vital information for HIV program implementers planning to decentralize the management of stable antiretroviral therapy clients.

Understanding the impact of a residential housing programme for people living with HIV/AIDS: a realist evaluation protocol

INTRODUCTION

Housing instability and homelessness are significant barriers to medical treatment for people living with HIV/AIDS. For these individuals, lack of stable housing and stigma is associated with insufficient access to care, poor adherence to medication and higher cost burdens to the healthcare system. This protocol reports on the efforts to evaluate Sanctum V.1.0, a hospice and transitional care home for adults with HIV/AIDS in Saskatoon, Saskatchewan, Canada. The current project was developed out of a need to identify how Sanctum V.1.0 produces varying programme outcomes to assist in endeavours to replicate the programme in other geographic locations.

METHODS AND ANALYSIS

A realist evaluation will be conducted to explore how and why Sanctum V.1.0 is successful or unsuccessful, in which circumstances and for whom. Rather than explore the degree to which a programme is effective, realist evaluations seek to uncover mechanisms that explain processual links between programme inputs and outcomes. The completed first phase of the project involved the development of an initial realist programme theory. Phases 2 and 3 will consist of methods to test, refine and validate the initial theory using various data sources.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the institutional review board at the University of Saskatchewan on 2 July 2020. Results will be disseminated according to stakeholders' desires.

Explaining the impact of mHealth on maternal and child health care in low- and middle-income countries: a realist synthesis

Background

Despite the growing global application of mobile health (mHealth) technology in maternal and child health, contextual factors, and mechanisms by which interventional outcomes are generated, have not been subjected to a systematic examination. In this study, we sought to uncover context, mechanisms, and outcome elements of various mHealth interventions based on implementation and evaluation studies to formulate theories or models explicating how mHealth interventions work (or not) both for health care providers and for pregnant women and mothers.

Method

We undertook a realist synthesis. An electronic search of five online databases (PubMed/Medline, Google Scholar, Scopus, Academic Search Premier and Health Systems Evidence) was performed. Using appropriate Boolean phrases terms and selection procedures, 32 articles were identified. A theory-driven approach, narrative synthesis, was applied to synthesize the data. Thematic content analysis was used to delineate elements of the intervention, including its context, actors, mechanisms, and outcomes. Abduction and retroduction were applied using a realist evaluation heuristic tool to formulate generative theories.

Results

We formulated two configurational models illustrating how and why mHealth impacts implementation and uptake of maternal and child health care. Implementation-related mechanisms include buy-in from health care providers, perceived support of health care providers’ motivation and perceived ease of use and usefulness. These mechanisms are influenced by adaptive health system conditions including organization, resource availability, policy implementation dynamics, experience with technology, network infrastructure and connectivity. For pregnant women and mothers, mechanisms that trigger mHealth use and consequently uptake of maternal and child health care include perceived satisfaction, motivation and positive psychological support. Information overload was identified as a potential negative mechanism impacting the uptake of maternal and child health care. These mechanisms are influenced by health system conditions, socio-cultural characteristics, socio-economic and demographics characteristics, network infrastructure and connectivity and awareness.

Conclusion

Models developed in this study provide a detailed understanding of implementation and uptake of mHealth interventions and how and why they impact maternal and child health care in low- and middle-income countries. These models provide a foundation for the ‘white box’ of theory-driven evaluation of mHealth interventions and can improve rollout and implementation where required.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03684-x.

"Dispense antiretrovirals daily!" restructuring the delivery of HIV services to optimize antiretroviral initiation among men in Malawi

BACKGROUND

Gender disparities exist in the scale-up and uptake of HIV services with men being disproportionately under-represented in the services. In Eastern and Southern Africa, of the people living with HIV infection, more adult women than men were on treatment highlighting the disparities in HIV services. Delayed initiation of antiretroviral treatment creates a missed opportunity to prevent transmission of HIV while increasing HIV and AIDS-associated morbidity and mortality. The main objective of this study was to assess the strategies that men prefer for Antiretroviral Therapy (ART) initiation in Blantyre, Malawi.

METHODS

This was a qualitative study conducted in 7 Health facilities in Blantyre from January to July 2017. We selected participants following purposive sampling. We conducted 20 in-depth interviews (IDIs) with men of different HIV statuses, 17 interviews with health care workers (HCWs), and 14 focus group discussions (FGDs) among men of varying HIV statuses. We digitally recorded all the data, transcribed verbatim, managed using NVivo, and analysed it thematically.

RESULTS

Restructuring the delivery of antiretroviral (ARVs) treatment and conduct of ART clinics is key to optimizing early initiation of treatment among heterosexual men in Blantyre. The areas requiring restructuring included: Clinic days by offering ARVs daily; Clinic hours to accommodate schedules of men; Clinic layout and flow that preserves privacy and establishment of male-specific clinics; ARV dispensing procedures where clients receive more pills to last them longer than 3 months. Additionally there is need to improve the packaging of ARVs, invent ARVs with less dosing frequency, and dispense ARVs from the main pharmacy. It was further suggested that the test-and-treat strategy be implemented with fidelity and revising the content in counseling sessions with an emphasis on the benefits of ARVs.

CONCLUSION

The success in ART initiation among men will require a restructuring of the current ART services to make them accessible and available for men to initiate treatment. The inclusion of people-centered approaches will ensure that individual preferences are incorporated into the initiation of ARVs. The type, frequency, distribution, and packaging of ARVs should be aligned with other medicines readily available within a health facility to minimize stigma.

HIV-Adapted Group Prenatal Care: Assessing Viral Suppression and Postpartum Retention in Care

Viral suppression and postpartum retention in care have far-reaching health implications for pregnant women living with HIV and their children, yet remain public health challenges. Prenatal care presents a unique opportunity to engage pregnant women in care. The purpose of this study is to evaluate whether group prenatal care is effective in impacting these outcomes for pregnant women living with HIV. A retrospective cohort study was performed of all women living with HIV who obtained prenatal care from a community-based health center between 2013 and 2019. Women who spoke English or Spanish, remained within the system, and had not participated in group prenatal care previously were included. Women self-selected a prenatal care model: 85 selected group care and 109 elected individual care. Group prenatal care followed a standard Centering Pregnancy^® curriculum with the addition of HIV-related topics. The primary outcomes of the study were viral suppression (viral load <20 copies/mL) and postpartum retention in care (attending at least one or two visits with HIV primary care within 12 months postpartum). After adjusting for potential confounding factors, women who participated in group prenatal care were significantly more likely to have at least one HIV primary care visit postpartum {adjusted odds ratio (aOR) = 2.71 [95% confidence interval (CI 1.14-6.46)]; p = 0.024}, and had a trend for achieving viral suppression by the time of delivery [aOR = 2.29 (95% CI 0.94-5.55); p = 0.068]. We have demonstrated that group prenatal care for pregnant women living with HIV is feasible and effective, with positive impacts on retention in care and viral suppression, factors that affect long-term outcomes from patients living with HIV.

Retention in care and viral suppression in differentiated service delivery models for HIV treatment delivery in sub-Saharan Africa: a rapid systematic review

INTRODUCTION

Differentiated service delivery (DSD) models for antiretroviral treatment (ART) for HIV are being scaled up in the expectation that they will better meet the needs of patients, improve the quality and efficiency of treatment delivery and reduce costs while maintaining at least equivalent clinical outcomes. We reviewed the recent literature on DSD models to describe what is known about clinical outcomes.

METHODS

We conducted a rapid systematic review of peer-reviewed publications in PubMed, Embase and the Web of Science and major international conference abstracts that reported outcomes of DSD models for the provision of ART in sub-Saharan Africa from January 1, 2016 to September 12, 2019. Sources reporting standard clinical HIV treatment metrics, primarily retention in care and viral load suppression, were reviewed and categorized by DSD model and source quality assessed.

RESULTS AND DISCUSSION

Twenty-nine papers and abstracts describing 37 DSD models and reporting 52 discrete outcomes met search inclusion criteria. Of the 37 models, 7 (19%) were facility-based individual models, 12 (32%) out-of-facility-based individual models, 5 (14%) client-led groups and 13 (35%) healthcare worker-led groups. Retention was reported for 29 (78%) of the models and viral suppression for 22 (59%). Where a comparison with conventional care was provided, retention in most DSD models was within 5% of that for conventional care; where no comparison was provided, retention generally exceeded 80% (range 47% to 100%). For viral suppression, all those with a comparison to conventional care reported a small increase in suppression in the DSD model; reported suppression exceeded 90% (range 77% to 98%) in 11/21 models. Analysis was limited by the extensive heterogeneity of study designs, outcomes, models and populations. Most sources did not provide comparisons with conventional care, and metrics for assessing outcomes varied widely and were in many cases poorly defined.

CONCLUSIONS

Existing evidence on the clinical outcomes of DSD models for HIV treatment in sub-Saharan Africa is limited in both quantity and quality but suggests that retention in care and viral suppression are roughly equivalent to those in conventional models of care.

Participation in adherence clubs and on-time drug pickup among HIV-infected adults in Zambia: A matched-pair cluster randomized trial

BACKGROUND

Current models of HIV service delivery, with frequent facility visits, have led to facility congestion, patient and healthcare provider dissatisfaction, and suboptimal quality of services and retention in care. The Zambian urban adherence club (AC) is a health service innovation designed to improve on-time drug pickup and retention in HIV care through off-hours facility access and pharmacist-led group drug distribution. Similar models of differentiated service delivery (DSD) have shown promise in South Africa, but observational analyses of these models are prone to bias and confounding. We sought to evaluate the effectiveness and implementation of ACs in Zambia using a more rigorous study design.

METHODS AND FINDINGS

Using a matched-pair cluster randomized study design (ClinicalTrials.gov: NCT02776254), 10 clinics were randomized to intervention (5 clinics) or control (5 clinics). At each clinic, between May 19 and October 27, 2016, a systematic random sample was assessed for eligibility (HIV+, age ≥ 14 years, on ART >6 months, not acutely ill, CD4 count not <200 cells/mm3) and willingness to participate in an AC. Clinical and antiretroviral drug pickup data were obtained through the existing electronic medical record. AC meeting attendance data were collected at intervention facilities prospectively through October 28, 2017. The primary outcome was time to first late drug pickup (>7 days late). Intervention effect was estimated using unadjusted Kaplan-Meier survival curves and a Cox proportional hazards model to derive an adjusted hazard ratio (aHR). Medication possession ratio (MPR) and implementation outcomes (adoption, acceptability, appropriateness, feasibility, and fidelity) were additionally evaluated as secondary outcomes. Baseline characteristics were similar between 571 intervention and 489 control participants with respect to median age (42 versus 41 years), sex (62% versus 66% female), median time since ART initiation (4.8 versus 5.0 years), median CD4 count at study enrollment (506 versus 533 cells/mm3), and baseline retention (53% versus 55% with at least 1 late drug pickup in previous 12 months). The rate of late drug pickup was lower in intervention participants compared to control participants (aHR 0.26, 95% CI 0.15-0.45, p < 0.001). Median MPR was 100% in intervention participants compared to 96% in control participants (p < 0.001). Although 18% (683/3,734) of AC group meeting visits were missed, on-time drug pickup (within 7 days) still occurred in 51% (350/683) of these missed visits through alternate means (use of buddy pickup or early return to the facility). Qualitative evaluation suggests that the intervention was acceptable to both patients and providers. While patients embraced the convenience and patient-centeredness of the model, preference for traditional adherence counseling and need for greater human resources influenced intervention appropriateness and feasibility from the provider perspective. The main limitations of this study were the small number of clusters, lack of viral load data, and relatively short follow-up period.

CONCLUSIONS

ACs were found to be an effective model of service delivery for reducing late ART drug pickup among HIV-infected adults in Zambia. Drug pickup outside of group meetings was relatively common and underscores the need for DSD models to be flexible and patient-centered if they are to be effective.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02776254.

Evaluation of human immunodeficiency virus-adapted group prenatal care

BACKGROUND

Efforts to further decrease perinatal transmission of HIV include efforts to improve engagement and retention in prenatal care. Group prenatal care has been reported to have benefits in certain other high-risk groups of pregnant women but has not been previously evaluated in pregnant women living with HIV.

OBJECTIVE

This study aimed to evaluate changes in HIV knowledge, stigma, social support, depression, self-efficacy, and medication adherence after HIV-adapted group prenatal care.

STUDY DESIGN

All women living with HIV who presented for prenatal care at ≤30 weeks' gestation in Harris Health System (Houston, TX) between September 2013 and December 2017 were offered either group or individual HIV-focused prenatal care. Patients were recruited for the study at their initial prenatal visit. HIV topics, such as HIV facts, disclosure, medication adherence, safe sex and conception, retention in care, and postdelivery baby testing, were added to the standard CenteringPregnancy curriculum (ten 2-hour sessions per pregnancy). Knowledge and attitudes toward factors associated with adherence to HIV treatment regimens (stigma, loneliness, perceived social support, and depressive symptoms) were compared on written pre- and postsurveys. Surveys included 58 items derived from validated scales, with Likert and dichotomous responses. McNemar's test, Wilcoxon signed-rank test, and paired t-tests compared pre- and postsurvey responses.

RESULTS

A total of 190 women living with HIV received prenatal care in the clinic during the study period, 93 (49%) of whom participated in CenteringHIV. A total of 66 Centering participants enrolled in the study and 42 of those completed the pre- and postsurveys. Among women in the Centering program who completed pre- and postsurveys, significant differences were noted with improved perceived social support from family (P=.011) and friends (P=.005), decreased depression (Edinburg Postnatal Depression Scale, ≥10; 43% vs 18%; P<.001; Edinburg Postnatal Depression Scale score mean (standard deviation), 9.3 (5.8) pre vs 5.2 (4.9) post; P<.001), and decreased missed medication doses related to depressed mood (P=.014). No statistically significant differences were noted in HIV knowledge, HIV stigma, attitude, or self-efficacy.

CONCLUSION

HIV-focused group prenatal care may positively affect perceived social support and depression scores, factors that are closely associated with antiretroviral adherence and retention in the care for pregnant women living with HIV.

A Review of Differentiated Service Delivery for HIV Treatment: Effectiveness, Mechanisms, Targeting, and Scale

PURPOSE OF REVIEW

Differentiated service delivery (DSD) models were initially developed as a means to combat suboptimal long-term retention in HIV care, and to better titrate limited health systems resources to patient needs, primarily in low-income countries. The models themselves are designed to streamline care along the HIV care cascade and range from individual to group-based care and facility to community-based health delivery systems. However, much remains to be understood about how well and for whom DSD models work and whether these models can be scaled, are sustainable, and can reach vulnerable and high-risk populations. Implementation science is tasked with addressing some of these questions through systematic, scientific inquiry. We review the available published evidence on the implementation of DSD and suggest further health systems innovations needed to maximize the public health impact of DSD and future implementation science research directions in this expanding field.

RECENT FINDINGS

While early observational data supported the effectiveness of various DSD models, more recently published trials as well as evaluations of national scale-up provide more rigorous evidence for effectiveness and performance at scale. Deeper understanding of the mechanism of effect of various DSD models and generalizability of studies to other countries or contexts remains somewhat limited. Relative implementability of DSD models may differ based on patient preference, logistical complexity of model adoption and maintenance, human resource and pharmacy supply chain needs, and comparative cost-effectiveness. However, few studies to date have evaluated comparative implementation or cost-effectiveness from a health systems perspective. While DSD represents an exciting and promising "next step" in HIV health care delivery, this innovation comes with its own set of implementation challenges. Evidence on the effectiveness of DSD generally supports the use of most DSD models, although it is still unclear which models are most relevant in diverse settings and populations and which are the most cost-effective. Challenges during scale-up highlight the need for accurate differentiation of patients, sustainable inclusion of a new cadre of health care worker (the community health care worker), and substantial strengthening of existing pharmacy supply chains. To maximize the public health impact of DSD, systems need to be patient-centered and adaptive, as well as employ robust quality improvement processes.

Household-focused interventions to enhance the treatment and management of HIV in low- and middle-income countries: a scoping review

BACKGROUND

HIV remains a major public health challenge in many low- and middle-income countries (LMICs). The initiation of a greater number of people living with HIV (PLHIV) onto antiretroviral therapy (ART) following the World Health Organization's 'universal test and treat' recommendation has the potential to overstretch already challenged health systems in LMICs. While various mainstream and community-based care models have been implemented to improve the treatment outcomes of PLHIV, little effort has been made to harness the potential of the families or households of PLHIV to enhance their treatment outcomes. To this end, we sought to explore the characteristics and effectiveness of household-focused interventions in LMICs on the management of HIV as measured by levels of adherence, viral suppression and different dimensions of HIV competence. Additionally, we sought to explore the mechanisms of change to explain how the interventions achieved the expected outcomes.

METHODS

We systematically reviewed the literature published from 2003 to 2018, obtained from six electronic databases. We thematically analysed the 11 selected articles guided by the population, intervention, comparison and outcome (PICO) framework. Following the generative causality logic, whereby mechanisms are postulated to mediate an intervention and the outcomes, we applied a mechanism-based inferential reasoning, retroduction, to identify the mechanisms underlying the interventions to understand how these interventions are expected to work.

RESULTS

The identified HIV-related interventions with a household focus were multi-component and multi-dimensional, incorporating aspects of information sharing on HIV; improving communication; stimulating social support and promoting mental health. Most of the interventions sought to empower and stimulate self-efficacy while strengthening the perceived social support of the PLHIV. Studies reported a significant positive impact on improving various aspects of HIV competent household - positive effects on HIV knowledge, communication between household members, and improved mental health outcomes of youths living in HIV-affected households.

CONCLUSION

By aiming to strengthen the perceived social support and self-efficacy of PLHIV, household-focused HIV interventions can address various aspects of household HIV competency. Nevertheless, the role of the household as an enabling resource to improve the outcomes of PLHIV remains largely untapped by public HIV programmes; more research on improving household HIV competency is therefore required.

TRIAL REGISTRATION

PROSPERO registration: CRD42018094383.

Differentiated models of service delivery for antiretroviral treatment of HIV in sub-Saharan Africa: a rapid review protocol

BACKGROUND

To meet global targets for the treatment of HIV, high-prevalence countries are launching or expanding differentiated models of service delivery (DSD) for antiretroviral therapy (ART). Ongoing studies report on metrics specific to individual models of care, but little is known about the overall scale, impact, costs, and benefits of widespread implementation of DSD. We will conduct a rapid review of recent literature on DSD currently in use in sub-Saharan Africa and identify gaps in the literature with respect to the description of delivery models, coverage, effectiveness, and cost.

METHODS

We will use an adapted version of the preferred reporting items for systematic reviews and meta-analysis protocols (PRISMA-P) for reporting. To avoid repeating earlier reviews, only sources reporting data on interventions conducted and/or patients starting antiretroviral treatment since 1 January 2016 will be included. Other inclusion criteria: must report on HIV-positive patients receiving antiretroviral therapy (ART) for the treatment of HIV/AIDS in sub-Saharan Africa; must describe an antiretroviral care intervention and identify the location, visit frequency, provider, patient group, and intervention intensity; and must report at least one of the following outcomes: population coverage, intervention uptake, treatment outcomes, cost or resource allocation, acceptability, or feasibility.

EXCLUSION CRITERIA

receiving ART as part of prevention of mother-to-child transmission (PMTCT) program or receiving preventive ART (PEP or PrEP). This review will include peer-reviewed articles and conference abstracts. Publication databases to be searched include PubMed, EMBASE, and Web of Science. For analysis, where possible, we will group the DSD by key characteristics (e.g., population served, visit frequency, visit location) and then report means and/or medians of coverage and outcomes with confidence intervals or IQRs. We will also descriptively compare and contrast different models of care, implementation challenges, and other non-quantitative information.

DISCUSSION

This review will provide an initial picture of the status quo for the implementation of DSD in sub-Saharan Africa and identify directions for research and implementation support in the future. This big-picture analysis will be useful for ministries of health, implementers, and donor agencies to inform decision-making on DSD scale-up.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42019118230.

'At this [adherence] club, we are a family now': A realist theory-testing case study of the antiretroviral treatment adherence club, South Africa

Background

An estimated 7.9 million people were living with HIV in South Africa in 2017, with 63.3% of them remaining in antiretroviral therapy (ART) care and 62.9% accessing ART. Poor retention in care and suboptimal adherence to ART undermine the successful efforts of initiating people living with HIV on ART. To address these challenges, the antiretroviral adherence club intervention was designed to streamline ART services to 'stable' patients. Nevertheless, it is poorly understood exactly how and why and under what health system conditions the adherence club intervention works.

Objectives

The aim of this study was to test a theory on how and why the adherence club intervention works and in what health system context(s) in a primary healthcare facility in the Western Cape Province.

Method

Within the realist evaluation framework, we applied a confirmatory theory-testing case study approach. Kaplan-Meier descriptions were used to estimate the rates of dropout from the adherence club intervention and virological failure as the principal outcomes of the adherence club intervention. Qualitative interviews and non-participant observations were used to explore the context and identify the mechanisms that perpetuate the observed outcomes or behaviours of the actors. Following the retroduction logic of making inferences, we configured information obtained from quantitative and qualitative approaches using the intervention-context-actor-mechanism-outcome heuristic tool to formulate generative theories.

Results

We confirmed that patients on ART in adherence clubs will continue to adhere to their medication and remain in care because their self-efficacy is improved; they are motivated or are being nudged.

Conclusion

A theory-based understanding provides valuable lessons towards the adaptive implementation of the adherence club intervention.

The role of support groups in linking and retaining newly diagnosed clients in HIV care in a peri-urban location in South Africa

Although South Africa has the largest number of people on antiretroviral therapy (ART) in the world, many HIV clients drop out of care immediately after HIV diagnosis. This qualitative study explored the perceptions and experiences of newly diagnosed clients on the role support groups play in linking and retaining newly diagnosed clients in HIV care in Mbandazayo peri-urban location. The data were analysed using the thematic content analysis approach. Data revealed four mechanisms through which support groups appeared to link and retain newly diagnosed clients in the HIV care continuum. First, support groups were a formal link between newly diagnosed clients and health facilities. Second, support groups mitigated the effects of both felt and enacted stigma, thereby facilitating acceptance of HIV diagnosis among newly diagnosed clients. Third, support groups were an advocacy and networking tool for newly diagnosed clients to make their health related needs, challenges, and concerns known to local health clinics, thereby forging and maintaining a close relationship with their local health facilities. Last, support groups were spaces within the community where practical needs of newly diagnosed clients are met, which in turn help in retaining them within support groups, and facilitate their linkage and retention in the HIV continuum of care in Mbandazayo. Our findings suggest that HIV support groups are critical in enhancing linkages and retention of newly diagnosed clients in HIV care. With the introduction of universal test and treat (UTT) in South Africa, our findings suggest that support groups can play a significant role in retaining HIV care clients who are diagnosed and immediately enrolled on ART.

Strategies for engaging men in HIV services

The importance of men in the global HIV response is increasingly recognised. In most settings, men are less engaged in HIV services and have worse health outcomes than women. The multiple gender, social, economic, political, and institutional factors behind these patterns are well documented. More recently, researchers have been reporting evidence on strategies aimed at improving the engagement of men in HIV services. Several promising approaches exist, including community-based outreach programmes, gender-transformative interventions to shift gender norms and practices, and the development of more responsive, male-friendly health services. Challenges remain, however, in terms of cost and sustainability, intersecting inequalities like race and class, and the difficulty of changing community-level gender norms. Future research should focus on developing theory-informed interventions and evaluations, on improving the understanding of specific subpopulations of men, and on broadening the evidence base beyond the few countries that produce most research in this field.

Differentiated service delivery: a qualitative study of people living with HIV and accessing care in a tertiary facility in Ghana

BACKGROUND

In 2014, the Joint United Nations Program on HIV/AIDS (UNAIDS) set out a treatment target with the objective to help end the AIDS epidemic by 2030. This was supported by the UNAIDS '90-90-90' target that by 2020, 90% of all people living with HIV (PLHIV) will know their HIV status; 90% of all those diagnosed with HIV will be on sustained antiretroviral therapy; and 90% of all people receiving antiretroviral therapy will have viral suppression. The concept of offering differentiated care services using community-based models is evidence-based and is suggested as a means to bring this target into reality. This study sought to explore the possible predictors and acceptability of Community-based health service provision among PLHIV accessing ART services at the Cape Coast Teaching Hospital (CCTH) in Ghana.

METHODS

A qualitative study, using 5 focus group discussions (FGD) of 8 participants per group, was conducted at the HIV Clinic in CCTH, in the Central Region of Ghana. Facilitators administered open-ended topic-guided questions. Answers were audio recorded, later transcribed and combined with notes taken during the discussions. Themes around Facility-based and Community-based service delivery and sub-themes developed from the codes, were verified and analyzed by the authors, with the group as the unit for analysis.

RESULTS

Participants expressed preference for facility-based service provision with the construct that, it ensures comprehensive health checks before provision of necessary medications. PLHIV in this study wished that the facility-based visits be more streamlined so "stable clients" could visit twice in a year to reduce the associated time and financial cost. The main barrier to community-based service delivery was concerns about stigmatization and abandonment in the community upon inadvertent disclosure of status.

CONCLUSIONS

Although existing evidence suggests that facility-based care was relatively more expensive and time consuming, PLHIV preferred facility-based individualized differentiated model to a community-based model. The fear of stigma and discrimination was very strong and is the main barrier to community-based model among PLHIV in this study and this needs to be explored further and managed.

Unravelling how and why the Antiretroviral Adherence Club Intervention works (or not) in a public health facility: A realist explanatory theory-building case study

Background

Although empirical evidence suggests that the adherence club model is more effective in retaining people living with HIV in antiretroviral treatment care and sustaining medication adherence compared to standard clinic care, it is poorly understood exactly how and why this works. In this paper, we examined and made explicit how, why and for whom the adherence club model works at a public health facility in South Africa.

Methods

We applied an explanatory theory-building case study approach to examine the validity of an initial programme theory developed a priori. We collected data using a retrospective cohort quantitative design to describe the suppressive adherence and retention in care behaviours of patients on ART using Kaplan-Meier methods. In conjunction, we employed an explanatory qualitative study design using non-participant observations and realist interviews to gain insights into the important mechanisms activated by the adherence club intervention and the relevant contextual conditions that trigger the different mechanisms to cause the observed behaviours. We applied the retroduction logic to configure the intervention-context-actor-mechanism-outcome map to formulate generative theories.

Results

A modified programme theory involving targeted care for clinically stable adult patients (18 years+) receiving antiretroviral therapy was obtained. Targeted care involved receiving quick, uninterrupted supply of antiretroviral medication (with reduced clinic visit frequencies), health talks and counselling, immediate access to a clinician when required and guided by club rules and regulations within the context of adequate resources, and convenient (size and position) space and proper preparation by the club team. When grouped for targeted care, patients feel nudged, their self-efficacy is improved and they become motivated to adhere to their medication and remain in continuous care.

Conclusion

This finding has implications for understanding how, why and under what health system conditions the adherence club intervention works to improve its rollout in other contexts.

"Patients Are Not Following the [Adherence] Club Rules Anymore": A Realist Case Study of the Antiretroviral Treatment Adherence Club, South Africa

There is growing evidence that differentiated care models employed to manage treatment-experienced patients on antiretroviral therapy could improve adherence to medication and retention in care. We conducted a realist evaluation to determine how, why, for whom, and under what health system context the adherence club intervention works (or not) in real-life implementation. In the first phase, we developed an initial program theory of the adherence club intervention. In this study, we report on an explanatory theory-testing case study to test the initial theory. We conducted a retrospective cohort analysis and an explanatory qualitative study to gain insights into the important mechanisms activated by the adherence club intervention and the relevant context conditions that trigger the different mechanisms to achieve the observed outcomes. This study identified potential mitigating circumstances under which the adherence club program could be implemented, which could inform the rollout and implementation of the adherence club intervention.

Retention on ART and predictors of disengagement from care in several alternative community-centred ART refill models in rural Swaziland

INTRODUCTION

A broad range of community-centred care models for patients stable on anti-retroviral therapy (ART) have been proposed by the World Health Organization to better respond to patient needs and alleviate pressure on health systems caused by rapidly growing patient numbers. Where available, often a single alternative care model is offered in addition to routine clinical care. We operationalized several community-centred ART delivery care models in one public sector setting. Here, we compare retention in care and on ART and identify predictors of disengagement with care.

METHODS

Patients on ART were enrolled into three community-centred ART delivery care models in the rural Shiselweni region (Swaziland), from 02/2015 to 09/2016: Community ART Groups (CAGs), comprehensive outreach care and treatment clubs. We used Kaplan-Meier estimates to describe crude retention in care model and retention on ART (including patients who returned to clinical care). Multivariate Cox proportional hazard models were used to determine factors associated with all-cause attrition from care model and disengagement with ART.

RESULTS

A total of 918 patients were enrolled. CAGs had the most participants with 531 (57.8%). Median age was 44.7 years (IQR 36.3 to 54.4), 71.8% of patients were female, and 62.6% fulfilled eligibility criteria for community ART. The 12-month retention in ART was 93.7% overall; it was similar between model types (p = 0.52). A considerable proportion of patients returned from community ART to clinical care, resulting in lower 12 months retention in care model (82.2% overall); retention in care model was lowest in CAGs at 70.4%, compared with 86.3% in outreach and 90.4% in treatment clubs (p < 0.001). In multivariate Cox regression models, patients in CAGs had a higher risk of disengaging from care model (aHR 3.15, 95% CI 2.01 to 4.95, p < 0.001) compared with treatment clubs. We found, however, no difference in attrition in ART between alternative model types.

CONCLUSIONS

Concurrent implementation of three alternative community-centred ART models in the same region was feasible. Although a considerable proportion of patients returned back to clinical care, overall ART retention was high and should encourage programme managers to offer community-centred care models adapted to their specific setting.

Building reliable supply chains for noncommunicable disease commodities: lessons learned from HIV and evidence needs

OBJECTIVE

Successful noncommunicable disease (NCD) management requires a reliable supply chain. The objectives of this article are to examine lessons learned from HIV supply chain initiatives, describe opportunities to advance supply chain systems for NCD health commodities based on HIV supply chain successes and identify areas where additional research is still needed for reliable NCD supply chains in LMICs.

DESIGN

We describe practical experiences gained from developing HIV supply chain systems and how those lessons can be used to inform NCD supply chain systems.

METHODS

Supply chain challenges with HIV commodities in low and middle-income countries (LMICs) are identified and categorized using literature review and expert experiences. Solutions are described on the basis of lessons learned from global HIV initiatives. Opportunities to further advance NCD supply chain systems are recommended.

RESULTS

Supply chain challenges can be organized into two groups: 1) resource mobilization and 2) resource utilization. Global HIV initiatives have responded to resource mobilization challenges by increasing availability of funding, filling human resource gaps, improving essential storage and creating better transport mechanisms and information technology infrastructure. These initiatives have assisted in better resource utilization by strengthening procurement processes, standardizing and simplifying supply chain systems, reducing integrity and security vulnerabilities and harnessing the power of better data. Advances achieved through HIV initiatives are readily transferrable to NCD supply chains with minimal additional investment. Research opportunities exist to identify the most efficient and cost-effective ways to develop more reliable supply chains for NCDs.

A realist approach to eliciting the initial programme theory of the antiretroviral treatment adherence club intervention in the Western Cape Province, South Africa

Background

The successful initiation of people living with HIV/AIDS on antiretroviral therapy (ART) in South Africa has engendered challenges of poor retention in care and suboptimal adherence to medication. The adherence club intervention was implemented in the Metropolitan area of the Western Cape Province to address these challenges. The adherence club programme has shown potential to relieve clinic congestion, improve retention in care and enhance treatment adherence in the context of rapidly growing HIV patient populations being initiated on ART. Nevertheless, how and why the adherence club intervention works is not clearly understood. We aimed to elicit an initial programme theory as the first phase of the realist evaluation of the adherence club intervention in the Western Cape Province.

Methods

The realist evaluation approach guided the elicitation study. First, information was obtained from an exploratory qualitative study of programme designers’ and managers’ assumptions of the intervention. Second, a document review of the design, rollout, implementation and outcome of the adherence clubs followed. Third, a systematic review of available studies on group-based ART adherence support models in Sub-Saharan Africa was done, and finally, a scoping review of social, cognitive and behavioural theories that have been applied to explain adherence to ART. We used the realist evaluation heuristic tool (Intervention-context-actors-mechanism-outcome) to synthesise information from the sources into a configurational map. The configurational mapping, alignment of a specific combination of attributes, was based on the generative causality logic – retroduction.

Results

We identified two alternative theories: The first theory supposes that patients become encouraged, empowered and motivated, through the adherence club intervention to remain in care and adhere to the treatment. The second theory suggests that stable patients on ART are being nudged through club rules and regulations to remain in care and adhere to the treatment with the goal to decongest the primary health care facilities.

Conclusion

The initial programme theory describes how (dynamics) and why (theories) the adherence club intervention is expected to work. By testing theories in “real intervention cases” using the realist evaluation approach, the theories can be modified, refuted and/or reconstructed to elicit a refined theory of how and why the adherence club intervention works.

Electronic supplementary material

The online version of this article (10.1186/s12874-018-0503-0) contains supplementary material, which is available to authorized users.

Unearthing how, why, for whom and under what health system conditions the antiretroviral treatment adherence club intervention in South Africa works: A realist theory refining approach

BACKGROUND

Poor retention in care and suboptimal adherence to antiretroviral treatment (ART) undermine its successful rollout in South Africa. The adherence club intervention was designed as an adherence-enhancing intervention to enhance the retention in care of patients on ART and their adherence to medication. Although empirical evidence suggests the effective superiority of the adherence club intervention to standard clinic ART care schemes, it is poorly understood exactly how and why it works, and under what health system contexts. To this end, we aimed to develop a refined programme theory explicating how, why, for whom and under what health system contexts the adherence club intervention works (or not).

METHODS

We undertook a realist evaluation study to uncover the programme theory of the adherence club intervention. We elicited an initial programme theory of the adherence club intervention and tested the initial programme theory in three contrastive sites. Using a cross-case analysis approach, we delineated the conceptualisation of the intervention, context, actor and mechanism components of the three contrastive cases to explain the outcomes of the adherence club intervention, guided by retroductive inferencing.

RESULTS

We found that an intervention that groups clinically stable patients on ART in a convenient space to receive a quick and uninterrupted supply of medication, health talks, counselling, and immediate access to a clinician when required works because patients' self-efficacy improves and they become motivated and nudged to remain in care and adhere to medication. The successful implementation and rollout of the adherence club intervention are contingent on the separation of the adherence club programme from other patients who are HIV-negative. In addition, there should be available convenient space for the adherence club meetings, continuous support of the adherence club facilitators by clinicians and buy-in from the health workers at the health-care facility and the community.

CONCLUSION

Understanding what aspects of antiretroviral club intervention works, for what sections of the patient population, and under which community and health systems contexts, could inform guidelines for effective implementation in different contexts and scaling up of the intervention to improve population-level ART adherence.

Interactive Two-Way mHealth Interventions for Improving Medication Adherence: An Evaluation Using The Behaviour Change Wheel Framework

BACKGROUND

Medication adherence is an important but highly complex set of behaviors, which for life-threatening and infectious diseases such as HIV carry critical consequences for individual and public health. There is growing evidence that mobile phone text messaging interventions (mHealth) connecting providers with patients positively impact medication adherence, particularly two-way engagement platforms that require bidirectional communication versus one-way in which responses are not mandatory. However, mechanisms of action have not been well defined. The Behavior Change Wheel is a comprehensive framework for behavior change that includes an all-encompassing model of behavior known as Capability Opportunity Motivation-Behavior and is complemented by a taxonomy of behavior change techniques. Evaluating mHealth interventions for medication adherence using these tools could provide useful insights that may contribute to optimizing their integration into the healthcare system and successful scaling-up.

OBJECTIVE

This study aimed to help address the current knowledge gap regarding how two-way mHealth interventions for medication adherence may work by applying the Behavior Change Wheel to characterize WelTel: an interactive digital health outreach platform with robust evidence for improving adherence to antiretroviral therapy.

METHODS

To characterize how WelTel may promote medication adherence, we applied the Behavior Change Wheel to systematically (1) generate a behavioral diagnosis through mapping known antiretroviral therapy adherence barriers onto the Capability Opportunity Motivation-Behavior model of behavior, (2) specify the behavior change techniques that WelTel delivers, (3) link identified behavior change techniques to corresponding intervention functions of the Behavior Change Wheel, and (4) connect these behavior change techniques and intervention functions to respective Capability Opportunity Motivation-Behavior influences on behavior to determine potential mechanisms of action.

RESULTS

Our evaluation of WelTel using the Behavior Change Wheel suggests that most of its impact is delivered primarily through its personalized communication component, in which 8 different behavior change techniques were identified and linked with 5 intervention functions (environmental restructuring, enablement, education, persuasion, and training). Its mechanisms of action in promoting antiretroviral therapy adherence may involve addressing all Capability Opportunity Motivation-Behavior influences on behavior (physical and psychological capability, physical and social opportunity, reflective and automatic motivation).

CONCLUSIONS

Systematically unpacking the potential active ingredients of effective interventions facilitates the creation and implementation of more parsimonious, tailored, and targeted approaches. Evaluating WelTel using the Behavior Change Wheel has provided valuable insights into how and why such interactive two-way mHealth interventions may produce greater impact than one-way in addressing both nonintentional and intentional forms of nonadherence. The application of the Behavior Change Wheel for evidence synthesis across mHealth interventions targeting various conditions would contribute to strengthening the knowledge base regarding how they may work to impact medication adherence behavior.

Evaluation of a health system strengthening initiative in the Zambian prison system

Introduction

In 2013, the Zambian Correctional Service (ZCS) partnered with the Centre for Infectious Disease Research in Zambia on the Zambian Prisons Health System Strengthening project, seeking to tackle structural, organisational and cultural weaknesses within the prison health system. We present findings from a nested evaluation of the project impact on high, mid-level and facility-level health governance and health service arrangements in the Zambian Correctional Service.

Methods

Mixed methods were used, including document review, indepth interviews with ministry (11) and prison facility (6) officials, focus group discussions (12) with male and female inmates in six of the eleven intervention prisons, and participant observation during project workshops and meetings. Ethical clearance and verbal informed consent were obtained for all activities. Analysis incorporated deductive and iterative inductive coding.

Results

Outcomes: Improved knowledge of the prison health system strengthened political and bureaucratic will to materially address prison health needs. This found expression in a tripartite Memorandum of Understanding between the Ministry of Home Affairs, Ministry of Health (MOH) and Ministry of Community Development, and in the appointment of a permanent liaison between MOH and ZCS. Capacity-building workshops for ZCS Command resulted in strengthened health planning and management outcomes, including doubling ZCS health professional workforce (from 37 to78 between 2014 and 2016), new preservice basic health training for incoming ZCS officers and formation of facility-based prison health committees with a mandate for health promotion and protection. Mechanisms: continuous and facilitated communication among major stakeholders and the emergence of interorganisational trust were critical. Enabling contextual factors included a permissive political environment, a shift within ZCS from a ‘punitive’ to ‘correctional’ organisational culture, and prevailing political and public health concerns about the spread of HIV and tuberculosis.

Conclusion

While not a panacea, findings demonstrate that a ‘systems’ approach to seemingly intractable prison health system problems yielded a number of short-term tactical and long-term strategic improvements in the Zambian setting. Context-sensitive application of such an approach to other settings may yield positive outcomes.

Conceptualising the Factors Affecting Retention in Care of Patients on Antiretroviral Treatment in Kabwe District, Zambia, Using the Ecological Framework

BACKGROUND

HIV remains a major public health challenge in Zambia. The roll-out of antiretroviral treatment (ART) has engendered new challenges in retention in care.

OBJECTIVE

To conceptualise the factors affecting retention in care of ART patients at three primary healthcare facilities using the ecological framework.

METHOD

Qualitative data were collected through in-depth interviews with 45 ART patients and three focus group discussions with 20 healthcare providers from three primary healthcare facilities in Kabwe district, Zambia, and subjected to thematic content analysis.

RESULTS

Individual level barriers to retention in care included side effects, gaining weight, belief in faith healing, and use of herbal remedies and alcohol. Interpersonal barriers such as stigma and nondisclosure of HIV status were reported. At the institutional level, inadequate space in the clinic, long waiting times, long travel distances, and shortage of third-line drugs presented barriers to retention in care. Food shortages and patient mobility were reported as community barriers to retention in care.

CONCLUSION

The ecological framework conceptualises the complex and dynamic factors affecting retention in ART care and highlights the need for multifaceted interventions that combine health education, disease management, and opportunities for income generation in a socially responsive and accountable environment.