Acceptability of community-based adherence clubs among health facility staff in South Africa: a qualitative study

Negative clinic experiences as a barrier to care for people with HIV and their impact on patient preferences for intervention support: a qualitative study in Cape Town, South Africa

We conducted qualitative research among people with HIV (PWH) and care providers in Cape Town, South Africa to understand the impact of negative clinic experiences on adherence and support preferences. In-depth interviews were conducted with 41 patients with an unsuppressed viral load or a treatment gap, and focus group discussions with physicians, nurses, counselors, and community health workers. Questions addressed treatment history and adherence barriers, then participants evaluated evidence-based adherence interventions for potential scale up. Inductive analysis examined care experiences and corresponding preference for intervention options. More than half of PWH described negative experiences during clinic visits, including mistreatment by staff and clinic administration issues, and these statements were corroborated by providers. Those with negative experiences in care stated that fear of mistreatment led to nonadherence. Most patients with negative experiences preferred peer support groups or check-in texts to clinic-based interventions. We found that PWH's negative clinic experiences were a primary reason behind nonadherence and influenced preferences for support mechanisms. These findings emphasize the importance of HIV treatment adherence interventions at multiple levels both in and outside of the clinic, and providing more comprehensive training to providers to better serve PWH in adherence counseling, especially those who are most vulnerable..

Strategies that enabled access to chronic care during the COVID-19 pandemic and beyond in South Africa

Background

The COVID-19 epidemic has revealed disturbing information about how chronic diseases are treated globally. Healthcare providers and coronavirus response teams have primarily reported on how individuals with chronic conditions sought care and treatment. However, individuals' experiences of patients are yet unknown.

Aim

This study aimed to explore those strategies that enabled patients with chronic diseases access to chronic care and treatment during and beyond the COVID-19 pandemic.

Setting

The study was conducted in the predominantly rural district of the Northwest Province, South Africa.

Methods

An explorative qualitative research design was followed. Information-rich participants were chosen using a purposive sampling technique. Individual face-to-face interviews were used to gather data. Data saturation was achieved after interviewing n = 28 people in total. The six steps of Braun and Clarke thematic data analysis were used to analyse the data.

Results

The study revealed three themes, which includes improved healthcare structural systems, shift from traditional chronic care to digital care services and medication refill and buddy system.

Conclusion

The findings of this study revealed a range of effective and noteworthy approaches that facilitated access to treatment and continuity of care. As a result, enhancing telemedicine as well as structural systems such as appointment scheduling, decanting choices, mobile and medication home delivery can improve access to care and treatment.

Contribution

The burden of disease and avoidable death will be eventually addressed by maximising the use of telemedicine and sustaining the new norm of ongoing care through digital and remote care and decanting strategies.

Understanding health outcome drivers among adherence club patients in clinics of Gauteng, South Africa: a structural equation modelling (SEM) approach

BACKGROUND

There has been growing interest in understanding the drivers of health outcomes, both in developed and developing countries. The drivers of health outcomes, on the other hand, are the factors that influence the likelihood of experiencing positive or negative health outcomes. Human Immunodeficiency Virus (HIV) continues to be a significant global public health challenge, with an estimated 38 million people living with the aim of this study was therefore to develop and empirically test a conceptual research model using SEM, aimed at explaining the magnitude of various factors influencing HIV and other health outcomes among patients attending Adherence Clubs.

METHOD

This was a cross sectional survey study design conducted in 16 health facilities in the City of Ekurhuleni in Gauteng Province, South Africa. A total of 730 adherence club patients were systematically sampled to participate in a closed ended questionnaire survey. The questionnaire was assessed by Cronbach's alpha coefficient for internal consistency. The proposed model was tested using structural equation modelling (AMOS software: ADC, Chicago, IL, USA).

RESULTS

A total of 730 adherence club members participated in the study. Of these, 425 (58.2%) were female and 305 (41.8%) were male. The overall results indicated a good reliability of all the scale involved in this study as Cronbach alphas ranged from 0.706 to 0.874, and composite reliability from 0.735 to 0.874. The structural model showed that the constructs health seeking behavior (β = 0.267, p = 0.000), health care services (β = 0.416, p = 0.000), stigma and discrimination (β = 0.135, p = 0.022) significantly predicted health outcomes and explained 45% of its variance. The construct healthcare service was the highest predictor of health outcomes among patients in adherence clubs.

CONCLUSION

Patient health seeking behaviour, healthcare services, stigma and discrimination were associated with perceived health outcomes. Since adherence clubs have been found to have a significant impact in improving patient outcomes and quality of life, there is a need to ensure replication of this model.

Barriers and facilitators to the implementation and scale up of differentiated service delivery models for HIV treatment in Africa: a scoping review

BACKGROUND

In the face of health-system constraints, local policymakers and decision-makers face difficult choices about how to implement, expand and institutionalize antiretroviral therapy (ART) services. This scoping review aimed to describe the barriers and facilitators to the implementation and scale up of differentiated service delivery (DSD) models for HIV treatment in Africa.

METHODS

PubMed, Web of Science, Embase, Scopus, CINAHL, Global Health, Google, and Google Scholar databases were searched. There was no start date thereby all references up until May 12, 2021, were included in this review. We included studies reported in the English language focusing on stable adult people living with human immune deficiency virus (HIV) on ART and the healthcare providers in Africa. Studies related to children, adolescents, pregnant and lactating women, and key populations (people who inject drugs, men having sex with men, transgender persons, sex workers, and prisoners), and studies about effectiveness, cost, cost-effectiveness, and pre or post-exposure prophylaxis were excluded. A descriptive analysis was done.

RESULTS

Fifty-seven articles fulfilled our eligibility criteria. Several factors influencing DSD implementation and scale-up emerged. There is variability in the reported factors across DSD models and studies, with the same element serving as a facilitator in one context but a barrier in another. Perceived reduction in costs of visit for patients, reduction in staff workload and overburdening of health facilities, and improved or maintained patients' adherence and retention were reported facilitators for implementing DSD models. Patients' fear of stigma and discrimination, patients' and providers' low literacy levels on the DSD model, ARV drug stock-outs, and supply chain inconsistencies were major barriers affecting DSD model implementation. Stigma, lack of model adoption from providers, and a lack of resources were reported as a bottleneck for the DSD model scale up. Leadership and governance were reported as both a facilitator and a barrier to scaling up the DSD model.

CONCLUSIONS

This review has important implications for policy, practice, and research as it increases understanding of the factors that influence DSD model implementation and scale up. Large-scale studies based on implementation and scale up theories, models, and frameworks focusing on each DSD model in each healthcare setting are needed.

"That makes me feel human": a qualitative evaluation of the acceptability of an HIV differentiated care intervention for formerly incarcerated people re-entering community settings in South Africa

Background

Correctional settings in South Africa have disproportionately high rates of HIV infection; a large number of inmates living with HIV return to the community each year. The transition community adherence club (TCAC) intervention was a differentiated care delivery approach with structural and peer components designed to increase antiretroviral therapy (ART) adherence and HIV care engagement following release from incarceration. The objective of this study was to assess the acceptability of the TCAC intervention among HIV-infected community re-entrants to inform program revisions and future intervention designs.

Methods

This was a qualitative study set within a randomized controlled trial (RCT) of the TCAC intervention in South Africa. We conducted semi-structured, in-depth interviews with 16 re-entrants living with HIV and assigned to the intervention arm. All interviews were audio-recorded, transcribed, translated, and de-identified. Transcripts were coded and analyzed using content analysis, and acceptability was assessed using the Theoretical Framework of Acceptability (TFA).

Results

Overall, study participants reported that the TCAC intervention was acceptable. Development of supportive relationships between participants, non-judgmental attitudes from peer-facilitators, and perceived effectiveness of the intervention to support ART adherence and HIV care were noted as the most valued components. An altruistic desire to help other participants facing similar post-incarceration and HIV-related challenges was a key motivator for TCAC attendance. A lack of access to reliable transportation to intervention sites and clinic-based medication collection were described as burdens to program participation. Illicit drug use by other group members and negative social influences were also identified as potential barriers to optimal program engagement.

Conclusion

The TCAC was a well-accepted model of differentiated care delivery among re-entrants living with HIV in South Africa. To further enhance intervention acceptability for future scale-ups, program revisions should address logistical barriers related to reaching TCAC sites and implementing ART distribution at TCAC group sessions.

How the Term 'Self-Management' is Used in HIV Research in Low- and Middle-Income Countries: A Scoping Review

This scoping review assessed how the term 'self-management' (SM) is used in peer-reviewed literature describing HIV populations in low- and middle-income countries (LMIC). This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. OVID Medline, Embase, CAB Abstracts, and EBSCO CINAHL, Scopus, and Cochrane Library were searched up to September 2021 for articles with SM in titles, key words, or abstracts. Two team members independently screened the titles and abstracts, followed by the full-text. A data extraction tool assisted with collecting findings. A total of 103 articles were included. Since 2015, there has been a 74% increase in articles that use SM in relation to HIV in LMIC. Fifty-three articles used the term in the context of chronic disease management and described it as a complex process involving active participation from patients alongside providers. Many of the remaining 50 articles used SM as a strategy for handling one's care by oneself, with or without the help of community or family members. This demonstrates the varied conceptualizations and uses of the term in LMIC, with implications for the management of HIV in these settings. Future research should examine the applicability of SM frameworks developed in high-income settings for LMIC.

Acceptability and Preferences of Two Different Community Models of ART Delivery in a High Prevalence Urban Setting in Zambia: Cluster-Randomized Trial, Nested in the HPTN 071 (PopART) Study

Community delivery of Antiretroviral therapy (ART) is a novel innovation to increase sustainable ART coverage for People living with HIV (PLHIV) in resource limited settings. Within a nested cluster-randomised sub-study in two urban communities that participated in the HPTN 071 (PopART) trial in Zambia we investigated individual acceptability and preferences for ART delivery models. Stable PLHIV were enrolled in a cluster-randomized trial of three different models of ART: Facility-based delivery (SoC), Home-based delivery (HBD) and Adherence clubs (AC). Consenting individuals were asked to express their stated preference for ART delivery options. Those assigned to the community models of ART delivery arms could choose ("revealed preference") between the assigned arm and facility-based delivery. In total 2489 (99.6%) eligible individuals consented to the study and 95.6% chose community models of ART delivery rather than facility-based delivery when offered a choice. When asked to state their preference of model of ART delivery, 67.6% did not state a preference of one model over another, 22.8% stated a preference for HBD, 5.0% and 4.6% stated a preference for AC and SoC, respectively. Offering PLHIV choices of community models of ART delivery is feasible and acceptable with majority expressing HBD as their stated preferred option.

Rates of viral suppression in a cohort of people with stable HIV from two community models of ART delivery versus facility-based HIV care in Lusaka, Zambia: a cluster-randomised, non-inferiority trial nested in the HPTN 071 (PopART) trial

BACKGROUND

Non-facility-based antiretroviral therapy (ART) delivery for people with stable HIV might increase sustainable ART coverage in low-income and middle-income countries. Within the HPTN 071 (PopART) trial, two interventions, home-based delivery (HBD) and adherence clubs (AC), which included groups of 15-30 participants who met at a communal venue, were compared with standard of care (SoC). In this trial we looked at the effectiveness and feasibility of these alternative models of care. Specifically, this trial aimed to assess whether these models of care had similar virological suppression to that of SoC 12 months after enrolment.

METHODS

This was a three-arm, cluster-randomised, non-inferiority trial, done in two urban communities in Lusaka, Zambia included in the HPTN 071 trial. The two communities were split into zones, which were randomly assigned (1:1:1) to the three treatment strategies: 35 zones to the SoC group, 35 zones to the HBD group, and 34 zones to the AC group. ART and adherence support were delivered once every 3 months at home for the HBD group, in groups of 15-30 people in the AC group, or in the clinic for the SoC group. Adults with HIV who were receiving first-line ART for at least 6 months, virally suppressed using national HIV guidelines in the last 12 months, had no other health conditions requiring the clinicians attention, live in the study catchment area, and provided written informed consent, were eligible for inclusion. The primary endpoint was viral suppression at 12 months (with a 6 month final measurement window [ie, 9-15 months]), defined as less than 1000 HIV RNA copies per mL, with a non-inferiority margin of 5%.

FINDINGS

Between May 5 and Dec 19, 2017, 9900 individuals were screened for inclusion, of whom 2489 (25·1%) participants were enrolled into the trial: 781 (31%) in the SoC group, 852 (34%) in the HBD group, and 856 (34%) in the AC group. A higher proportion of participants had viral load measurements in the primary outcome window in the HBD (581 [61%]of 852 participants) and AC (485 [57%] of 856 participants) groups than in the SoC (390 [50%] of 781 patients) group (p=0·0021). Of the 1096 missing observations, 152 (13·8%) were attributable to either deaths (25 [16%] participants), relocations (37 [24%] participants), or lost to follow-up (90 [59%]); 690 (63·0%) participants had viral load results outside the window period; and 254 (23·2%) did not have a viral load result. The prevalence of viral suppression was estimated to be 98·3% (95% CI 96·6 to 99·7) in the SoC group, 98·7% (97·5 to 99·6) in the HBD group, and 99·2% (98·4 to 99·8) in the AC group. This gave an estimated risk difference of 0·3% (95% CI -1·5 to 2·4) for the HBD group compared with the SoC group and 0·9% (-0·8 to 2·8) for the AC group compared with the SoC group. There was strong evidence (p<0·0001) that both community ART models were non-inferior to the SoC group (p<0·0001).

INTERPRETATION

Community models of ART delivery were as effective as facility-based care in terms of viral suppression.

FUNDING

National Institute of Allergy and Infectious Diseases, The International Initiative for Impact Evaluation (3ie), the Bill & Melinda Gates Foundation, National Institute on Drug Abuse, National Institute of Mental Health, and President's Emergency Plan for AIDS Relief.

Alternative mechanisms for delivery of medication in South Africa: A scoping review

BACKGROUND

The number of people in South Africa with chronic conditions is a challenge to the health system. In response to the coronavirus infection, health services in Cape Town introduced home delivery of medication by community health workers. In planning for the future, they requested a scoping review of alternative mechanisms for delivery of medication to patients in primary health care in South Africa.

METHODS

Databases were systematically searched using a comprehensive search strategy to identify studies from the last 10 years. A methodological guideline for conducting scoping reviews was followed. A standardised template was used to extract data and compare study characteristics and findings. Data was analysed both quantitatively and qualitatively.

RESULTS

A total of 4253 publications were identified and 26 included. Most publications were from the last 5 years (n = 21), research (n = 24), Western Cape (n = 15) and focused on adherence clubs (n = 17), alternative pick-up-points (n = 14), home delivery (n = 5) and HIV (n = 17). The majority of alternative mechanisms were supported by a centralised dispensing and packaging system. New technology such as smart lockers and automated pharmacy dispensing units have been piloted. Patients benefited from these alternatives and had improved adherence. Available evidence suggests alternative mechanisms were cheaper and more beneficial than attending the facility to collect medication.

CONCLUSION

A mix of options tailored to the local context and patient choice that can be adequately managed by the system would be ideal. More economic evaluations are required of the alternatives, particularly before going to scale and for newer technology.

Will differentiated care for stable HIV patients reduce healthcare systems costs?

INTRODUCTION

South Africa's National Department of Health launched the National Adherence Guidelines for Chronic Diseases in 2015. These guidelines include adherence clubs (AC) and decentralized medication delivery (DMD) as two differentiated models of care for stable HIV patients on antiretroviral therapy. While the adherence guidelines do not suggest that provider costs (costs to the healthcare system for medications, laboratory tests and visits to clinics or alternative locations) for stable patients in these differentiated models of care will be lower than conventional, clinic-based care, recent modelling exercises suggest that such differentiated models could substantially reduce provider costs. In the context of continued implementation of the guidelines, we discuss the conditions under which provider costs of care for stable HIV patients could fall, or rise, with AC and DMD models of care in South Africa.

DISCUSSION

In prior studies of HIV care and treatment costs, three main cost categories are antiretroviral medications, laboratory tests and general interaction costs based on encounters with health workers. Stable patients are likely to be on the national first-line regimen (Tenofovir/Entricitabine/Efavarinz (TDF/FTC/EFV)), so no difference in the costs of medications is expected. Laboratory testing guidelines for stable patients are the same regardless of the model of care, so no difference in laboratory costs is expected as well. Based on existing information regarding the costs of clinic visits, AC visits and DMD drug pickups, we expect that for some clinics, visit costs for DMD or AC models of care could be less, but modestly so, than for conventional, clinic-based care. For other clinics, however, DMD or AC models could have higher visit costs (see Table 2).

CONCLUSIONS

The standard of care for stable patients has already been "differentiated" for years in South Africa, prior to the roll out of the new adherence guidelines. AC and DMD models of care, when implemented as envisioned in the guidelines, are unlikely to generate substantive reductions or increases in provider costs of care.

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.

Retention in care and factors critical for effectively implementing antiretroviral adherence clubs in a rural district in South Africa

INTRODUCTION

Differentiated models of care that include referral of antiretroviral treatment (ART) clients to adherence clubs are an important strategy to help clinics manage increased number of clients living with HIV in resource-constrained settings. This study reported on (i) clinical outcomes among ART clients attending community-based adherence clubs and (ii) experiences of adherence clubs and perceptions of factors key to successful adherence club implementation among clients and healthcare workers.

METHODS

A retrospective cohort analysis of routine data and a descriptive analysis of data collected through self-administered surveys completed by clients and healthcare workers were completed. Clients starting ART at the study clinic, between January 2014 and December 2015, were included in the cohort analysis and followed up until December 2016. The survey data were collected from August to September 2017. The primary outcome for the cohort analysis was a comparison of loss to follow-up (LTFU) between clients staying in clinic care and those referred to adherence clubs. Survey data reported on client experiences of and healthcare worker perceptions of adherence club care.

RESULTS

Cohort analysis reported on 465 participants, median baseline CD4 count 374 (IQR: 234 to 532) cells/μl and median follow-up time 20.7 (IQR 14.1 to 27.7) months. Overall, 202 (43.4%) participants were referred to an adherence club. LTFU was lower in those attending an adherence club (aHR =0.25, 95% CI: 0.11 to 0.56). This finding was confirmed on analysis restricted to those eligible for adherence club referral (aHR =0.28, 95% CI: 0.12 to 0.65). Factors highlighted as associated with successful adherence club implementation included: (i) referral of stable clients to the club, (ii) an ideal club size of ≥20 members, (iii) club services led by a counsellor (iv) using churches or community halls as venues (v) effective communication between all parties, and (vi) timely delivery of prepacked medication.

CONCLUSIONS

This study showed good clinical outcomes, positive patient experiences and healthcare worker perceptions of the adherence club model. Factors associated with successful adherence club implementation, highlighted in this study, can be used to guide implementers in the scale-up of adherence club services across varied high-burden settings.

Perspectives on ART adherence among Zambian adults living with HIV: insights raised using HIV-related disability frameworks

Anti-retroviral treatment (ART) has improved the survival of people living with HIV in Africa. Living with chronic HIV comes with new health and functional challenges and the need to manage ART adherence. The Sepo Study applied disability frameworks to better understand living with chronic HIV while using ART. The study followed 35 people (18 women, 17 men) living with HIV and on ART 6 months or longer in private and public health facilities in Lusaka, Zambia over 18-months (2012-2015). A total of 99 in-depth interviews were conducted. Conventional content analysis and NVIVOv10 were applied to analyse the data. Participants were adhering to ART at the times of the interviews and therefore less likely to report major challenges with adherence. Three main themes emerged from the data related to adherence. Firstly, ART was regarded as "giving life", which underscored adherence. Secondly, all participants described strategies for to managehealth and functional limitations, which they attributed as side-effects or chronicity. Thirdly, participants described experiences of uncertainty, including the efficacy of new regimens, potential loss of functioning, risk of new health problems, and death. Long-term ART managment in Africa needs to integrate rehabilitation approaches to address functional limitations, uncertainties, strengthen and support for adherence.

Most new HIV infections, vertical transmissions and AIDS-related deaths occur in lower-prevalence countries

OBJECTIVES

The Joint United Nations Programme on HIV/AIDS (UNAIDS) targets aim to reduce new HIV infections below 500,000 per year by 2020. Despite targeted prevention programmes, total new infections remained in 2016 and 2017 at 1,800,000 cases. We have aimed to analyse data from 2017 and to compare HIV incidence, AIDS-related deaths and provision of antiretroviral therapy (ART) to adults, pregnant women and children living with HIV in lower- and higher-prevalence countries. Vertical or mother-to-child transmission (MTCT) and early infant diagnosis (EID) rates were also investigated.

METHODS

UNAIDSinfo data use the Spectrum model to represent country-level HIV data. Countries with epidemics over 40,000 HIV cases were separated into higher prevalence (≥4.5%) and lower prevalence (<4.5%). Least squares linear regression, weighted by epidemic size and controlled for gross domestic product/capita, was used to compare HIV prevalence with estimated ART coverage in adults (≥15 years), children (0-14 years), pregnant women, and EID rates and MTCT rates. Data were then compared between higher- and lower-prevalence groups, including numbers of new HIV infections and AIDS-related deaths.

RESULTS

Data were available for 56 countries. Twelve higher-prevalence countries accounted for 16.7 million and 44 lower-prevalence ones for 15.1 million people living with HIV, altogether making up 87.5% of the global estimate. Lower-prevalence countries had less ART coverage for adults, pregnant women and children, lower EID rates and higher AIDS-related death levels. There were more new HIV infections in adults and children in lower- than higher-prevalence countries.

CONCLUSIONS

Most new HIV infections, MTCTs and AIDS-related deaths occurred in countries with an HIV prevalence rate below 4.5%. Many of these countries are not targeted by access programmes, such as the President' Emergency Plan for AIDS Relief. More intensive programmes of diagnosis and treatment are needed in these countries in the effort to reduce global new HIV infections below 500,000 per year by 2020.

What do the implementation outcome variables tell us about the scaling-up of the antiretroviral treatment adherence clubs in South Africa? A document review

Background

The successful initiation of people living with HIV on antiretroviral treatment (ART) in South Africa fomented challenges of poor retention in care and suboptimal adherence to medication. Following evidence of the potential of adherence clubs (ACs) to improve patient retention in ART and adherence to medication, the South African National Department of Health drafted a policy in 2016 encouraging the rollout of ACs nationwide. However, little guidance on the rollout strategy has been provided to date, and the national adoption status of the AC programme is unclear. To this end, we aimed to review the effectiveness of the rollout of the antiretroviral AC intervention in South Africa to date through an implementation research framework.

Methods

We utilised a deductive thematic analysis of documents of the AC programme in South Africa obtained from searching various databases from December 2017 to July 2018. The implementation outcome variables (acceptability, appropriateness, adoption, feasibility, fidelity, implementation cost, coverage and sustainability) were applied to frame and describe the effectiveness of the national rollout of the AC programme in South Africa.

Results

We identified 32 eligible documents that were included for analysis. Our analysis showed that ACs were highly acceptable by patients and health stakeholders given the observed benefits, including decongestion of clinics, increased social support for patients and the low cost of implementation. Evidence suggests that the AC model proved to be effective in improving adherence to ART and retention in care. Based on the success of ACs in the Western Cape, ACs are currently being implemented in all of the other South African provinces.

Conclusion

The inherent adaptability of the AC model should allow innovative strategies to maximise the use of existing resources. Therefore, the challenge is not limited to acquiring additional resources and support, but also includes the efficient use of available resources. Emerging challenges with AC programmes need to be addressed by increasing communication between stakeholders and fostering a culture of learning between facilities. As the AC programme expands and adapts to accommodate more people living with HIV and different population groups, policies should be designed to overcome present and anticipated challenges to enable its success.

Implementation science in resource-poor countries and communities

Background

Implementation science in resource-poor countries and communities is arguably more important than implementation science in resource-rich settings, because resource poverty requires novel solutions to ensure that research results are translated into routine practice and benefit the largest possible number of people.

Methods

We reviewed the role of resources in the extant implementation science frameworks and literature. We analyzed opportunities for implementation science in resource-poor countries and communities, as well as threats to the realization of these opportunities.

Results

Many of the frameworks that provide theoretical guidance for implementation science view resources as contextual factors that are important to (i) predict the feasibility of implementation of research results in routine practice, (ii) explain implementation success and failure, (iii) adapt novel evidence-based practices to local constraints, and (iv) design the implementation process to account for local constraints. Implementation science for resource-poor settings shifts this view from “resources as context” to “resources as primary research object.” We find a growing body of implementation research aiming to discover and test novel approaches to generate resources for the delivery of evidence-based practice in routine care, including approaches to create higher-skilled health workers—through tele-education and telemedicine, freeing up higher-skilled health workers—through task-shifting and new technologies and models of care, and increasing laboratory capacity through new technologies and the availability of medicines through supply chain innovations. In contrast, only few studies have investigated approaches to change the behavior and utilization of healthcare resources in resource-poor settings. We identify three specific opportunities for implementation science in resource-poor settings. First, intervention and methods innovations thrive under constraints. Second, reverse innovation transferring novel approaches from resource-poor to research-rich settings will gain in importance. Third, policy makers in resource-poor countries tend to be open for close collaboration with scientists in implementation research projects aimed at informing national and local policy.

Conclusions

Implementation science in resource-poor countries and communities offers important opportunities for future discoveries and reverse innovation. To harness this potential, funders need to strongly support research projects in resource-poor settings, as well as the training of the next generation of implementation scientists working on new ways to create healthcare resources where they lack most and to ensure that those resources are utilized to deliver care that is based on the latest research results.

Application of machine learning models in predicting length of stay among healthcare workers in underserved communities in South Africa

BACKGROUND

Human resource planning in healthcare can employ machine learning to effectively predict length of stay of recruited health workers who are stationed in rural areas. While prior studies have identified a number of demographic factors related to general health practitioners' decision to stay in public health practice, recruitment agencies have no validated methods to predict how long these health workers will commit to their placement. We aim to use machine learning methods to predict health professional's length of practice in the rural public healthcare sector based on their demographic information.

METHODS

Recruitment and retention data from Africa Health Placements was used to develop machine-learning models to predict health workers' length of practice. A cross-validation technique was used to validate the models, and to evaluate which model performs better, based on their respective aggregated error rates of prediction. Length of stay was categorized into four groups for classification (less than 1 year, less than 2 years, less than 3 years, and more than 3 years). R, a statistical computing language, was used to train three machine learning models and apply 10-fold cross validation techniques in order to attain evaluative statistics.

RESULTS

The three models attain almost identical results, with negligible difference in accuracy. The "best"-performing model (Multinomial logistic classifier) achieved a 47.34% [SD 1.63] classification accuracy while the decision tree model achieved an almost comparable 45.82% [SD 1.69]. The three models achieved an average AUC of approximately 0.66 suggesting sufficient predictive signal at the four categorical variables selected.

CONCLUSIONS

Machine-learning models give us a demonstrably effective tool to predict the recruited health workers' length of practice. These models can be adapted in future studies to incorporate other information beside demographic details such as information about placement location and income. Beyond the scope of predicting length of practice, this modelling technique will also allow strategic planning and optimization of public healthcare recruitment.

Implementation and evaluation of a therapeutic patient education programme during a clinical trial in Yaoundé, Cameroon - Trial ANRS-12286/MOBIDIP

OBJECTIVES

High adherence is needed to maintain antiretroviral therapy efficacy. Few attempts at therapeutic patient education (TPE) have been made in sub-Saharan Africa. We describe patients' achievements before intervention and identified needs, TPE programme implementation and evaluation, and patients' satisfaction.

METHODS

The TPE programme was proposed to patients in the ANRS-12286/MOBIDIP trial. Beforehand, a directory of competences to manage HIV infection was designed. Patients' HIV-related knowledge and skills assessment was realised, leading to an educational contract. Evaluation was performed using a standardised collection form and a satisfaction survey.

RESULTS

Of 154 patients, 146 underwent TPE. During a median of 1.8 years, 47% of patients had ≥3 consultations. Educational assessment revealed limited knowledge about HIV disease. Conversely, patients had frequently managed issues of adherence or disclosure. A median of 12 objectives were considered per patient, and 75% were attained. Objectives from the cognitive domain were less frequently attained. Patients appeared satisfied with the intervention: more emphasis was placed on psycho-affective aspects or experience-sharing than on the acquisition of knowledge.

CONCLUSION

Active listening, know-how and a space for discussion appear more important for patients than knowledge on disease or treatments.

PRACTICE IMPLICATIONS

In HIV care, the directory of learning objectives should be revised to include more objectives concerning practical skills for disease management.