Retention in Differentiated Care: Multiple Measures Analysis for a Decentralized HIV Care and Treatment Program in North Central Nigeria

Stability in care and risk of loss to follow-up among clients receiving community health worker-led differentiated HIV care: Results from a prospective cohort study in northern Tanzania

BACKGROUND

HIV services in Tanzania are facility-based but facilities are often overcrowded. Differentiated care models (DCM) have been introduced into the National Guidelines. We piloted a Community Health Worker (CHW)-led HIV treatment club model (CHW-DCM) in an urban region, and assessed its effectiveness in comparison to the standard of care (SoC, facility-based model), in terms of stability in care, loss to follow-up (LTFU) and treatment adherence.

METHODS

In two clinics in the Shinyanga region, clients established on ART (defined as stable clients by national guidelines as on first-line ART >6 months, undetectable viral load, no opportunistic infections or pregnancy, and good adherence) were offered CHW-DCM. This prospective cohort study included all stable clients who enrolled in CHW-DCM between July 2018 and March 2020 (CHW-DCM) and compared them to stable clients who remained in SoC during that period. Multivariable Cox regression models were used to analyse factors associated with continued stability in care and the risk of LTFU during 18 months of follow-up; treatment adherence was assessed by pill count and compared using Chi-square tests.

RESULTS

Of 2472 stable clients, 24.5% received CHW-DCM and 75.5% SoC. CHW-DCM clients were slightly older (mean 42.8 vs. 37.9 years) and more likely to be female (36.2% vs. 32.2%). Treatment adherence was better among CHW-DCM than SoC: 96.6% versus 91.9% and 98.5% versus 92.2%, respectively (both p = 0.001). SoC clients were more likely to not remain stable over time than CHW-DCM (adjusted Hazard ratio [AHR] = 2.68; 95% CI: 1.86-3.90). There was no difference in LTFU (adjusted hazard ratio [AHR] = 1.54; 95%CI: 0.82-2.93).

CONCLUSION

Clients attending CHW-DCM demonstrated better stability in care and treatment adherence than SoC, and the risk of LTFU was not increased. These findings demonstrate the potential of CHW in delivering community-based HIV services in the local Tanzanian context. These results could be used to extend this CHW-DCM model to similar settings.

Understanding why and how youth-friendly health services improve viral load suppression among adolescents and young people living with HIV in Nigeria: realist evaluation with qualitative comparative analysis

INTRODUCTION

Youth-friendly health service (YFHS) approaches are essential to better outcomes for young people. We evaluated attainment of viral load suppression among young people living with HIV (YPLHIV) enrolled in an HIV treatment programme implementing YFHS models in Nigeria.

METHODS

A realist evaluation using qualitative and quantitative programme data from 10 implementing health facilities. We used qualitative information to explore how and why viral load suppression was attained across different settings and quantitative data to describe patterns and associations between youth-friendly structures and processes of care, care retention and viral load suppression. To consolidate the theories, we used qualitative comparative analysis to identify the necessary and sufficient conditions for attaining viral load suppression, using 30 YPLHIV as cases.

RESULTS

Between baseline (2018) and study-end (May 2022), viral load suppression coverage increased in 8 of the 10 study facilities. The number of facilities with viral load suppression coverage ≥90% rose from two to seven, while one facility remained unchanged, and another had a decline in coverage. Among the 30 selected YPLHIV cases, 18 had viral load suppression during the first test and 24 at the second test. However, viral load suppression attainment varied in different contexts. We identified the different YFHS interventions and key mechanisms that influenced viral load suppression in different contexts.

CONCLUSION

YFHS interventions can improve young people's engagement with HIV services, but their effectiveness depends on specific mechanisms and contextual factors influencing their response to interventions. By exploring how and why viral load suppression was attained in different contexts, the findings will improve the design and implementation of strategies to improve outcomes in young people, which will be relevant for achievement of global goals to eliminate HIV by 2030.

Conceptualising engagement with HIV care for people on treatment: the Indicators of HIV Care and AntiRetroviral Engagement (InCARE) Framework

BACKGROUND

As the crisis-based approach to HIV care evolves to chronic disease management, supporting ongoing engagement with HIV care is increasingly important to achieve long-term treatment success. However, 'engagement' is a complex concept and ambiguous definitions limit its evaluation. To guide engagement evaluation and development of interventions to improve HIV outcomes, we sought to identify critical, measurable dimensions of engagement with HIV care for people on treatment from a health service-delivery perspective.

METHODS

We used a pragmatic, iterative approach to develop a framework, combining insights from researcher experience, a narrative literature review, framework mapping, expert stakeholder input and a formal scoping review of engagement measures. These inputs helped to refine the inclusion and definition of important elements of engagement behaviour that could be evaluated by the health system.

RESULTS

The final framework presents engagement with HIV care as a dynamic behaviour that people practice rather than an individual characteristic or permanent state, so that people can be variably engaged at different points in their treatment journey. Engagement with HIV care for those on treatment is represented by three measurable dimensions: 'retention' (interaction with health services), 'adherence' (pill-taking behaviour), and 'active self-management' (ownership and self-management of care). Engagement is the product of wider contextual, health system and personal factors, and engagement in all dimensions facilitates successful treatment outcomes, such as virologic suppression and good health. While retention and adherence together may lead to treatment success at a particular point, this framework hypothesises that active self-management sustains treatment success over time. Thus, evaluation of all three core dimensions is crucial to realise the individual, societal and public health benefits of antiretroviral treatment programmes.

CONCLUSIONS

This framework distils a complex concept into three core, measurable dimensions critical for the maintenance of engagement. It characterises elements that the system might assess to evaluate engagement more comprehensively at individual and programmatic levels, and suggests that active self-management is an important consideration to support lifelong optimal engagement. This framework could be helpful in practice to guide the development of more nuanced interventions that improve long-term treatment success and help maintain momentum in controlling a changing epidemic.

Same-Day Antiretroviral Therapy Initiation as a Predictor of Loss to Follow-up and Viral Suppression Among People With Human Immunodeficiency Virus in Sub-Saharan Africa

BACKGROUND

Treat-All guidelines recommend initiation of antiretroviral therapy (ART) for all people with HIV (PWH) on the day of diagnosis when possible, yet uncertainty exists about the impact of same-day ART initiation on subsequent care engagement. We examined the association of same-day ART initiation with loss to follow-up and viral suppression among patients in 11 sub-Saharan African countries.

METHODS

We included ART-naive adult PWH from sites participating in the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium who enrolled in care after Treat-All implementation and prior to January 2019. We used multivariable Cox regression to estimate the association between same-day ART initiation and loss to follow-up and Poisson regression to estimate the association between same-day ART initiation and 6-month viral suppression.

RESULTS

Among 29 017 patients from 63 sites, 18 584 (64.0%) initiated ART on the day of enrollment. Same-day ART initiation was less likely among those with advanced HIV disease versus early-stage disease. Loss to follow-up was significantly lower among those initiating ART ≥1 day of enrollment, compared with same-day ART initiators (20.6% vs 27.7%; adjusted hazard ratio: .66; 95% CI .57-.76). No difference in viral suppression was observed by time to ART initiation (adjusted rate ratio: 1.00; 95% CI: .98-1.02).

CONCLUSIONS

Patients initiating ART on the day of enrollment were more frequently lost to follow-up than those initiating later but were equally likely to be virally suppressed. Our findings support recent World Health Organization recommendations for providing tailored counseling and support to patients who accept an offer of same-day ART.

Measuring patient engagement with HIV care in sub-Saharan Africa: a scoping study

INTRODUCTION

Engagement with HIV care is a multi-dimensional, dynamic process, critical to maintaining successful treatment outcomes. However, measures of engagement are not standardized nor comprehensive. This undermines our understanding of the scope of challenges with engagement and whether interventions have an impact, complicating patient and programme-level decision-making. This study identified and characterized measures of engagement to support more consistent and comprehensive evaluation.

METHODS

We conducted a scoping study to systematically categorize measures the health system could use to evaluate engagement with HIV care for those on antiretroviral treatment. Key terms were used to search literature databases (Embase, PsychINFO, Ovid Global-Health, PubMed, Scopus, CINAHL, Cochrane and the World Health Organization Index Medicus), Google Scholar and stakeholder-identified manuscripts, ultimately including English evidence published from sub-Saharan Africa from 2014 to 2021. Measures were extracted, organized, then reviewed with key stakeholders.

RESULTS AND DISCUSSION

We screened 14,885 titles/abstracts, included 118 full-texts and identified 110 measures of engagement, categorized into three engagement dimensions ("retention," "adherence" and "active self-management"), a combination category ("multi-dimensional engagement") and "treatment outcomes" category (e.g. viral load as an end-result reflecting that engagement occurred). Retention reflected status in care, continuity of attendance and visit timing. Adherence was assessed by a variety of measures categorized into primary (prescription not filled) and secondary measures (medication not taken as directed). Active self-management reflected involvement in care and self-management. Three overarching use cases were identified: research to make recommendations, routine monitoring for quality improvement and strategic decision-making and assessment of individual patients.

CONCLUSIONS

Heterogeneity in conceptualizing engagement with HIV care is reflected by the broad range of measures identified and the lack of consensus on "gold-standard" indicators. This review organized metrics into five categories based on the dimensions of engagement; further work could identify a standardized, minimum set of measures useful for comprehensive evaluation of engagement for different use cases. In the interim, measurement of engagement could be advanced through the assessment of multiple categories for a more thorough evaluation, conducting sensitivity analyses with commonly used measures for more comparable outputs and using longitudinal measures to evaluate engagement patterns. This could improve research, programme evaluation and nuanced assessment of individual patient engagement in HIV care.

Measuring patient engagement with HIV care in sub-Saharan Africa: a scoping study

INTRODUCTION

Engagement with HIV care is a multi-dimensional, dynamic process, critical to maintaining successful treatment outcomes. However, measures of engagement are not standardized nor comprehensive. This undermines our understanding of the scope of challenges with engagement and whether interventions have an impact, complicating patient and programme-level decision-making. This study identified and characterized measures of engagement to support more consistent and comprehensive evaluation.

METHODS

We conducted a scoping study to systematically categorize measures the health system could use to evaluate engagement with HIV care for those on antiretroviral treatment. Key terms were used to search literature databases (Embase, PsychINFO, Ovid Global-Health, PubMed, Scopus, CINAHL, Cochrane and the World Health Organization Index Medicus), Google Scholar and stakeholder-identified manuscripts, ultimately including English evidence published from sub-Saharan Africa from 2014 to 2021. Measures were extracted, organized, then reviewed with key stakeholders.

RESULTS AND DISCUSSION

We screened 14,885 titles/abstracts, included 118 full-texts and identified 110 measures of engagement, categorized into three engagement dimensions ("retention," "adherence" and "active self-management"), a combination category ("multi-dimensional engagement") and "treatment outcomes" category (e.g. viral load as an end-result reflecting that engagement occurred). Retention reflected status in care, continuity of attendance and visit timing. Adherence was assessed by a variety of measures categorized into primary (prescription not filled) and secondary measures (medication not taken as directed). Active self-management reflected involvement in care and self-management. Three overarching use cases were identified: research to make recommendations, routine monitoring for quality improvement and strategic decision-making and assessment of individual patients.

CONCLUSIONS

Heterogeneity in conceptualizing engagement with HIV care is reflected by the broad range of measures identified and the lack of consensus on "gold-standard" indicators. This review organized metrics into five categories based on the dimensions of engagement; further work could identify a standardized, minimum set of measures useful for comprehensive evaluation of engagement for different use cases. In the interim, measurement of engagement could be advanced through the assessment of multiple categories for a more thorough evaluation, conducting sensitivity analyses with commonly used measures for more comparable outputs and using longitudinal measures to evaluate engagement patterns. This could improve research, programme evaluation and nuanced assessment of individual patient engagement in HIV care.

Exploring Estimates and Reasons for Lost to Follow-Up Among People Living With HIV on Antiretroviral Therapy in Kisumu County, Kenya

BACKGROUND

A better understanding why people living with HIV (PLHIV) become lost to follow-up (LTFU) and determining who is LTFU in a program setting is needed to attain HIV epidemic control.

SETTING

This retrospective cross-sectional study used an evidence-sampling approach to select health facilities and LTFU patients from a large HIV program supporting 61 health facilities in Kisumu County, Kenya.

METHODS

Eligible PLHIV included adults 18 years and older with at least 1 clinic visit between September 1, 2016, and August 31, 2018, and were LTFU (no clinical contact for ≥90 days after their last expected clinic visit). From March to June 2019, demographic and clinical variables were collected from a sample of LTFU patient files at 12 health facilities. Patient care status and retention outcomes were determined through program tracing.

RESULTS

Of 787 LTFU patients selected and traced, 36% were male, median age was 30.5 years (interquartile range: 24.6-38.0), and 78% had their vital status confirmed with 560 (92%) alive and 52 (8%) deceased. Among 499 (89.0%) with a retention outcome, 233 (46.7%) had stopped care while 266 (53.3%) had self-transferred to another facility. Among those who had stopped care, psychosocial reasons were most common {65.2% [95% confidence interval (CI): 58.9 to 71.1]} followed by structural reasons [29.6% (95% CI: 24.1 to 35.8)] and clinic-based reasons [3.0% (95% CI: 1.4 to 6.2)].

CONCLUSION

We found that more than half of patients LTFU were receiving HIV care elsewhere, leading to a higher overall patient retention rate than routinely reported. Similar strategies could be considered to improve the accuracy of reporting retention in HIV care.

Comparing Patients' Experiences in Three Differentiated Service Delivery Models for HIV Treatment in South Africa

Differentiated service delivery for HIV treatment seeks to enhance medication adherence while respecting the preferences of people living with HIV. Nevertheless, patients' experiences of using these differentiated service delivery models or approaches have not been qualitatively compared. Underpinned by the tenets of descriptive phenomenology, we explored and compared the experiences of patients in three differentiated service delivery models using the National Health Services' Patient Experience Framework. Data were collected from 68 purposively selected people living with HIV receiving care in facility adherence clubs, community adherence clubs, and quick pharmacy pick-up. Using the constant comparative thematic analysis approach, we compared themes identified across the different participant groups. Compared to facility adherence clubs and community adherence clubs, patients in the quick pharmacy pick-up model experienced less information sharing; communication and education; and emotional/psychological support. Patients' positive experience with a differentiated service delivery model is based on how well the model fits into their HIV disease self-management goals.

How community ART delivery may improve HIV treatment outcomes: Qualitative inquiry into mechanisms of effect in a randomized trial of community-based ART initiation, monitoring and re-supply (DO ART) in South Africa and Uganda

Introduction

UNAIDS fast track targets for ending the AIDS epidemic by 2030 call for viral suppression in 95% of people using antiretroviral therapy (ART) to treat HIV infection. Difficulties in linking to care following a positive HIV test have impeded progress towards meeting treatment targets. Community‐based HIV services may reduce linkage barriers and have been associated with high retention and favourable clinical outcomes. We use qualitative data from The Delivery Optimization of Antiretroviral Therapy (DO ART) Study, a three‐arm randomized trial of community ART initiation, monitoring and re‐supply conducted in western Uganda and KwaZulu‐Natal South Africa, to identify mechanisms through which community ART delivery may improve treatment outcomes, defined as viral suppression in people living with HIV (PLHIV).

Methods

We conducted open‐ended interviews with a purposeful sample of 150 DO ART participants across study arms and study sites, from October 2016 to November 2019. Interviews covered experiences of: (1) HIV testing; (2) initiating and refilling ART; and (3) participating in the DO ART Study. A combined inductive content analytic and thematic approach was used to characterize mechanisms through which community delivery of ART may have contributed to viral suppression in the DO ART trial.

Results

The analysis yielded four potential mechanisms drawn from qualitative data representing the perspectives and priorities of DO ART participants. Empowering participants to schedule, re‐schedule and select the locations of community‐based visits via easy phone contact with clinical staff is characterized as flexibility. Integration refers to combining the components of clinic‐based visits into single interaction with a healthcare provider. Providers” willingness to talk at length with participants during visits, addressing non‐HIV as well as HIV‐related concerns, is termed “a slower pace”. Finally, increased efficiency denotes the time savings and increased income‐generating opportunities for participants brought about by delivering services in the community.

Conclusions

Understanding the mechanisms through which HIV service delivery innovations produce an effect is key to transferability and potential scale‐up. The perspectives and priorities of PLHIV can indicate actionable changes for HIV care programs that may increase engagement in care and improve treatment outcomes.

Adolescence and the risk of ART non-adherence during a geographically focused public health intervention: an analysis of clinic records from Nigeria

The risk of poor antiretroviral therapy (ART) adherence among adolescents is a challenge to controlling HIV. This study aims to provide guidance for geographically focussed public health interventions to improve adherence. Through clinic records, it investigates adolescents' non-adherence risk and clinic-level differences in regions of Nigeria which were part of PEPFAR's geographical pivot. Records (n = 26,365) were selected using systematic random sampling from all PEPFAR-supported facilities (n = 175) in targeted Local Government Areas across three regions in Nigeria. Adolescents' risk of non-adherence was estimated using region-specific random-effects models accounting for clinic-level variation. These were adjusted for sex, whether a patient had to travel to a different region, clinic location (urban/rural), clinic type (primary, secondary, tertiary). Despite regional variations, adolescents were at higher risk of non-adherence compared to adults. A similar, but weaker, association was found for children. Patients attending tertiary facilities for ART in the South-South region exhibited very high risk of non-adherence. Adolescents and children are at an increased risk of poor ART adherence in rural regions of Nigeria. Regional differences and facility type are critical factors. Future public health programmes focused on the risk of poor adherence targeting "high-prevalence areas" should be sensitive to contextual differences and age-appropriate care.

Retention in HIV care and its predictors among HIV-infected men who have sex with men in Plateau state, North Central Nigeria

Background:

Retention in HIV care is the constancy of engagement in HIV treatment, care and support services which is essential to reducing morbidity and mortality associated with the infection as well as halting the development of resistance to antiretroviral therapy (ART). In most African countries, Nigeria inclusive, men who have sex with men (MSM) are major contributors to HIV/AIDS burden. HIV-positive MSM are generally understudied and mostly underserved due to social, political and legislation factors resulting in limited characterization and documentation of the existing health disparities particularly with regards to retention in HIV care. It was against this backdrop that we conducted this study to assess the level of retention in HIV care and its predictors among MSM linked to HIV care.

Methods:

A cross-sectional study conducted among 114 HIV-positive MSM in 2019 using interviewer-administered questionnaire. Data analysis was carried out using version 7 of Epi Info statistical software version 7 and a probability value of less than 0.05 used as the cut-off for drawing statistically significant conclusion.

Results:

The average age in years of the respondents was 26.0 ± 5.4 while 43 (37.7%) of the participants were adequately retained in HIV care. Adequate retention in HIV care was found to be predicted by awareness of regular male partner's HIV status (AOR = 11.2; 95% confidence interval [CI] = 1.924–65.167) and financial difficulty (AOR = 0.1; 95% CI = 0.022–0.840).

Conclusions:

A suboptimal level of retention in HIV care was demonstrated in the study with awareness of male partner's HIV status and financial buoyancy as its main predictors.

Health Care Providers' Challenges to High-Quality HIV Care and Antiretroviral Treatment Retention in Rural South Africa

Provision of high-quality HIV care is challenging, especially in rural primary care clinics in high HIV burden settings. We aimed to better understand the main challenges to quality HIV care provision and retention in antiretroviral treatment (ART) programs in rural South Africa from the health care providers' perspective. We conducted semi-structured qualitative interviews with 23 providers from nine rural clinics. Using thematic and framework analysis, we found that providers and patients face a set of complex and intertwined barriers at the structural, programmatic, and individual levels. More specifically, analyses revealed that their challenges are primarily structural (i.e., health system- and microeconomic context-specific) and programmatic (i.e., clinic- and provider-specific) in nature. We highlight the linkages that providers draw between the challenges they face, the motivation to do their job, the quality of the care they provide, and patients' dissatisfaction with the care they receive, all potentially resulting in poor retention in care.

Antiretroviral therapy in community pharmacies - Implementation and outcomes of a differentiated drug delivery model in Nigeria

INTRODUCTION

The World Health Organization recommended differentiated models of care portends opportunities to decongest hospitals providing antiretroviral therapy (ART) and improve retention, especially in developing countries. A community pharmacy-based ART refill model was implemented where stable clients were devolved to community pharmacies for routine refills at a service fee, to promote private sector participation and sustainability of ART services. The aim of this study was to assess the feasibility, acceptability and outcomes of this model in Nigeria.

METHODS

A population-based retrospective analysis of the community pharmacy ART refill program of the United States Agency for International Development-funded 'Strengthening Integrated Delivery of HIV/AIDS Services' project in Lagos, Rivers, Cross River and Akwa Ibom States from October 2016 to February 2018 was conducted. Standard descriptive statistical methods were used for baseline demographic and clinical characteristics of study participants. Outcomes were assessed using the Chi-square test and a multivariate logistic regressions model. Statistical significance was defined at α-level of 0.05. Analyses were performed using SPSS for Windows version 23 (IBM Corp, Armonk, USA).

RESULTS

A total of 10015 participants representing 14.4% of ART clients in 50 hospitals opted for this model and were devolved to 244 community pharmacies. All clients consented and paid a service fee of N1000 (about $3) per refill visit. Median follow-up duration was 6 months. Prescription refill rate was 95% (95% CI 94.2-95.3). Retention rate was 98% while viral suppression was 99.12%. Refill rates were significantly affected by ART duration, regimen, age and location (P < 0.001, 0.004, 0.034 and < 0.001 respectively).

CONCLUSIONS

This community pharmacy ART refill model of differentiated care is feasible and acceptable by clients and providers and demonstrated excellent clinical outcomes of retention and viral suppression. The ability and willingness of some clients to contribute financially to their HIV care was also demonstrated.

Tipping the balance towards long-term retention in the HIV care cascade: A mixed methods study in southern Mozambique

Background

The implementation of quality HIV control programs is crucial for the achievement of the UNAIDS 90-90-90 targets and to motivate people living with HIV (PLWHIV) to link and remain in HIV-care. The aim of this mixed method cross-sectional study was to estimate the linkage and long-term retention in care of PLWHIV and to identify factors potentially interfering along the HIV-care continuum in southern Mozambique.

Methods

A home-based semi-structured interview was conducted in 2015 to explore barriers and facilitators to the HIV-care cascade among individuals that had been newly HIV-diagnosed in community testing campaigns in 2010 or 2012. Linkage and long-term retention were estimated retrospectively through client self-reports and clinical records. Cohen's Kappa coefficient was calculated to measure the agreement between participant self-reported and documented cascade outcomes.

Results

Among the 112 interviewed participants, 24 (21.4%) did not disclose their HIV-positive serostatus to the interviewer. While 84 (75.0%) self-reported having enrolled in care, only 69 (61.6%) reported still being in-care 3–5 years after diagnosis of which 17.4% reported having disengaged and re-engaged. An important factor affecting optimal continuum in HIV-care was the impact of the fear-based authoritarian relationship between the health system and the patient that could act as both driver and barrier.

Conclusion

Special attention should be given to quantify and understand repeated cycles of patient disengagement and re-engagement in HIV-care. Strategies to improve the relationship between the health system and patients are still needed in order to optimally engage PLWHIV for long-term periods.

Status of HIV-infected patients classified as lost to follow up from a large antiretroviral program in southwest Nigeria

Background

Loss to follow-up (LTFU) is a term used to classify patients no longer being seen in a clinical care program, including HIV treatment programs. It is unclear if these patients have transferred their care services elsewhere, died, or if there are other reasons for their LTFU. To better understand the status of patients meeting the criteria of LTFU, we traced a sample of HIV-infected patients that were LTFU from the Lagos University Teaching Hospital (LUTH) antiretroviral program.

Methods

We conducted a cross-sectional study of HIV-infected adult patients who enrolled for care between 2010 and 2014 at LUTH and were considered LTFU. Patients with locator information were traced using phone calls. Face-to-face interviews were used to collect data from successfully traced and consenting participants. Predictors of LTFU from LUTH, disengagement from care and willingness to re-engage in care in LUTH were assessed.

Results

Of 6108 registered patients, 3397 (56%) were LTFU and being unmarried was a predictor of being LTFU from LUTH. Of 425 patients that were traced, 355 (84%) were alive and 70 (16%) were dead. Two hundred and sixty-eight patients consented to interviews; 96 (35.8%) of these had transferred to another clinic for care while 172 (64.2%) were disengaged from care. More than half (149/268; 55.6%) were not on antiretroviral therapy (ART). Some of the primary reasons for LTFU were; long distance to clinic (56%) and feeling healthy (6.7%). Predictor of disengagement from care within the interviewed cohort was not having started ART. The predictors of willingness to re-engage in care included, not having started ART, male sex and longer duration in HIV care prior to LTFU.

Conclusion

Most of the interviewed cohort that was LTFU were truly disengaged from care and not on ART. Interventions are required to address processes of re-engagement of patients that are LTFU.

Evaluation of the clinical outcomes of the Test and Treat strategy to implement Treat All in Nigeria: Results from the Nigeria Multi-Center ART Study

In December 2016, the Nigerian Federal Ministry of Health updated its HIV guidelines to a Treat All approach, expanding antiretroviral therapy (ART) eligibility to all individuals with HIV infection, regardless of CD4+ cell count, and recommending ART be initiated within two weeks of HIV diagnosis (i.e., the Test and Treat strategy). The Test and Treat policy was first piloted in 32 local government areas (LGAs). The primary objective of this study was to evaluate the clinical outcomes of adult patients initiated on ART within two weeks of HIV diagnosis during this pilot. We conducted a retrospective cohort analysis of patients who initiated ART within two weeks of new HIV diagnosis between October 2015 and September 2016 in eight randomly selected LGAs participating in the Test and Treat pilot study. 2,652 adults were newly diagnosed and initiated on ART within two weeks of HIV diagnosis. Of these patients, 8% had documentation of a 12-month viral load measurement, and 13% had documentation of a six-month viral load measurement. Among Test and Treat patients with a documented viral load, 79% were suppressed (≤400 copies/ml) at six months and 78% were suppressed at 12 months. By 12 months post-ART initiation, 34% of the patients who initiated ART under the Test and Treat strategy were lost to follow-up. The median CD4 cell count among patients initiating ART within two weeks of HIV diagnosis was 323 cells/mm³ (interquartile range, 161–518). While randomized controlled trials have demonstrated that Test and Treat strategies can improve patient retention and increase viral suppression compared to standard of care, these findings indicate that the effectiveness of Test and Treat in some settings may be far lower than the efficacy demonstrated in randomized controlled trials. Significant attention to the way Test and Treat strategies are implemented, monitored, and improved particularly related to early retention, can help expand access to ART for all patients.

HIV/AIDS health services in Manaus, Brazil: patient perception of quality and its influence on adherence to antiretroviral treatment

BACKGROUND

Patient satisfaction is an important factor for both assessing the quality of healthcare and predicting positive health outcomes. This study assesses the influence of HIV/AIDS patients' perception of the quality of health services on adherence to antiretroviral treatment using the decentralized care model in Manaus, Brazil.

METHODS

We conducted a non-randomized, cross-sectional analysis to explore the relationship between patient satisfaction and adherence to antiretroviral treatment (ART) in Manaus, Amazonas, Brazil. We also compared patient satisfaction levels at the city's main hospital with those at smaller health units established to decentralize HIV/AIDS healthcare. Using survey responses from 812 patients and health data from 713 patients, we conducted descriptive and regression analyses to identify health center characteristics associated with higher patient satisfaction and higher adherence to treatment.

RESULTS

We found a clear and positive relationship between patient satisfaction with the quality of health services and adherence to ART. Patients who had better access to their health center and its services -mainly in the form of convenient location, shorter commute times, and shorter wait times- tended to rate the quality of services higher and were also more likely to adhere to ART. We also found higher levels of patient satisfaction and adherence to ART among patients served at decentralized health units than among patients served at the main hospital.

CONCLUSIONS

The study's results emphasize the importance of patients' experience at the health center for improved health outcomes. While many of the factors that play a role in whether a patient adheres to ART or not are beyond the control of the health center, our findings highlight that health centers can importantly contribute to increased ART adherence by improving such experience. The study also showcases the potential benefits of decentralizing HIV care to increase patient satisfaction and, with it, adherence to ART.