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Belay YA, Yitayal M, Atnafu A, Taye FA. Barriers and facilitators to the implementation and scale up of differentiated service delivery models for HIV treatment in Africa: a scoping review. BMC Health Serv Res 2022; 22:1431. [PMID: 36443853 PMCID: PMC9703668 DOI: 10.1186/s12913-022-08825-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 11/10/2022] [Indexed: 11/29/2022] Open
Abstract
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.
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Affiliation(s)
- Yihalem Abebe Belay
- grid.449044.90000 0004 0480 6730Department of Public Health, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia ,grid.59547.3a0000 0000 8539 4635Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Mezgebu Yitayal
- grid.59547.3a0000 0000 8539 4635Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Asmamaw Atnafu
- grid.59547.3a0000 0000 8539 4635Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Fitalew Agimass Taye
- grid.1022.10000 0004 0437 5432Department of Accounting, Finance, and Economics, Griffith University, Brisbane, Australia
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Otanga H, Semujju B, Mwaniki L, Aungo J. Peer support and social networking interventions in diabetes self-management in Kenya and Uganda: A scoping review. PLoS One 2022; 17:e0273722. [PMID: 36155494 PMCID: PMC9512220 DOI: 10.1371/journal.pone.0273722] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 08/11/2022] [Indexed: 11/19/2022] Open
Abstract
Background
Diabetes mellitus is a growing worldwide health challenge especially in sub-Saharan Africa. While the use and effectiveness of diabetes self-management interventions is well documented in high-income countries, little information exists in sub-Saharan Africa. Therefore, this study attempted to synthesize information in the literature on the use and efficacy of peer support and social networking in diabetes self-management in Kenya and Uganda.
Objective
The purpose of this scoping review is to summarize research on the extent of use and efficacy of peer support and social networking interventions in diabetes self-management in Kenya and Uganda.
Design
We searched PubMed, ScienceDirect and Cochrane Library databases for articles reporting peer support and social networking interventions in Kenya and Uganda published in English between 2000 and September 2021. Key words encapsulated three major themes: peer support, social networking and self-management. Hand searches were also conducted to select eligible papers. Data was extracted using a form prepared and piloted in line with PRISMA-ScR guidelines.
Results
Thirteen peer reviewed articles were selected for analysis. Eleven studies reported peer support interventions while two focused on social networks in diabetes self-management. Peer support and social networking interventions incorporated microfinance and group medical visits, diabetes self-management education, telephone support and Medication Adherence Clubs. Most interventions were delivered by multidisciplinary teams comprising nurses and other professionals, peer educators, peer leaders and community health workers. Most interventions were effective and led to improvements in HbA1c and blood pressure, eating behaviors and physical activity and social support.
Conclusions
The limited studies available show that peer support and social networking interventions have mixed results on health and other outcomes. Importantly, most studies reported significant improvements in clinical outcomes. Further research is needed on the nature and mechanisms through which peer support and social network characteristics affect health outcomes.
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Enslin D, Mallya P. Factors influencing treatment adherence in hypertension and HIV management in South Africa: A comparative literature review. S Afr Fam Pract (2004) 2022; 64:e1-e10. [PMID: 36073101 PMCID: PMC10064525 DOI: 10.4102/safp.v64i1.5434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 03/29/2022] [Accepted: 04/11/2022] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Hypertension (HTN) is the most significant risk factor for cardiovascular disease (CVD) in South Africa (SA), with one in three people over the age of 25 suffering from HTN. Whilst human immunodeficiency virus and acquired immunodeficiency syndrome (HIV/AIDS) are the leading causes of death in South Africa, CVD is in the top 10 causes of death, demonstrating the importance of detecting and controlling blood pressure early on. This study aimed to review adherence factors to antihypertensive medication and antiretroviral therapy (ART) and evaluate the resulting factors influencing adherence discrepancies within the South African population. METHODS A comprehensive literature review was carried out. PubMed, ScienceDirect, Cochrane and Embase were searched for English publications between 2000 and 2021. RESULTS A total of 50 articles covering quantitative and qualitative studies were included. Many studies identified poor adherence levels to antihypertensive treatment, reaching a substandard adherence rate of 41.9%, whilst most studies on the HIV-positive population reported good levels of adherence, with adherence rates of more than 90%. Being of the male gender, advanced age, low socioeconomic status and a low level of education were associated with unsatisfactory adherence rates in both groups. Within the HIV group, more participants had better knowledge concerning the extent of their disease and its required treatments. CONCLUSION The results present substandard adherence levels to antihypertensives compared with antiretroviral (ARV) adherence, despite the influence of more non-adherence factors in the HIV group. The authors recommend better adherence counselling for patients with HTN during every clinic visit, regular healthcare worker training and the implementation of ART adherence programmes in patients with hypertension.
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Affiliation(s)
- Dimitra Enslin
- Department of Health Sciences, Faculty of Life Sciences and Education, University of South Wales, Pontypridd.
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Vanyoro K. Suspicious bodies: anti-citizens and biomedical anarchists in South Africa’s public health care system. Anthropology Southern Africa 2022. [DOI: 10.1080/23323256.2022.2044360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Kudakwashe Vanyoro
- African Centre for Migration & Society, University of the Witwatersrand, Johannesburg, South Africa
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Naggirinya AB, Kyomugisha EL, Nabaggala MS, Nasasira B, Akirana J, Oseku E, Kiragga A, Castelnuovo B, King RL, Katabira E, Byonanebye DM, Lamorde M, Parkes-Ratanshi R. Willingness to pay for an mHealth anti-retroviral therapy adherence and information tool: Transitioning to sustainability, Call for life randomised study experience in Uganda. BMC Med Inform Decis Mak 2022; 22:52. [PMID: 35219309 PMCID: PMC8882291 DOI: 10.1186/s12911-022-01782-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 02/15/2022] [Indexed: 11/21/2022] Open
Abstract
Introduction Evidence shows benefit of digital technology for people living with human immunodeficiency virus on antiretroviral therapy adherence and retention in care, however, scalability and sustainability have scarcely been evaluated. We assessed participants’ willingness to pay a fee for mHealth “Call for life Uganda” support, a mobile-phone based tool with the objective to assess sustainability and scalability. Methods “Call for Life study”, approved by Makerere University, School of Public Health research & ethics committee, at 2 sites in Uganda, evaluated a MoTech based software “CONNECT FOR LIFE™” mHealth tool termed “Call for life Uganda”. It provides short messages service or Interactive Voice Response functionalities, with a web-based interface, allows a computer to interact with humans through use of voice and tones input via keypad. Participants were randomized at 1:1 ratio to Standard of Care or standard of care plus Call for life Uganda. This sends pill reminders, visit reminders, voice messages and self-reported symptom support. At study visits 18 and 24 months, through mixed method approach we assessed mHealth sustainability and scalability. Participants were interviewed on desire to have or continue adherence support and willingness to pay a nominal fee for tool. We computed proportions willing to pay (± 95% confidence interval), stratified by study arm and predictors of willingness to continue and to pay using multivariate logistic regression model backed up by themes from qualitative interviews. Results 95% of participants were willing to continue using C4LU with 77.8% willing to pay for the service. Persons receiving care at the peri-urban clinic (OR 3.12, 95% CI 1.43–9.11.86) and those with exposure to the C4LU intervention (OR 4.2, 95% CI 1.55–11.84) were more likely to continue and pay for the service. Qualitative interviews revealed mixed feelings regarding amounts to pay, those willing to pay, argued that since they have been paying for personal phone calls/messages, they should not fail to pay for Call for life.
Conclusions Payment for the service offers opportunities to scale up and sustain mHealth interventions which may not be priorities for government funding. A co-pay model could be acceptable to PLHIV to access mHealth services in low resource settings.
Clinical Trial Number NCT 02953080. Supplementary Information The online version contains supplementary material available at 10.1186/s12911-022-01782-0.
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Mukumbang FC, Ndlovu S, van Wyk B. Comparing Patients' Experiences in Three Differentiated Service Delivery Models for HIV Treatment in South Africa. Qual Health Res 2022; 32:238-254. [PMID: 34911400 PMCID: PMC8727825 DOI: 10.1177/10497323211050371] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
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.
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Affiliation(s)
- Ferdinand C. Mukumbang
- University of the Western Cape, Cape Town, South Africa
- School of Medicine, University of Washington, Seattle, WA, USA
| | | | - Brian van Wyk
- University of the Western Cape, Cape Town, South Africa
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Gichane MW, Wechsberg WM, Ndirangu J, Howard B, Bonner CP, Browne FA, Zule WA. Sustainability of a gender-focused HIV and alcohol risk-reduction intervention in usual care settings in South Africa: a mixed methods analysis. AIDS Care 2021; 33:11-17. [PMID: 34538158 DOI: 10.1080/09540121.2021.1966694] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Intervention sustainability is a critical yet understudied aspect of implementation science research. To address this gap, we examined the sustainability of the Women's Health CoOp (WHC), a gender-focused, evidence-based, HIV and alcohol risk-reduction intervention, after an implementation trial. We used a mixed methods design consisting of questionnaires (n = 12), 3 focus groups (n = 11), and a semistructured interview conducted with interventionists implementing the WHC in clinics and substance use treatment programs in Cape Town, South Africa. Five out of 8 facilities implemented the WHC beyond the 6-month implementation period, and 4 were still implementing the WHC as of October 2019. Sustainability ranged from approximately 8 months to more than 3 years. At the most recent assessment, interventionists delivered the intervention to 0-20 participants in the past month. Qualitative findings indicate that long-term sustainability would require support from upper management, staff dedicated to the WHC, and booster trainings. The WHC was sustained postimplementation. Integrating the program into usual care would be feasible; however, human resources, financial, and institutional support would be needed for sustainability. To move implementation science forward, it is essential to determine sustainability beyond the presence and involvement of researchers.
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Affiliation(s)
| | - Wendee M Wechsberg
- RTI International, Research Triangle Park, NC, USA.,Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Department of Psychology, North Carolina State University, Raleigh, NC, USA.,Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | | | | | - Courtney Peasant Bonner
- RTI International, Research Triangle Park, NC, USA.,Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Felicia A Browne
- RTI International, Research Triangle Park, NC, USA.,Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Singh NS, Scott K, George A, LeFevre AE, Ved R. A tale of 'politics and stars aligning': analysing the sustainability of scaled up digital tools for front-line health workers in India. BMJ Glob Health 2021; 6:bmjgh-2021-005041. [PMID: 34312147 PMCID: PMC8728367 DOI: 10.1136/bmjgh-2021-005041] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 05/27/2021] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION India has become a lighthouse for large-scale digital innovation in the health sector, particularly for front-line health workers (FLHWs). However, among scaled digital health solutions, ensuring sustainability remains elusive. This study explores the factors underpinning scale-up of digital health solutions for FLHWs in India, and the potential implications of these factors for sustainability. METHODS We assessed five FLHW digital tools scaled at the national and/or state level in India. We conducted in-depth interviews with implementers, technology and technical partners (n=11); senior government stakeholders (n=5); funders (n=1) and evaluators/academics (n=3). Emergent themes were grouped according to a broader framework that considered the (1) digital solution; (2) actors; (3) processes and (4) context. RESULTS The scale-up of digital solutions was facilitated by their perceived value, bounded adaptability, support from government champions, cultivation of networks, sustained leadership and formative research to support fit with the context and population. However, once scaled, embedding digital health solutions into the fabric of the health system was hampered by challenges related to transitioning management and ownership to government partners; overcoming government procurement hurdles; and establishing committed funding streams in government budgets. Strong data governance, continued engagement with FLHWs and building a robust evidence base, while identified in the literature as critical for sustainability, did not feature strongly among respondents. Sustainability may be less elusive once there is more consensus around the roles played between national and state government actors, implementing and technical partners and donors. CONCLUSION The use of digital tools by FLHWs offers much promise for improving service delivery and health outcomes in India. However, the pathway to sustainability is bespoke to each programme and should be planned from the outset by investing in people, relationships and service delivery adjustments to navigate the challenges involved given the dynamic nature of digital tools in complex health systems.
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Affiliation(s)
- Neha S Singh
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Kerry Scott
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Asha George
- School of Public Health, University of the Western Cape, Faculty of Community and Health Sciences, Cape Town, Western Province, South Africa
| | - Amnesty Elizabeth LeFevre
- School of Public Health and Family Medicine, University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Rajani Ved
- National Health Systems Resource Centre, New Delhi, Delhi, India
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Rattine-Flaherty E, Burton S. The role of pharmacy personnel in promoting adherence to antiretroviral therapy in the Eastern Cape: communication barriers and breakthroughs. Afr J AIDS Res 2021; 20:165-171. [PMID: 34264163 DOI: 10.2989/16085906.2021.1925310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background: Many people living with HIV struggle to adhere to their antiretroviral therapy, leading to suboptimal health outcomes and increased costs to the healthcare system. Due to their unique training and position in the health care system, South African pharmacists and pharmacy support personnel have the potential to improve adherence through effective patient counselling. However, they are often underutilised and face multiple barriers to providing these services. The aim of this study was to examine how pharmacists and pharmacy personnel view their impact upon the medication adherence behaviours of people living with and receiving medication therapy for HIV.Methods: The study used an exploratory qualitative research design. Our research team conducted in-depth interviews with 24 pharmacy personnel working in public health clinics in the Eastern Cape of South Africa, then used thematic analysis of the qualitative research data to determine the results.Results: Pharmacy personnel identified three key sets of communication challenges that limited effective patient counselling on antiretroviral therapy. These included environmental barriers presented by clinic design, language barriers between patients and pharmacy personnel, and varying communication styles and education levels of pharmacy staff and patients. Additionally, pharmacy personnel described innovative strategies they use to improve patient-provider communication and address adherence issues.Conclusions: Pharmacy personnel working in public health clinics face daily communication challenges as they attempt to provide counselling to patients with HIV. Both the clinic environment and the complex nature of HIV treatment serve as barriers to patient comprehension. In the face of these challenges, pharmacy personnel do their best to implement strategies that enhance patient counselling and address concerns about adherence. Increased attention should be paid to reducing the barriers to pharmacy-based patient counselling and utilising pharmacy personnel to enhance patient understanding and adherence to antiretroviral therapy.
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Affiliation(s)
| | - Sue Burton
- Department of Pharmacy, Nelson Mandela University, Gqeberha, South Africa; currently Pharmacy Department, Rhodes University, Makhanda, South Africa
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Abstract
The rising global burden of chronic non-communicable diseases (NCDs) has put a strain on healthcare systems globally, especially in low- and middle-income countries, which have seen disproportionate mortality rates due to non-communicable diseases. These deaths are in part due to challenges with medication adherence, which are compounded by lack of access to medication and weak community support systems. This paper aims to propose a potential solution using models of service delivery in HIV/AIDS, given the many similarities between NCD and HIV/AIDS. Models that have been particularly effective in HIV/AIDS are the community-based peer-support medication delivery groups: medication adherence clubs and community antiretroviral therapy (ART) groups. The positive outcomes from these models, including improved medication adherence and patient satisfaction, provide evidence for their potential success when applied to non-communicable diseases, particularly hypertension and cardiovascular disease.
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Adams S, Mulubwa M, van Huyssteen M, Bheekie A. Access to chronic medicines: patients' preferences for a last kilometre medicine delivery service in Cape Town, South Africa. BMC Fam Pract 2021; 22:43. [PMID: 33618657 PMCID: PMC7899209 DOI: 10.1186/s12875-021-01392-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 02/09/2021] [Indexed: 01/31/2023]
Abstract
Background Chronic patients are required to access their chronic medicines on a regular basis, often only to refill their repeat prescriptions. Adherence to chronic medicines is challenging and has stimulated health care providers to devise differentiated service delivery models of care to decentralise chronic medicine distribution to decrease the frequency of medicine collection at health care facilities. One such option includes a last kilometre medicine delivery service. This study investigated chronic patients’ preferences for a last kilometre medicine delivery service model. Methods An exploratory non-randomised quantitative study was conducted over 4 weeks at four public sector primary health care facilities in Cape Town, South Africa. Data was collected on a structured questionnaire from chronic patients queuing to receive medication at each facility’s pharmacy waiting area. Patient demographics were noted to align with preferences for chronic medicine service delivery characteristics including; mobile ordering, fee for service and location for delivery. Chi-square test and frequencies were employed to analyse data using SPSS version 23. Results A total of 116 patients participated in this study. Most were interested in a medicine delivery service (80.2%) and were willing to use a mobile application to order their medicines (84.5%). Almost all patients (96.8%) preferred that their medicines be delivered to their home. More than three quarters of participants were willing to pay for the service (77.6%). Chi-square test showed that gender, age group, employment status, distance to the health facility and /or average waiting time at the clinic significantly influenced the preference for certain characteristics of the medicine delivery service (p < 0.05). Conclusion Most participants were interested in a last kilometre medicine delivery service, especially those older than 45 years, waiting for more than 6 h at the facility, and staying within one kilometre radius of the clinic. More studies are needed to establish the influence of patients’ employment status and the distance to health facility on interest in the medicine delivery service. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-021-01392-1.
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Affiliation(s)
- Siraaj Adams
- Iyeza Health, 4 Phatha Close, Harare Business Square, Khayelitsha, Cape Town, South Africa
| | - Mwila Mulubwa
- School of Pharmacy, University of the Western Cape, Private bag X17, Bellville, Cape Town, South Africa
| | - Mea van Huyssteen
- School of Pharmacy, University of the Western Cape, Private bag X17, Bellville, Cape Town, South Africa.
| | - Angeni Bheekie
- School of Pharmacy, University of the Western Cape, Private bag X17, Bellville, Cape Town, South Africa
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Nyondo-Mipando AL, Kapesa LS, Salimu S, Kazuma T, Mwapasa V. "Dispense antiretrovirals daily!" restructuring the delivery of HIV services to optimize antiretroviral initiation among men in Malawi. PLoS One 2021; 16:e0247409. [PMID: 33617561 PMCID: PMC7899340 DOI: 10.1371/journal.pone.0247409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 02/07/2021] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
- Alinane Linda Nyondo-Mipando
- Department of Health Systems and Policy, School of Public Health and Family Medicine, College of Medicine, Blantyre, Malawi
| | - Leticia Suwedi Kapesa
- Department of Health Systems and Policy, School of Public Health and Family Medicine, College of Medicine, Blantyre, Malawi
| | - Sangwani Salimu
- Department of Health Systems and Policy, School of Public Health and Family Medicine, College of Medicine, Blantyre, Malawi
| | - Thokozani Kazuma
- Department of Health Systems and Policy, School of Public Health and Family Medicine, College of Medicine, Blantyre, Malawi
| | - Victor Mwapasa
- Department of Public Health, School of Public Health and Family Medicine, College of Medicine, Blantyre, Malawi
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Finci I, Flores A, Gutierrez Zamudio AG, Matsinhe A, de Abreu E, Issufo S, Gaspar I, Ciglenecki I, Molfino L. Outcomes of patients on second- and third-line ART enrolled in ART adherence clubs in Maputo, Mozambique. Trop Med Int Health 2020; 25:1496-1502. [PMID: 32959934 PMCID: PMC7756444 DOI: 10.1111/tmi.13490] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objectives Adherence clubs (AC) offer patient‐centred access to antiretroviral therapy (ART) while reducing the burden on health facilities. AC were implemented in a health centre in Mozambique specialising in patients with a history of HIV treatment failure. We explored the impact of AC on retention in care and VL suppression of these patients. Methods We performed a retrospective analysis of patients enrolled in AC receiving second‐ or third‐line ART. The Kaplan–Meier estimates were used to analyse retention in care in health facility, retention in AC and viral load (VL) suppression (VL < 1000 copies/mL). Predictors of attrition and VL rebound (VL ≥ 1000 copies/mL) were assessed using multivariable proportional hazards regression. Results The analysed cohort contained 699 patients, median age 40 years [IQR: 35–47], 428 (61%) female and 97% second‐line ART. Overall, 9 (1.3%) patients died, and 10 (1.4%) were lost to follow‐up. Retention in care at months 12 and 24 was 98.9% (95% CI: 98.2–99.7) and 96.4% (95% CI: 94.6–98.2), respectively. Concurrently, 85.8% (95% CI: 83.1–88.2) and 80.9% (95% CI: 77.8–84.1) of patients maintained VL suppression. No association between predictors and all‐cause attrition or VL rebound was detected. Among 90 patients attending AC and simultaneously having VL rebound, 64 (71.1%) achieved VL resuppression, 10 (11.1%) did not resuppress, and 14 (15.6%) had no subsequent VL result. Conclusion Implementation of AC in Mozambique was successful and demonstrated that patients with a history of HIV treatment failure can be successfully retained in care and have high VL suppression rate when enrolled in AC. Expansion of the AC model in Mozambique could improve overall retention in care and VL suppression while reducing workload in health facilities.
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Affiliation(s)
- I Finci
- Médecins sans Frontières, Maputo, Mozambique
| | - A Flores
- Médecins sans Frontières, Maputo, Mozambique
| | | | - A Matsinhe
- Médecins sans Frontières, Maputo, Mozambique
| | - E de Abreu
- Médecins sans Frontières, Maputo, Mozambique
| | - S Issufo
- Ministry of Health, Maputo, Mozambique
| | - I Gaspar
- Ministry of Health, Maputo, Mozambique
| | | | - L Molfino
- Médecins sans Frontières, Maputo, Mozambique
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Baron D, Scorgie F, Ramskin L, Khoza N, Schutzman J, Stangl A, Harvey S, Delany-Moretlwe S. "You talk about problems until you feel free": South African adolescent girls' and young women's narratives on the value of HIV prevention peer support clubs. BMC Public Health 2020; 20:1016. [PMID: 32590969 PMCID: PMC7320560 DOI: 10.1186/s12889-020-09115-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 06/15/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Daily oral pre-exposure prophylaxis (PrEP) can reduce HIV infection in adolescent girls and young women if used consistently during periods of risk. The EMPOWER study evaluated peer-based clubs incorporating an empowerment curriculum offered to adolescent girls and young women (16-24 years) in South Africa and Tanzania for adherence support. METHODS Using serial in-depth interviews (n = 33), we assessed the benefits and challenges of club attendance among 13 EMPOWER participants in the Johannesburg site who were randomised to clubs. We used a summary matrix of coded data to support a narrative, case-based analysis. Four case studies are presented. RESULTS Club participants reported benefits such as increased self-esteem and self-efficacy, reduced isolation, and greater insight into gender-based violence and strategies to address it. Day-to-day PrEP adherence was not the only topic discussed in clubs; participants also appreciated the safe space for sharing problems (such as relationship conflict and PrEP stigma) and found interactive exercises helpful in improving partner communication. CONCLUSIONS Findings support the use of peer-based clubs using a structured empowerment approach, which may offer valuable PrEP initiation support to adolescent girls and young women in settings with high HIV and gender-based violence prevalence. TRIAL REGISTRATION Pan African Clinical Trials Registry PACTR202006754762723 , 5 April 2020, retrospectively registered.
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Affiliation(s)
- Deborah Baron
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, 22 Esselen Street, Hillbrow, Johannesburg, 2001, South Africa
| | - Fiona Scorgie
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, 22 Esselen Street, Hillbrow, Johannesburg, 2001, South Africa.
| | - Lethabo Ramskin
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, 22 Esselen Street, Hillbrow, Johannesburg, 2001, South Africa
| | - Nomhle Khoza
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, 22 Esselen Street, Hillbrow, Johannesburg, 2001, South Africa
| | | | - Anne Stangl
- International Center for Research on Women, Washington, DC, USA
| | - Sheila Harvey
- London School of Hygiene and Tropical Medicine (LSHTM), London, UK
- Mwanza Intervention Trials Unit (MITU), National Institute for Medical Research, Mwanza, Tanzania
| | - Sinead Delany-Moretlwe
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, 22 Esselen Street, Hillbrow, Johannesburg, 2001, South Africa
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15
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Kehoe K, Boulle A, Tsondai PR, Euvrard J, Davies MA, Cornell M. Long-term virologic responses to antiretroviral therapy among HIV-positive patients entering adherence clubs in Khayelitsha, Cape Town, South Africa: a longitudinal analysis. J Int AIDS Soc 2020; 23:e25476. [PMID: 32406983 PMCID: PMC7224308 DOI: 10.1002/jia2.25476] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 02/06/2020] [Accepted: 02/20/2020] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION In South Africa, an estimated 4.6 million people were accessing antiretroviral therapy (ART) in 2018. As universal Test and Treat is implemented, these numbers will continue to increase. Given the need for lifelong care for millions of individuals, differentiated service delivery models for ART services such as adherence clubs (ACs) for stable patients are required. In this study, we describe long-term virologic outcomes of patients who have ever entered ACs in Khayelitsha, Cape Town. METHODS We included adult patients enrolled in ACs in Khayelitsha between January 2011 and December 2016 with a recorded viral load (VL) before enrolment. Risk factors for an elevated VL (VL >1000 copies/mL) and confirmed virologic failure (two consecutive VLs >1000 copies/mL one year apart) were estimated using Cox proportional hazards models. VL completeness over time was assessed. RESULTS Overall, 8058 patients were included in the analysis, contributing 16,047 person-years of follow-up from AC entry (median follow-up time 1.7 years, interquartile range [IQR]:0.9 to 2.9). At AC entry, 74% were female, 46% were aged between 35 and 44 years, and the median duration on ART was 4.8 years (IQR: 3.0 to 7.2). Among patients virologically suppressed at AC entry (n = 8058), 7136 (89%) had a subsequent VL test, of which 441 (6%) experienced an elevated VL (median time from AC entry 363 days, IQR: 170 to 728). Older age (adjusted hazard ratio [aHR] 0.64, 95% confidence interval [CI] 0.46 to 0.88), more recent year of AC entry (aHR 0.76, 95% CI 0.68 to 0.84) and higher CD4 count (aHR 0.67, 95% CI 0.54 to 0.84) were protective against experiencing an elevated VL. Among patients with an elevated VL, 52% (150/291) with a repeat VL test subsequently experienced confirmed virologic failure in a median time of 112 days (IQR: 56 to 168). Frequency of VL testing was constant over time (82 to 85%), with over 90% of patients remaining virologically suppressed. CONCLUSIONS This study demonstrates low prevalence of elevated VLs and confirmed virologic failure among patients who entered ACs. Although ACs were expanded rapidly, most patients were well monitored and remained stable, supporting the continued rollout of this model.
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Affiliation(s)
- Kathleen Kehoe
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- Khayelitsha ART Programme and Médecins Sans FrontièresCape TownSouth Africa
- Health Impact Assessment Provincial Government of the Western CapeCape TownSouth Africa
| | - Priscilla R Tsondai
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Jonathan Euvrard
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- Khayelitsha ART Programme and Médecins Sans FrontièresCape TownSouth Africa
| | - Mary Ann Davies
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- Health Impact Assessment Provincial Government of the Western CapeCape TownSouth Africa
| | - Morna Cornell
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
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Flämig K, Decroo T, van den Borne B, van de Pas R. ART adherence clubs in the Western Cape of South Africa: what does the sustainability framework tell us? A scoping literature review. J Int AIDS Soc 2020; 22:e25235. [PMID: 30891928 PMCID: PMC6531844 DOI: 10.1002/jia2.25235] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 12/19/2018] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION In 2007, the antiretroviral therapy (ART) adherence club (AC) model was introduced to South Africa to combat some of the health system barriers to ART delivery, such as staff constraints and increasing patient load causing clinic congestion. It aimed to absorb the growing number of stable patients on treatment, ensure quality of care and reduce the workload on healthcare workers. A pilot project of ACs showed improved outcomes for club members with increased retention in care, reduced loss to follow-up and a reduction in viral rebound. In 2011, clubs were rolled out across the Cape Metro District with promising clinical outcomes. This review investigates factors that enable or jeopardize sustainability of the adherence club model in the Western Cape of South Africa. METHODS A scoping literature review was carried out. Electronic databases, organizations involved in ACs and reference lists of relevant articles were searched. Findings were analysed using a sustainability framework of five key components: (1) Design and implementation processes, (2) Organizational capacity, (3) Community embeddedness, (4) Enabling environment and (5) Context. RESULTS AND DISCUSSION The literature search identified 466 articles, of which six were included in the core review. Enablers of sustainability included the collaborative implementation process with collective learning sessions, the programme's flexibility, the high acceptability, patient participation and political support (to some extent). Jeopardizing factors revolved around financial constraints as non-governmental organizations are the main supporters of ACs by providing staff and technical support. CONCLUSIONS The results showed convincing factors that enable sustainability of ACs in the long term and identified areas for future research. Community embeddedness of clubs with empowerment and participation of patients, is a strong enabler to the sustainability of the model. Further policies are recommended to regulate the role of lay healthcare workers, ensure the reliability of the drug supply and the funding of club activities.
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Affiliation(s)
- Kornelia Flämig
- Maastricht Centre for Global Health, Maastricht University, Maastricht, The Netherlands
| | - Tom Decroo
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium.,Research Foundation Flanders, Brussels, Belgium
| | - Bart van den Borne
- Maastricht Centre for Global Health, Maastricht University, Maastricht, The Netherlands.,Faculty of Health, Medicine and Life Science, Maastricht, The Netherlands
| | - Remco van de Pas
- Maastricht Centre for Global Health, Maastricht University, Maastricht, The Netherlands.,Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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Bock P, Gunst C, Maschilla L, Holtman R, Grobbelaar N, Wademan D, Dunbar R, Fatti G, Kruger J, Ford N, Hoddinott G, Meehan S. Retention in care and factors critical for effectively implementing antiretroviral adherence clubs in a rural district in South Africa. J Int AIDS Soc 2019; 22:e25396. [PMID: 31588668 PMCID: PMC6778813 DOI: 10.1002/jia2.25396] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 09/03/2019] [Indexed: 12/22/2022] Open
Abstract
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.
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Affiliation(s)
- Peter Bock
- Desmond Tutu TB CentreDepartment of Paediatrics and Child HealthFaculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
| | - Colette Gunst
- Department of HealthWestern Cape GovernmentCape Winelands DistrictSouth Africa
- Division of Family Medicine and Primary Health CareFaculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
| | - Leonard Maschilla
- Department of HealthWestern Cape GovernmentCape Winelands DistrictSouth Africa
| | - Rory Holtman
- Department of HealthWestern Cape GovernmentCape TownSouth Africa
| | | | - Dillon Wademan
- Desmond Tutu TB CentreDepartment of Paediatrics and Child HealthFaculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
| | - Rory Dunbar
- Desmond Tutu TB CentreDepartment of Paediatrics and Child HealthFaculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
| | - Geoffrey Fatti
- Kheth’ Impilo AIDS Free LivingCape TownSouth Africa
- Division of Epidemiology and BiostatisticsDepartment of Global HealthFaculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
| | - James Kruger
- Department of HealthWestern Cape GovernmentCape TownSouth Africa
| | | | - Graeme Hoddinott
- Desmond Tutu TB CentreDepartment of Paediatrics and Child HealthFaculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
| | - Sue‐Ann Meehan
- Desmond Tutu TB CentreDepartment of Paediatrics and Child HealthFaculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
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