Person-centred interventions to improve patient-provider relationships for HIV services in low- and middle-income countries: a systematic review

INTRODUCTION

Person-centred care (PCC) has been recognized as a critical element in delivering quality and responsive health services. The patient-provider relationship, conceptualized at the core of PCC in multiple models, remains largely unexamined in HIV care. We conducted a systematic review to better understand the types of PCC interventions implemented to improve patient-provider interactions and how these interventions have improved HIV care continuum outcomes and person-reported outcomes (PROs) among people living with HIV in low- and middle-income countries.

METHODS

We searched databases, conference proceedings and conducted manual targeted searches to identify randomized trials and observational studies published up to January 2023. The PCC search terms were guided by the Integrative Model of Patient-Centeredness by Scholl. We included person-centred interventions aiming to enhance the patient-provider interactions. We included HIV care continuum outcomes and PROs.

RESULTS

We included 28 unique studies: 18 (64.3%) were quantitative, eight (28.6.%) were mixed methods and two (7.1%) were qualitative. Within PCC patient-provider interventions, we inductively identified five categories of PCC interventions: (1) providing friendly and welcoming services; (2) patient empowerment and improved communication skills (e.g. supporting patient-led skills such as health literacy and approaches when communicating with a provider); (3) improved individualized counselling and patient-centred communication (e.g. supporting provider skills such as training on motivational interviewing); (4) audit and feedback; and (5) provider sensitisation to patient experiences and identities. Among the included studies with a comparison arm and effect size reported, 62.5% reported a significant positive effect of the intervention on at least one HIV care continuum outcome, and 100% reported a positive effect of the intervention on at least one of the included PROs.

DISCUSSION

Among published HIV PCC interventions, there is heterogeneity in the components of PCC addressed, the actors involved and the expected outcomes. While results are also heterogeneous across clinical and PROs, there is more evidence for significant improvement in PROs. Further research is necessary to better understand the clinical implications of PCC, with fewer studies measuring linkage or long-term retention or viral suppression.

CONCLUSIONS

Improved understanding of PCC domains, mechanisms and consistency of measurement will advance PCC research and implementation.

Initial supplementary dose of dolutegravir in second-line antiretroviral therapy: a non-comparative, double-blind, randomised placebo-controlled trial

BACKGROUND

Dolutegravir concentrations are reduced by efavirenz induction effect necessitating twice daily dolutegravir dosing when co-administered. Efavirenz induction persists for several weeks after stopping, which could potentially select for dolutegravir resistance if switching occurred with unsuppressed HIV-1 RNA levels and standard dolutegravir dosing. We evaluated the need for a lead-in supplementary dolutegravir dose in adults failing first-line tenofovir-emtricitabine-efavirenz (TEE).

METHODS

We conducted a randomised, double-blind, placebo-controlled, phase 2 trial in Khayelitsha, South Africa. Eligible patients had virologic failure (two consecutive HIV-1 RNA≥1000 copies/mL) on first-line TEE. Participants were randomly assigned (1:1) to switch to tenofovir-lamivudine-dolutegravir (TLD) with a supplementary 50 mg dolutegravir dose or placebo taken 12 hours later for 14 days. Primary outcome was proportion with HIV-1 RNA<50 copies/mL at week 24. This study was not powered to compare arms.

RESULTS

130 participants were randomised (65 to each arm). Median baseline HIV-1 RNA was 4.0 log10 copies/mL and 76% had baseline resistance to both tenofovir and lamivudine. One participant died and two were lost to follow-up. At week 24, 55/64 (86%, 95% confidence interval [CI], 75-93%) in the supplementary dolutegravir arm and 53/65 (82%, 95% CI, 70-90%) in the placebo arm had HIV-1 RNA<50 copies/mL. Grade 3 or 4 adverse events were similar in frequency between arms. None of six participants (3 in each arm) eligible for resistance testing by 24 weeks developed dolutegravir resistance.

CONCLUSIONS

Our findings do not support the need for initial dolutegravir dose adjustment in patients switching to TLD who failed first-line TEE.

Social determinants of health and the double burden of disease in Nepal: a secondary analysis

Background

As the global burden of disease evolves, lower-resource countries like Nepal face a double burden of non-communicable and infectious disease. Rapid adaptation is required for Nepal’s health system to provide life-long, person-centred care while simultaneously improving quality of infectious disease services. Social determinants of health be key in addressing health disparities and could direct policy decisions to promote health and manage the disease burden. Thus, we explore the association of social determinants with the double burden of disease in Nepal.

Methods

This is a retrospective, ecological, cross-sectional analysis of infectious and non-communicable disease outcome data (2017 to 2019) and data on social determinants of health (2011 to 2013) for 753 municipalities in Nepal. Multinomial logistic regression was conducted to evaluate the associations between social determinants and disease burden.

Results

The ‘high-burden’ combined double burden (non-communicable and infectious disease) outcome was associated with more accessible municipalities, (adjOR3.94[95%CI2.94–5.28]), municipalities with higher proportions of vaccine coverage (adjOR12.49[95%CI3.05–51.09]) and malnutrition (adjOR9.19E103[95%CI19.68E42-8.72E164]), lower average number of people per household (adjOR0.32[95%CI0.22–0.47]) and lower indigenous population (adjOR0.20[95%CI0.06–0.65]) compared to the ‘low-burden’ category on multivariable analysis. ‘High-burden’ of non-communicable disease was associated with more accessible municipalities (adjOR1.93[95%CI1.45–2.57]), higher female proportion within the municipality (adjOR1.69E8[95%CI3227.74–8.82E12]), nutritional deficiency (adjOR1.39E17[95%CI11799.83–1.64E30]) and malnutrition (adjOR2.17E131[95%CI4.41E79-1.07E183]) and lower proportions of population under five years (adjOR1.05E-10[95%CI9.95E-18–0.001]), indigenous population (adjOR0.32[95%CI0.11–0.91]), average people per household (adjOR0.44[95%CI0.26–0.73]) and households with no piped water (adjOR0.21[95%CI0.09–0.49]), compared to the ‘low-burden’ category on adjusted analysis. ‘High burden’ of infectious disease was also associated with more accessible municipalities (adjOR4.29[95%CI3.05–6.05]), higher proportions of population under five years (adjOR3.78E9[95%CI9418.25–1.51E15]), vaccine coverage (adjOR25.42[95%CI7.85–82.29]) and malnutrition (adjOR4.29E41[95%CI12408.29–1.48E79]) and lower proportions of households using firewood as fuel (adjOR0.39[95%CI0.20–0.79]) (‘moderate-burden’ category only) compared to ‘low-burden’.

Conclusions

While this study produced imprecise estimates and cannot be interpreted for individual risk, more accessible municipalities were consistently associated with higher disease burden than remote areas. Female sex, lower average number per household, non-indigenous population and poor nutrition were also associated with higher burden of disease and offer targets to direct interventions to reduce the burden of infectious and non-communicable disease and manage the double burden of disease in Nepal.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13905-3.

Twenty-four-month outcomes from a cluster-randomized controlled trial of extending antiretroviral therapy refills in ART adherence clubs

INTRODUCTION

The antiretroviral therapy (ART) adherence club (AC) model has supported clinically stable HIV patients' retention with group ART refills and psychosocial support. Reducing visit frequency by increasing ART refills to six months could further benefit patients and unburden health systems. We conducted a pragmatic non-inferiority cluster randomized trial comparing standard of care (SoC) ACs and six-month refill intervention ACs in a primary care facility in Khayelitsha, South Africa.

METHODS

Existing community-based and facility-based ACs were randomized to either SoC or intervention ACs. SoC ACs met five times annually, receiving two-month refills with a four-month refill over year-end. Blood was drawn at one AC visit with a clinical assessment at the next. Intervention ACs met twice annually receiving six-month refills, with an individual blood collection visit before the annual clinical assessment AC visit. The first study visits were in October and November 2017 and participants followed for 27 months. We report retention in care, viral load completion and viral suppression (<400 copies/mL) 24 months after enrolment and calculated intention-to-treat risk differences for the primary outcomes using generalized estimating equations specifying for clustering by AC.

RESULTS

Of 2150 participants included in the trial, 977 were assigned to the intervention arm (40 ACs) and 1173 to the SoC (48 ACs). Patient characteristics at enrolment were similar across groups. Retention in care at 24 months was similarly high in both arms: 93.6% (1098/1173) in SoC and 92.6% (905/977) in the intervention arm, with a risk difference of -1.0% (95% CI: -3.2 to 1.3). The intervention arm had higher viral load completion (90.8% (999/1173) versus 85.1% (887/977)) and suppression (87.3% (969 /1173) versus 82.6% (853/977)) at 24 months, with a risk difference for completion of 5.5% (95% CI: 1.5 to 9.5) and suppression of 4.6% (95% CI: 0.2 to 9.0).

CONCLUSIONS

Intervention AC patients receiving six-month ART refills showed non-inferior retention in care, viral load completion and viral load suppression to those in SoC ACs, adding to a growing literature showing good outcomes with extended ART dispensing intervals.

AntiRetroviral Therapy In Second-line: investigating Tenofovir-lamivudine-dolutegravir (ARTIST): protocol for a randomised controlled trial

Background: Dolutegravir has superior efficacy and tolerability than lopinavir-ritonavir in second-line antiretroviral therapy after failure of a first-line non-nucleoside reverse transcriptase inhibitors-based regimen, when dolutegravir is accompanied by at least one fully active nucleoside reverse transcriptase inhibitor (NRTI). Resistance testing to select NRTIs is not feasible in low- and middle-income countries due to cost and limited laboratory capacity. Evidence suggests that recycling tenofovir plus lamivudine or emtricitabine backbone with dolutegravir could provide an effective second-line option. This study aims to determine the virologic efficacy of tenofovir-lamivudine-dolutegravir (TLD) with and without a lead-in supplementary dose of dolutegravir (to counteract the inducing effect of efavirenz) in patients failing a first-line regimen of tenofovir-emtricitabine-efavirenz (TEE). Methods: We will perform a parallel group, randomised (1:1), double blind, placebo-controlled, Phase II trial, comparing TLD fixed dose combination daily with a lead-in supplementary 50 mg dolutegravir dose versus matching placebo taken 12 hours later for the first 14 days, in patients failing a first-line TEE regimen. The trial will be set in two primary care clinics in Khayelitsha; a large, peri-urban informal settlement in Cape Town, South Africa. We will enrol 130 participants, with follow-up to 48 weeks. The primary endpoint is proportion achieving viral load <50 copies/mL at week 24 using a modified intention-to-treat analysis and the U.S. Food and Drug Administration snapshot algorithm. Secondary endpoints include virologic suppression at weeks 12 and 48, time to suppression, emergence of dolutegravir and new NRTI resistance mutations, safety, and tolerability. Discussion: Impaired viral fitness due to NRTI resistance mutations and dolutegravir's high barrier to resistance provide rationale for switching patients from a failing TEE regimen to TLD; however, clinical evidence regarding virologic efficacy is lacking. This study provides estimates of such a strategy's early virologic efficacy with and without a supplementary dolutegravir dosing. Registration: ClinicalTrials.gov NCT03991013 (19/06/2019).

Qualitative interview study exploring frontline managers' contributions to hand hygiene standards and audit: Local knowledge can inform practice

BACKGROUND

Frontline managers promote hand hygiene standards and adherence to hand hygiene protocols. Little is known about this aspect of their role.

METHODS

Qualitative interview study with frontline managers on 2 acute admission wards in a large National Health Service Trust in the United Kingdom.

RESULTS

Managers reported that hand hygiene standards and audit were modeled on World Health Organization guidelines. Hand hygiene outside the immediate patient zone was not documented but managers could identify when additional indications for hand hygiene presented. They considered that audit was worthwhile to remind staff that hand hygiene is important but did not regard audit findings as a valid indicator of practice. Managers identified differences in the working patterns of nurses and doctors that affect the number and types of hand hygiene opportunities and barriers to hand hygiene. Ward managers were accepted as the custodians of hand-hygiene standards.

CONCLUSIONS

Frontline managers identified many of the issues currently emerging as important in contemporary infection prevention practice and research and could apply them locally. Their views should be represented when hand hygiene guidelines are reviewed and updated.

A cluster randomized controlled trial of extending ART refill intervals to six-monthly for anti-retroviral adherence clubs

BACKGROUND

The antiretroviral therapy (ART) adherence club (AC) differentiated service delivery model, where clinically stable ART patients receive their ART refills and psychosocial support in groups has supported clinically stable patients' retention and viral suppression. Patients and health systems could benefit further by reducing visit frequency and increasing ART refills. We designed a cluster-randomized control trial comparing standard of care (SoC) ACs and six-month ART refill (Intervention) ACs in a large primary care facility in Khayelitsha, South Africa.

METHODS

Existing ACs were randomized to either the control (SOC ACs) or intervention (Intervention ACs) arm. SoC ACs meet five times annually, receiving two-month ART refills with a four-month ART refill over year-end. Blood is drawn at the AC visit ahead of the clinical assessment visit. Intervention ACs meet twice annually receiving six-month ART refills, with a third individual visit for routine blood collection anytime two-four weeks before the annual clinical assessment AC visit. Primary outcomes will be retention in care, annual viral load assessment completion and viral load suppression. (<400copies/mL) after 2 years. Ethics approval has been granted by the University of Cape Town (HREC 652/2016) and the Medecins Sans Frontieres (MSF) Ethics Review Board (#1639). Results will be published in peer-reviewed journals and made widely available through presentations and briefing documents.

DISCUSSION

Evaluation of an extended ART refill interval in adherence clubs will provide evidence towards novel model adaptions that can be made to further improve convenience for patients and leverage health system efficiencies.

TRIAL REGISTRATION

Registered with the Pan African Clinical Trial Registry: PACTR201810631281009. Registered 11 September 2018.

An audit of the complications of intercostal chest drain insertion in a high volume trauma service in South Africa

INTRODUCTION

Intercostal chest drain (ICD) insertion is a commonly performed procedure in trauma and may be associated with significant morbidity.

METHODS

This was a retrospective review of ICD complications in a major trauma service in South Africa over a four-year period from January 2010 to December 2013.

RESULTS

A total of 1,050 ICDs were inserted in 1,006 patients, of which 91% were male. The median patient age was 24 years (interquartile range [IQR]: 20-29 years). There were 962 patients with unilateral ICDs and 44 with bilateral ICDs. Seventy-five per cent (758/1,006) sustained penetrating trauma and the remaining 25% (248/1006) sustained blunt trauma. Indications for ICD insertion were: haemopneumothorax (n=338), haemothorax (n=314), simple pneumothorax (n=265), tension pneumothorax (n=79) and open pneumothorax (n=54). Overall, 203 ICDs (19%) were associated with complications: 18% (36/203) were kinked, 18% (36/203) were inserted subcutaneously, 13% (27/203) were too shallow and in 7% (14/203) there was inadequate fixation resulting in dislodgement. Four patients (2%) sustained visceral injuries and two sustained vascular injuries. Forty-one per cent (83/203) were inserted outside the 'triangle of safety' but without visceral or vascular injuries. One patient had the ICD inserted on the wrong side. Junior doctors inserted 798 ICDs (76%) while senior doctors inserted 252 (24%). Junior doctors had a significantly higher complication rate (24%) compared with senior doctors (5%) (p<0.001). There was no mortality as a direct result of ICD insertion. </sec> Conclusions ICD insertion is associated with a high rate of complications. These complications are significantly higher when junior doctors perform the procedure. A multifaceted quality improvement programme is needed to improve the situation.

Leucocyte entry and endothelial E-selectin expression following intradermal Propionibacterium acnes administration

Immune responses in porcine skin to intradermal inoculation of heat-killed Propionibacterium acnes (HKPA), the major bacterial agent associated with human inflammatory acne, were studied. Pigs were chosen as experimental animals because their skin is similar in structure and composition to that of man and because the use of genetically inbred pigs enables leucocytes to be transferred between animals without eliciting rejection responses. Two pigs were sensitized intradermally with 10 mg of HKPA and were challenged 2 weeks later with doses ranging from 1-100 microg of HKPA in various intradermal sites on the ventral aspect of the abdomen. Four further pigs, previously sensitized with Bacillus Calmette-Guérin (BCG) but not HKPA, were challenged with purified protein derivative (PPD) of bovine tuberculin and HKPA. Entry of(51)Cr-labelled peripheral blood lymphocytes (PBLs) over 48 h was studied in all the challenge sites. Peak PBL entry occurred at 4 h, remaining sustained up to 24 h. There was a dose-dependent effect of HKPA on the level of PBL entry, which was antigen-specific, as few leucocytes were seen in PPD-challenge sites in HKPA-sensitized pigs or in HKPA-challenged sites in BCG-sensitized pigs. There was also a substantial influx of(111)Indium-labelled neutrophils into the lesions. Lymphocytes present were predominantly of the CD3(+)CD2(+)T-cell subset, although gammadelta TCR(+)cells were present also, particularly after 24 h. E-selectin was markedly upregulated on dermal endothelium in the P. acnes sites. The histological infiltration and kinetics were similar to those reported in human inflammatory acne.