Costs of streamlined HIV care delivery in rural Ugandan and Kenyan clinics in the SEARCH Study

Shade, Starley B.; Osmand, Thomas; Luo, Alex; Aine, Ronald; Elly, Assurah; Mwebaza, Betty; Mwai, Daniel; Owaraganise, Asiphas; Mwangwa, Florence; Ayieko, James; Black, Douglas; Brown, Lillian B.; Clark, Tamara D.; Kwarisiima, Dalsone; Thirumurthy, Harsha; Cohen, Craig R.; Bukusi, Elizabeth A.; Charlebois, Edwin D.; Balzer, Laura B.; Kamya, Moses R.; Petersen, Maya; Havlir, Diane V.; Jain, Vivek

doi:10.1097/qad.0000000000001958

Cited by 26 publications

(25 citation statements)

References 35 publications

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“…Although our data were collected between 2014 and 2016, studies published after this period strongly suggest that task shifting from physicians to nurses in HIV care is still common in health facilities in Uganda. Hence, our study findings still resonate with current practice [12,[37][38][39][40][41][42][43]. These data and subsequent published studies point to a mounting evidence base supporting an expanded role for nurses and other non-physician cadre in the quest to accelerate progress towards UNAIDS's 95-95-95 targets and in advancing the universal health coverage (UHC) agenda [5,23,44].…”

Section: Discussionsupporting

confidence: 80%

Reimagining the role of the nursing workforce in Uganda after more than a decade of ART scale-up

Zakumumpa

2020

Hum Resour Health

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Background: The expanding roles and increasing importance of the nursing workforce in health services delivery in resource-limited settings is not adequately documented and sufficiently recognized in the current literature. Drawing upon the theme of 2020 as the International Year of the Nurse and the Midwife, we set out to describe how the role of nurses expanded tremendously in health facilities in Uganda during the era of anti-retroviral therapy (ART) scale-up that commenced in June 2004. Methods: We employed a mixed-methods sequential explanatory research design. Phase I entailed a crosssectional health facility survey (n = 195) to assess the extent to which human resource management strategies (such as task shifting) were common. Phase II entailed a qualitative multiple case study of 16 (of the 195) health facilities for an in-depth understanding of the strategies adopted (e.g. nurse-centred HIV care). Descriptive analyses were performed in STATA (v 13) while qualitative data were analysed by thematic approach. Results: We found that nurses were the most represented cadre of health workers involved in the overall leadership of HIV clinics across Uganda. Most nurse-led HIV clinics were based in rural settings; however, this trend was fairly even across setting (rural/urban/peri-urban). While 181 (93%) health facilities allowed non-physician cadre to prescribe ART, a number of health facilities (n = 36) or 18% deliberately adopted nurse-led HIV care models. Nurses were empowered to be multi-skilled with a wide range of competencies across the HIV care continuum right from HIV testing to mainstream clinical HIV disease management. In several facilities, nursing cadre were the backbone of ART service delivery. A select number of facilities devised differentiated models of task shifting from physicians to nurses in which the latter handled patients who were stable on ART. Conclusion: Overall, our study reveals a wide expansion in the scope-of-practice of nurses during ART scale-up in Uganda. Nurses were thrust in roles of HIV disease management that were traditionally the preserve of physicians. Our study underscores the importance of reforming regulatory frameworks governing nursing workforce scope of practice such as the need for developing a policy on task shifting which is currently lacking in Uganda.

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Section: Discussionsupporting

confidence: 80%

Reimagining the role of the nursing workforce in Uganda after more than a decade of ART scale-up

Zakumumpa

2020

Hum Resour Health

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“…We compared scaled-up costs of community ART delivery with estimates from previous studies of the annual per-person estimates of the cost of clinic ART in South Africa 17 and Uganda. 18 We used the study viral suppression rates and costs to estimate the cost per person virally suppressed through community-based ART compared with clinic ART (appendix p 13).…”

Section: Discussionmentioning

confidence: 99%

“…At scale, we project that the cost of community-based ART could be similar to previously published estimates of the cost of clinic ART. 17,18 However, questions remain regarding how community-based ART could be implemented at scale in the absence of established delivery platforms and systems. Refining components of the community-based ART delivery strategy could decrease or contain costs, which might be necessary in areas where the density of clients is low.…”

Section: Discussionmentioning

confidence: 99%

“…Using the annual cost of $249 per person for clinic-based ART 17 in South Africa and the viral suppression rates observed in the study groups, the annual cost per person virally suppressed was $402-422 in the clinic group and $325-390 in the community-based group in South Africa (appendix p 13). Similarly in Uganda, using the annual cost of $291 per person for streamlined clinic-based ART, 18 the annual cost per person virally suppressed was $214 in the clinic-based group and $275 in the community-based group.…”

Section: Betweenmentioning

confidence: 99%

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Community-based antiretroviral therapy versus standard clinic-based services for HIV in South Africa and Uganda (DO ART): a randomised trial

Barnabas

Szpiro

Rooyen

et al. 2020

The Lancet Global Health

115

125

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Background Community-based delivery of antiretroviral therapy (ART) for HIV, including ART initiation, clinical and laboratory monitoring, and refills, could reduce barriers to treatment and improve viral suppression, reducing the gap in access to care for individuals who have detectable HIV viral load, including men who are less likely than women to be virally suppressed. We aimed to test the effect of community-based ART delivery on viral suppression among people living with HIV not on ART. Methods We did a household-randomised, unblinded trial (DO ART) of delivery of ART in the community compared with the clinic in rural and peri-urban settings in KwaZulu-Natal, South Africa and the Sheema District, Uganda. After community-based HIV testing, people living with HIV were randomly assigned (1:1:1) with mobile phone software to community-based ART initiation with quarterly monitoring and ART refills through mobile vans; ART initiation at the clinic followed by mobile van monitoring and refills (hybrid approach); or standard clinic ART initiation and refills. The primary outcome was HIV viral suppression at 12 months. If the difference in viral suppression was not superior between study groups, an a-priori test for non-inferiority was done to test for a relative risk (RR) of more than 0•95. The cost per person virally suppressed was a co-primary outcome of the study. This study is registered with ClinicalTrials.gov, NCT02929992.

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“…We now have solid evidence that in SSA, UTT is feasible in a variety of public health–funded settings and can rapidly achieve high levels of viral suppression and reduce HIV incidence and deaths faster than the status quo. Importantly, all UTT trials evaluated testing strategies designed to be feasible for implementation at scale; while some cost effectiveness analyses are currently underway, those published shows costs in line with alternative approaches, and support the cost effectiveness of a UTT approach . In modelled projections based on HPTN 071, HIV incidence would be reduced by up to 50% if the intervention were continued to 2030 .…”

Section: Discussionmentioning

confidence: 99%

What do the Universal Test and Treat trials tell us about the path to HIV epidemic control?

et al. 2020

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Introduction Achieving HIV epidemic control globally will require new strategies to accelerate reductions in HIV incidence and mortality. Universal test and treat (UTT) was evaluated in four randomized population‐based trials (BCPP/Ya Tsie, HPTN 071/PopART, SEARCH, ANRS 12249/TasP) conducted in sub‐Saharan Africa (SSA) during expanded antiretroviral treatment (ART) eligibility by World Health Organization guidelines and the UNAIDS 90‐90‐90 campaign. Discussion These three‐year studies were conducted in Botswana, Zambia, Uganda, Kenya and South Africa in settings with baseline HIV prevalence from 4% to 30%. Key observations across studies were: (1) Universal testing (implemented via a variety of home and community‐based testing approaches) achieved >90% coverage in all studies. (2) When coupled with robust linkage to HIV care, rapid ART start and patient‐centred care, UTT achieved among the highest reported population levels of viral suppression in SSA. Significant gains in population‐level viral suppression were made in regions with both low and high baseline population viral load; however, viral suppression gains were not uniform across all sub‐populations and were lower among youth. (3) UTT resulted in marked reductions in community HIV incidence when universal testing and robust linkage were present. However, HIV elimination targets were not reached. In BCPP and HPTN 071, annualized HIV incidence was approximately 20% to 30% lower in the intervention (which included universal testing) compared to control arms (no universal testing). In SEARCH (where both arms had universal testing), incidence declined 32% over three years. (4) UTT reduced HIV associated mortality by 23% in the intervention versus control communities in SEARCH, a study in which mortality was comprehensively measured. Conclusions These trials provide strong evidence that UTT inclusive of universal testing increases population‐level viral suppression and decreases HIV incidence and mortality faster than the status quo in SSA and should be adapted at a sub‐country level as a public health strategy. However, more is needed, including integration of new prevention interventions into UTT, in order to reach UNAIDS HIV elimination targets.

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Costs of streamlined HIV care delivery in rural Ugandan and Kenyan clinics in the SEARCH Study

Cited by 26 publications

References 35 publications

Reimagining the role of the nursing workforce in Uganda after more than a decade of ART scale-up

Reimagining the role of the nursing workforce in Uganda after more than a decade of ART scale-up

Community-based antiretroviral therapy versus standard clinic-based services for HIV in South Africa and Uganda (DO ART): a randomised trial

What do the Universal Test and Treat trials tell us about the path to HIV epidemic control?

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