Interventions to improve early retention of patients in antiretroviral therapy programmes in sub-Saharan Africa: A systematic review

Abstract

Background Several interventions to improve long term retention (12 months and above) on treatment have been rigorously evaluated in Sub-Saharan Africa (SSA). However, research on interventions to improve retention of patients in the early stages of treatment (6 months) during this era of Universal Test and Treat has only recently emerged. The aim of this study is to systematically map evidence of interventions used to improve early retention of patients in antiretroviral therapy (ART) programmes in SSA. Methods We searched PubMed, EMBASE and Cochrane electronic databases to identify studies describing interventions aimed at improving early retention in ART treatment. We applied the methodological frameworks by Arksey and O’Malley (2005) and Levac et al. (2010). We also followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Interventions were categorized according to key broad areas in the existing literature. Results A total of 2,241 articles were identified of which 19 met the inclusion criteria and were eligible for this review, with the majority either being randomized control trials 32% (n = 6) or cohort studies 32% (n = 6). The studies reviewed were conducted in 11 SSA countries. The most common interventions described under key broad areas included: Health system interventions such as Universal Test-and-Treat, integration of ART initiation, HIV Testing and Counselling and Antenatal Care services and reduction of ART drug costs; Patient centered approaches such as fast track ART initiation, Differentiated Drug Delivery models and point of care HIV birth testing; Behavioral interventions and support through lay counselors, mentor mothers, nurse counselors and application of quality improvement interventions and financial incentives. Majority of the studies targeted the HIV positive adults and pregnant women. Conclusion With the introduction of Universal Test-and-Treat and same-day initiation of ART, findings suggest that adoption of policies that expand ART uptake with the goal of reducing HIV transmission at the population level, promoting patient centered approaches such as fast track ART initiation, Differentiated Service Delivery models and providing adequate support through Mentor Mothers, lay and nurse counselors may improve early retention in HIV care in SSA. However, these interventions have only been tested in few countries in the region which points to how hard evidence based HIV programming is. Further research investigating the impact of individual and a combination of interventions to improve early retention in HIV care, including for various groups at high risk of attrition, is warranted across SSA countries to fast track the achievement of 95-95-95 Joint United Nations Programme on HIV/AIDS (UNAIDS) targets by 2030.

Challenges of hepatitis B treatment in rural Sub‐Saharan Africa: Treatment initiation and outcomes from a public hospital‐based clinic in Kono, Sierra Leone

“…Geographic barriers to accessing healthcare are associated with dramatically worse morbidity and mortality, 31,32 with decentralization being an important strategy for overcoming those barriers 33 . Such decentralization has been shown to improve access to testing, linkage to care, and treatment for hepatitis C and HIV in resource‐limited settings 34–36 . Additionally, the establishment of HBV services within a clinic specializing in the care of chronic diseases was important to reinforce the need for long‐term monitoring of HBV‐related sequelae, including cirrhosis and hepatocellular carcinoma.…”

“…Among patients not initiated on treatment, education programs uniquely tailored to their context may be required, as well as streamlined monitoring systems 44 . Conversely, mentorship programs and differentiated care delivery models that facilitate patient‐centred values such as the ability to pick up medications from community pharmacies instead of central pharmacies for stable patients may best augment retention for those initiated on therapy 36 …”

“…In total, 623 individuals were enrolled in the HBV clinic over 2 years, 285 (45.8%) of whom identified as women (Table 1), and 17 (2.7%) were pregnant. The median age of was 30 years (IQR [23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40]. The most frequent referral source to the HBV clinic was from the public government outpatient primary care clinic, which referred 289 (46.4%) of the patients enrolled, while 57 (9.2%) patients were referred from the hospital inpatient ward, 26 (4.2%) were referred from community-based HBV screening campaigns, 13 (2.1%) were referred from a primary health facility operated by Partners In Health, and 14 (2.3%) were referred from other outpatient centres.…”

“…Retention in care was defined as a documented follow-up visit at least 1 year after enrolment. We enrolled 623 individuals in care, median age of 30 years (IQR [23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40]. Of 617 patients with available data, 97 (15.7%) had cirrhosis.…”

Factors associated with poor outcomes among people living with HIV started on anti-retroviral therapy before and after implementation of “test and treat” program in Coastal Kenya

“…Another cohort in Masaka, Uganda, found PLHIV starting ARTs within seven days of HIV diagnosis had higher risk of lost to follow-up [ 14 ]. Systematic reviews report varying interventions to improve retention on care but with mixed outcomes [ 15 ]. Various studies have also reported different predictors of attrition for different follow-up times and in different settings, some before and others after the universal test and treat policy [ 13 , 14 , 16 ].…”