Results from a proactive follow-up intervention to improve linkage and retention among people living with HIV in Uganda: a pre-/post- study

Abstract

BackgroundDespite gains in HIV testing and treatment access in sub-Saharan Africa, patient attrition from care remains a problem. Evidence is needed of real-world implementation of low-cost, scalable, and sustainable solutions to reduce attrition. We hypothesized that more proactive patient follow-up and enhanced counseling by health facilities would improve patient linkage and retention.MethodsAt 20 health facilities in Central Uganda, we implemented a quality of care improvement intervention package that included training lay health workers in best practices for patient follow-up and counseling, including improved appointment recordkeeping, phone calls and home visits to lost patients, and enhanced adherence counseling strategies; and strengthening oversight of these processes. We compared patient linkage to and retention in HIV care in the 9 months before implementation of the intervention to the 9 months after implementation. Data were obtained from facility-based registers and files and analysed using multivariable logistic regression.ResultsAmong 1900 patients testing HIV-positive during the study period, there was not a statistically significant increase in linkage to care after implementing the intervention (52.9% versus 54.9%, p = 0.63). However, among 1356 patients initiating antiretroviral therapy during the follow-up period, there were statistically significant increases in patient adherence to appointment schedules (44.5% versus 55.2%, p = 0.01) after the intervention. There was a small increase in Ministry of Health-defined retention in care (71.7% versus 75.7%, p = 0.12); when data from the period of intervention ramp-up was dropped, this increase became statistically significant (71.7% versus 77.6%, p = 0.01). The increase in retention was more dramatic for patients under age 19 years (N = 84; 64.0% versus 83.9%, p = 0.01). The cost per additional patient retained in care was $47.ConclusionsImproving patient tracking and counseling practices was relatively low cost and enhanced patient retention in care, particularly for pediatric and adolescent patients. This approach should be considered for scale-up in Uganda and elsewhere. However, no impact was seen in improved patient linkage to care with this proactive follow-up intervention.Trial registrationPan African Clinical Trial Registry #PACTR201611001756166. Registered August 31, 2016.

A Cascade of Interventions to Promote Adherence to Antiretroviral Therapy in African Countries

“…**Trial also reported in "Target population: all PLHIV prescribed ART" [57] For PLHIV initiated on ART but have disengaged from care, providing cash incentives shows distinct promise in improving retention in HIV care, for perinatal women living with HIV and those who are food insecure [83 •• , 84 •• ]. Amounts needed to make a difference are likely to be small, covering transport costs of getting to clinics and possibly making a minimal contribution to basic food items [81]. Tracing those LTFU is widely practised in African countries, but the evidence we found suggests this should be performed in a targeted way, prioritising those who can be seen face-to-face by a peer worker who has been trained to be encouraging and use problem-solving approaches [81, 82 •• ].…”

“…Amounts needed to make a difference are likely to be small, covering transport costs of getting to clinics and possibly making a minimal contribution to basic food items [ 81 ]. Tracing those LTFU is widely practised in African countries, but the evidence we found suggests this should be performed in a targeted way, prioritising those who can be seen face-to-face by a peer worker who has been trained to be encouraging and use problem-solving approaches [ 81 , 82 •• ]. Current evidence is lacking on cost-effectiveness of comprehensive health systems strengthening interventions to improve retention in care.…”

“…Prior to Treat All, influential studies, such as one in Kenya, had shown that intensive adherence counselling at and shortly after ART initiation, including both education and problem-solving around barriers to adherence, resulted in a significant impact on adherence and virologic treatment failure during an 18-month follow-up [ 80 ]. Building on this, an uncontrolled evaluation of a health systems strengthening intervention across all ages and population groups in Uganda included training and supervision of expert patients and staff in best practices for follow-up and funds for telephone follow-up [ 81 ]. Only minimal, statistically insignificant changes were seen in the proportion attending at least one ART visit by 6 months post initiation (76% versus 72%; p = 0.12), and there were small changes in secondary outcomes such as increase in the mean number of appointments; however, post hoc analyses showed effects to be superior for younger patients.…”

Interventions to Improve Adherence to Antiretroviral Therapy (ART) in Sub-Saharan Africa: An Updated Systematic Review

“…Studies that did not measure adherence as an outcome were excluded from the systematic review. Thirty-one journal articles met the inclusion criteria [ 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 ] and were included in the systematic review. Figure 1 shows the flowchart of the systematic review process.…”

The impact of PEPFAR transition on HIV service delivery at health facilities in Uganda

“…HIV outreach is an important service linking facilities and communities. This study did not define outreach precisely, but it is likely to include bringing HIV testing services to populations that do not regularly seek care at facilities, particularly men and adolescents [37], as well as providing adherence counseling, defaulter tracing, and other efforts that have been demonstrated as successful in improving retention in care [38, 39].…”