Strategies for Optimizing Clinic Efficiency in a Community-Based Antiretroviral Treatment Programme in Uganda

Alamo, Stella; Wagner, Glenn; Ouma, Joseph; Sunday, Pamela; Laga, Marie; Colebunders, Robert; Wâbwire-Mângen, Fred

doi:10.1007/s10461-012-0199-9

Cited by 43 publications

(39 citation statements)

References 19 publications

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“…Differentiated HIV care has been proposed to provide appropriate care to different populations within clinics. The modest body of rigorous evidence on differentiated care to date, however, largely focuses on strategies for stable patients [30][31][32][33][34][35][36]. Far less has been written about strategies for unstable patients, a population much harder to manage.…”

Section: Discussionmentioning

confidence: 99%

Effectiveness of interventions for unstable patients on antiretroviral therapy in South Africa: results of a cluster‐randomised evaluation

Fox

Pascoe

Huber

et al. 2018

Tropical Med Int Health

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Background As loss from HIV care is an ongoing challenge globally, interventions are needed for patients who don't achieve or maintain ART stability. The 2015 South African National Adherence Guidelines (AGL) for Chronic Diseases include two interventions targeted at unstable patients: early tracing of patients who miss visits (TRIC) and enhanced adherence counselling (EAC). Methods As part of a cluster‐randomised evaluation at 12 intervention and 12 control clinics in four provinces, intervention sites implemented the AGL interventions, while control sites retained standard care. We report on outcomes of EAC for patients with an elevated viral load (>400 copies/ml) and for TRIC patients who missed a visit by >5 days. We estimated risk differences (RD) of 3 and 12‐month viral resuppression (<400 copies/ml) and 12‐month retention with cluster adjustment using generalised estimating equations and controlled for imbalances using difference‐in‐differences compared to all eligible in 2015, prior to intervention roll‐out. Results For EAC, we had 358 intervention and 505 control site patients (61% female, median ART initiation CD4 count 154 cells/μl). We found no difference between arms in 3‐month resuppression (RD: −1.7%; 95%CI: −4.3% to 0.9%), but <20% of patients had a repeat viral load within 3 months (19.8% intervention, 13.5% control). Including the entire clinic population eligible for EAC with a repeat viral load at all evaluation sites (n = 934), intervention sites showed a small increase in 3‐month resuppression (28% vs. 25%, RD 3.0%; 95%CI: −2.7% to 8.8%). Adjusting for baseline differences increased the RD to 8.1% (95% CI: −0.1% to 17.2%). However, we found no differences in 12‐month suppression (RD: 1.5%; 95% CI: −14.1% to 17.1% but suppression was low overall at 40%) or retention (RD: 2.8%; 95% CI: −7.5% to 13.2%). For TRIC, we enrolled 155 at intervention sites and 248 at control sites (44% >40 years, 67% female, median CD4 count 212 cells/μl). We found no difference between groups in return to care by 12 months (RD: −6.8%; 95% CI: −17.7% to 4.8%). During the study period, control sites continued to use tracing within standard care, however, potentially masking intervention effects. Conclusions Enhanced adherence counselling showed no benefit over 12 months. Implementation of the tracing intervention under the new guidelines was similar to the standard of care. Interventions that aim to return unstable patients to care should incorporate active monitoring to determine if the interventions are effective.

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Section: Discussionmentioning

confidence: 99%

Effectiveness of interventions for unstable patients on antiretroviral therapy in South Africa: results of a cluster‐randomised evaluation

Fox

Pascoe

Huber

et al. 2018

Tropical Med Int Health

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“…Together, task shifting and reduction of intensity of follow up achieved saving of large number of physicians' consultations (41, 116 physician visits averted in 2014), creating extra physicians' time for co-morbid, severely sick or patients failing ART. Research conducted by Alamo et al presents evidence that such approaches improve patient flow, reduce waiting time and increase patients' and providers' satisfaction [10]. At the same time, studies conducted in similar urban context of Uganda show that facility-based interventions are cost-effective and have positive effect on patient'sa d h e rence [11,12].…”

Section: Discussionmentioning

confidence: 99%

“…The MSF facilitybased model of care was designed to optimize HIV care by differentiating ART delivery according to age and clinical characteristics, thereby allowing programs to save specialized expertise for the management of complicated cases with severe co-morbidities. The model was based on existing evidence for the facility based differentiated models showing good treatment outcomes with improved adherence, increasing patient and staff satisfaction, reduction of waiting time and service delivery for more patients with the same number of staff [10][11][12].…”

Section: Introductionmentioning

confidence: 99%

Implications of differentiated care for successful ART scale‐up in a concentrated HIV epidemic in Yangon, Myanmar

Mesic

Fontaine²,

Aye

et al. 2017

Journal of the International AIDS Society

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Introduction: National AIDS Programme in Myanmar has made significant progress in scaling up antiretroviral treatment (ART) services and recognizes the importance of differentiated care for people living with HIV. Indeed, long centred around the hospital and reliant on physicians, the country’s HIV response is undergoing a process of successful decentralization with HIV care increasingly being integrated into other health services as part of a systematic effort to expand access to HIV treatment. This study describes implementation of differentiated care in Médecins Sans Frontières (MSF)-supported programmes and reports its outcomes.Methods: A descriptive cohort analysis of adult patients on antiretroviral treatment was performed. We assessed stability of patients as of 31 December 2014 and introduced an intervention of reduced frequency of physicians’ consultations for stable patients, and fast tract ART refills. We measured a number of saved physician’s visits as the result of this intervention. Main outcomes, remained under care, death, lost to follow up, treatment failure, were assessed on 31 December 2015 and reported as rates for different stable groups.Results: On 31 December 2014, our programme counted 16, 272 adult patients enrolled in HIV care, of whom 80.34% were stable. The model allowed for an increase in the average number of patients one medical team could care for – from 745 patients in 2011 to 1, 627 in 2014 – and, thus, a reduction in the number of teams needed. An assessment of stable patients enrolled on ART one year after the implementation of the new model revealed excellent outcomes, aggregated for stable patients as 98.7% remaining in care, 0.4% dead, 0.8% lost to follow-up, 0.8% clinical treatment failure and 5.8% with immunological treatment failure.Conclusions: Implementation of a differentiated model reduced the number of visits between stable clients and physicians, reduced the medical resources required for treatment and enabled integrated treatment of the main co-morbidities. We hope that these findings will encourage other stakeholders to implement innovative models of HIV care in Myanmar, further expediting the scale up of ART services, the decentralization of treatment and the integration of care for the main HIV co-morbidities in this context.

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“…More important, this may also indicate that facility‐based delivery still has higher absorptive capacities waiting to be utilized. Studies have shown that strategies to remove facility‐level barriers (such as reduction in long waiting times) in antiretroviral treatment programmes often result in increased uptake of treatment . While scaling up ART access through community approaches is important, the opportunities for improving facility ART uptake should not be overlooked.…”

Section: Discussionmentioning

confidence: 99%

Bridging the HIV treatment gap in Nigeria: examining community antiretroviral treatment models

et al. 2018

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IntroductionSignificant gaps persist in providing HIV treatment to all who are in need. Restricting care delivery to healthcare facilities will continue to perpetuate this gap in limited resource settings. We assessed a large‐scale community‐based programme for effectiveness in identifying people living with HIV and linking them to antiretroviral treatment.MethodsA retrospective secular trend study of 14 high burden local government areas of Nigeria was conducted in which two models of community antiretroviral treatment delivery were implemented: Model A (on‐site initiation) and Model B (immediate referral) clusters. Model A cluster offered services within communities, from HIV diagnosis to immediate antiretroviral therapy initiation and some follow‐up. Model B cluster offered services for HIV diagnosis up to baseline evaluation and provided referral for antiretroviral therapy initiation to nearest health facility providing HIV services. For controls, we selected and cluster‐matched 34 local government areas where community antiretroviral treatment delivery was not implemented. Outcomes of interest were: the number of people identified as HIV positive and the number of HIV‐positive individuals started on antiretroviral treatment; from June 2014 to May 2016. We used interrupted time‐series analysis to estimate outcome levels and trends across the pre‐and post‐intervention periods.ResultsBefore community antiretrovial treatment introduction, Model A cluster identified, per 100,000 catchment population, 500 HIV‐positives (95% CI: 399.66 to 601.41) and initiated 216 HIV‐positives on antiretroviral treatment (95% CI: 152.72 to 280.10). Model B cluster identified 32 HIV‐positives (95% CI: 25.00 to 40.51) and initiated 8 HIV‐positives on antiretroviral treatment (95% CI: 5.54 to 10.33). After commART introduction, Model A cluster showed an immediate significant increase in 744 HIV‐positive persons (p = 0.00, 95% CI: 360.35 to 1127.77) and 560 HIV‐positives initiated on treatment (p = 0.00, 95% CI: 260.56 to 859.64). Model B cluster showed an immediate significant increase in 30 HIV‐positive persons identified (p = 0.01, 95% CI: 8.38 to 51.93) but not in the number of HIV‐positives initiated on treatment. Model B cluster showed increased month‐on‐month trends of both outcomes of interest (3.4, p = 0.02, 95% CI: 0.44 to 6.38).ConclusionBoth community‐models had similar population‐level effectiveness for rapidly identifying people living with HIV but differed in effectively transitioning them to treatment. Comprehensiveness, integration and attention to barriers to care are important in the design of community antiretroviral treatment delivery.

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Strategies for Optimizing Clinic Efficiency in a Community-Based Antiretroviral Treatment Programme in Uganda

Cited by 43 publications

References 19 publications

Effectiveness of interventions for unstable patients on antiretroviral therapy in South Africa: results of a cluster‐randomised evaluation

Effectiveness of interventions for unstable patients on antiretroviral therapy in South Africa: results of a cluster‐randomised evaluation

Implications of differentiated care for successful ART scale‐up in a concentrated HIV epidemic in Yangon, Myanmar

Bridging the HIV treatment gap in Nigeria: examining community antiretroviral treatment models

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