Task-shifting from doctors to non-doctors for initiation and maintenance of antiretroviral therapy

McCaul, Michael; Kredo, Tamara; Volmink, Jimmy

doi:10.7196/samjnew.8271

Cited by 59 publications

(69 citation statements)

References 5 publications

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“…While retention in care was less than the 97% reported from the pilot study of facility-based adherence clubs [14], these are promising outcomes. Limited outcome data are available from other community-based programmes with most community models providing home-based ART delivery [26,27]. The exception is the community adherence group (CAG) model in Mozambique with 98% retention in care after 12 months [21].…”

Section: Discussionmentioning

confidence: 99%

Implementation of community‐based adherence clubs for stable antiretroviral therapy patients in Cape Town, South Africa

Grimsrud

Sharp

Kalombo

et al. 2015

Journal of the International AIDS Society

152

201

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IntroductionCommunity-based models of antiretroviral therapy (ART) delivery have been recommended to support ART expansion and retention in resource-limited settings. However, the evidence base for community-based models of care is limited. We describe the implementation of community-based adherence clubs (CACs) at a large, public-sector facility in peri-urban Cape Town, South Africa.MethodsStarting in May 2012, stable ART patients were down-referred from the primary care community health centre (CHC) to CACs. Eligibility was based on self-reported adherence, >12 months on ART and viral suppression. CACs were facilitated by four community health workers and met every eight weeks for group counselling, a brief symptom screen and distribution of pre-packed ART. The CACs met in community venues for all visits including annual blood collection and clinical consultations. CAC patients could send a patient-nominated treatment supporter (“buddy”) to collect their ART at alternate CAC visits. Patient outcomes [mortality, loss to follow-up and viral rebound (>1000 copies/ml)] during the first 18 months of the programme are described using Kaplan–Meier methods.Results and DiscussionFrom June 2012 to December 2013, 74 CACs were established, each with 25–30 patients, providing ART to 2133 patients. CAC patients were predominantly female (71%) and lived within 3 km of the facility (70%). During the analysis period, 9 patients in a CAC died (<0.1%), 53 were up-referred for clinical complications (0.3%) and 573 CAC patients sent a buddy to at least one CAC visit (27%). After 12 months in a CAC, 6% of patients were lost to follow-up and fewer than 2% of patients retained experienced viral rebound.ConclusionsOver a period of 18 months, a community-based model of care was rapidly implemented decentralizing more than 2000 patients in a high-prevalence, resource-limited setting. The fundamental challenge for this out of facility model was ensuring that patients receiving ART within a CAC were viewed as an extension of the facility and part of the responsibility of CHC staff. Further research is needed to support down-referral sooner after ART initiation and to describe patient experiences of community-based ART delivery.

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Section: Discussionmentioning

confidence: 99%

Implementation of community‐based adherence clubs for stable antiretroviral therapy patients in Cape Town, South Africa

Grimsrud

Sharp

Kalombo

et al. 2015

Journal of the International AIDS Society

152

201

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“…Clinical outcomes among adults HIV care in decentralized programmes with nurse-led care have been comparable to those in secondary healthcare facilities [7,8,12,13]. Provision of HIV care to children and adolescents is associated with additional complexities, which may impact on clinical outcomes [9].…”

Section: Introductionmentioning

confidence: 99%

Clinical outcomes in children and adolescents initiating antiretroviral therapy in decentralized healthcare settings in Zimbabwe

McHugh

Simms

Dauya

et al. 2017

Journal of the International AIDS Society

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Introduction: Decentralized HIV care for adults does not appear to compromise clinical outcomes. HIV care for children poses additional clinical and social complexities. We conducted a prospective cohort study to investigate clinical outcomes in children aged 6–15 years who registered for HIV care at seven primary healthcare clinics (PHCs) in Harare, Zimbabwe. Methods: Participants were recruited between January 2013 and December 2014 and followed for 18 months. Rates of and reasons for mortality, hospitalization and unscheduled PHC attendances were ascertained. Cox proportional modelling was used to determine the hazard of death, unscheduled attendances and hospitalization. Results: We recruited 385 participants, median age 11 years (IQR: 9–13) and 52% were female. The median CD4 count was 375 cells/mm3 (IQR: 215–599) and 77% commenced ART over the study period, with 64% of those who had viral load measured achieving an HIV viral load <400 copies/ml. At 18 months, 4% of those who started ART vs. 24% of those who remained ART‐naïve were lost‐to‐follow‐up (p < 0.001). Hospitalization and mortality rates were low (8.14/100 person‐years (pyrs) and 2.86/100 pyrs, respectively). There was a high rate of unscheduled PHC attendances (34.94/100 pyrs), but only 7% resulted in hospitalization. Respiratory disease was the major cause of hospitalization, unscheduled attendances and death. CD4 count <350cells/mm3 was a risk factor for hospitalization (aHR 3.6 (95%CI 1.6–8.2)). Conclusions: Despite only 64% of participants achieving virological suppression, clinical outcomes were good and high rates of retention in care were observed. This demonstrates that in an era moving towards differentiated care in addition to implementation of universal treatment, decentralized HIV care for children is achievable. Interventions to improve adherence in this age‐group are urgently needed.

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“…5,[26][27][28][29][30] Recent systematic reviews demonstrate that treatment outcomes among patients primarily receiving care from CHWs or nurses are comparable to outcomes among patients cared for by doctors. 31,32 In addition, CHW systems are cost-effective and rapidly scalable units of the healthcare system. 33 In South Africa, CHWs, also known as community caregivers or home-based caregivers, have been employed by NGOs and the Department of Health for the duration of the HIV/AIDS epidemic.…”

Section: Introductionmentioning

confidence: 99%

“I Have to Push Him with a Wheelbarrow to the Clinic”: Community Health Workers' Roles, Needs, and Strategies to Improve HIV Care in Rural South Africa

Loeliger

Niccolai

Mtungwa

et al. 2016

AIDS Patient Care and STDs

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With a 19.2% HIV prevalence, South Africa has the largest HIV/AIDS epidemic worldwide. Despite a recent scale-up of public sector HIV resources, including community-based programs to expand HIV care, suboptimal rates of antiretroviral therapy (ART) initiation and adherence persist. As community stakeholders with basic healthcare training, community health workers (CHWs) are uniquely positioned to provide healthcare and insight into potential strategies to improve HIV treatment outcomes. The study goal was to qualitatively explore the self-perceived role of the CHW, unmet CHW needs, and strategies to improve HIV care in rural KwaZulu-Natal, South Africa. Focus groups were conducted in May-August 2014, with 21 CHWs working in Msinga subdistrict. Interviews were audio-recorded, transcribed, and translated from Zulu into English. A hybrid deductive and inductive analytical method borrowed from grounded theory was applied to identify emergent themes. CHWs felt they substantially contributed to HIV care provision but were inadequately supported by the healthcare system. CHWs' recommendations included: (1) sufficiently equipping CHWs to provide education, counseling, social support, routine antiretroviral medication, and basic emergency care, (2) modifying clinical practice to provide less stigmatizing, more patient-centered care, (3) collaborating with traditional healers and church leaders to reduce competition with ART and provide more holistic care, and (4) offsetting socioeconomic barriers to HIV care. In conclusion, CHWs can serve as resources when designing and implementing interventions to improve HIV care. As HIV/AIDS policy and practice evolves in South Africa, it will be important to recognize and formally expand CHWs' roles supporting the healthcare system.

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Task-shifting from doctors to non-doctors for initiation and maintenance of antiretroviral therapy

Cited by 59 publications

References 5 publications

Implementation of community‐based adherence clubs for stable antiretroviral therapy patients in Cape Town, South Africa

Implementation of community‐based adherence clubs for stable antiretroviral therapy patients in Cape Town, South Africa

Clinical outcomes in children and adolescents initiating antiretroviral therapy in decentralized healthcare settings in Zimbabwe

“I Have to Push Him with a Wheelbarrow to the Clinic”: Community Health Workers' Roles, Needs, and Strategies to Improve HIV Care in Rural South Africa

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