Understanding the factors that impact effective uptake and maintenance of HIV care programs in South African primary health care clinics

Abstract

Background There is an increasingly urgent gap in knowledge regarding the translation of effective HIV prevention and care programming into scaled clinical policy and practice. Challenges limiting the translation of efficacious programming into national policy include the paucity of proven efficacious programs that are reasonable for clinics to implement and the difficulty in moving a successful program from research trial to scaled programming. This study aims to bridge the divide between science and practice by exploring health care providers’ views on what is needed to implement new HIV programs within existing HIV care. Methods We conducted 20 in-depth interviews with clinic managers and clinic program implementing staff and five key informant interviews with district health managers overseeing programming in the uMgungundlovu District of KwaZulu-Natal Province, South Africa. Qualitative data were analyzed using a template approach. A priori themes were used to construct templates of relevance, including current care context for HIV and past predictors of successful implementation. Data were coded and analyzed by these templates. Results Heath care providers identified three main factors that impact the integration of HIV programming into general clinical care: perceived benefits, resource availability, and clear communication. The perceived benefits of HIV programs hinged on the social validation of the program by early adopters. Wide program availability and improved convenience for providers and patients increased perceived benefit. Limited staffing capacity and a shortage of space were noted as resource constraints. Programs that specifically tackled these constraints through clinic decongestion were reported as being the most successful. Clear communication with all entities involved in clinic-based programs, some of which include external partners, was noted as central to maximizing program function and provider uptake. Conclusions Amid the COVID-19 pandemic, new programs are continuously being developed for implementation at the primary health care level. A better understanding of the factors that facilitate and prevent programmatic success will improve public health outcomes. Implementation is likely to be most successful when programs capitalize on endorsements from early adopters, tackle resource constraints, and foster greater communication among partners responsible for implementation.

Adapting and testing measures of organizational context in primary care clinics in KwaZulu-Natal, South Africa

“…Our study has multiple strengths, including use of implementation science frameworks and organizational readiness theory to propose measures of organizational context in primary care facilities in South Africa. This work expands on the qualitative work attesting to the importance of organizational context in implementing and maintaining interventions in this setting [17,20,21,39]. We relied on a majority South African Expert Panel to prioritize constructs and items for measurement, and we conducted detailed cognitive interviews to revise and clarify items.…”

“…Research in South Africa from our team and others has found that program implementation can be heavily influenced by clinic leadership, particularly leaders’ problem-solving skills, in addition to provider teamwork and clinic environment such as material and human resources [ 17 – 20 ]. Qualitative assessment across multiple levels of the health system in KwaZulu-Natal Province identified perceived benefits of a particular program as well as broader resource availability and clear communication as factors shaping integration of HIV programming into general care [ 21 ]. Recent research on implementation of maternal health quality improvement underscored the importance of leadership, teamwork, and provider motivation in maintaining consistent implementation of interventions, particularly in the face of external factors such as the COVID-19 pandemic, budget cuts, and labor actions [ 20 ].…”

Costs of home-delivered antiretroviral therapy refills for persons living with HIV: evidence from a pilot randomized controlled trial in KwaZulu-Natal, South Africa

“…These methods, particularly when clients can flexibly choose the most convenient option, can strengthen individuals' commitment to care [46,47]. Additionally, community-based ART resupply can increase coverage in rural areas [48] and reduce clinic congestion [49]. At scale, home-delivered ART could be optimized using a centralized warehouse to fulfill and dispatch delivery trucks that synchronize deliveries to neighboring locations, similar to what is used in the private sector by Amazon [50].…”