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Sustainability of the streamlined ART (START-ART) implementation intervention strategy among ART-eligible adult patients in HIV clinics in public health centers in Uganda: a mixed methods study.

ABSTRACT: Background:Despite increasing access to antiretroviral therapy (ART), the proportion of eligible patients initiated on treatment remains suboptimal. Only 64.6% of the people living with HIV (PLHIV) globally were initiated on ART by June 2019. The streamlined ART (START-ART) implementation study was based on the PRECEDE model, which suggests that "predisposing, enabling, and reinforcing" factors are needed to create behavior change. START-ART increased ART initiation within 2 weeks of eligibility by 42%. However, the gains from some implementation interventions erode over time. We evaluated facilitators and barriers to sustainability of this streamlined ART initiation in the year following the implementation period. Methods:We designed a mixed-methods explanatory sequential study to examine the sustainability of START-ART implementation. Quantitative component consisted of cross-sectional patient chart reviews of routinely collected data; qualitative component consisted of key informant interviews of health workers in START-ART facilities 2 years after conclusion of the implementation period. We analyzed data from 15 public health centers of Mbarara district, where the START-ART implementation was carried out. We included PLHIV aged >?18?years who initiated ART from June 2013 to July 2016. The START-ART implementation took place from June 2013 to June 2015 while the sustainability period was from August 2015 to July 2016. Results:A total of 863 ART-eligible patients were sampled. The median CD4 count was 348 cells/ml (IQR 215-450). During the intervention, 338 (77.4%) eligible patients initiated on ART within 2 weeks compared with 375 (88.2%) during the sustainability period (risk difference 10.8%; 95% CI 5.9-15.8%). In 14 of the 15 health centers, the intervention was sustained. During key informant interviews, rapid ART initiation sustainability was attributed to counseling skills that were obtained during intervention and availability of point-of-care (POC) CD4 PIMA machine. Failure to sustain the intervention was attributed to three specific barriers: lack of training after the intervention, transfer of trained staff to other health facilities, and shortage of supplies like cartridges for POC CD4 PIMA machine. Conclusion:Rapid ART initiation was sustained in most health centers. Skills acquired during the intervention and functional POC CD4 machine facilitated while staff transfers and irregular laboratory supplies were barriers to sustainability of rapid ART initiation.

SUBMITTER: Katuramu R

PROVIDER: S-EPMC7427962 | biostudies-literature | 2020

REPOSITORIES: biostudies-literature

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Sustainability of the streamlined ART (START-ART) implementation intervention strategy among ART-eligible adult patients in HIV clinics in public health centers in Uganda: a mixed methods study.

Katuramu Richard R Kamya Moses R MR Sanyu Naome N Armstrong-Hough Mari M Semitala Fred C FC

Implementation science communications 20200330

<h4>Background</h4>Despite increasing access to antiretroviral therapy (ART), the proportion of eligible patients initiated on treatment remains suboptimal. Only 64.6% of the people living with HIV (PLHIV) globally were initiated on ART by June 2019. The streamlined ART (START-ART) implementation study was based on the PRECEDE model, which suggests that "predisposing, enabling, and reinforcing" factors are needed to create behavior change. START-ART increased ART initiation within 2 weeks of eli ...[more]

PMID: 32885194

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Project description:Tailored delivery strategies are important for optimizing the benefit and overall reach of PrEP in sub-Saharan Africa. An integrated approach of delivering time-limited PrEP in combination with ART to serodifferent couples encourages PrEP use in the HIV-negative partner as a bridge to sustained ART use. Although PrEP has been delivered in ART clinics for many years, the processes involved in integrating PrEP into ART services are not well understood. The Partners PrEP Program was a stepped-wedge cluster randomized trial of integrated PrEP and ART delivery for HIV serodifferent couples in 12 public health facilities in central Uganda (Clinicaltrials.gov NCT03586128). Using qualitative data, we identified and characterized key implementation processes that explain how PrEP delivery was integrated into existing ART services in the Partners PrEP Program. In-depth interviews were conducted with a purposefully-selected sub-sample of 83 members of 42 participating serodifferent couples, and with 36 health care providers implementing integrated delivery. High quality training, technical supervision, and teamwork were identified as key processes supporting providers to implement PrEP delivery. Interest in the PrEP program was promoted through the numerous ways health care providers made integrated ART and PrEP meaningful for serodifferent couples, including tailored counseling messages, efforts to build confidence in integrated delivery, and strategies to create demand for PrEP. Couples in the qualitative sample responded positively to providers' efforts to promote the integrated strategy. HIV-negative partners initiated PrEP to preserve their relationships, which inspired their partners living with HIV to recommit to ART adherence. Lack of disclosure among couples and poor retention on PrEP were identified as barriers to implementation of the PrEP program. A greater emphasis on understanding the meaning of PrEP for users and its contribution to implementation promises to strengthen future research on PrEP scale up in sub-Saharan Africa.

Project description:BACKGROUND:Although Differentiated Service Delivery (DSD) for anti-retroviral therapy (ART) has been rolled-out nationally in several countries since World Health Organization (WHO)'s landmark 2016 guidelines, there is little research evaluating post-implementation outcomes. The objective of this study was to explore patients' and HIV service managers' perspectives on barriers to implementation of Differentiated ART service delivery in Uganda. METHODS:We employed a qualitative descriptive design involving 124 participants. Between April and June 2019 we conducted 76 qualitative interviews with national-level HIV program managers (n = 18), District Health Team leaders (n = 24), representatives of PEPFAR implementing organizations (11), ART clinic in-charges (23) in six purposively selected Uganda districts with a high HIV burden (Kampala, Luwero, Wakiso, Mbale, Budadiri, Bulambuli). Six focus group discussions (48 participants) were held with patients enrolled in DSD models in case-study districts. Data were analyzed by thematic approach as guided by a multi-level analytical framework: Individual-level factors; Health-system factors; Community factors; and Context. RESULTS:Our data shows that multiple barriers have been encountered in DSD implementation. Individual-level: Individualized stigma and a fear of detachment from health facilities by stable patients enrolled in community-based models were reported as bottlenecks. Socio-economic status was reported to have an influence on patient selection of DSD models. Health-system: Insufficient training of health workers in DSD delivery and supply chain barriers to multi-month ART dispensing were identified as constraints. Patients perceived current selection of DSD models to be provider-intensive and not sufficiently patient-centred. Community: Community-level stigma and insufficient funding to providers to fully operationalize community drug pick-up points were identified as limitations. CONTEXT:Frequent changes in physical addresses among urban clients were reported to impede the running of patient groups of rotating ART refill pick-ups. CONCLUSION:This is one of the first multi-stakeholder evaluations of national DSD implementation in Uganda since initial roll-out in 2017. Multi-level interventions are needed to accelerate further DSD implementation in Uganda from demand-side (addressing HIV-related stigma, community engagement) and supply-side dimensions (strengthening ART supply chain capacities, increasing funding for community models and further DSD program design to improve patient-centeredness).

Project description:BackgroundIn South Africa the ever increasing demand for antiretroviral treatment (ART) runs the risk of leading to sub-optimal care in public sector ART clinics that are overburdened and under resourced. This study assessed the quality of ART services to identify service areas that require improvement.MethodsA cross-sectional study was carried out at 16 of 17 public ART clinics in the target area in greater Pretoria, South Africa. Trained participant observers presented as ART qualifying HIV positive patients that required a visit to assess treatment readiness. They evaluated each facility on five different occasions between June and November 2009, assessing the time it took to get an appointment, the services available and accessed, service quality and the duration of the visit. Services (reception area, clinician's consultation, HIV counselling, pharmacy, nutrition counselling and social worker's assessment) were assessed against performance standards that apply to all clinics. Service quality was expressed as scores for clinic performance (CPS) and service performance (SPS), defined as the percentage of performance standards met per clinic and service area.ResultsIn most of the clinics (62.5%) participant observers were able to obtain an appointment within one week, although on the day of their visit essential services could not always be accessed. The median CPS of the assessed facilities was 68.5 with four clinics not meeting minimum standards (CPS > 60). The service areas that performed least well were the clinician's consultation (SPS 67.3) and HIV counselling (SPS 70.7). Most notably, clinicians performed a physical examination in only 41.1% of the visits and rarely did a complete TB symptom screening. Counsellors frequently failed to address prevention of HIV transmission.ConclusionsOverall public sector ART clinics in greater Pretoria were easily accessible and their services were of an acceptable quality. However, the time spent at the clinic to complete the services was found to be very long and there was considerable variation in adherence to performance standards within the services, particularly in respect of clinician's consultation and counselling. Clinic management needs to ensure efficient clinic organisation and to improve adherence to performance standards in key service areas.

Project description:BackgroundEffective strategies are needed to increase implementation and sustainability of evidence-based tobacco dependence treatment (TDT) in public health systems in low- and middle-income countries (LMICs). Our two-arm cluster randomized controlled trial (VQuit) found that a multicomponent implementation strategy was effective in increasing provider adherence to TDT guidelines in commune health center (CHCs) in Vietnam. In this paper, we present findings from a post-implementation qualitative assessment of factors influencing effective implementation and program sustainability.MethodsWe conducted semi-structured qualitative interviews (n = 52) with 13 CHC medical directors (i.e., physicians), 25 CHC health care providers (e.g., nurses), and 14 village health workers (VHWs) in 13 study sites. Interviews were transcribed and translated into English. Two qualitative researchers used both deductive (guided by the Consolidated Framework for Implementation Research) and inductive approaches to analysis.ResultsFacilitators of effective implementing of TDT included training and point-of-service tools (e.g., desktop chart with prompts for offering brief counseling) that increased knowledge and self-efficacy, patient demand for TDT, and a referral system, available in arm 2, which reduced the provider burden by shifting more intensive cessation counseling to a trained VHW. The primary challenges to sustainability were competing priorities that are driven by the Ministry of Health and may result in fewer resources for TDT compared with other health programs. However, providers and VHWs suggested several options for adapting the intervention and implementation strategies to address challenges and increasing engagement of local government committees and other sectors to sustain gains.ConclusionOur findings offer insights into how a multicomponent implementation strategy influenced changes in the delivery of evidence-based TDT. In addition, the results illustrate the dynamic interplay between barriers and facilitators for sustaining TDT at the policy and community/practice level, particularly in the context of centralized public health systems like Vietnam's. Sustaining gains in practice improvement and clinical outcomes will require strategies that include ongoing engagement with policymakers and other stakeholders at the national and local level, and planning for adaptations and subsequent resource allocations in order to meet the World Health Organization's goals promoting access to effective treatment for all tobacco users.Trial registrationNCT02564653 , registered September 2015.

Project description:BackgroundWhereas many adolescents and young people with HIV require the transfer of care from paediatric/adolescent clinics to adult ART clinics, this transition is beset with a multitude of factors that have the potential to hinder or facilitate the process, thereby raising ethical challenges of the transition process. Decisions made regarding therapy, such as when and how to transition to adult HIV care, should consider ethical benefits and risks. Understanding and addressing ethical challenges in the healthcare transition could ensure a smooth and successful transition. The purpose of this study was to analyze the ethical challenges of transitioning HIV care for adolescents into adult HIV clinics.MethodsData presented were derived from 191 adolescents attending nine different health facilities in Uganda, who constituted 18 focus group discussions. In the discussions, facilitators and barriers regarding adolescents transitioning to adult HIV clinics were explored. Guided by the Silences Framework for data interpretation, thematic data analysis was used to analyze the data. The principles of bioethics and the four-boxes ethics framework for clinical care (patient autonomy, medical indications, the context of care, and quality of life) were used to analyze the ethical issues surrounding the transition from adolescent to adult HIV care.ResultsThe key emerging ethical issues were: reduced patient autonomy; increased risk of harm from stigma and loss of privacy and confidentiality; unfriendly adult clinics induce disengagement and disruption of the care continuum; patient preference to transition as a cohort, and contextual factors are critical to a successful transition.ConclusionThe priority outcomes of the healthcare transition for adolescents should address ethical challenges of the healthcare transition such as loss of autonomy, stigma, loss of privacy, and discontinuity of care to ensure retention in HIV care, facilitate long-term self-care, offer ongoing all-inclusive healthcare, promote adolescent health and wellbeing and foster trust in the healthcare system. Identifying and addressing the ethical issues related to what hinders or facilitates successful transitions with targeted interventions for the transition process may ensure adolescents and young people with HIV infection remain healthy across the healthcare transition.

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Dataset Information

Sustainability of the streamlined ART (START-ART) implementation intervention strategy among ART-eligible adult patients in HIV clinics in public health centers in Uganda: a mixed methods study.

Publications

Sustainability of the streamlined ART (START-ART) implementation intervention strategy among ART-eligible adult patients in HIV clinics in public health centers in Uganda: a mixed methods study.

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