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3g. HIV/AIDS, TB: Facility Level Assessment and Interventions to Promote Adherence
Effects of Patient Tracking Systems and Providers Incentives on Patient Appointment Keeping in Rwanda
1Rwanda Biomedical Center/Institute of HIV/AIDS, Disease Prevention and Control; 2Ministry of Health/Rwanda; 3Internation Network for Rationale of Use of Drug -IAA; 4Management Sciences for Health
Problem statement: Evidence is lacking on system-level interventions to improve adherence to antiretroviral therapy (ART) and retention in care in Rwanda.
Objectives: The study aimed to assess the effects of a pharmacy-based patient tracking system and HIV clinic incentives on appointment keeping and retention in care.
Design: This was a 25-month longitudinal cohort study that employed both quantitative and qualitative methods. We analyzed changes in adherence and retention using segmented regression of interrupted time-series data and survival analysis. Patient and clinic staff interviews at baseline and follow-up and review of national and local changes in policy and care provided contextual information.
Setting: HIV/AIDS care and treatment clinics in Rwanda
Study population: Adults diagnosed with HIV/AIDS who were either on treatment for at least 6 months at the start of the study or newly started on treatment during the 25-month follow-up.
Intervention: 6 randomly selected facilities (group 1) received training, pharmacy-based patient tracking tools, and financial incentives; 6 facilities (group 2) received training and tracking tools only; the remaining 6 served as controls
Outcome measures: We measured 3 indicators using information in pharmacy appointment registers: percentage of visits occurring on and before the scheduled date (indicator 1), percentage within 3 days after the scheduled date (indicator 2), and percentage between 3-30 days (indicator 3). We also measured loss to follow-up, defined by the national program as a gap of more than 90 days in treatment.
Result: A total of 3,223 adults, experienced and newly treated patients, from 18 health facilities were enrolled over time. Demographic characteristics were similar across cohorts. Baseline attendance rates in all facilities were high: 82.5% of visits on or before scheduled date, 91.4% within 3 days; 97.8% within 30 days. Despite high baseline rates, time-series models indicated statistically significant improvements in appointment keeping on or before, within 3 days after, and within 30 days after scheduled visit dates among experienced and newly treated patients in group 1 and control facilities. No statistically significant changes occurred among patients in group 2 facilities which received only training and tracking tools. Results for survival analysis corroborated these findings. Qualitative results indicated unintentional spillover of the intervention in 2 control facilities.
Conclusion: Despite high attendance rates prior to the intervention, provision of financial incentives, together with tracking tools and staff training, resulted in improved appointment keeping of patients on ART.
Funding source: The study is part of the INRUD Initiative on Adherence to Antiretrovirals funded by the Swedish International Development Agency and Management Sciences for Health.
Intervention Strategy in Improving Art Adherence In Tanzania
1Management Sciences for Health, Tanzania, United Republic of; 2Ministry of Health and Social Welfare; 3Muhimbili University of Health and Allied Sciences; 4HARVARD UNIVERSITY
Problem Statement: For a successful patient outcome, a high level of adherence to antiretrovirals (ART) is needed. A 2008 report in Tanzania indicated poor clinic attendance and high rate of lost to follow up.
Objectives: To measure the effects of strengthening appointment and tracking systems in improving attendance in ART clinics.
Design: A multifaceted intervention study with staggered implementation. An interrupted time series analysis was applied and comparisons were made with a control group.
Setting: The study was conducted in Coast and Morogoro regions involving three district ART sites from both public and faith based organizations as intervention sites in each region, and one facility as control. Selection of the regions and districts based on feasibility and the existence of strong community outreach programs.
Study Population: Facilities that had at least 150 patients on ART and accessible by the study team were selected. At each facility, 2 cohorts of patients were recruited: (1) 100 patients on treatment for at least 9 months at baseline, and (2) up to 20 patients initiating ART each month from 6 months before baseline.
Interventions: A one-year intervention study involved introduction of an appointment diary, negotiated appointments with patients, and strengthening linkage with communities to trace missing patients.
Outcome Measures: Percentage of patients with missed visits by more than 3 days, time until newly treated patients miss visits by more >3 days or >14 days and lost to follow-up.
Results: In both regions, between 15% and 20% of experienced patients miss visits by >3 days each month prior to the interventions. After intervention, the rate declined to about 11% in Coast facilities but not in Morogoro and Control facilities. In Coast, the intervention had no apparent effect in increasing the time until newly treated patients missed visits compared to the comparison facilities while for Morogoro, newly treated patients had much smaller increases in the rates of missed visits compared to the control facilities. There was also a substantial reduction in rates of loss to follow-up over time in Morogoro region compared to comparison facilities.
Conclusions: The interventions show some impact on improving appointment keeping and adherence to ART among patients in Tanzania. The success of the interventions depend on number of staff, supervision reliability of transport to the clinic, and good documentation.
Funding Sources: Swedish International Development Cooperation Agency
Nonadherence to HAART: A Cross-Sectional Two-Site Hospital-Based Study
1Indian Institute of Health Management Research, Jaipur, India; 2All India Institute of Medical Sciences, New Delhi, India; 3Lok Nayak Hospital, New Delhi, India
Problem statement: Initially, AIDS patients had to buy antiretroviral drugs from the open market. The Government of India introduced free HAART through antiretroviral therapy (ART) centers in April 2004. It was expected that the number of these centers would increase substantially in future. There was a concern that free drugs would be less valued and, therefore, adherence was likely to be low.
Objectives: To describe the pattern of adherence to HAART and ascertain factor(s) associated with nonadherence in adults in a typical public sector, tertiary care hospital setting, so that appropriate interventions could be suggested to improve adherence
Design: Cross-sectional hospital-based study
Setting: Study was done at two sites: the All India Institute of Medical Sciences (AIIMS) and the Lok Nayak Hospital (LNJP) at New Delhi. Both hospitals offered tertiary level care in public sector. At the time of the study, AIIMS did not dispense drugs for free; hence patients had to procure the drugs at their own cost. At LNJP, patients were provided free HAART.
Study population: In total, 300 patients were enrolled (200 at LNJP and 100 at AIIMS). These included AIDS patients who attend outpatient clinics, are on self-administered HAART for at least one week, and are age 18 years or older.
Outcome measure(s): Adherence was defined as not having missed even a single pill over the previous four-day period on self-reporting.
Results: The majority of patients at both study sites belonged to the 31–40 age group
and were male. Mean family income of these patients was similar. Pooled adherence for both the study sites was 75.7%. Adherence at AIIMS was 47%, whereas it was 90% at LNJP. This difference was statistically significant (p<0.001). Multiple logistic regression analysis showed that those who reported not having been counseled about the importance of HAART were 9.2 times more likely to report nonadherence than those who reported having been counseled [OR -9.2 (95% CI 3.2–25.8) p< 0.001]; those having to pay out-of-pocket for HAART at AIIMS were 7.7 times more likely to report nonadherence than those getting free HAART at LNJP [OR -7.7 (95% CI 3.9–15.1) p< 0.001]; and those who reported continued HIV risk behavior even after being started on HAART were 6.3 times more likely to report nonadherence than those who did not report continued risk behavior [OR -6.3 (95% CI 2.1–18.9) p=0.001].
Conclusion: Study provided the much-needed data on adherence among patients receiving free HAART through national program and provided evidence that the concern of low adherence among those receiving free HAART was unfounded. Thus, the national program on HAART was a step in right direction and would be beneficial to AIDS patients. While scaling up of ART program, the government should emphasize simultaneous recruitment of counselors, and physicians should be made aware of the need to inquire about and counsel patients against continued HIV risk behavior.
Funding source(s): None
Tracking of Inter-Facility Patient Transfers and Retention on Antiretroviral Treatment in Namibia
1Management Sciences for Health/Strengthening Pharmaceutical Systems (SPS)/Namibia; 2Ministry of Health and Social Services (MoHSS); 3I-TECH, Namibia; 4United States Agency for International Development (USAID)
Problem Statement: The public sector in Namibia started to provide and roll out antiretroviral therapy (ART) services in 2003. By September 2009, a total of 70,496 patients representing more than 80 percent of those in need were on record at public sector pharmacies as receiving antiretroviral (ARV) medicines through 101 ART sites, including outreach (35 main and 66 outreach sites). Namibia has reported an average of 99% availability of ARVs in district and referral hospitals since October 2007. With larger numbers of patients on medications, an increasing level of attention is being focused on adherence to treatment. The Electronic Dispensing Tool (EDT) is one of two computerized systems used to manage and monitor patients receiving ARVs and can be found at all ART sites in Namibia. EDT data from the individual ART sites are aggregated at the national level onto the pharmacy ART National Database (NDB). A report from October 2009 from the NDB showed that 2,290 patients were recorded as having transferred out since 2005.
Objective: The aims of the study were to determine the level of patient retention on therapy and the outcome of patients who transferred out from any facility in Namibia that uses EDT.
Study design and population: A retrospective cohort analysis of patients who started treatment in 2008 and who were recorded as transferred out was done. Data from EDT and NDB was used to determine the percentage of patients who were readmitted into any facility after transferring out from any public facility in Namibia. The data was also used to determine the status of all those patients readmitted as of September 2009 and determine any treatment gaps. between transfer out and readmission.
Results: 456 (2.2%) patients were on record as transferring out in 2008 from public health facilities providing ART services countrywide out of 20,576 initiated. . Only 202 (45%) of these 456 patients were readmitted back into the system: 77% of these readmitted patients were still active on treatment, 1.5% had died, and 12% were lost to follow up. The treatment gap between transfer out and readmission ranged from 0 months (62%) to 8 months (3%). There was no significant difference between male and female patients in terms of readmission after transferring out.
Conclusions: An electronic patient record system in conjunction with a national data repository system was found to be useful in tracking patients between ART sites in a country with high patient mobility. The transfer of patients between facilities should be accompanied by appropriate monitoring in order to track the patient that are not re-absorbed into the system). Appropriate patient tracking and referral measures ensure that the referring and receiving facilities are aware of the arrival of the patient through a feedback loop and will decrease the interval between transfer out and re-uptake, thereby increasing patient retention on treatment.
Funding Sources: US Agency for International Development/Namibia