Abstract
BackgroundA major obstacle facing many lower-income countries in establishing and maintaining HIV treatment programmes is the scarcity of trained health care providers. To address this shortage, the World Health Organization has recommend task shifting to HIV-infected peers.MethodsWe designed a model of HIV care that utilizes HIV-infected patients, community care coordinators (CCCs), to care for their clinically stable peers with the assistance of preprogrammed personal digital assistants (PDAs). Rather than presenting for the standard of care, monthly clinic visits, in this model, patients were seen every three months in clinics and monthly by their CCCs in the community during the interim two months. This study was conducted in Kosirai Division, western Kenya, where eight of the 24 sub-locations (defined geographic areas) within the division were randomly assigned to the intervention with the remainder used as controls.Prior to entering the field, CCCs underwent intensive didactic training and mentoring related to the assessment and support of HIV patients, as well as the use of PDAs. PDAs were programmed with specific questions and to issue alerts if responses fell outside of pre-established parameters. CCCs were regularly evaluated in six performance areas. An impressionistic analysis on the transcripts from the monthly group meetings that formed the basis of the continuous feedback and quality improvement programme was used to assess this model.ResultsAll eight of the assigned CCCs successfully passed their training and mentoring, entered the field and remained active for the two years of the study. On evaluation of the CCCs, 89% of their summary scores were documented as superior during Year 1 and 94% as superior during Year 2. Six themes emerged from the impressionistic analysis in Year 1: confidentiality and "community" disclosure; roles and responsibilities; logistics; clinical care partnership; antiretroviral adherence; and PDA issues. At the end of the trial, of those patients not lost to follow up, 64% (56 of 87) in the intervention and 52% (58 of 103) in the control group were willing to continue in the programme (p = 0.26).ConclusionWe found that an antiretroviral treatment delivery model that shifted patient monitoring and antiretroviral dispensing tasks into the community by HIV-infected patients was both acceptable and feasible.Trial registrationClinicalTrials.gov ID NCT00371540
Highlights
We found that an antiretroviral treatment delivery model that shifted patient monitoring and antiretroviral dispensing tasks into the community by HIV-infected patients was both acceptable and feasible
Despite this documented benefit and a concerted international effort to roll out antiretroviral treatment (ART), only four countries in sub-Saharan Africa (Senegal, Rwanda, Botswana and Namibia) have achieved the "3 by 5" goal of treating at least half of the persons who are living with HIV/AIDS and need treatment[11]
Given World Health Organization (WHO) estimates of a shortfall of 817,992 health care providers in the African region, it will be impossible to meet the existing demand for antiretroviral care if we continue to rely on the traditional physician, clinical officer- and nurse-based model of ART delivery [15]
Summary
Two-thirds of the approximately 33 million HIV-infected people globally reside in the resource-constrained countries of sub-Saharan Africa, where more than 50% of the population lives in rural areas [1,2]. The clinical benefits of antiretroviral treatment (ART) for individuals residing in resource-poor settings have been documented in multiple studies [4,5,6,7,8,9,10] Despite this documented benefit and a concerted international effort to roll out ART, only four countries in sub-Saharan Africa (Senegal, Rwanda, Botswana and Namibia) have achieved the "3 by 5" goal of treating at least half of the persons who are living with HIV/AIDS and need treatment[11]. A major obstacle faced by many lower-income countries is establishing and maintaining HIV treatment programmes in rural areas, where trained health care providers and adequate infrastructure are scarce [12,13]. A major obstacle facing many lower-income countries in establishing and maintaining HIV treatment programmes is the scarcity of trained health care providers To address this shortage, the World Health Organization has recommend task shifting to HIV-infected peers
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