Abstract
BackgroundDespite gains in HIV testing and treatment access in sub-Saharan Africa, patient attrition from care remains a problem. Evidence is needed of real-world implementation of low-cost, scalable, and sustainable solutions to reduce attrition. We hypothesized that more proactive patient follow-up and enhanced counseling by health facilities would improve patient linkage and retention.MethodsAt 20 health facilities in Central Uganda, we implemented a quality of care improvement intervention package that included training lay health workers in best practices for patient follow-up and counseling, including improved appointment recordkeeping, phone calls and home visits to lost patients, and enhanced adherence counseling strategies; and strengthening oversight of these processes. We compared patient linkage to and retention in HIV care in the 9 months before implementation of the intervention to the 9 months after implementation. Data were obtained from facility-based registers and files and analysed using multivariable logistic regression.ResultsAmong 1900 patients testing HIV-positive during the study period, there was not a statistically significant increase in linkage to care after implementing the intervention (52.9% versus 54.9%, p = 0.63). However, among 1356 patients initiating antiretroviral therapy during the follow-up period, there were statistically significant increases in patient adherence to appointment schedules (44.5% versus 55.2%, p = 0.01) after the intervention. There was a small increase in Ministry of Health-defined retention in care (71.7% versus 75.7%, p = 0.12); when data from the period of intervention ramp-up was dropped, this increase became statistically significant (71.7% versus 77.6%, p = 0.01). The increase in retention was more dramatic for patients under age 19 years (N = 84; 64.0% versus 83.9%, p = 0.01). The cost per additional patient retained in care was $47.ConclusionsImproving patient tracking and counseling practices was relatively low cost and enhanced patient retention in care, particularly for pediatric and adolescent patients. This approach should be considered for scale-up in Uganda and elsewhere. However, no impact was seen in improved patient linkage to care with this proactive follow-up intervention.Trial registrationPan African Clinical Trial Registry #PACTR201611001756166. Registered August 31, 2016.
Highlights
MethodsAt 20 health facilities in Central Uganda, we implemented a quality of care improvement intervention package that included training lay health workers in best practices for patient follow-up and counseling, including improved appointment recordkeeping, phone calls and home visits to lost patients, and enhanced adherence counseling strategies; and strengthening oversight of these processes
Despite gains in HIV testing and treatment access in sub-Saharan Africa, patient attrition from care remains a problem
Linkage to care The study sample to assess linkage to care initially included 1945 patients. 2 patients were excluded from the sample because they died over follow-up and 43 were excluded because they were reported as transferring to another facility over follow-up and this information could not be corroborated
Summary
Study setting This study was implemented in 20 randomly selected facilities across 14 districts in Central Uganda meeting the following criteria: Offered ART to pediatric and adult patients starting January 1, 2015 or earlier, low estimated annual retention among patients on ART (approximately 35–75% in 2015 using national District Health Information System (DHIS) 2 estimates), and high ART patient volume (> 120 patients enrolled in 2015 according to DHIS 2). Because the retention outcome required 6 months of follow-up out of the 9-month study periods, all patients who initiated ART at study facilities between December 25, 2015 and March 25, 2016 and were listed on the ART register were included in the pre-intervention retention assessment; patients initiating between November 14, 2016 and February 14, 2017 were included in the post-intervention retention assessment. Patient data were collected for the 6 months after ART initiation, and secondary analyses assessed the proportion of patients attending a first ART follow-up appointment, at least 4, 5, or 6 appointments over 6 months, mean number of appointments per patient, and adherence to appointment visit schedule (defined as coming to the facility within 1 week of the scheduled appointment). Costing Program costs were calculated, including the cost of the trainings, facility funding for phone airtime and home visits, and program supervision, and used to estimate the cost per additional patient linked to care and cost per additional patient retained in care by dividing the cost over a defined period to the number of additional patients linked to and retained in care over that timeframe using study outcome data
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