Abstract
BackgroundAdolescent-friendly policies aim to tailor HIV services for adolescents and young adults aged 10–24 years (AYA) to promote health outcomes and improve retention in HIV care and treatment. However, few interventions focus on improving healthcare worker (HCW) competencies and skills for provision of high-quality adolescent care. Standardized patients (SPs) are trained actors who work with HCWs in mock clinical encounters to improve clinical assessment, communication, and empathy skills. This stepped-wedge randomized controlled trial will evaluate a clinical training intervention utilizing SPs to improve HCW skills in caring for HIV-positive AYA, resulting in increased retention in care.Methods/designThe trial will utilize a stepped-wedge design to evaluate a training intervention using SPs to train HCWs in assessment, communication, and empathy skills for AYA HIV care. We will recruit 24 clinics in Kenya with an active electronic medical record (EMR) system and at least 40 adolescents enrolled in HIV care per site. Stratified randomization by county will be used to assign clinics to one of four waves – time periods when they receive the intervention – with each wave including six clinics. From each clinic, up to 10 HCWs will participate in the training intervention. SP training includes didactic sessions in adolescent health, current guidelines, communication skills, and motivational interviewing techniques. HCW participants will rotate through seven standardized SP scenarios, followed by SP feedback, group debriefing, and remote expert evaluation. AYA outcomes will be assessed using routine clinic data. The primary outcome is AYA retention in HIV care, defined as returning for first follow-up visit within 6 months of presenting to care, or returning for a first follow-up visit after re-engagement in care in AYA with a previous history of being lost to follow-up. Secondary outcomes include HCW competency scores, AYA satisfaction with care, and AYA clinical outcomes including CD4 and viral load. Additional analyses will determine cost-effectiveness of the intervention.DiscussionThis trial will contribute valuable information to HIV programs in Kenya and other low-resource settings, providing a potentially scalable strategy to improve quality of care and retention in critical HIV services in this population.Trial registrationClinicalTrials.gov, ID: NCT02928900. Registered 26 August 2016.
Highlights
Adolescent-friendly policies aim to tailor HIV services for adolescents and young adults aged 10–24 years (AYA) to promote health outcomes and improve retention in HIV care and treatment
There is a lack of scalable, evidence-based interventions that build adolescent-friendly capacities in healthcare worker (HCW) and that have been linked to improved AYA care outcomes [29, 30]
We review a random sample of video-taped encounters in each intervention wave and rate actor fidelity according to a standardized checklist that has been adapted for this study [44]
Summary
With global commitment to combat the HIV epidemic among AYA, and limited evidence of what works, it is important to evaluate novel and potentially scalable strategies to improve HIV outcomes in this population in Sub-Saharan Africa. This study is responsive to the Kenyan Ministry of Health request for novel interventions to inform the implementation of new adolescent-friendly HIV service guidelines [52, 53]. This study will provide data on core AYA HIV indicators for the UN “90-90-90” targets from a range of geographic and epidemiologic settings in Kenya. We will monitor these changes with the facility survey and evaluate them in the analysis This intervention targets HCWs to improve AYA retention in HIV care. A standardized patient intervention for HCW has the potential to promote high-quality patient-centered HIV services for AYA by providing HCWs with technical skills and pragmatic experiences. Author details 1Department of Global Health, University of Washington, 325 9th Avenue, Box 359932, Seattle, WA 98104, USA. 2Department of Paediatrics and Child Health/Kenyatta National Hospital, University of Nairobi, Nairobi, Kenya. 3VCT and HIV Prevention Unit/Youth Centre, Kenyatta National Hospital, Nairobi, Kenya. 4Clinical Skills and Simulation Center, Howard University Health Sciences, Washington DC, USA. 5Department of Biostatistics, University of Washington, Seattle, WA, USA. 6Department of Pediatrics, University of Washington, Seattle, WA, USA. 7Department of Epidemiology, University of Washington, Seattle, WA, USA. 8Department of Psychosocial and Community Health, University of Washington, Seattle, WA, USA. 9Department of Medicine, University of Washington, Seattle, WA, USA
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