Implementation fidelity of HIV care continuum among healthcare workers in Agincourt healthcare facilities
Date
2018
Authors
Molepo, Lorraine Mabotse
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Abstract
Introduction
The Joint United Nations Programme on HIV/AIDS (UNAIDS) has set a target to end the Acquired Immuno-Deficiency Syndrome (AIDS) epidemic by 2030, following their proposed 90-90-90 goals. In line with this, the HIV Care Continuum (HCC) was implemented as the standard of care by the South African National Department of Health to be practiced in all government facilities with HIV positive patients. A conceptual framework for Implementation Fidelity (IF) was used to determine the extent of fidelity to the HCC in rural Mpumalanga Province, northeast South Africa.
Methods
A convergent parallel mixed-method approach was used to collect information from two primary healthcare facilities (PHC). Quantitative data were collected from 200 patient record files through an IF checklist toolkit (based on the 2015 HIV treatment guidelines (HTGs)); and qualitative data were collected through in-depth interviews with eight healthcare workers (HCWs) attending to HIV positive patients at these facilities. Interviews were designed in line with the IF framework to explore factors affecting fidelity to the HCC. A fidelity score was generated by tallying all the ‘yes’ responses to the IF checklist toolkit, and a final fidelity score was ranked as high or low fidelity, based on the fidelity mean score. We used logistic regression models to identify predictors associated with the outcome of treatment adherence. Quantitative analyses were done using STATA 14. MAXQDA 12 was used to analyse the HCWs’ interviews. Results Females comprised 72.0% of the study sample and approximately 2/3 of the participants had a CD4 count of 350 and below (CD4≤350) upon HIV diagnosis. The average overall fidelity
score was 32 out of 37, with 10% of the participants being defaulters. Females were more likely to be retained in care compared to males (OR 0.47, 95% CI 0.22-1.03, p=0.06) as were older patients. For every age increase of 10 years, participants were more likely to be retained in care (OR 0.71, 95% CI 0.51-0.99, p=0.045). Those not due to start ART according to the 2015 HTGs (CD4>500) were also less likely to be retained in care, though this was not statistically significant (OR 1.47, CI 0.52-4.17, p=0.460). Gender and age interaction was not statistically significant (OR 0.73, 95% CI 0.39-1.35, p=0.315). Findings from the interviews revealed that guidelines were being followed; that is, patients were counselled and blood specimens drawn according to the guidelines. HCWs stated that they had difficulties in retaining patients in care. They further reported that although following the guidelines is a time consuming task, they do follow them because their priority is patients’ health and wellbeing. HCWs continue to welcome referral systems to hospitals, as this aided in treating patients that could not be treated at their healthcare facilities, but stigma continues to be a challenge and contributes to the difficulties in retaining patients in care. Discussion Although a positive attitude and a willingness to follow the guidelines was reported by the HCWs, they still struggled to ensure patients’ adherence to care and to trace patients who defaulted. Stigma continues to contribute to retention failure. Socio-demographic factors and moderating factors contribute to the extent of retention in care. Factors contributing to HIV retention failure should be addressed to ensure that fidelity to the HCC is maintained to decrease challenges in executing the new Universal test and treat (UTT) guidelines currently being practiced across government healthcare facilities in South Africa.
Description
A research protocol submitted to the School of Public Health, University of The Witwatersrand, Johannesburg, in partial fulfillment of the requirements for Master of Science Epidemiology (Implementation Science) for the year 2016.
Keywords
HIV Care Continuum, Implementation Fidelity