Task-Shifting and Task-Sharing Models of Antiretroviral Therapy Service Delivery and Adult Adherence to Antiretroviral Drugs in Tanzania, Uganda, and Zambia: A Mixed Method Study

Antiretroviral therapy;adherence;sub-Saharan Africa;health services research;differentiated care;Social & Behavioral Interventions

Tsui, SharonCelentano, David D. ;

Johns Hopkins University

关键词: Antiretroviral therapy;    adherence;    sub-Saharan Africa;    health services research;    differentiated care;    Social & Behavioral Interventions;   

Others  :  https://jscholarship.library.jhu.edu/bitstream/handle/1774.2/58646/TSUI-DISSERTATION-2017.pdf?sequence=1&isAllowed=y

瑞士|英语

来源: JOHNS HOPKINS DSpace Repository

【 摘 要 】

Background: Adherence to antiretroviral therapy (ART) underlies the success of HIV prevention and treatment. Significant research has focused on understanding how individual, interpersonal, community, and structural factors influence adherence. Few studies, however, have examined how models of care – the combinations of services together with task-shifting of responsibilities to different cadres of staff – may support patient adherence. Methods: Manuscript 1 used cluster analysis and Delphi survey methods to identify task-shifting/task-sharing models of ART delivery among 19 routine ART programs in Tanzania, Uganda, and Zambia. Manuscript 2 used multivariable logistic regression to examine the association between task-shifting/task-sharing models of care and adherence. Adherence was measured by medication possession ratio (MPR) >90%. The analysis adjusted for clustering at the clinic level and adjusted for individual-level factors known to influence patient adherence. Manuscript 3 used a qualitative case study methodology with four purposively selected ART clinics in Uganda that represented unique task-shifting/task-sharing models of HIV care. Data collection included direct observations, analysis of documents and audio-visual materials, and 79 in-depth interviews with 39 ART providers and 40 ART clients. Cross-case analysis was then used to explore healthcare delivery factors that may facilitate patient adherence to ART. Results: The cluster analysis identified three task-shifting/task-sharing models. The main differences across models were the availability of medical doctors, the scope of clinical responsibility assigned to nurses, and the use of lay health care workers. Patients in the doctor-led model were more likely than patients in the mixed-model (where doctors, clinical officers and nurses shared clinical responsibilities) to have incomplete adherence with an MPR <90% (adjusted relative risk (aRR): 1.60, 95% confidence interval (CI): 1.03, 2.48). Patients in the doctor-led model also showed a non-significant trend towards being more likely than patients in the task-shifted model (where doctors shifted clinical responsibilities to clinical officers and nurses) to have MPR<90% (aRR=1.58, 95% CI 0.88, 2.85%). There was no evidence of difference in MPR<90% between patients in the mixed-model and task-shifted model. The qualitative case study found longer antiretroviral drug refills, expert patients, and routine pill counts to be three programmatic factors supporting patient adherence. Conclusions: The structure of ART service provision – including staffing patterns and the range of supportive services offered – can influence patient adherence. With increasing country ownership of ART programs in sub-Saharan Africa, the recommendation for immediate initiation of treatment for all people living with HIV, and the use of new models of care delivery such as differentiated care, it is important to continue to examine to effectively structure ART programs can be structured to support optimal patient adherence.