Doing patient-centredness versus achieving public health targets: A critical review of interactional dilemmas in ART adherence support

Abstract

Anti-retroviral Therapy (ART) transformed HIV into a chronic disease but its individual and public health benefits depend on high levels of adherence. The large and rising number of people on ART, now also used as prevention, puts considerable strain on health systems and providers in low and middle as well as high-income countries, which are our focus here. Delivering effective adherence support is thus crucial but challenging, especially given the promotion of patient-centredness and shared decision making in HIV care. To illuminate the complexities of ART adherence support delivered in and through clinical encounters, we conducted a multi-disciplinary interpretative literature review. We reviewed and synthesized 82 papers published post 1997 (when ART was introduced) belonging to three bodies of literature: public health and psychological studies of ART communication; anthropological and sociological studies of ART; and conversation analytic studies of patient-centredness and shared decision-making. We propose three inter-related tensions which make patient-centredness particularly complex in this infectious disease context: achieving trust versus probing about adherence; patient-centredness versus reaching public health targets; and empowerment versus responsibilisation as 'therapeutic citizens'. However, there is a dearth of evidence concerning how precisely ART providers implement patient-centredness, shared-decision making in practice, and enact trust and therapeutic citizenship. We show how conversation analysis could lead to new, actionable insights in this respect.

Service Use and Resilience among Adolescents Living with HIV in Blantyre, Malawi

“…In our study, health workers in teen-club settings played a double role as a provider and mentor and were able to form positive and caring relationships with ALHIV. The shift away from a paternalistic focus on health worker relationships with ALHIV is critical to developing autonomy, informed choices and decision making among ALHIV [ 66 ]. In a positive clinic environment, with comprehensive and ‘bundled programmes’, ALHIV felt a sense of belonging and felt in control of decision-making, contributing to resilience.…”

“…Prioritising the ART clinic and TCC among ALHIV is not unexpected given their health needs and the DSD policy drives to provide patient-centred care [ 66 67 ]. In our study context, health workers provided extensive psychosocial support to ensure ALHIV contributed to how services were delivered, that they understood them, and experienced a sense of belonging and satisfaction over time.…”

Voluntary medical male circumcision for HIV prevention among adolescents in Kenya: Unintended consequences of pursuing service-delivery targets

“…[48–54] Yet in South Africa and elsewhere, studies have indicated that the pursuit of targets (for uptake of combination antiretroviral therapy) may be at odds with quality of care. [55] This study identifies multiple unintended consequences linked directly or indirectly to the use of targets for VMMC services in Kenya. As detailed above, these include pressures associated with VMMC client availability, extra burdening of facilities, overworked clinical staff, deviations from the standard of care, and long waits at the clinic.…”

Is patient satisfaction the key to promote compliance in health care sector?

“…In fact, relationships based on structural ties allow the customer to play an important role in shaping the service provision process even where the relationship is characterized by a substantial information asymmetry. Such circumstances make the patient's acceptance of physician recommendations easier to achieve (de Koka et al, 2018).…”