Effect and implementation experience of intensive adherence counseling in a public HIV care center in Uganda: a mixed-methods study

Abstract

Background Intensive adherence counseling (IAC) is an intervention recommended by the World Health Organization to improve anti-retroviral therapy (ART) adherence among people living with HIV on ART with unsuppressed viral load; and in 2016, the intervention was implemented in Uganda. This study evaluated the effect and experiences of providing IAC in an urban HIV care center in Kampala, Uganda. Methods This was a sequential explanatory mixed-method study that compared viral load suppression during IAC implementation (intervention) to the period before IAC at Kisenyi Health centre IV. Data were abstracted from patient files and viral load register. The effect of IAC on viral load suppression and associated factors were analyzed using modified Poisson regression with robust standard errors. Using in-depth interviews and an inductive analysis approach in Atlas-ti 8. We also explored experiences of providing IAC among healthcare workers. Results A total of 500 records were sampled: 249 (49.8%) in the intervention period and 251 (51.2%) in the pre-intervention period. The mean age was lower during the intervention period 33.1 (± 12.0) than 36.5 (± 13.4) in the pre- intervention period, p = 0.002. More clients were currently on Protease-based regimen in the pre-intervention period 179 (71.3%) than 135 (54.2%) in the intervention period, p ≤ 0.001. In the intervention period, all eligible clients received IAC [249/249 (100.0%)]. Overall, 325 (65.0%) received IAC and of these, 143 (44.1%) achieved viral load suppression compared to 46 (26.3%) who received regular counseling. Receiving IAC significantly increased viral load suppression by 22% (aPR 1.22, 95% CI 1.01–1.47). Clients on Protease-based regimen were less likely to suppress than those on Efavirenz or Nevirapine-based regimens (aPR 0.11, 95% CI 0.08–0.15). All the interviewed healthcare workers lauded IAC for improving ART adherence. However, patient and health care system related factors hindered adherence during IAC. Conclusions The full potential of IAC in achieving viral load suppression in this setting has not been reached due to a combination of the patient and health care system related factors. Provision of adequate IAC necessities and use of patient centered approach should be emphasized to obtain the maximum benefit of the intervention.

Barriers and facilitators to the utilization of the intensive adherence counselling framework by healthcare providers in Uganda: a qualitative study

“…It is difficult for the clients to follow instructions from the health care providers if they do not know how to communicate to the clients. This finding is similar to another study conducted in Uganda on the experience of IAC in a public health center in Kampala [ 11 ]. Additionally, sensitization prior to introducing an intervention is key in disseminating evidence-based practice [ 28 ].…”

“…Like elsewhere [ 22 , 23 ], studies have been conducted in Uganda to assess implementation of IAC from the lens of the health care providers (family and health workers) [ 11 , 24 , 25 ], and PLHIV [ 26 , 27 ]. In this study we focused on the healthcare providers and explored the barriers to the utilization of the UMOH IAC framework in order to identify potential solutions that may be more broadly applicable and feasible [ 19 ].…”

“…In 2016, the consolidated guidelines for prevention and treatment of HIV in Uganda were developed with a framework on IAC to be followed [8]. Studies have shown that IAC achieves VL suppression in over 70.5% of PLHIV on ART with a non-suppressed VL [9][10][11][12]. Accordingly, based on the UMOH, VL monitoring was considered the gold standard for adherence and approving treatment response; therefore all PLHIV undergo a VL test 6 months after starting treatment, at 12 months and thereafter annually if the patient is stable on ART [5,8].…”

Barriers and Facilitators to Successful Intensive Adherence Counseling in Rural Northern Uganda: An Exploratory Interview with HIV-Positive Clients Using the COM-B Framework

“…3 Previous studies found IAC to be associated with enhanced viral load suppression among HIV-1 clients who were previously non-suppressed. [6][7][8] Conversely, evidence from other contexts indicates that there are sub-optimal HIV-1 viral load suppression rates following the IAC program. [9][10][11][12] Informal interactions with HIV healthcare providers in the context of rural northern Uganda also indicated that some HIV-positive clients remain virally non-suppressed even after IAC.…”

“…11 A structured exploration of the barriers and facilitators to successful IAC using the Capacity, Opportunity, and Motivation, for Behavior (B) change framework (COM-B framework) from the perspective of HIV-positive clients, may yield valuable information that may inform the design of interventions to harness the full potential of IAC as found in previous studies. [6][7][8] Therefore, the purpose of this study was to explore the barriers and facilitators to successful IAC among HIV-positive clients seeking care in public health facilities in rural northern Uganda.…”