Linkage to intensive adherence counselling among HIV-positive persons on ART with detectable viral load in Gomba district, rural Uganda

Abstract

Background Antiretroviral therapy (ART) adherence is a primary determinant of sustained viral suppression, HIV transmission risk, disease progression and death. The World Health Organization recommends that adherence support interventions be provided to people on ART, but implementation is suboptimal. We evaluated linkage to intensive adherence counselling (IAC) for persons on ART with detectable viral load (VL). Methods Between January and December 2017, we conducted a retrospective chart review of HIV-positive persons on ART with detectable VL (> 1000 copies/ml), in Gomba district, rural Uganda. We abstracted records from eight HIV clinics; seven health center III’s (facilities which provide basic preventive and curative care and are headed by clinical officers) and a health center IV (mini-hospital headed by a medical doctor). Linkage to IAC was defined as provision of IAC to ART clients with detectable VL within three months of receipt of results at the health facility. Descriptive statistics and multivariable logistic regression analyses were used to evaluate factors associated with linkage to IAC. Results Of 4,100 HIV-positive persons on ART for at least 6 months, 411 (10%) had detectable VL. The median age was 32 years (interquartile range [IQR] 13–43) and 52% were female. The median duration on ART was 3.2 years (IQR 1.8–4.8). A total of 311 ART clients (81%) were linked to IAC. Receipt of ART at a Health Center level IV was associated with a two-fold higher odds of IAC linkage compared with Health Center level III (adjusted odds ratio [aOR] 1.78; 95% CI 1.00–3.16; p = 0.01). Age, gender, marital status and ART duration were not related to IAC linkage. Conclusions Linkage to IAC was high among persons with detectable VL in rural Uganda, with greater odds of linkage at a higher-level health facility. Strategies to optimize IAC linkage at lower-level health facilities for persons with suboptimal ART adherence are needed.

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

“…According to the consolidated guidelines for prevention and treatment of HIV in Uganda [8], the IAC framework consists of 5A's which are methodically given for the healthcare providers to follow in a regular pattern (typically one month apart for three sessions) when dealing with a non-suppressed VL. The 5A's include: (1) Assess -explaining purpose of session, disclosing the VL test results and what the implications are; determining the level of adherence and assessing possible barriers; (2) Advise-identifying gaps in client information, telling them the benefits of good adherence, and discussing possible consequences of non-adherence; (3) Assist-evaluating with the client the possible causes of the barriers and brainstorming possible strategies to overcoming them, and discussing the benefits of each option; (4) Agree on -the team agreeing on the way forward to address each key barriers, evaluating each action point while documenting the plan on the IAC session form which is filed for review in the next session;…”

“…Although provision of IAC entails a multidisciplinary team (clinicians, nurses, counselors, family members, and peers [ 1 , 5 , 8 ], with a clear framework for IAC and support for clients with detectable VL, there is paucity of information about their utilization of the IAC framework and the factors affecting implementation [ 14 ].…”

“…Uganda Ministry of Health (UMOH) embraced the World Health Organization (WHO) recommendation for all people living with human immunodeficiency virus (PLHIV) with a viral load (VL) exceeding 1000 copies/ mL to receive intensive adherence counselling (IAC) [1][2][3][4]. According to the WHO, VL failure is where there is a persistent detectable VL (two times consecutively when measured within a 3-month interval with adherence support) after at least 6 months of starting antiretroviral therapy (ART) [5][6][7].…”

Improving Viral Load Suppression Among Men and Children Active in Care Through Community-Designed and Led Solutions: Protocol for Retrospective Closed Cohort Study in Eastern Uganda

“…For newly diagnosed individuals living with HIV, in addition to adjusting to life living with a chronic disease, GYSI factors impact an individual’s perceptions, beliefs, attitudes, and decisions, which impact their behavior and, ultimately, health outcomes, namely VLS. Social and behavior change (SBC) programs have a history of increasing VLS, especially among high-risk populations in Uganda [ 10 , 11 ]. SBC is rooted in Social and Behavior Theories that support the necessity of interventions aimed at improving health behaviors [ 12 ].…”

“…Additionally, SBC has been effective in increasing ART adherence for youth living with HIV in Uganda [ 16 ]. The Ugandan MOH and USAID SBCA have taken steps to streamline SBC efforts to increase VLS [ 10 , 11 ].…”