Patient and health worker experiences of differentiated models of care for stable HIV patients in Malawi: A qualitative study

Abstract

IntroductionSeveral models of differentiated care for stable HIV patients on antiretroviral therapy (ART) in Malawi have been introduced to ensure that care is efficient and patient-centered. Three models have been prioritized by the government for a deeper and broader understanding: adjusted appointment spacing through multi-month scripting (MMS); fast-track drug refills (FTRs) on alternating visits; and community ART groups (CAGs) where rotating group members collect medications at the facility for all members. This qualitative study aimed to understand the challenges and successes of implementing these models of care and of the process of patient differentiation.MethodsA qualitative study was conducted as a part of a broader process evaluation in 30 purposefully selected ART facilities between February and May 2016. Semi-structured, in-depth interviews with 32 health workers that managed and coordinated ART clinics and 30 focus groups were held with 216 ART patients. Interviews and focus groups were audio recorded, transcribed, and coded thematically.ResultsParticipants reported that the models of differentiated care have yielded key benefits, including: reduced patients’ travel and visit time, decongestion of facilities, and enhanced social support. Participants suggested that these benefits could lead to improved HIV treatment outcomes for patients. At the same time, some challenges were reported, such as inconsistent stocks of drugs, which can inhibit implementation of MMS. For CAGs, the group-based nature of the model presented some unique problems, such as conflicts within groups or concerns about privacy. Health workers also described some of the reasons why eligible patients may not receive the models or conversely why ineligible patients sometimes get the models.ConclusionsDocumenting patient and health worker perspectives on models of differentiated care is critical to understanding and improving these models. While these models can offer important benefits, the models may not be appropriate for all sites or patients, and patient status and needs may change over time. Key challenges should be recognized and addressed for optimal utilization of the models.

Engaging men in HIV programmes: a qualitative study of male engagement in community‐based antiretroviral refill groups in Zimbabwe

“…Similar findings have been reported in studies in rural Uganda and South Africa, among others . Gender dynamics were also an undercurrent in a Malawi study where tension between traditional patriarchal household roles and the expected equality of men and women in a CARG was noted as a challenge . Our study adds to this emerging literature by suggesting a direct link between stigma, masculinity concerns and low male involvement in community‐based DSDM.…”

“…Perceptions of CARG benefits and disadvantages among study participants were consistent with data from Malawi, South Africa and Mozambique [31][32][33][34][35][36]. When asked specifically about reasons why men might not participate in CARGs, participants identified fear of HIV-related stigma, lack of information about CARGs, lack of male-only groups and few perceived personal benefits of CARG membership.…”

“…Studies of male engagement in HIV peer support groups have found that income‐generating activities may cushion men from HIV‐related stigma . A Malawi study found that income‐generating activities, though not part of the formal CARG structure, were spontaneously initiated and highly valued . Linking CARGs to local organizations that offer such support may be more feasible and sustainable than requiring individual HFs and/or MoHCC to play this role.…”

“…Lack of information about health services has long been cited as a common barrier to men's healthcare-utilization behaviour globally [39] and more recently, to low uptake of community-based DSDM. In a Malawi study, ART patients not enrolled in CAGs also reported little awareness of the model [31,32], whereas in a South African study of adherence clubs, participants were confused about eligibility criteria, enrolment procedures and referral criteria [33]. Better and intensified information and education campaigns, preferably in workplace and entertainment venues, are needed to reach more men and more effectively.…”

Reimagining the role of the nursing workforce in Uganda after more than a decade of ART scale-up

“…In a number of health facilities running community-based platforms of HIV care such as home-based visits, the monitoring of patients within communities was nurse-led. Our findings find resonance with the currently topical Differentiated Service Delivery (DSD) agenda [39], [40], [41]. DSD calls for tailoring HIV care to the needs of individual patients including differentiating the cadre assigned to manage patients based on clinical criteria such as those who are stable and those who are not [9], [39].…”