Understanding uptake of an intervention to accelerate antiretroviral therapy initiation in Uganda via qualitative inquiry

Abstract

IntroductionThe Streamlined Antiretroviral Therapy Initiation Strategy (START‐ART) study found that a theory‐based intervention using opinion leaders to inform and coach health care providers about the risks of treatment delay, provision of point of care (POC) CD4 testing machines (PIMA) and reputational incentives, led to rapid rise in ART initiation. We used qualitative research methods to explore mechanisms of provider behaviour change.MethodsWe conducted in‐depth interviews (IDIs) with 24 health care providers and nine study staff to understand perceptions, attitudes and the context of changes in ART initiation practices. Analyses were informed by the Theoretical Domains Framework.ResultsRapid dissemination of new practices was enabled in the environmental context of an existing relationship based on communication, implementation and accountability between Makerere University Joint AIDS Program (MJAP), a Ugandan University‐affiliated organization that provided technical oversight for HIV service delivery at the health facilities where the intervention was implemented, and a network of health facilities operated by the Uganda Ministry of Health. Coaching carried out by field coordinators from MJAP strengthened influence and informal accountability for carrying out the intervention. Frontline health workers held a pre‐existing strong sense of professional identity. They were proud of attainment of new knowledge and skills and gratified by providing what they perceived to be higher quality care. Peer counsellors, who were not explicitly targeted in the intervention design, effectively substituted some functions of health care providers; as role models for successful ART uptake, they played a crucial role in creating demand for rapid ART initiation through interactions with patients. Point of care (POC) CD4 testing enabled immediate action and relieved providers from frustrations of lost or delayed laboratory results, and led to higher patient satisfaction (due to reduced costs because of ability to initiate ART right away, requiring fewer return trips to clinic).ConclusionsQualitative data revealed that a multicomponent intervention to change provider behaviour succeeded in the context of strong institutional and individual relationships between a University‐affiliated organization, government facilities, and peer health workers (who acted as a crucial link between stakeholders) and the community. Fostering stable institutional relationships between institutional actors (non‐governmental organization (NGOs) and ministry‐operated facilities) as well as between facilities and the community (through peer health workers) can enhance uptake of innovations targeting the HIV cascade in similar clinical settings.

Expansion of HIV testing in Eswatini: stakeholder perspectives on reaching the first 90

“…In terms of international partners, respondents described how international funding enabled programme inception, while also serving as an incentive to perform and achieve results. The impact of these "global health initiatives" (GHI) -international donors and partners -has been reviewed in Africa (Chima & Homedes, 2015;) and shown to be a positive factor in uptake of ART initiation (Semitala et al, 2017). recommend following existing guidance to improve GHI's efficacy which emphasizes strengthening the wider health systems (Caines et al, 2004).…”

Integrated delivery of antiretroviral treatment and pre‐exposure prophylaxis to HIV‐1 serodiscordant couples in East Africa: a qualitative evaluation study in Uganda

“…Other PrEP demonstration projects, as well as combination prevention and rapid treatment studies, employ diverse strategies for delivering interventions . This qualitative evaluation study is among the first to examine how these strategies are put into practice and what they mean to those involved, thereby helping to explain their mechanisms of effect .…”

Sustainability of the streamlined ART (START-ART) implementation intervention strategy among ART-eligible adult patients in HIV clinics in public health centers in Uganda: a mixed methods study

“…The sustainability of implementing this intervention may have been enhanced because it was conducted within an HIV program, the Makerere University Joint AIDS Program. After the intervention period ended, MJAP continued to provide technical oversight for comprehensive HIV service delivery to the health centers that participated in the study [23]. This emphasizes the need for implementation research studies to engage with partners that are likely to continue implementing the intervention after the research study is over.…”

“…We previously carried out and evaluated a multicomponent implementation intervention in the streamlined ART (START-ART) implementation study (Clini-calTrials.gov, number NCT01810289) in Uganda which has been reported elsewhere [12,13]. The implementation intervention consisted of provider education about the importance of rapid ART initiation, introduction of novel technology of testing for CD4 counts using pointof-care CD4 PIMA machine, and provision of reinforcing feedback to the health care providers, to increase the rapidity and completeness of ART initiation [12].…”