Need for improvements in clinical practice to retain patients in pre-antiretroviral therapy care: Data from rural clinics in North West Province, South Africa.

We examined current challenges with patient engagement in HIV prevention and care in South Africa by assessing the procedures of eight public health clinics in the North West Province. Procedures consisted of (1) an inventory/audit of the HIV Counseling and Testing, pre-antiretroviral therapy (pre-ART), and antiretroviral therapy (ART) patient registers; (2) extraction of data from a convenience sample of 39 HIV-positive patient files; and (3) 13 key informant interviews with clinic staff to characterize retention and re-engagement practices for patients. Incomplete registers revealed little evidence of follow-up services, particularly for pre-ART patients. The more detailed examination of patient files indicated substantial disparities in the proportion of pre-ART versus ART patients retained in care. Key informant interviews contextualized the data, with providers describing multiple procedures for tracking and ensuring service delivery for ART patients and fewer procedures to retain pre-ART patients. These findings suggest that enhanced strategies are needed for ensuring continued engagement in HIV care, with a particular emphasis on improving the retention of pre-ART patients. The preventive benefits of ART scale-up may not be achieved if improvements are not made in the proportion of earlier-stage HIV-positive patients who are successfully engaged in care

Need for improvements in clinical practice to retain patients in pre-antiretroviral therapy care: Data from rural clinics in North West Province, South Africa.

We examined current challenges with patient engagement in HIV prevention and care in South Africa by assessing the procedures of eight public health clinics in the North West Province. Procedures consisted of (1) an inventory/audit of the HIV Counseling and Testing, pre-antiretroviral therapy (pre-ART), and antiretroviral therapy (ART) patient registers; (2) extraction of data from a convenience sample of 39 HIV-positive patient files; and (3) 13 key informant interviews with clinic staff to characterize retention and re-engagement practices for patients. Incomplete registers revealed little evidence of follow-up services, particularly for pre-ART patients. The more detailed examination of patient files indicated substantial disparities in the proportion of pre-ART versus ART patients retained in care. Key informant interviews contextualized the data, with providers describing multiple procedures for tracking and ensuring service delivery for ART patients and fewer procedures to retain pre-ART patients. These findings suggest that enhanced strategies are needed for ensuring continued engagement in HIV care, with a particular emphasis on improving the retention of pre-ART patients. The preventive benefits of ART scale-up may not be achieved if improvements are not made in the proportion of earlier-stage HIV-positive patients who are successfully engaged in care

Engaging HIV-positive clients in care: acceptability and mechanisms of action of a peer navigation program in South Africa.

Antiretroviral therapy (ART) could curtail the HIV epidemic, but its impact is diminished by low uptake. We developed a peer navigation program to enhance engagement in HIV care, ART adherence, and behavioral prevention. In preparation for a randomized controlled trial, the program was piloted over four months at two primary health clinics in South Africa's North West Province. Newly diagnosed, HIV-positive clients met regularly with navigators to address barriers to care, adherence, and prevention. To assess program acceptability and feasibility and characterize the mechanisms of action, we surveyed 25 clients who completed navigation services and conducted interviews with 10 clients, four navigators, and five clinic providers. Clients expressed near universal approval for the program and were satisfied with the frequency of contact with navigators. HIV stigma emerged as a primary driver of barriers to care. Navigators helped clients overcome feelings of shame through education and by modeling how to live successfully with HIV. They addressed discrimination fears by helping clients disclose to trusted individuals. These actions, in turn, facilitated clients' care engagement, ART adherence, and HIV prevention efforts. The findings suggest peer navigation is a feasible approach with potential to maximize the impact of ART-based HIV treatment and prevention strategies

Impact of SMS and peer navigation on retention in HIV care among adults in South Africa: results of a three-arm cluster randomized controlled trial.

IntroductionFew interventions have demonstrated improved retention in care for people living with HIV (PLHIV) in sub-Saharan Africa. We tested the efficacy of two personal support interventions - one using text messaging (SMS-only) and the second pairing SMS with peer navigation (SMS+PN) - to improve HIV care retention over one year.MethodsIn a cluster randomized control trial (NCT# 02417233) in North West Province, South Africa, we randomized 17 government clinics to three conditions: SMS-only (6), SMS+PN (7) or standard of care (SOC; 4). Participants at SMS-only clinics received appointment reminders, biweekly healthy living messages and twice monthly SMS check-ins. Participants at SMS+PN clinics received SMS appointment reminders and healthy living messages and spoke at least twice monthly with peer navigators (PLHIV receiving care) to address barriers to care. Outcomes were collected through biweekly clinical record extraction and surveys at baseline, six and 12 months. Retention in HIV care over one year was defined as clinic visits every three months for participants on antiretroviral therapy (ART) and CD4 screening every six months for pre-ART participants. We used generalized estimating equations, adjusting for clustering by clinic, to test for differences across conditions.ResultsBetween October 2014 and April 2015, we enrolled 752 adult clients recently diagnosed with HIV (SOC: 167; SMS-only: 289; SMS+PN: 296). Individuals in the SMS+PN arm had approximately two more clinic visits over a year than those in other arms (p < 0.01) and were more likely to be retained in care over one year than those in SOC clinics (54% vs. 38%; OR: 1.77, CI: 1.02, 3.10). Differences between SMS+PN and SOC conditions remained significant when restricting analyses to the 628 participants on ART (61% vs. 45% retained; OR: 1.78, CI: 1.08, 2.93). The SMS-only intervention did not improve retention relative to SOC (40% vs. 38%, OR: 1.12, CI: 0.63, 1.98).ConclusionsA combination of SMS appointment reminders with personalized, peer-delivered support proved effective at enhancing retention in HIV care over one year. While some clients may only require appointment reminders, the SMS+PN approach offers increased flexibility and tailored, one-on-one support for patients struggling with more substantive challenges

Prevalence, motivation, and outcomes of clinic transfer in a clinical cohort of people living with HIV in North West Province, South Africa

IntroductionContinuity of care is an attribute of high-quality health systems and a necessary component of chronic disease management. Assessment of health information systems for HIV care in South Africa has identified substantial rates of clinic transfer, much of it undocumented. Understanding the reasons for changing sources of care and the implications for patient outcomes is important in informing policy responses.MethodsIn this secondary analysis of the 2014 - 2016 I-Care trial, we examined self-reported changes in source of HIV care among a cohort of individuals living with HIV and in care in North West Province, South Africa. Individuals were enrolled in the study within 1 year of diagnosis; participants completed surveys at 6 and 12 months including items on sources of care. Clinical data were extracted from records at participants' original clinic for 12 months following enrollment. We assessed frequency and reason for changing clinics and compared the demographics and care outcomes of those changing and not changing source of care.ResultsSix hundred seventy-five (89.8%) of 752 study participants completed follow-up surveys with information on sources of HIV care; 101 (15%) reported receiving care at a different facility by month 12 of follow-up. The primary reason for changing was mobility (N=78, 77%). Those who changed clinics were more likely to be young adults, non-citizens, and pregnant at time of diagnosis. Self-reported clinic attendance and ART adherence did not differ based on changing clinics. Those on ART not changing clinics reported 0.66 visits more on average than were documented in clinic records.ConclusionAt least 1 in 6 participants in HIV care changed clinics within 2 years of diagnosis, mainly driven by mobility; while most appeared lost to follow-up based on records from the original clinic, self-reported visits and adherence were equivalent to those not changing clinics. Routine clinic visits could incorporate questions about care at other locations as well as potential relocation, particularly for younger, pregnant, and non-citizen patients, to support existing efforts to make HIV care records portable and facilitate continuity of care across clinics.Trial registrationThe original trial was registered with ClinicalTrials.gov , NCT02417233, on 12 December 2014

Impact of short message service and peer navigation on linkage to care and antiretroviral therapy initiation in South Africa

ObjectiveWe examine the efficacy of short message service (SMS) and SMS with peer navigation (SMS + PN) in improving linkage to HIV care and initiation of antiretroviral therapy (ART).DesignI-Care was a cluster randomized trial conducted in primary care facilities in North West Province, South Africa. The primary study outcome was retention in HIV care; this analysis includes secondary outcomes: linkage to care and ART initiation.MethodsEighteen primary care clinics were randomized to automated SMS ( n  = 7), automated and tailored SMS + PN ( n  = 7), or standard of care (SOC; n  = 4). Recently HIV diagnosed adults ( n  = 752) were recruited from October 2014 to April 2015. Those not previously linked to care ( n  = 352) contributed data to this analysis. Data extracted from clinical records were used to assess the days that elapsed between diagnosis and linkage to care and ART initiation. Cox proportional hazards models and generalized estimating equations were employed to compare outcomes between trial arms, overall and stratified by sex and pregnancy status.ResultsOverall, SMS ( n  = 132) and SMS + PN ( n  = 133) participants linked at 1.28 [95% confidence interval (CI): 1.01-1.61] and 1.60 (95% CI: 1.29-1.99) times the rate of SOC participants ( n  = 87), respectively. SMS + PN significantly improved time to ART initiation among non-pregnant women (hazards ratio: 1.68; 95% CI: 1.25-2.25) and men (hazards ratio: 1.83; 95% CI: 1.03-3.26) as compared with SOC.ConclusionResults suggest SMS and peer navigation services significantly reduce time to linkage to HIV care in sub-Saharan Africa and that SMS + PN reduced time to ART initiation among men and non-pregnant women. Both should be considered candidates for integration into national programs.Trial registrationNCT02417233, registered 12 December 2014; closed to accrual 17 April 2015