Chalker, J, 2017. Improving ART adherence at reproductive and child health clinics integrating Option B+ in Tanzania, 3ie Impact Evaluation Report 59. New Delhi: International Initiative for Impact Evaluation (3ie)
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This randomised evaluation looked at whether orienting staff at reproductive and child health clinics improves patient appointment attendance rates.
Tanzania’s adoption of ‘Option B+’, to prevent mother to child transmission of HIV, has made it possible for all HIV-positive pregnant women to receive antiretroviral therapy (ART), regardless of their CD4 count, at any official Mother and Child Health (MCH) clinic. However, reports have shown significant issues with retention and adherence to treatment. Specifically, missing appointments has been identified as a key detriment to retention and adherence. Accordingly, Management Sciences for Health trained MCH clinic personnel to use an appointment and patient tracking system in order to improve outcomes. The study addressed policy questions surrounding individual and system-level barriers to ART adherence, including long wait times, forgetfulness and stigma.
The primary outcome of interest is the proportion of HIV-positive women adhering to scheduled appointments and ART continuity. Secondary outcomes of interest include clinic attendance within three and seven days of scheduled date, medication possession ratio, time until occurrence of a gap in clinic attendance of fifteen or more days, perceptions about clinic efficiency, patient engagement with care and loss to follow-up (> 60 days).
The intervention included training for two staff members from each facility on how to use the appointment tracking system and conducting four rounds of supportive supervision at each intervention clinic at monthly intervals to reinforce this training.
Theory of change
The theory of change is that a standardized appointment and patient tracking system will reduce clinic congestion and facilitate a patient’s ability to attend appointments. Proper training of staff will promote appropriate use of the system. The theory also proposes that predisposing, enabling and reinforcing factors that operate at different levels of society (e.g. side effects, forgetting, stigma, transportation costs, long wait times and inability to identify and reach out to patients who miss visits) influence health behaviors such as ART adherence and retention. The patient tracking system with improved community outreach will encourage patients to stay in care, provide reminders and incentives to keep appointments as well as improve appointment-keeping. Finally, the researchers believe that a system of monitoring will help establish a culture of continuous quality improvement, which will result in staff’s participation in finding creative solutions to enable and improve patient adherence to care, further offering a positive clinic experience.
The study used a two-armed, matched pair design, with random assignment to the intervention. Eight districts in Mbeya region were matched and then one from each pair was randomly assigned the intervention. To create an equal number of facilities in each district, one clinic was randomly dismissed from each of two districts. Matching was based on ART patient volume. At baseline, researchers collected data on established patients: women who initiated ART at least five months prior to initial data collection, and had attended the clinic within the previous three months. They included 1,226 women in control facilities and 1,922 in intervention facilities, using data from pharmacy and clinic records. At the final data collection (five months after the final supervisory visit), the authors collected data from 970 women in the control group and 1,433 in the intervention who were still on treatment in the same facility in 2016. In addition, they included an additional group of women who had recently begun treatment—in the 6-12 months prior to the intervention (109 in control and 120 in intervention) and six months after the intervention (180 control, 204 intervention), for whom they collected visit data from initiation to up to six months post-initiation. Additionally, researchers also collected qualitative data through interviews at baseline in intervention districts with clinic staff members, district staff members and women on ART at each clinic. For the end-line study, they interviewed clinic staff members, district staff members, and women on ART at both intervention and control facilities.
The manual system of appointment tracking and subsequent community outreach for patients who missed appointments was low cost and relatively simple to implement with two days of training and subsequent supervisory visits. The intervention significantly improved appointment-keeping and consistent availability of antiretroviral medicines in the intervention group compared to the control group for patients on long-term ART. Missed visits by one or more days decreased by 13.7 percentage points (95% CI: -15.4 – 12.1), and a significant increase in percentage of patients with a percentage of days covered greater than 95percent of 6.6 percentage points (95% CI 4.7 – 8.4). The facility staff were able to control their workload, identify missing patients rapidly, work with existing community organizations, and bring back missing patients into care. At the same time, patients noted that they were able to choose convenient days for their appointments and spent much less time waiting in the clinic.
Cost efficiency analysis
For the 1,443 women on treatment recorded by the assessments, an extra 105 women would be expected to achieve 95percent of days covered. The overall cost of all of the trainings and supervision, including car hire, flights, hotels, and other expenses was approximately US$30,000. On this basis, it cost around USD278 for one extra woman to achieve 95 percent of days covered by dispensed medicine. For the second line treatment was USD779 more expensive than first line for one year, so any degree of prevention of resistance saved considerable sums.
Implications for implementers
All facilities (both intervention and control) had been given the appointment books and missing patient registers some months before, but hey were not using them to their potential at the beginning of the intervention. Mass training and dissemination of materials were not enough to ensure that the system is used correctly. Many interventions, such as introducing new recording systems, add to the administrative burden of facility staff and are unpopular and often unsuccessful. In this instance, however, staff at one trained clinic appreciated the new system because it empowered them to even out their workload and decongest crowded clinics. Patients and staff alike had pointed out overcrowding and long waiting times as major problems.
Implications for policy and practice
The evidence for the efficacy of appointment systems and community outreach as a system-level strategy to improve continuity of ART treatment is considerable. It is time that policymakers adopt such systems for all ART clinics, be they Option B+ or not. The intervention is inexpensive and the results are convincing. If the ministry took on this activity on a wider scale in collaboration with regional health offices and implementation partners in the area, it would be considerably less costly, especially if it were incorporated into routine supervisory activities.