Stender, SC, Furlane, G, Bazant, E, LeFevre, A, Lou, AD, Malek, AM, Korte, JE and Ouattara, K, 2018. Effectiveness evaluation of first phase integrated chronic care model to improve prevention, care and support for people living with HIV in Côte d’Ivoire, 3ie Grantee Final Report. New Delhi: International Initiative for Impact Evaluation (3ie)
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This study evaluates the impact of an integrated chronic care model on adult adherence and retention rates among people living with HIV (PLHIV). It is embedded within an intervention funded by the US Centers for Disease Control and Prevention. The objective of the evaluation was to determine the effectiveness, acceptability and cost-effectiveness of the first phase of the model.
In 2015, Côte d’Ivoire had an estimated HIV prevalence of 3.5 per cent for persons 15-49 years of age, the highest in francophone West Africa. Despite this, only 35per cent of PLHIV received antiretroviral therapy (ART), and less than half received the treatment according to national guidelines at the time (CD4<350mm3).
The aim of this intervention is to improve client enrolment in HIV care and long-term adherence to ART.
Information from the intervention is expected to provide evidence to decision makers on how to optimise HIV outcomes and advance the health policy discussion in Côte d’Ivoire on integrating health services and related standards and protocols.
- Does the implementation of the model result in an increased rate of retention in care at 30, 60, 90 and 180 days among PLHIV?
- Is there an increased rate of adherence to treatment among PLHIV on ART (defined as the percentage of days covered with treatment), collection of antiretrovirals within three days of need for refill (based on number of pills previously dispensed), and clinical appointment attendance within defined time-period (based upon time since ART initiated)?
- What are enablers and barriers to retention in care and adherence to HIV treatment that are service and client-related, and do these vary for intervention and control sites?
- How is HIV care and treatment coordinated and integrated with other health services, and do these vary for intervention and control sites?
- What are client recommendations to improve HIV service delivery and retention in care?
The model has these core components: (1) a proactive team approach to care; (2) care focused on the client with a strong long-term provider and client relationship (3) seamless referral systems (4) task shifting to enable care as close to the client as possible and( 5) improved community and health facility linkages. At the policy level, the model is expected to improve service delivery by assisting managers and health care providers to operationalise and prioritize existing vertical, disease or condition-specific policies through a single integrated chronic care policy. The model also encourages providers to offer comprehensive services, including empowering the client to self-manage his/her condition and seek ongoing care at the appropriate level, in addition to offering treatment.
Theory of change
The programme inputs include a minimum package of integrated care, decentralised care, scheduling system and community engagement through chronic clubs, as well a home visits to provide psychosocial support for PLHIV and/or other chronic diseases. The package of integrated activities is made available to clients at intervention sites to ensure that PLHIV receive these services—or be seamlessly referred to a health facility that offers them. The focus on the patient and his other family aims to improve the client and provider relationship. Additionally, the community components contribute to change in sociocultural norms, increased self-efficacy, and changes in attitudes and beliefs. This, in turn, leads to improved health status and health seeking behaviour. Increased adherence and retention to HIV care and treatment are the expected outcome based on these inputs.
The evaluation is a mixed-method study with a quasi-experimental quantitative component. Both difference-in-difference analyses and propensity score matching have been used to compare outcome measures in intervention sites in one region of Côte d’Ivoire with matched comparison sites in a neighbouring region. The two regions are similar in many ways, but only one of them received the chronic care intervention.
The first step towards model implementation was a series of trainings and updates for clinical providers and community health workers on the components of the model.
Fundamental aspects of the model that were implemented across most sites included nurse initiation of ART and commencement of chronic clubs.
Downward referral of ART clients, home visits by community health workers, and patient care team meetings started later in the implementation phase across most sites. Results are likely impacted by level of implementation at each facility during the period of evaluation.
- The difference-in-difference analyses showed that the intervention region had substantially and significantly better retention than the control region among clients with a higher initial CD4 count at the 30-day timepoint.
- The propensity score analysis did not show significant differences in 30-day, 90-day, or 180-day retention between the two regions.
- Qualitative analyses showed that enablers to ART adherence included facilitating access to medications, providers following up with clients, counselling and encouragement of social support and partner disclosure of HIV status.
- Barriers to adherence included difficulty in HIV disclosure and stigma, the need to skip appointments due to social responsibilities, limited ability to pay for roundtrip transport costs to the clinic and travel outside the region for work or social responsibilities.