Sharon Tsui1, Caitlin E Kennedy1, Lawrence H Moulton1, Larry W Chang1,2, Jason E Farley2,3,4,5, Kwasi Torpey6, Eric van Praag7, Olivier Koole8,9, Nathan Ford10, Fred Wabwire-Mangen11, Julie A Denison1. 1. Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. 2. Department of Medicine - Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA. 3. The REACH Initiative of The Johns Hopkins School of Nursing, Baltimore, MD, USA. 4. University of KwaZulu Natal, Durban, South Africa. 5. Association of Nurses in AIDS Care, Akron, OH, USA. 6. School of Public Health, University of Ghana College of Health Sciences, Accra, Ghana. 7. FHI 360, Dar es Salaam, Tanzania. 8. Clinical Sciences Department, Institute of Tropical Medicine, Antwerp, Belgium. 9. Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK. 10. Department HIV, World Health Organization, Geneva, Switzerland. 11. Department of Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda.
Abstract
OBJECTIVE: How clinics structure the delivery of antiretroviral therapy (ART) services may influence patient adherence. We assessed the relationship between models of HIV care delivery and adherence as measured by medication possession ratio (MPR) among treatment-experienced adults in Tanzania, Uganda and Zambia. METHODS: Eighteen clinics were grouped into three models of HIV care. Model 1-Traditional and Model 2-Mixed represented task-sharing of clinical services between physicians and clinical officers, distinguished by whether nurses played a role in clinical care; in Model 3-Task-Shifted, clinical officers and nurses shared clinical responsibilities without physicians. We assessed MPR among 3,419 patients and calculated clinic-level MPR summaries. We then calculated the mean differences of percentages and adjusted residual ratio (aRR) of the association between models of care and incomplete adherence, defined as a MPR <90%, adjusting for individual-level characteristics. RESULTS: In the adjusted analysis, patients in Model 1-Traditional were more likely than patients in Model 2-Mixed to have MPR <90% (aRR = 1.60, 95% CI 1-2.48). Patients in Model 1-Traditional were no more likely than patients in Model 3-Task-Shifted to have a MPR <90% (aRR = 1.58, 95% 0.88-2.85). There was no evidence of differences in MPR <90% between Model 2-Mixed and Model 3-Task-Shifted (aRR = 0.99, 95% CI 0.59-1.66). CONCLUSION: Non-physician-led ART programmes were associated with adherence levels as good as or better than physician-led ART programmes. Additional research is needed to optimise models of care to support patients on lifelong treatment.
OBJECTIVE: How clinics structure the delivery of antiretroviral therapy (ART) services may influence patient adherence. We assessed the relationship between models of HIV care delivery and adherence as measured by medication possession ratio (MPR) among treatment-experienced adults in Tanzania, Uganda and Zambia. METHODS: Eighteen clinics were grouped into three models of HIV care. Model 1-Traditional and Model 2-Mixed represented task-sharing of clinical services between physicians and clinical officers, distinguished by whether nurses played a role in clinical care; in Model 3-Task-Shifted, clinical officers and nurses shared clinical responsibilities without physicians. We assessed MPR among 3,419 patients and calculated clinic-level MPR summaries. We then calculated the mean differences of percentages and adjusted residual ratio (aRR) of the association between models of care and incomplete adherence, defined as a MPR <90%, adjusting for individual-level characteristics. RESULTS: In the adjusted analysis, patients in Model 1-Traditional were more likely than patients in Model 2-Mixed to have MPR <90% (aRR = 1.60, 95% CI 1-2.48). Patients in Model 1-Traditional were no more likely than patients in Model 3-Task-Shifted to have a MPR <90% (aRR = 1.58, 95% 0.88-2.85). There was no evidence of differences in MPR <90% between Model 2-Mixed and Model 3-Task-Shifted (aRR = 0.99, 95% CI 0.59-1.66). CONCLUSION: Non-physician-led ART programmes were associated with adherence levels as good as or better than physician-led ART programmes. Additional research is needed to optimise models of care to support patients on lifelong treatment.
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