In resource-limited settings--where a massive scale-up of HIV services has occurred in the last 5 years--both understanding the extent of and improving retention in care presents special challenges. First, retention in care within the decentralizing network of services is likely higher than existing estimates that account only for retention in clinic, and therefore antiretroviral therapy services may be more effective than currently believed. Second, both magnitude and determinants of patient retention vary substantially and therefore encouraging the conduct of locally relevant epidemiology is needed to inform programmatic decisions. Third, socio-structural factors such as program characteristics, transportation, poverty, work/child care responsibilities, and social relations are the major determinants of retention in care, and therefore interventions to improve retention in care should focus on implementation strategies. Research to assess and improve retention in care for HIV-infected patients can be strengthened by incorporating novel methods such as sampling-based approaches and a causal analytic framework.
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"Increased provider satisfaction is of great value in high-volume ART settings such as these where high patient load can lead to burn-out among providers. Increased ART patient satisfaction is strongly correlated with better engagement with care (e.g., attending clinic visits), adherence to ARV and other health outcomes (Geng et al., 2010). In conclusion, the findings of this study suggest that patients can be trained to improve their interactions with their providers, a quality that has been shown empirically to have a direct impact onUnknown or missing 19 (6.4%) 13 (4.5%) a Pearson's chi square (1df), p = .005. "
[Show abstract][Hide abstract] ABSTRACT: In order to increase patient active engagement during patient-provider interactions, we developed and implemented patient training sessions in four antiretroviral therapy (ART) clinics in Namibia using a "Patient Empowerment" training curriculum. We examined the impact of these trainings on patient-provider interactions after the intervention. We tested the effectiveness of the intervention using a randomized parallel group design, with half of the 589 enrolled patients randomly assigned to receive the training immediately and the remaining randomized to receive the training 6 months later. The effects of the training on patient engagement during medical consultations were measured at each clinic visit for at least 8 months of follow-up. Each consultation was audiotaped and then coded using the Roter Interaction Analysis System (RIAS). RIAS outcomes were compared between study groups at 6 months. Using intention-to-treat analysis, consultations in the intervention group had significantly higher RIAS scores in doctor facilitation and patient activation (adjusted difference in score 1.19, p = .004), doctor information gathering (adjusted difference in score 2.96, p = .000), patient question asking (adjusted difference in score .48, p = .012), and patient positive affect (adjusted difference in score 2.08, p = .002). Other measures were higher in the intervention group but did not reach statistical significance. We have evidence that increased engagement of patients in clinical consultation can be achieved via a targeted training program, although outcome data were not available on all patients. The patient training program was successfully integrated into ART clinics so that the trainings complemented other services being provided.
"However, there are arguments that it also perpetuates a " conveyor belt " approach to nursing (van der Walt & Schwartz, 2002, p. 1001), disempowers patients (Garner & Volmink, 2000), and puts—as we also show— an additional burden on them and their resources because of the need for frequent clinic visits. Acute ill health and transport costs can here create additional access barriers; these issues can be equally problematic for people on ART (Geng et al., 2010; Kapella et al., 2009; Sagbakken, Frich, & Bjune, 2008). A public service providing free ART and TB treatment is thus a necessary but not sufficient aspect of enabling widespread access to therapy in resource-limited settings. "
"The first, a systematic review, reported self-transfer rates of 12–54% amongst patients found alive (Brinkhof et al. 2009). The second, a narrative review, estimated a crude unweighted median self-transfer rate of 48.5% amongst those reported in 14 cited studies as LTFU (Geng et al. 2010b). We systematically reviewed outcomes reported in tracing studies of adult ART patients who are reported as LTFU in low-and middle-income countries (LMICs) to provide an updated assessment of the extent to which self-transfers – a positive outcome – contributed to the overall proportion of people considered to be lost to care. "
[Show abstract][Hide abstract] ABSTRACT: Objective
To ascertain estimates of adult patients, recorded as lost to follow-up (LTFU) within antiretroviral treatment (ART) programmes, who have self-transferred care, died or truly stopped ART in low- and middle-income countries.Methods
PubMed, EMBASE, Web of Science, Science Direct, LILACS, IndMed and AIM databases (2003-2013) and IAS/AIDS conference abstracts (2011-2013) were searched for tracing studies reporting the proportion of traced patients found to have self-transferred, died or stopped ART. These estimates were then combined using random-effects meta-analysis. Risk of bias was assessed through subgroup and sensitivity analyses.Results28 studies were eligible for inclusion, reporting true outcomes for 10,806 traced patients attending approximately 258 ART facilities. None were from outside sub-Saharan Africa. 23 studies reported 4.5-54.4% traced LTFU patients self-transferring care, providing a pooled estimate of 18.6% (95% CI 15.8-22.0%). A significant positive association was found between rates of self-transfer and LTFU in the ART cohort. The pooled estimates for unreported deaths was 38.8% (95% CI 30.8-46.8%; 27 studies), and 28.6% (95% CI 21.9-36.0%; 20 studies) for patients stopping ART. A significant decrease in unreported deaths from 50.0% (95% CI 41.5-58.4%) to 30.0% (95% CI 21.1-38.9%) was found comparing study periods before and after 31/12/2007.Conclusions
Substantial unaccounted for transfers and deaths among patients LTFU confirms that retention and mortality is underestimated where the true outcomes of LTFU patients are not ascertained.This article is protected by copyright. All rights reserved.
Full-text · Article · Nov 2014 · Tropical Medicine & International Health