A systematic review of the effectiveness of strategies to improve health care provider performance in low- and middle-income countries: Methods and descriptive results.

BACKGROUND: Health care provider (HCP) performance in low- and middle-income countries (LMICs) is often inadequate. The Health Care Provider Performance Review (HCPPR) is a comprehensive systematic review of the effectiveness and cost of strategies to improve HCP performance in LMICs. We present the HCPPR's methods, describe methodological and contextual attributes of included studies, and examine time trends of study attributes. METHODS: The HCPPR includes studies from LMICs that quantitatively evaluated any strategy to improve HCP performance for any health condition, with no language restrictions. Eligible study designs were controlled trials and interrupted time series. In 2006, we searched 15 databases for published studies; in 2008 and 2010, we completed searches of 30 document inventories for unpublished studies. Data from eligible reports were double-abstracted and entered into a database, which is publicly available. The primary outcome measure was the strategy's effect size. We assessed time trends with logistic, Poisson, and negative binomial regression modeling. We were unable to register with PROSPERO (International Prospective Register of Systematic Reviews) because the protocol was developed prior to the PROSPERO launch. RESULTS: We screened 105,299 citations and included 824 reports from 499 studies of 161 intervention strategies. Most strategies had multiple components and were tested by only one study each. Studies were from 79 countries and had diverse methodologies, geographic settings, HCP types, work environments, and health conditions. Training, supervision, and patient and community supports were the most commonly evaluated strategy components. Only 33.6% of studies had a low or moderate risk of bias. From 1958-2003, the number of studies per year and study quality increased significantly over time, as did the proportion of studies from low-income countries. Only 36.3% of studies reported information on strategy cost or cost-effectiveness. CONCLUSIONS: Studies have reported on the efficacy of many strategies to improve HCP performance in LMICs. However, most studies have important methodological limitations. The HCPPR is a publicly accessible resource for decision-makers, researchers, and others interested in improving HCP performance.

Effectiveness of strategies to improve health-care provider practices in low-income and middle-income countries: a systematic review.

BACKGROUND: Inadequate health-care provider performance is a major challenge to the delivery of high-quality health care in low-income and middle-income countries (LMICs). The Health Care Provider Performance Review (HCPPR) is a comprehensive systematic review of strategies to improve health-care provider performance in LMICs. METHODS: For this systematic review we searched 52 electronic databases for published studies and 58 document inventories for unpublished studies from the 1960s to 2016. Eligible study designs were controlled trials and interrupted time series. We only included strategy-versus-control group comparisons. We present results of improving health-care provider practice outcomes expressed as percentages (eg, percentage of patients treated correctly) or as continuous measures (eg, number of medicines prescribed per patient). Effect sizes were calculated as absolute percentage-point changes. The summary measure for each comparison was the median effect size (MES) for all primary outcomes. Strategy effectiveness was described with weighted medians of MES. This study is registered with PROSPERO, number CRD42016046154. FINDINGS: We screened 216 477 citations and selected 670 reports from 337 studies of 118 strategies. Most strategies had multiple intervention components. For professional health-care providers (generally, facility-based health workers), the effects were near zero for only implementing a technology-based strategy (median MES 1·0 percentage points, IQR -2·8 to 9·9) or only providing printed information for health-care providers (1·4 percentage points, -4·8 to 6·2). For percentage outcomes, training or supervision alone typically had moderate effects (10·3-15·9 percentage points), whereas combining training and supervision had somewhat larger effects than use of either strategy alone (18·0-18·8 percentage points). Group problem solving alone showed large improvements in percentage outcomes (28·0-37·5 percentage points), but, when the strategy definition was broadened to include group problem solving alone or other strategy components, moderate effects were more typical (12·1 percentage points). Several multifaceted strategies had large effects, but multifaceted strategies were not always more effective than simpler ones. For lay health-care providers (generally, community health workers), the effect of training alone was small (2·4 percentage points). Strategies with larger effect sizes included community support plus health-care provider training (8·2-125·0 percentage points). Contextual and methodological heterogeneity made comparisons difficult, and most strategies had low quality evidence. INTERPRETATION: The impact of strategies to improve health-care provider practices varied substantially, although some approaches were more consistently effective than others. The breadth of the HCPPR makes its results valuable to decision makers for informing the selection of strategies to improve health-care provider practices in LMICs. These results also emphasise the need for researchers to use better methods to study the effectiveness of interventions. FUNDING: Bill & Melinda Gates Foundation, CDC Foundation.

A group randomized trial using an appointment system to improve adherence to ART at reproductive and child health clinics implementing Option B+ in Tanzania.

INTRODUCTION: In October 2013, Tanzania adopted Option B+ under which HIV-positive pregnant women are initiated on antiretroviral therapy in reproductive and child health clinics at diagnosis. Studies have shown that adherence and retention to antiretroviral treatment can be problematic. METHODS: We implemented a group randomized controlled trial in 24 reproductive and child health clinics in eight districts in Mbeya region. The trial tested the impact of implementing paper-based appointment tracking and community outreach systems on the rate of missed appointments and number of days covered by dispensed antiretroviral medications among women previously established on antiretroviral therapy. We used interrupted time series analysis to assess study outcomes. Clinic staff and patients in intervention clinics were aware of the intervention because of change in clinic procedures; data collectors knew the study group assignment. RESULTS: Three months pre-intervention, we identified 1924 and 1226 patients established on antiretroviral therapy for six months or more in intervention and control clinics, respectively, of whom 83.4% and 86.9% had one or more post-intervention visits. The unadjusted rate of missed visits declined from 36.5% to 34.4% in intervention clinics and increased from 38.9% to 45.5% in control clinics following the intervention. Interrupted time series analyses demonstrated a net decrease of 13.7% (95% CI [-15.4,-12.1]) for missed visits at six months post-intervention. Similar differential changes were observed for visits missed by 3, 7, 15, or 60 days. CONCLUSION: Appointment-tracking and community outreach significantly improved appointment-keeping for women on antiretroviral therapy. The facility staff controlled their workload better, identified missing patients rapidly, and worked with existing community organizations. There is now enough evidence to scale up this approach to all antiretroviral therapy and Option B+ reproductive and child health clinics in Tanzania as well as to evaluate the intervention in medical clinics that treat other chronic health conditions. TRIAL REGISTRATION: Registry for International Development Impact Evaluations ID-55310280d8757.

Can formalizing links among community health workers, accredited drug dispensing outlet dispensers, and health facility staff increase their collaboration to improve prompt access to maternal and child care? A qualitative study in Tanzania.

BACKGROUND: In Tanzania, progress toward achieving the 2015 Millennium Development Goals for maternal and newborn health was slow. An intervention brought together community health workers, health facility staff, and accredited drug dispensing outlet (ADDO) dispensers to improve maternal and newborn health through a mechanism of collaboration and referral. This study explored barriers, successes, and promising approaches to increasing timely access to care by linking the three levels of health care provision. METHODS: The study was conducted in the Kibaha district, where we applied qualitative approaches with in-depth interviews and focus group discussions. In-depth interview participants included retail drug shop dispensers (36), community health workers (45), and health facility staff members (15). We conducted one focus group discussion with district officials and four with mothers of newborns and children under 5 years old. RESULTS: Relationships among the three levels of care improved after the linkage intervention, especially for ADDO dispensers and health facility staff who previously had no formal communication pathway. The study participants perceptions of success included improved knowledge of case management and relationships among the three levels of care, more timely access to care, increased numbers of patients/customers, more meetings between community health workers and health facility staff, and a decrease in child and maternal mortality. Reported challenges included stock-outs of medicines at the health facility, participating ADDO dispensers who left to work in other regions, documentation of referrals, and lack of treatment available at health facilities on the weekend. The primary issue that threatens the sustainability of the intervention is that local council health management team members, who are responsible for facilitating the linkage, had not made any supervision visits and were therefore unaware of how the program was running. CONCLUSION: The study highlights the benefits of approaches that link different levels of care providers to improve access to maternal and child health care. To strengthen this collaboration further, health campaign platforms should include retail drug dispensers as a type of community health care provider. To increase linkage sustainability, the council health management team needs to develop feasible supervision plans.

Understanding the Role of Accredited Drug Dispensing Outlets in Tanzania's Health System.

INTRODUCTION: People in many low-income countries access medicines from retail drug shops. In Tanzania, a public-private partnership launched in 2003 used an accreditation approach to improve access to quality medicines and pharmaceutical services in underserved areas. The government scaled up the accredited drug dispensing outlet (ADDO) program nationally, with over 9,000 shops now accredited. This study assessed the relationships between community members and their sources of health care and medicines, particularly antimicrobials, with a specific focus on the role ADDOs play in the health care system. METHODS: Using mixed methods, we collected data in four regions. We surveyed 1,185 households and audited 96 ADDOs and 84 public/nongovernmental health facilities using a list of 17 tracer drugs. To determine practices in health facilities, we interviewed 1,365 exiting patients. To assess dispensing practices, mystery shoppers visited 306 ADDOs presenting one of three scenarios (102 each) about a child's respiratory symptoms. RESULTS AND DISCUSSION: Of 614 household members with a recent acute illness, 73% sought outside care-30% at a public facility and 31% at an ADDO. However, people bought medicines more often at ADDOs no matter who recommended the treatment; of the 581 medicines that people had received, 49% came from an ADDO. Although health facilities and ADDOs had similar availability of antimicrobials, ADDOs had more pediatric formulations available (p<0.001). The common perception was that drugs from ADDOs are more expensive, but the difference in the median cost to treat pneumonia was relatively minimal (US$0.26 in a public facility and US$0.30 in an ADDO). Over 20% of households said they had someone with a chronic condition, with 93% taking medication, but ADDOs are allowed to sell very few chronic care-related medicines. ADDO dispensers are trained to refer complicated cases to a health facility, and notably, 99% of mystery shoppers presenting a pneumonia scenario received an antimicrobial (54%), a referral (90%), or both (45%), which are recommended practices for managing pediatric pneumonia. However, one-third of the dispensers needlessly sold antibiotics for cold symptoms, and 85% sold an antibiotic on request. In addition, the pneumonia scenario elicited more advice on handling the illness than the cold symptoms scenario (61% vs. 15%; p<0.0001), but overall, only 44% of the dispensers asked any of the shoppers about danger signs potentially associated with pneumonia in a child. CONCLUSION: ADDOs are the principal source of medicines in Tanzania and an important part of a multi-faceted health care system. Poor prescribing in health facilities, poor dispensing at ADDOs, and inappropriate patient demand continue to contribute to inappropriate medicines use. Therefore, while accreditation has attempted to address the quality of pharmaceutical services in private sector drug outlets, efforts to improve access to and use of medicines in Tanzania need to target ADDOs, public/nongovernmental health facilities, and the public to be effective.

What roles do accredited drug dispensing outlets in Tanzania play in facilitating access to antimicrobials? Results of a multi-method analysis.

BACKGROUND: People in low-income countries purchase a high proportion of antimicrobials from retail drug shops, both with and without a prescription. Tanzania's accredited drug dispensing outlet (ADDO) program includes dispenser training, enforcement of standards, and the legal right to sell selected antimicrobials. We assessed the role of ADDOs in facilitating access to antimicrobials. METHODS: We purposively chose four regions, randomly selected three districts and five wards per district. Study methods included interviews at 1200 households regarding care-seeking for acute illness and knowledge about antimicrobials; mystery shoppers visiting 306 ADDOs posing as a caregiver of a child with 1) pneumonia, 2) mild acute respiratory infection (ARI), or 3) a runny nose and request for co-trimoxazole; and audits of antimicrobial availability and prices at 84 public health facilities (PHFs) and 96 ADDOs. RESULTS: Four hundred sixty seven (76 %) members from 367 (77 %) households had recently sought care outside the home for acute illness; 128 had purchased antimicrobials, of which 61 % had been recommended by a doctor or nurse and 32 % by an ADDO dispenser. Only 29 % obtained the antimicrobial at a PHF, whereas, 48 % purchased them at an ADDO. Most thought that ADDOs are convenient place for care, usually have needed medicines, and have high quality services and products, contrasting with 66 % who reported dissatisfaction with PHF waiting times and 56 % with medicine availability. One-third (34 %) of mystery shoppers presenting the mild ARI scenario were inappropriately sold an antimicrobial and 85 % were sold one on request; encouragingly, 99 % presenting a case of pneumonia received either an antimicrobial, referral to a trained provider, or request to bring the child for examination. Overall, 63 and 60 % of the 15 tracer antimicrobials were in stock in ADDOs and PHFs, respectively; ADDOs had significantly more antimicrobial formulations for children available (83 vs. 51 %). Of 369 records of antimicrobial sales in 47 ADDOs, 63 % were dispensed on prescription. CONCLUSION: ADDOs have increased access to antimicrobials in Tanzania. Community members see them as integral to the health system. Antimicrobials are overused due to poor ADDO dispensing, poor PHF prescribing, and inappropriate public demand. Multi-pronged interventions are needed to address all determinants.

What motivates antibiotic dispensing in accredited drug dispensing outlets in Tanzania? A qualitative study.

BACKGROUND: Tanzania introduced the accredited drug dispensing outlet (ADDO) program more than a decade ago. Previous evaluations have generally shown that ADDOs meet defined standards of practice better than non-accredited outlets. However, ADDOs still face challenges with overuse of antibiotics for acute respiratory infections (ARI) and simple diarrhea, which contributes to the emergence of drug resistance. This study aimed to explore the attitudes of ADDO owners and dispensers toward antibiotic dispensing and to learn how accreditation has influenced their dispensing behavior. METHODS: The study used a qualitative approach. We conducted in-depth interviews with ADDO owners and dispensers in Ruvuma and Tanga regions where the government implemented the ADDO program under centralized and decentralized approaches, respectively; a secondary aim was to compare differences between the two regions. RESULTS: Findings indicate that the ADDO program has brought about positive changes in knowledge of dispensing practices. Respondents were able to correctly explain treatment guidelines for ARI and diarrhea. Almost all dispensers and owners indicated that unnecessary use of antibiotics contributed to antimicrobial resistance. Despite this knowledge, translating it to appropriate dispensing practice is still low. Dispensers' behavior is driven by customer demand, habit ("mazoea"), following inappropriate health facility prescriptions, and the need to make a profit. Although the majority of dispensers reported that they had intervened in situations where customers asked for antibiotics unnecessarily, they tended to give in to clients' requests. Small variations were noted between the two study regions; for example, some dispensers in Ruvuma reported sending clients with incorrect prescriptions back to the health facility, a practice that may reflect regional differences in ADDO implementation and in Integrated Management of Childhood Illness training. Dispensers in rural settings reported more challenges in managing ARI and diarrhea than their urban counterparts did. CONCLUSION: To reduce inappropriate antibiotic use, integrated interventions must include communities, health facilities, and ADDOs. Periodic refresher training with an emphasis on communication skills is crucial in helping dispensers deal with customers who demand antibiotics. Responsible authorities should ensure that ADDOs always have the necessary tools and resources available.

A systematic review of health system barriers and enablers for antiretroviral therapy (ART) for HIV-infected pregnant and postpartum women.

BACKGROUND: Despite global progress in the fight to reduce maternal mortality, HIV-related maternal deaths remain persistently high, particularly in much of Africa. Lifelong antiretroviral therapy (ART) appears to be the most effective way to prevent these deaths, but the rates of three key outcomes--ART initiation, retention in care, and long-term ART adherence--remain low. This systematic review synthesized evidence on health systems factors affecting these outcomes in pregnant and postpartum women living with HIV. METHODS: Searches were conducted for studies addressing the population of interest (HIV-infected pregnant and postpartum women), the intervention of interest (ART), and the outcomes of interest (initiation, adherence, and retention). Quantitative and qualitative studies published in English since January 2008 were included. A four-stage narrative synthesis design was used to analyze findings. Review findings from 42 included studies were categorized according to five themes: 1) models of care, 2) service delivery, 3) resource constraints and governance challenges, 4) patient-health system engagement, and 5) maternal ART interventions. RESULTS: Low prioritization of maternal ART and persistent dropout along the maternal ART cascade were key findings. Service delivery barriers included poor communication and coordination among health system actors, poor clinical practices, and gaps in provider training. The few studies that assessed maternal ART interventions demonstrated the importance of multi-pronged, multi-leveled interventions. CONCLUSIONS: There has been a lack of emphasis on the experiences, needs and vulnerabilities particular to HIV-infected pregnant and postpartum women. Supporting these women to successfully traverse the maternal ART cascade requires carefully designed and targeted interventions throughout the steps. Careful design of integrated service delivery models is of critical importance in this effort. Key knowledge gaps and research priorities were also identified, including definitions and indicators of adherence rates, and the importance of cumulative measures of dropout along the maternal ART cascade.

Improving adherence to antiretroviral treatment in Uganda with a low-resource facility-based intervention.

OBJECTIVE: To assess the effects of facility-based interventions using existing resources to improve overall patient attendance and adherence to antiretroviral therapy (ART) at ART-providing facilities in Uganda. METHODS: This was an interventional study which tracked attendance and treatment adherence of two distinct cohorts: experienced patients who had been on treatment for at least 12 months prior to the intervention and patients newly initiated on ART before or during the intervention. The interventions included instituting appointment system, fast-tracking, and giving longer prescriptions to experienced stable patients. Mixed-effects models were used to examine intervention effects on the experienced patients, while Cox proportional hazards models were used to determine the intervention effects on time until newly treated patients experienced gaps in medication availability. RESULTS: In all, 1481 patients' files were selected for follow-up from six facilities--720 into the experienced cohort, and 761 into the newly treated cohort. Among patients in the experienced cohort, the interventions were associated with a significant reduction from 24.4 to 20.3% of missed appointments (adjusted odds ratio (AOR): 0.67; 95% confidence interval (CI): 0.59-0.77); a significant decrease from 20.2 to 18.4% in the medication gaps of three or more days (AOR: 0.69; 95% CI: 0.60-0.79); and a significant increase from 4.3 to 9.3% in the proportion of patients receiving more than 30 days of dispensed medication (AOR: 2.35; 95% CI: 1.91-2.89). Among newly treated patients, the interventions were associated with significant reductions of 44% (adjusted hazard rate (AHR): 0.56, 95% CI: 0.42-0.74) and 38% (AHR: 0.62; 95% CI: 0.45-0.85) in the hazards of experiencing a medication gap of 7 and 14 days or more, respectively. CONCLUSIONS: Patients' adherence was improved with low-cost and easily implemented interventions using existing health facilities' resources. We recommend that such interventions be considered for scale-up at national levels as measures to improve clinic attendance and ART adherence among patients in Uganda and other low-resource settings in sub-Saharan Africa.

Appointment systems are essential for improving chronic disease care in resource-poor settings: learning from experiences with HIV patients in Africa.

Lessons learned from treating patients with HIV infection can inform care systems for other chronic conditions. For antiretroviral treatment, attending appointments on time correlates with medication adherence; however, HIV clinics in East Africa, where attendance rates vary widely, rarely include systems to schedule appointments or to track missed appointments or patient follow-up. An introduction of low-cost, paper-based patient appointment and tracking systems led to an improvement in timely clinic attendance rates and tracking missing patients. An effective appointment system is critical to managing patients with chronic conditions and can be introduced in resource-limited settings, possibly without having to add staff.

Facility-level intervention to improve attendance and adherence among patients on anti-retroviral treatment in Kenya--a quasi-experimental study using time series analysis.

BACKGROUND: Achieving high rates of adherence to antiretroviral therapy (ART) in resource-poor settings comprises serious, but different, challenges in both the first months of treatment and during the life-long maintenance phase. We measured the impact of a health system-oriented, facility-based intervention to improve clinic attendance and patient adherence. METHODS: This was a quasi-experimental, longitudinal, controlled intervention study using interrupted time series analysis. The intervention consisted of (1) using a clinic appointment diary to track patient attendance and monitor monthly performance; (2) changing the mode of asking for self-reported adherence; (3) training staff on adherence concepts, intervention methods, and use of monitoring data; (4) conducting visits to support facility teams with the implementation.We conducted the study in 12 rural district hospitals (6 intervention, 6 control) in Kenya and randomly selected 1894 adult patients over 18 years of age in two cohorts: experienced patients on treatment for at least one year, and newly treated patients initiating ART during the study. Outcome measures were: attending the clinic on or before the date of a scheduled appointment, attending within 3 days of a scheduled appointment, reporting perfect adherence, and experiencing a gap in medication supply of more than 14 days. RESULTS: Among experienced patients, the percentage attending the clinic on or before a scheduled appointment increased in both level (average total increase immediately after intervention) (+5.7%; 95% CI=2.1, 9.3) and trend (increase per month) (+1.0% per month; 95% CI=0.6, 1.5) following the intervention, as did the level and trend of those keeping appointments within three days (+4.2%; 95% CI=1.6, 6.7; and +0.8% per month; 95% CI=0.6, 1.1, respectively). The relative difference between the intervention and control groups based on the monthly difference in visit rates increased significantly in both level (+6.5; 95% CI=1.4, 11.6) and trend (1.0% per month; 95% CI=0.2, 1.8) following the intervention for experienced patients attending the clinic within 3 days of their scheduled appointments.The decrease in the percentage of experienced patients with a medication gap greater than 14 days approached statistical significance (-11.3%; 95% CI=-22.7, 0.1), and the change seemed to persist over 11 months after the intervention. All facility staff used appointment-keeping data to calculate adherence and discussed outcomes regularly. CONCLUSION: The appointment-tracking system and monthly performance monitoring was strengthened, and patient attendance was improved. Scale-up to national level may be considered.

Multiple ART Programs Create a Dilemma for Providers to Monitor ARV Adherence in Uganda.

BACKGROUND: Increased availability and accessibility of antiretroviral therapy (ART) has improved the length and quality of life amongst people living with HIV/AIDS. This has changed the landscape for care from episodic to long-term care that requires more monitoring of adherence. This has led to increased demand on human resources, a major problem for most ART programs. This paper presents experiences and perspectives of providers in ART facilities, exploring the organizational factors affecting their capacity to monitor adherence to ARVs. METHODS: From an earlier survey to test adherence indicators and rank facilities as good, medium or poor adherence performances, six facilities were randomly selected, two from each rank. Observations on facility set-up, provider-patient interactions and key informant interviews were carried out. The strengths, weaknesses, opportunities and threats identified by health workers as facilitators or barriers to their capacity to monitor adherence to ARVs were explored during group discussions. RESULTS: Findings show that the performance levels of the facilities were characterized by four different organizational ART programs operating in Uganda, with apparent lack of integration and coordination at the facilities. Of the six facilities studied, the two high adherence performing facilities were Non-Governmental Organization (NGO) programs, while facilities with dual organizational programs (Governmental/NGO) performed poorly. Working conditions, record keeping and the duality of programs underscored the providers' capacity to monitor adherence. Overall 70% of the observed provider-patient interactions were conducted in environments that ensured privacy of the patient. The mean performance for record keeping was 79% and 50% in the high and low performing facilities respectively. Providers often found it difficult to monitor adherence due to the conflicting demands from the different organizational ART programs. CONCLUSION: Organizational duality at facilities is a major factor in poor adherence monitoring. The different ART programs in Uganda need to be coordinated and integrated into a single well resourced program to improve ART services and adherence monitoring. The focus on long-term care of patients on ART requires that the limitations to providers' capacity for monitoring adherence become central during the planning and implementation of ART programs.

Peer counselors' role in supporting patients' adherence to ART in Ethiopia and Uganda.

Our aim was to explore peer counselors' work and their role in supporting patients' adherence to antiretroviral treatment (ART) in resource-limited settings in Ethiopia and Uganda. Qualitative semi-structured interviews were conducted with 79 patients, 17 peer counselors, and 22 providers in ART facilities in urban and rural areas of Ethiopia and Uganda. Two main categories with related subcategories emerged from the analysis. The first main category, peer counselors as facilitators of adherence, describes how peer counselors played an important role by acting as role models, raising awareness, and being visible in the community. They were also recognized for being close to the patients while acting as a bridge to the health system. They provided patients with an opportunity to individually talk to someone who was also living with HIV, who had a positive and life-affirming attitude about their situation, and were willing to share personal stories of hope when educating and counseling their patients. The second main category, benefits and challenges of peer counseling, deals with how peer counselors found reward in helping others while at the same time acknowledging their limitations and need of support and remuneration. Their role and function were not clearly defined within the health system and they received negligible financial and organizational support. While peer counseling is acknowledged as an essential vehicle for treatment success in ART support in sub-Saharan Africa, a formal recognition and regulation of their role should be defined. The issue of strategies for disclosure to support adherence, while avoiding or reducing stigma, also requires specific attention. We argue that the development and implementation of support to peer counselors are crucial in existing and future ART programs, but more research is needed to further explore factors that are important to sustain and strengthen the work of peer counselors.

Measuring adherence to antiretroviral treatment in resource-poor settings: the clinical validity of key indicators.

BACKGROUND: Access to antiretroviral therapy has dramatically expanded in Africa in recent years, but there are no validated approaches to measure treatment adherence in these settings. METHODS: In 16 health facilities, we observed a retrospective cohort of patients initiating antiretroviral therapy. We constructed eight indicators of adherence and visit attendance during the first 18 months of treatment from data in clinic and pharmacy records and attendance logs. We measured the correlation among these measures and assessed how well each predicted changes in weight and CD4 count. RESULTS: We followed 488 patients; 63.5% had 100% coverage of medicines during follow-up; 2.7% experienced a 30-day gap in treatment; 72.6% self-reported perfect adherence in all clinic visits; and 19.9% missed multiple clinic visits. After six months of treatment, mean weight gain was 3.9 kg and mean increase in CD4 count was 138.1 cells/mm3.Dispensing-based adherence, self-reported adherence, and consistent visit attendance were highly correlated. The first two types of adherence measure predicted gains in weight and CD4 count; consistent visit attendance was associated only with weight gain. CONCLUSIONS: This study demonstrates that routine data in African health facilities can be used to monitor antiretroviral adherence at the patient and system level.

Measuring adherence to antiretroviral treatment in resource-poor settings: the feasibility of collecting routine data for key indicators.

BACKGROUND: An East African survey showed that among the few health facilities that measured adherence to antiretroviral therapy, practices and definitions varied widely. We evaluated the feasibility of collecting routine data to standardize adherence measurement using a draft set of indicators. METHODS: Targeting 20 facilities each in Ethiopia, Kenya, Rwanda, and Uganda, in each facility we interviewed up to 30 patients, examined 100 patient records, and interviewed staff. RESULTS: In 78 facilities, we interviewed a total of 1,631 patients and reviewed 8,282 records. Difficulties in retrieving records prevented data collection in two facilities. Overall, 94.2% of patients reported perfect adherence; dispensed medicine covered 91.1% of days in a six month retrospective period; 13.7% of patients had a gap of more than 30 days in their dispensed medication; 75.8% of patients attended clinic on or before the date of their next appointment; and 87.1% of patients attended within 3 days.In each of the four countries, the facility-specific median indicators ranged from: 97%-100% for perfect self-reported adherence, 90%-95% of days covered by dispensed medicines, 2%-19% of patients with treatment gaps of 30 days or more, and 72%-91% of appointments attended on time. Individual facilities varied considerably.The percentages of days covered by dispensed medicine, patients with more than 95% of days covered, and patients with a gap of 30 days or more were all significantly correlated with the percentages of patients who attended their appointments on time, within 3 days, or within 30 days of their appointment. Self reported recent adherence in exit interviews was significantly correlated only with the percentage of patients who attended within 3 days of their appointment. CONCLUSIONS: Field tests showed that data to measure adherence can be collected systematically from health facilities in resource-poor settings. The clinical validity of these indicators is assessed in a companion article. Most patients and facilities showed high levels of adherence; however, poor levels of performance in some facilities provide a target for quality improvement efforts.

Voices on adherence to ART in Ethiopia and Uganda: a matter of choice or simply not an option?

This paper explores HIV patients' adherence to antiretroviral treatment (ART) in resource-limited contexts in Uganda and Ethiopia, where ART is provided free of charge. Qualitative semi-structured interviews were conducted with 79 patients, 17 peer counselors, and 22 providers in ART facilities in urban and rural areas of Ethiopia and Uganda. Interviewees voiced their experiences of, and views on ART adherence both from an individual and a system level perspective. Two main themes emerged from the content analysis: "Patients' competing costs and systems' resource constraints" and "Patients' trust in ART and quality of the patient-provider encounters." The first theme refers to how patients' adherence was challenged by difficulties in supporting themselves and their families, paying for transportation, for drug refill and follow-up as well as paying for registration fees, opportunistic infection treatment, and expensive referrals to other hospitals. The second theme describes factors that influenced patients' capacity to adhere: personal responsibility in treatment, trust in the effects of antiretroviral drugs, and trust in the quality of counseling. To grant patients a fair choice to successfully adhere to ART, transport costs to ART facilities need to be reduced. This implies providing patients with drugs for longer periods of time and arranging for better laboratory services, thus not necessitating frequent revisits. Services ought to be brought closer to patients and peripheral, community-based healthworkers used for drug distribution. There is a need for training providers and peer counselors, in communication skills and adherence counseling.

Monitoring adherence and defaulting for antiretroviral therapy in 5 East african countries: an urgent need for standards.

OBJECTIVES: A cross-sectional survey was performed in 24 systems of care providing antiretroviral medications in Ethiopia, Kenya, Rwanda, Tanzania, and Uganda to examine current practices in monitoring rates of treatment adherence and defaulting. RESULTS: Only 20 of 48 facilities reported routinely measuring individual patient adherence levels; only 12 measured rates of adherence for the clinic population. The rules for determining which patients were included in the calculation of rates were unclear. Fourteen different definitions of treatment defaulting were in use. Facilities routinely gather potentially useful data, but the frequency of doing so varied widely. CONCLUSIONS: Individual and program treatment adherence and defaulting are not routinely monitored; when done, the operational definitions and methods varied widely, making comparisons across programs unreliable. There is a pressing need to determine which measures are the most feasible and reliable to collect, the most useful for clinical counseling, and most informative for program management.

Private pharmacies in Hanoi, Vietnam: a randomized trial of a 2-year multi-component intervention on knowledge and stated practice regarding ARI, STD and antibiotic/steroid requests.

OBJECTIVES: To assess the effectiveness of a multi-component intervention on knowledge and reported practice amongst staff working in private pharmacies in Hanoi regarding four conditions: urethral discharge [sexually transmitted diseases (STD)], acute respiratory infection (ARI), and non-prescription requests for antibiotics and steroids. METHOD: Randomized controlled trial with staff working in 22 matched pair intervention and control private pharmacies who were administered a semistructured questionnaire on the four conditions before and 4 months after the interventions. The interventions focused on the four conditions and were in sequence (i) regulations enforcement; (ii) face-to-face education and (iii) peer influence. Outcome measures were knowledge and reported change in practice for correct management of tracer conditions. RESULTS: The intervention/control-pairs (22 after drop-outs) were analysed pre- and post-intervention using the Wilcoxon signed rank test. STD: More drug sellers stated they would ask about the health of the partner (P = 0.03) and more said they would advise condom use (P = 0.01) and partner notification (P = 0.04). ARI: More drug sellers stated they would ask questions regarding fever (P = 0.01), fewer would give antibiotics (P = 0.02) and more would give traditional medicines (P = 0.03). Antibiotics request: Fewer said they would sell a few capsules of cefalexin without a prescription (P = 0.02). Steroid requests: No statistical difference was seen in the numbers who said they would sell steroids without a prescription as numbers declined in both intervention and control groups (P = 0.12). CONCLUSION: The three interventions in series over 17 months were effective in changing the knowledge and reported practice of drug sellers in Hanoi.