Improving Viral Load Suppression Among Men and Children Active in Care Through Community-Designed and Led Solutions: Protocol for Retrospective Closed Cohort Study in Eastern Uganda.

BACKGROUND: In collaboration with facilities, communities, district local government, and the United States Agency for International Development (USAID) implementing partners, the iDARE methodology was implemented at the community level to address root causes of low HIV antiretroviral therapy adherence among men and children actively enrolled in care, resulting in low viral load suppression (VLS) in two districts in the eastern region of Uganda. The methodology encourages the use of cocreated sustainable solutions addressing gender, youth, and social inclusion issues to reduce barriers to care and reach the 95-95-95 Joint United Nations Programme on HIV/AIDS target for HIV epidemic control. We aim to measure the impact of iDARE on VLS for men and children active in care and investigate the practical scale up of the solutions designed using the iDARE methodology. OBJECTIVE: The primary objective of this study will be to measure the implementation impact of the iDARE methodology at the facility and community levels on VLS for people living with HIV. The secondary objective is to investigate the practical scale up of the iDARE methodology using evidence-based gender, youth, and social inclusion social behavior change packages to rapidly meet the Ugandan Ministry of Health targets for VLS. METHODS: A retrospective cohort study design will be used to analyze program data that aims to increase the rates of VLS in men and children who are classified as active in care using community engagement and quality improvement techniques. We will examine 3 pilot health centers' data from a USAID-funded program aimed at social behavior change to increase health-seeking behavior in Uganda. Based on the iDARE process and results, change packages were developed to highlight lessons learned and best practices in order to share with subsequent implementation sites. RESULTS: The USAID-funded Social and Behavior Change Activity began implementation of iDARE in September 2020, with baseline data collected in August 2020. CONCLUSIONS: Data on viral load suppression was collected from facilities on a monthly basis to record progress toward the 95-95-95 goal. The expected primary outcome is an increase in actively enrolled men and children reaching VLS in order to meet the Ugandan Ministry of Health target of 95% VLS among those active in care. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/32784.

A prospective cohort study of outcomes for isoniazid prevention therapy: a nested study from a national QI collaborative in Uganda.

BACKGROUND: Tuberculosis (TB) and human immunodeficiency virus (HIV) co-infection constitute a deadly infectious disease synergy disease and major public health problem throughout the world. The risk of developing active TB in people living with HIV (PLHIV) is 21 times higher than the rest of the world population. The overlap of latent TB infection and HIV infection has resulted in marked increases in TB incidence in countries with dual epidemics. Although antiretroviral therapy (ART) is the single most significant way to reduce incident TB in PLHIV, besides early ART initiation, isoniazid preventive therapy (IPT) is the key intervention to prevent TB among PLHIV. This prospective cohort and longitudinal study aimed to document; retention, adherence, development of active TB disease, possible adverse drug reactions and completion among patients initiated on IPT in Jan 2019. METHODS: This was both a prospective cohort and longitudinal study nested within a national quality improvement collaborative in which multiple quality improvement teams tested changes in care delivery to improve the delivery of IPT. The prospective cohort were HIV patients without TB disease initiated on a dosage of Isoniazid 300 mg/day for adults and 150 mg/day for children for a period of 6 months. Association statistics were used to describe patient characteristics and outcomes. Variables with p-value < 0.05 were used to determine linear by linear associations between patient characteristics assumed to influence both primary and secondary outcomes. Variables with a p-value < 0.05 were included in the logistical regression model. The final model included those factors that retained statistical significance. The odds ratios (OR) and adjusted OR (AOR) along with its 95% confidence interval were used to determine the power of relationship in determining the outcomes of interest. The model was tested for fitness using goodness-of-fit Hosmer-Lemeshow tests. RESULTS: The completion of IPT was at 89%. A significant proportion of patients adhered to treatment (89%) and kept their appointment schedules-retention (89%). All patients (100%) received IPT at each appointment visit. Only 4% of patients experienced side effects of isoniazid (INH) but none of them developed active TB at the end of the 6 month INH dose. Multivariate logistic regression analysis of covariates of IPT completion revealed a strong and statistical association between IPT completion and age, gender, retention and side effects of INH. Our multivariate model found that children below 15 years were less likely to complete INH than patients ≥ 15 years (AOR = 0.416, p = 0.230, df = 1). Female patients were 2 times more likely to complete INH dose than male patients (AOR = 1.598, p = 0.018). Patients who kept all their appointment schedules were 10 times more likely to complete IPT than those who missed one or more schedules (AOR = 10.726, p = 0.000, df = 1). We also found that patients who did not report any side effects associated with INH were 2 times more likely to complete INH (AOR = 1.958, p = 0.016, df = 1) than patients who reported one or more side effects. CONCLUSION: Treatment completion is the end-point of the IPT initiation strategy in Uganda. With a completion rate of 89%, our results seem re-assuring and suggest that improvement collaborative is an effective approach to achieving results through combined efforts. The high rates of completion are encouraging indicators of progress in the implementation of collaborative activities in the study setting. However, such collaboratives would require periodic evaluation to prevent possible relapses in progress attained.

Improving care for patients on antiretroviral therapy through a gap analysis framework.

OBJECTIVE: To improve quality of care through decreasing existing gaps in the areas of coverage, retention, and wellness of patients receiving HIV care and treatment. DESIGN: The antiretroviral therapy (ART) Framework utilizes improvement methods and the Chronic Care Model to address the coverage, retention, and wellness gaps in HIV care and treatment. This is a time-series study. SETTING: The ART Framework was applied in five health centers in Buikwe District, Uganda. PARTICIPANTS: Quality improvement teams, consisting of healthcare workers and expert patients, were established in each of the five healthcare facilities. INTERVENTION: The intervention period was October 2010 to September 2012. It consisted of quality improvement teams analyzing their facility and systems of care from the perspective of the Chronic Care Model to identify areas of improvement. They implemented the ART Framework, collected data and assessed outcomes, focused on self-management support for patients, to improve coverage, retention, and wellness gaps in HIV care and treatment. MAIN OUTCOME MEASURE(S): Coverage was defined as every patient who needs ART in the catchment area, receives it. Retention was defined as every patient who receives ART stays on ART, and wellness defined as having a positive clinical, immunological, and/or virological response to treatment without intolerable or unmanageable side-effects. RESULTS: Results from Buikwe show the gaps in coverage, retention, and wellness greatly decreased a gap in coverage of 44-19%, gap in retention of 49-24%, and gap in wellness of 53-14% during a 2-year intervention period. CONCLUSION: The ART Framework is an innovative and practical tool for HIV program managers to improve HIV care and treatment.