Interruptions in treatment among adults on anti-retroviral therapy before and after test-and-treat policy in Tanzania.

INTRODUCTION: The World Health Organization recommended the initiation of antiretroviral therapy (ART) for people living with HIV (PLHIV) regardless of CD4 cell counts. Tanzania adopted this recommendation known as test-and-treat policy in 2016. However, programmatic implementation of this policy has not been assessed since its initiation. The objective of the study was to assess the impact of this policy in Tanzania. METHODS: This was a cross-sectional study among PLHIV aged 15 years and older using routinely collected program data. The dependent variable was interruption in treatment (IIT), defined as no clinical contact for at least 90 days after the last clinical appointment. The main independent variable was test-and-treat policy status which categorized PLHIV into the before and after groups. Co-variates were age, sex, facility type, clinical stage, CD4 count, ART duration, and body mass index. The associations were assessed using the generalized estimating equation with inverse probability weighting. RESULTS: The study involved 33,979 PLHIV-14,442 (42.5%) and 19,537 (57.5%) were in the before and after the policy groups, respectively. Among those who experienced IIT, 4,219 (29%) and 7,322 (38%) were in the before and after the policy groups respectively. Multivariable analysis showed PLHIV after the policy was instated had twice [AOR 2.03; 95%CI 1.74-2.38] the odds of experiencing IIT than those before the policy was adopted. Additionally, higher odds of experiencing IIT were observed among younger adults, males, and those with advanced HIV disease. CONCLUSION: Demographic and clinical status variables were associated with IIT, as well as the test-and-treat policy. To achieve epidemic control, programmatic adjustments on continuity of treatment may are needed to complement the programmatic implementation of the policy.

Basic Accountability to Stop Ill-Treatment (BASI); Study Protocol for a Cluster Randomized Controlled Trial in Rural Tanzania.

Background: Poor health system experiences negatively affect the lives of poor people throughout the world. In East Africa, there is a growing body of evidence of poor quality care that in some cases is so poor that it is disrespectful or abusive. This study will assess whether community feedback through report cards (with and without non-financial rewards) can improve patient experience, which includes aspects of patient dignity, autonomy, confidentiality, communication, timely attention, quality of basic amenities, and social support. Methods/Design: This cluster-randomized controlled study will randomize 75 primary health care facilities in rural Pwani Region, Tanzania to one of three arms: private feedback (intervention), social recognition reward through public reporting (intervention), or no feedback (control). Within both intervention arms, we will give the providers at the study facilities feedback on the quality of patient experience the facility provides (aggregate results from all providers) using data from patient surveys. The quality indicators that we report will address specific experiences, be observable by patients, fall into well-identified domains of patient experience, and be within the realm of action by healthcare providers. For example, we will measure the proportion of patients who report that providers definitely "explained things in a way that was easy to understand." This feedback will be delivered by a medical doctor to all the providers at the facility in a small group session. A formal discussion guide will be used. Facilities randomized to the social recognition intervention reward arm will have two additional opportunities for social recognition. First, a poster that displays their achieved level of patient experience will be publicly posted at the health facility and village government offices. Second, recognition from senior officials at the local NGO and/or the Ministry of Health will be given to the facility with the best or most-improved patient experience ratings at endline. We will use surveys with parents/guardians of sick children to measure patient experience, and surveys with healthcare providers to assess potential mechanisms of effect. Conclusion: Results from this study will provide evidence for whether, and through what mechanisms, patient reported feedback can affect interpersonal quality of care. Pan African Clinical Trials Registry (PACTR): 201710002649121 Protocol version 7, November 8, 2017.