Intervention Strategy in Improving ART Adherence In Tanzania

Salama Mwakisu-MSH, Dr D Sando-NACP, Dr R. Malele-MUHAS, Bernard Rabiel-NACP, Dr G. Somi-NACP, Prof A. Massele-MUHAS, Dr Candida Moshiro MUHAS. Dr R. Mbwasi-MSH, Dr R. Swai-NACP, John Chalker-MSH, Dennis Ross-Degnan-Harvard Medical School

BACKGROUND

• 5.7% of Tanzanians age 15-49 years are HIV positive

• National HIV treatment program started 2004 – Now over 909 centres giving ART with 390,320

patients ever on ART as of March 2011

• Poor attendance and high drop out– 76% of ART patients have moderate to poor clinic

attendance– Only 53% of patients alive and on ART after 24

months (Care and Treatment Report 2008)

OBJECTIVES AND OUTCOMES

Objective • To measure the effects of strengthening appointment and

tracking systems in improving attendance in ART clinicsOutcome measures• % of experienced patients who attend scheduled

appointments:– On or before the day of the next appointment– Within 3 days following the day of their next

appointment• Time until newly treated patients miss visits by >3 or >14 days• % of patients lost to follow-up

STUDY METHODOLOGY

Study Design• A multifaceted longitudinal evaluation of a systems intervention with

staggered implementationSetting• 2 regions purposively selected based on proximity to Dar es Salaam and

existence of strong community outreach programs• In each region: 3 intervention & 1 control facilities Interventions• Strengthen appointment system

– Introduction of an appointment diary at health facilities – Negotiated appointments with patients

• Strengthening linkage with community Home-Based Care (HBC) programs– Improve mapping of patients’ residential locations at ART clinic– Introducing standardized HBC registers at facility and community level– Improve communication within clinic and between clinic and HBC

RESULTS: Change in Key OutcomesExample: % Missed Visits Among Experienced Patients

Coast intervention facilities Comparison facilities

Morogoro intervention facilities Comparison facilities

Facilities Variation in Response to InterventionExample: % Missed Visits in Coast FacilitiesFacility 1 Facility 2

Facility 3 Control

Small or No Changes in Missed Visits for New PatientsExample: Time Until Missing Visit by >3 Days

Coast intervention facilities Comparison facilities

Morogoro intervention facilities Comparison facilities

LESSONS LEARNT

• Implementing an appointment system and strengthening linkage with communities showed some impact – Reducing rates of missed visits among experienced patients – Small or no reductions in missed visits for new patients – Reducing rates of Lost to Follow-up

• Facilities vary in response to the interventions• Without an appointment system that can identify patients

who do not attend, it is impossible to estimate the size of the problem or to implement solutions.

• Many issues affect ability of patients to keep appointments beyond facility-related factors

POLICY IMPLICATIONS

• NACP has reviewed results and agreed to scale up the intervention to all facilities in Tanzania

• Conditions needed for successful scale-up:– For effective roll-out, initial training, and supportive supervision

during early days of implementation– Integrating monitoring visits into existing visits of NACP staff,

RHMT, CHMT and Partners will ensure good outcome of interventions

• Need to shift attention to actively preventing missing patients from becoming LTF instead of just monitoring rate of LTF

CHALLENGES AND FUTURE QUESTIONS

Challenges• The success of the interventions depends on number of staff,

reliability of transport to the clinic, and good documentation.• With appointment block system, health education has to be

provided at the beginning of each block instead of only once in the morning.

Future Questions• What will be the impact of scaling up the intervention?• What will be the cost implication of scaling up the

interventions?• What are the challenges facing CHBC in tracing missed clients

as opposed to tracing LTF?