The revolving door of HIV care: Revising the service delivery cascade to achieve the UNAIDS 95-95-95 goals.

Peter Ehrenkranz and co-authors present a cyclical cascade of care for people with HIV infection, aiming to facilitate assessment of outcomes.

Patient experiences of ART adherence clubs in Khayelitsha and Gugulethu, Cape Town, South Africa: A qualitative study.

BACKGROUND: Globally, 37 million people are in need of lifelong antiretroviral treatment (ART). With the continual increase in the number of people living with HIV starting ART and the need for life-long retention and adherence, increasing attention is being paid to differentiated service delivery (DSD), such as adherence clubs. Adherence clubs are groups of 25-30 stable ART patients who meet five times per year at their clinic or a community location and are facilitated by a lay health-care worker who distributes pre-packed ART. This qualitative study explores patient experiences of clubs in two sites in Cape Town, South Africa. METHODS: A total of 144 participants took part in 11 focus group discussions (FGDs) and 56 in-depth interviews in the informal settlements of Khayelitsha and Gugulethu in Cape Town, South Africa. Participants included current club members, stable patients who had never joined a club and club members referred back to clinician-led facility-based standard care. FGDs and interviews were conducted in isiXhosa, translated and transcribed into English, entered into NVivo, coded and thematically analysed. RESULTS: The main themes were 1) understanding and knowledge of clubs; 2) understanding of and barriers to enrolment; 3) perceived benefits and 4) perceived disadvantages of the clubs. Participants viewed membership as an achievement and considered returning to clinician-led care a 'failure'. Moving between clubs and the clinic created frustration and broke down trust in the health-care system. CONCLUSIONS: Adherence clubs were appreciated by patients, particularly time-saving in relation to flexible ART collection. Improved patient understanding of enrolment processes, eligibility and referral criteria and the role of clinical oversight is essential for building relationships with health-care workers and trust in the health-care system.

The missed potential of CD4 and viral load testing to improve clinical outcomes for people living with HIV in lower-resource settings.

In a Policy Forum, Peter Ehrenkranz and colleagues discuss the contribution of CD4 and viral load testing to outcomes for people with HIV in low- and middle-income countries.

The Case For Family-Centered Differentiated Service Delivery for HIV.

Differentiated care, or differentiated service delivery (DSD), is increasingly being promoted as one of the possible ways to address and improve access, quality, and efficiency of HIV prevention, care, and treatment. Family-centered care has long been promoted within the provision of HIV services, but the full benefits have not necessarily been realized. In this article, we bring together these two approaches and make the case for how family-centered DSD can offer benefits to both people affected by HIV and the health system. Family-centered DSD approaches are presented for HIV testing and antiretroviral therapy (ART) delivery, referencing policies, best practice examples, and evidence from the field. With differentiated family-centered ART delivery, the potential efficiencies gained by extending ART refills can both benefit clients by reducing the frequency and intensity of contact with the health service and lead to health system gains by not requiring multiple providers to care for one family. A family-centered DSD approach should also be leveraged along the HIV care cascade in the provision of prevention technologies and mobilizing family members to receive regular HIV testing. Furthermore, a family-centered lens should be applied wherever DSD is implemented to ensure that, for example, adolescents who are pregnant receive an adapted package of quality care.

Outcomes of a nurse-managed service for stable HIV-positive patients in a large South African public sector antiretroviral therapy programme.

OBJECTIVES: Models of care utilizing task shifting and decentralization are needed to support growing ART programmes. We compared patient outcomes between a doctor-managed clinic and a nurse-managed down-referral site in Cape Town, South Africa. METHODS: Analysis included all adults who initiated ART between 2002 and 2011 within a large public sector ART service. Stable patients were eligible for down-referral. Outcomes [mortality, loss to follow-up (LTFU), virologic failure] were compared under different models of care using proportional hazards models with time-dependent covariates. RESULTS: Five thousand seven hundred and forty-six patients initiated ART and over 5 years 41% (n = 2341) were down-referred; the median time on ART before down-referral was 1.6 years (interquartile range, 0.9-2.6). The nurse-managed down-referral site reported lower crude rates of mortality, LTFU and virologic failure compared with the doctor-managed clinic. After adjustment, there was no difference in the risk of mortality or virologic failure by model of care. However, patients who were down-referred were more likely to be LTFU than those retained at the doctor-managed site (adjusted hazard ratio, 1.36; 95% CI, 1.09-1.69). Increased levels of LTFU in the nurse-managed vs. doctor-managed service were observed in subgroups of male patients, those with advanced disease at initiation and those who started ART in the early years of the programme. CONCLUSION: Reorganization of ART maintenance by down-referral to nurse-managed services is associated with programme outcomes similar to those achieved using doctor-driven primary care services. Further research is necessary to identify optimal models of care to support long-term retention of patients on ART in resource-limited settings.

Universal definition of loss to follow-up in HIV treatment programs: a statistical analysis of 111 facilities in Africa, Asia, and Latin America.

BACKGROUND: Although patient attrition is recognized as a threat to the long-term success of antiretroviral therapy programs worldwide, there is no universal definition for classifying patients as lost to follow-up (LTFU). We analyzed data from health facilities across Africa, Asia, and Latin America to empirically determine a standard LTFU definition. METHODS AND FINDINGS: At a set "status classification" date, patients were categorized as either "active" or "LTFU" according to different intervals from time of last clinic encounter. For each threshold, we looked forward 365 d to assess the performance and accuracy of this initial classification. The best-performing definition for LTFU had the lowest proportion of patients misclassified as active or LTFU. Observational data from 111 health facilities-representing 180,718 patients from 19 countries-were included in this study. In the primary analysis, for which data from all facilities were pooled, an interval of 180 d (95% confidence interval [CI]: 173-181 d) since last patient encounter resulted in the fewest misclassifications (7.7%, 95% CI: 7.6%-7.8%). A secondary analysis that gave equal weight to cohorts and to regions generated a similar result (175 d); however, an alternate approach that used inverse weighting for cohorts based on variance and equal weighting for regions produced a slightly lower summary measure (150 d). When examined at the facility level, the best-performing definition varied from 58 to 383 d (mean=150 d), but when a standard definition of 180 d was applied to each facility, only slight increases in misclassification (mean=1.2%, 95% CI: 1.0%-1.5%) were observed. Using this definition, the proportion of patients classified as LTFU by facility ranged from 3.1% to 45.1% (mean=19.9%, 95% CI: 19.1%-21.7%). CONCLUSIONS: Based on this evaluation, we recommend the adoption of ≥180 d since the last clinic visit as a standard LTFU definition. Such standardization is an important step to understanding the reasons that underlie patient attrition and establishing more reliable and comparable program evaluation worldwide. Please see later in the article for the Editors' Summary.

Patterns of substance use in South Africa: results from the South African Stress and Health study.

BACKGROUND: There are limited data on substance use in South Africa. We describe patterns of substance use based on recent, nationally representative data. METHODS: Data were derived from the 2002-2004 South African Stress and Health (SASH) study. A nationally representative household probability sample of 4351 adults was interviewed using the paper and pencil version of the World Health Organization Composite International Diagnostic Interview (CIDI). Data are reported for lifetime use, socio-demographic correlates of use, and age of cohort predicting lifetime use for four classes of drugs. RESULTS: The estimate for cumulative occurrence of alcohol use was 38.7%, of tobacco smoking 30.0%, of cannabis use 8.4%, of other drug use 2.0%, and of extra-medical psychoactive drug use 19.3%. There were statistically significant associations between male gender and alcohol, tobacco, cannabis and other drug use. Coloureds and whites were more likely than blacks to have used alcohol, tobacco and other drugs. Clear cohort variations existed in the age of initiation of drug use; these were most marked for other drugs and for extra-medical drug use. Use of all drug types was much more common in recent cohorts, with a similar cumulative incidence of tobacco, alcohol and cannabis use across age cohorts. CONCLUSIONS: Epidemiological patterns of use for alcohol, tobacco, cannabis, other drugs and extra-medical drugs provide the first nationally representative data. New findings on race and exploratory data on time trends provide a foundation for future epidemiological work on drug use patterns across birth cohorts and population subgroups in South Africa.