CoChat
Sign Up
Cited by 141HIV/AIDS Research and InterventionsHIV/AIDS drug development and treatmentHealth Policy Implementation Science

Effects of a multicomponent intervention to streamline initiation of antiretroviral therapy in Africa: a stepped-wedge cluster-randomised trial

Open access
Amanyire, Gideon, Semitala, Fred C, Namusobya, Jennifer, Katuramu, Richard, Kampiire, Leatitia, Wallenta, Jeanna, Charlebois, Edwin, Camlin, Carol +6 more·2016·The Lancet HIV
DOI 10.1016/s2352-3018(16)30090-xPMC PMC5408866
Open this paper in CoChat — free account

Abstract

Background In Africa, up to 30% of HIV-infected patients who are clinically eligible for antiretroviral therapy (ART) do not start timely treatment. We assessed the effects of an intervention targeting prevalent health systems barriers to ART initiation on timing and completeness of treatment initiation. Methods In this stepped-wedge, non-blinded, cluster-randomised controlled trial, 20 clinics in southwestern Uganda were randomly assigned in groups of five clinics every 6 months to the intervention by a computerised random number generator. This procedure continued until all clinics had crossed over from control (standard of care) to the intervention, which consisted of opinion-leader-led training and coaching of front-line health workers, a point-of-care CD4 cell count testing platform, a revised counselling approach without mandatory multiple pre-initiation sessions, and feedback to the facilities on their ART initiation rates and how they compared with other facilities. Treatment-naive, HIV-infected adults (aged ≥18 years) who were clinically eligible for ART during the study period were included in the study population. The primary outcome was ART initiation 14 days after first clinical eligibility for ART. This study is registered with ClinicalTrials.gov, number NCT01810289. Findings Between April 11, 2013, and Feb 2, 2015, 12 024 eligible patients visited one of the 20 participating clinics. Median CD4 count was 310 cells per μL (IQR 179-424). 3753 of 4747 patients (weighted proportion 80%) in the intervention group had started ART by 2 weeks after eligibility compared with 2585 of 7066 patients (38%) in the control group (risk difference 41·9%, 95% CI 40·1-43·8). Vital status was ascertained in a random sample of 208 patients in the intervention group and 199 patients in the control group. Four deaths (2%) occurred in the intervention group and five (3%) occurred in the control group. Interpretation A multicomponent intervention targeting health-care worker behaviour increased the probability of ART initiation 14 days after eligibility. This intervention consists of widely accessible components and has been tested in a real-world setting, and is therefore well positioned for use at scale. Funding National Institute of Allergy and Infectious Diseases (NIAID) and the President's Emergency Fund for AIDS Relief (PEPFAR).

The claims and statistics of this paper haven’t been checked yet.

Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.

A few free checks a day · papers already verified open instantly · results are public

Integrity signals

Registry

Crossref · 10.1016/s2352-3018(16)30090-x

Cites

5 of 5 references verified0 citation errors · 0 not checkable

Statistics

Claims the paper makes

The claims and statistics of this paper haven’t been checked yet.

Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.

A few free checks a day · papers already verified open instantly · results are public

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

The self-check needs the paper’s full text.

Cites

Flagged first, then by citations

Research works printed but not linked: 28

  1. [1]Cooper ER Charurat M Mofenson L Combination antiretroviral strategies for the treatment of pregnant HIV-1-infected women and prevention of perinatal HIV-1 transmission J Acquir Immune Defic Syndr 2002 29 484 94 11981365
  2. [2]Egger M May M Chene G Prognosis of HIV-1-infected patients starting highly active antiretroviral therapy: a collaborative analysis of prospective studies Lancet 2002 360 119 29 12126821
  3. [4]Rosen S Fox MP Retention in HIV care between testing and treatment in sub-Saharan Africa: a systematic review PLoS Med 2011 8 e1001056 21811403 PMC3139665
  4. [5]Amuron B Namara G Birungi J Mortality and loss-to-follow-up during the pre-treatment period in an antiretroviral therapy programme under normal health service conditions in Uganda BMC Public Health 2009 9 290 19671185 PMC2734853
  5. [6]Zolopa A Andersen J Komarow L Early antiretroviral therapy reduces AIDS progression/death in individuals with acute opportunistic infections: a multicenter randomized strategy trial PLoS One 2009 4 e5575 19440326 PMC2680972
  6. [7]Havlir DV Kendall MA Ive P Timing of antiretroviral therapy for HIV-1 infection and tuberculosis N Engl J Med 2011 365 1482 91 22010914 PMC3327101
  7. [8]Zachariah R Reid SD Chaillet P Massaquoi M Schouten EJ Harries AD Viewpoint: why do we need a point-of-care CD4 test for low-income countries? Trop Med Int Health 2010 16 37 41 21371207
  8. [10]Mujugira A Celum C Thomas KK Delay of antiretroviral therapy initiation is common in East African HIV-infected individuals in serodiscordant partnerships J Acquir Immune Defic Syndr 2014 66 436 42 24798765 PMC4077929
  9. [11]Siedner MJ Lankowski A Haberer JE Rethinking the “pre” in pre-therapy counseling: no benefit of additional visits prior to therapy on adherence or viremia in Ugandans initiating ARVs PLoS One 2012 7 e39894 22761924 PMC3383698
  10. [12]Corbett EL Makamure B Cheung YB HIV incidence during a cluster-randomized trial of two strategies providing voluntary counselling and testing at the workplace, Zimbabwe AIDS 2007 21 483 89 17301567
  11. [13]Chamie G Kwarisiima D Clark TD Leveraging rapid community-based HIV testing campaigns for non-communicable diseases in rural Uganda PLoS One 2012 7 e43400 22916256 PMC3423366
  12. [15]Decroo T Telfer B Biot M Distribution of antiretroviral treatment through self-forming groups of patients in Tete province, Mozambique J Acquir Immune Defic Syndr 2011 56 e39 44 21084990
  13. [16]Decroo T Van Damme W Kegels G Remartinez D Rasschaert F Are expert patients an untapped resource for ART provision in sub-Saharan Africa? AIDS Res Treat 2012 2012 749718 22577527 PMC3345212
  14. [17]Chang LW Kagaayi J Nakigozi G Effect of peer health workers on AIDS care in Rakai, Uganda: a cluster-randomized trial PLoS One 2010 5 e10923 20532194 PMC2880005
  15. [18]Faal M Naidoo N Glencross DK Venter WD Osih R Providing immediate CD4 count results at HIV testing improves ART initiation J Acquir Immune Defic Syndr 2011 58 e54 59 21857356
  16. [19]Rosen S Maskew M Fox MP Initiating antiretroviral therapy for HIV at a patient’s first clinic visit: the RapIT randomized controlled trial PLoS Med 2016 13 e1002015 27163694 PMC4862681
  17. [21]Davis DA Thomson MA Oxman AD Haynes RB Evidence for the effectiveness of CME. A review of 50 randomized controlled trials JAMA 1992 268 1111 17 1501333
  18. [22]Green LW Krueter M Health program planning–an educational and ecological approach Philadelphia McGraw-Hill 2005
  19. [23]Mugavero MJ Westfall AO Zinski A Measuring retention in HIV care: the elusive gold standard J Acquir Immune Defic Syndr 2012 61 574 23011397 PMC3508092
  20. [24]Mugavero MJ Amico KR Horn T Thompson MA The state of engagement in HIV care in the United States: from cascade to continuum to control Clin Infect Dis 2013 57 1164 71 23797289
  21. [25]El-Sadr W Medard F Berthaud V Directly observed therapy for tuberculosis: the Harlem Hospital experience, 1993 Am J Public Health 1996 86 1146 49 8712276 PMC1380628
  22. [27]Hickey MD Salmen CR Omollo D Implementation and operational research: pulling the network together: quasiexperimental trial of a patient-defined support network intervention for promoting engagement in HIV care and medication adherence on Mfangano Island, Kenya J Acquir Immune Defic Syndr 2015 69 e127 34 25984711 PMC4485532
  23. [28]Salmen CR Hickey MD Fiorella KJ “Wan Kanyakla” (we are together): community transformations in Kenya following a social network intervention for HIV care Soc Sci Med 2015 147 332 40 26638145
  24. [29]Thirumurthy H Masters SH Rao S Effect of providing conditional economic compensation on uptake of voluntary medical male circumcision in Kenya: a randomized clinical trial JAMA 2014 312 703 11 25042290 PMC4268484
  25. [30]Fairall LR Bachmann MO Louwagie GM Effectiveness of antiretroviral treatment in a South African program: a cohort study Arch Intern Med 2008 168 86 93 18195200
  26. [31]Larson BA Schnippel K Brennan A Same-day CD4 testing to improve uptake of HIV care and treatment in South Africa: point-of-care is not enough AIDS Res Treat 2013 2013 941493 23956850 PMC3730392
  27. [33]Kotz D Spigt M Arts IC Crutzen R Viechtbauer W Use of the stepped wedge design cannot be recommended: a critical appraisal and comparison with the classic cluster randomized controlled trial design J Clin Epidemiol 2012 65 1249 52 22964070
  28. [35]Hussey MA Hughes JP Design and analysis of stepped wedge cluster randomized trials Contemp Clin Trials 2007 28 182 91 16829207

Cited by

Sorted by citations

Authors
Amanyire, G., Semitala, F. C., Namusobya, J., Katuramu, R., Kampiire, L., Wallenta, J., Charlebois, E., Camlin, C., Kahn, J., Chang, W., Glidden, D., Kamya, M., Havlir, D., & Geng, E.
Affiliations
  • Makerere University (UG)
  • University of California, San Francisco (US)
Corresponding author
Geng, Elvin
ORCID
Venue
The Lancet HIV
Publisher
Elsevier BV
Published
2016-11
Volume
3
Issue
11
Pages
e539-e548
ISSN
2352-3018 (ISSN-L)
DOI
10.1016/s2352-3018(16)30090-x
PMC
PMC5408866
OpenAlex
W2512229472
Cited by
141
References
5
Citations by year
2026: 8 · 2025: 12 · 2024: 13 · 2023: 10 · 2022: 18 · 2021: 14 · 2020: 15 · 2019: 23 · 2018: 12 · 2017: 13 · 2016: 3
FWCI
15.70
Type
journal article
Language
en
Open access
Licence
www.elsevier.com/tdm/userlicense/1.0/ (tdm)
Locations
  • The Lancet HIV (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
  • eScholarship (California Digital Library) (submittedVersion)
Funders
  • National Institute of Mental Health (P30MH062246)
  • National Institute of Allergy and Infectious Diseases (U01AI099959, UM1AI069496)
Topics
  • Health Sciences › Medicine › Infectious Diseases › HIV/AIDS Research and Interventions
  • Health Sciences › Medicine › Infectious Diseases › HIV/AIDS drug development and treatment
  • Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
Keywords
antiretroviral therapy initiation, HIV, health professions education, point-of-care CD4 testing, Uganda, Africa, multicomponent intervention, health system strengthening
MeSH terms
Adult, Africa, Drug Administration Schedule, Female, Humans, Male, Middle Aged, Uganda, HIV Infections, Treatment Outcome, CD4 Lymphocyte Count, Anti-HIV Agents, Viral Load, Antiretroviral Therapy, Highly Active, Young Adult, Time-to-Treatment

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

Are you an author, or do you see a problem with this page? Request a review