Impact of immediate initiation of antiretroviral therapy on HIV patient satisfaction
Abstract
Objectives: Immediate ART (or early access to ART for all, EAAA) is becoming a national policy in many countries in sub-Saharan Africa. It is plausible that the switch from delayed to immediate ART could either increase or decrease patient satisfaction with treatment. A decrease in patient satisfaction would likely have detrimental consequences for long-term retention and adherence, in addition to the value lost because of the worsening patient experience itself. We conducted a pragmatic stepped-wedge cluster-randomized controlled trial (SW-cRCT) to determine the causal impact of immediate treatment for HIV on patient satisfaction. Design: This seven-step SW-cRCT took place in 14 public-sector health facilities in Eswatini's Hhohho region, from September 2014 to August 2017. Methods: During each step of the trial, we randomly selected days for data collection at each study facility. During these days, a random sample of HIV patients were selected for outcome assessment. In total, 2629 patients provided data on their overall patient satisfaction and satisfaction with the following four domains of the patient experience using a five-point Likert scale: wait time, consultation time, involvement in treatment decisions, and respectful treatment. Higher values on the Likert scale indicated lower patient satisfaction. We analyzed the data using a multilevel ordered logistic regression model with individuals at the first level and health facilities at the second (cluster) level. Results: The proportional odds ratio (OR) comparing EAAA to control was 0.91 (95% CI 0.66–1.25) for overall patient satisfaction. For the specific domains of the patient experience, the ORs describing the impact of EAAA on satisfaction were 1.04 (95% CI 0.61–1.78) for wait time, 0.90 (95% CI 0.62–1.31) for involvement in treatment decisions, 0.86 (95% CI 0.61–1.20) for consultation time, and 1.35 (95% CI 0.93–1.96) for respectful treatment. These results were robust across a wide range of sensitivity analyses. Over time – and independent of EAAA – we observed a worsening trend for both overall patient satisfaction and satisfaction in the four domains of the patient experience we measured. Conclusion: Our findings support the policy change from delayed to immediate ART in sub-Saharan Africa. Immediate (versus delayed) ART in public-sector health facilities in Eswatini had no effect on either overall patient satisfaction or satisfaction with four specific domains of the patient experience. At the same time, we observed a strong secular trend of decreasing patient satisfaction in both the intervention and the control arm of the trial. Further implementation research should identify approaches to ensure high patient satisfaction as ART programs grow and mature.
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The stepped-wedge design in Ogbuoji et al. 2019 allowed phased implementation of the EAAA strategy, ensuring all facilities eventually received the intervention while enabling rigorous evaluation of its impact on patient satisfaction.
“To allow phased implementation of the EAAA strategy, ensuring all facilities eventually received the intervention while enabling rigorous evaluation of its impact on patient satisfaction”
From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [87]
The study in Ogbuoji et al. 2019 was powered to detect significant differences in patient satisfaction with a sample size of approximately 187 patients per step (14 clusters × 13.36 patients per cluster).
“The study was powered to detect significant differences in patient satisfaction with a sample size of approximately 187 patients per step (14 clusters × 13.36 patients per cluster)”
From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [87]
14 healthcare facilities in Ogbuoji et al. 2019 were randomized into pairs and then randomized to transition from the standard of care to the EAAA strategy at different time points, with two facilities transitioning every four months.
“14 healthcare facilities were randomized into pairs and then randomized to transition from the standard of care to the EAAA strategy at different time points, with two facilities transitioning every four months”
From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [87]
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Self-citation
- Authors
- Ogbuoji, O., Geldsetzer, P., Wong, C., Khan, S., Mafara, E., Lejeune, C., Walsh, F., Okello, V., & Bärnighausen, T.
- Affiliations
- Harvard University (US)
- Clinton Health Access Initiative (US)
- Ministry of Health (SZ)
- Corresponding author
- Ogbuoji, Osondu
- Venue
- AIDS
- Published
- 2020-02-01
- Volume
- 34
- Issue
- 2
- Pages
- 267-276
- ISSN
- 0269-9370 (ISSN-L)
- 1473-5571
- OpenAlex
- W2981219143
- Cited by
- 8
- References
- 21
- Citations by year
- 2026: 1 · 2024: 1 · 2021: 2 · 2020: 4
- FWCI
- 1.16
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- AIDS (publishedVersion)
- PubMed (publishedVersion)
- 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 › Patient Satisfaction in Healthcare
- Keywords
- immediate antiretroviral therapy, HIV, patient satisfaction, patient experience, waiting time, consultation time, patient involvement in treatment decisions, respectful treatment, public sector health facilities, Swaziland, sub-Saharan Africa, health policy change, retention in care, medication adherence
- MeSH terms
- Adult, Female, Humans, Male, Middle Aged, Eswatini, Time Factors, HIV Infections, Logistic Models, Patient Satisfaction, Public Sector, Anti-HIV Agents, Viral Load, Early Medical Intervention
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