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Cited by 9HIV/AIDS Research and InterventionsHealth Policy Implementation ScienceHIV/AIDS drug development and treatment

Sustainability of the streamlined ART (START-ART) implementation intervention strategy among ART-eligible adult patients in HIV clinics in public health centers in Uganda: a mixed methods study

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Katuramu, Richard, Kamya, Moses R., Sanyu, Naome, Armstrong-Hough, Mari, Semitala, Fred C.·2020·Implementation Science Communications
DOI 10.1186/s43058-020-00025-5PMC PMC7427962
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Abstract

Background: Despite increasing access to antiretroviral therapy (ART), the proportion of eligible patients initiated on treatment remains suboptimal. Only 64.6% of the people living with HIV (PLHIV) globally were initiated on ART by June 2019. The streamlined ART (START-ART) implementation study was based on the PRECEDE model, which suggests that “predisposing, enabling, and reinforcing” factors are needed to create behavior change. START-ART increased ART initiation within 2 weeks of eligibility by 42%. However, the gains from some implementation interventions erode over time. We evaluated facilitators and barriers to sustainability of this streamlined ART initiation in the year following the implementation period. Methods: We designed a mixed-methods explanatory sequential study to examine the sustainability of START-ART implementation. Quantitative component consisted of cross-sectional patient chart reviews of routinely collected data; qualitative component consisted of key informant interviews of health workers in START-ART facilities 2 years after conclusion of the implementation period. We analyzed data from 15 public health centers of Mbarara district, where the START-ART implementation was carried out. We included PLHIV aged > 18 years who initiated ART from June 2013 to July 2016. The START-ART implementation took place from June 2013 to June 2015 while the sustainability period was from August 2015 to July 2016. Results: A total of 863 ART-eligible patients were sampled. The median CD4 count was 348 cells/ml (IQR 215–450). During the intervention, 338 (77.4%) eligible patients initiated on ART within 2 weeks compared with 375 (88.2%) during the sustainability period (risk difference 10.8%; 95% CI 5.9–15.8%). In 14 of the 15 health centers, the intervention was sustained. During key informant interviews, rapid ART initiation sustainability was attributed to counseling skills that were obtained during intervention and availability of point-of-care (POC) CD4 PIMA machine. Failure to sustain the intervention was attributed to three specific barriers: lack of training after the intervention, transfer of trained staff to other health facilities, and shortage of supplies like cartridges for POC CD4 PIMA machine. Conclusion: Rapid ART initiation was sustained in most health centers. Skills acquired during the intervention and functional POC CD4 machine facilitated while staff transfers and irregular laboratory supplies were barriers to sustainability of rapid ART initiation.

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  • Most prior sustainability studies included small, homogeneous samples and based conclusions mostly on qualitative retrospective assessments rather than statistical tests of association.

    “However, this knowledge is greatly limited because most studies included small, homogeneous samples, and their conclusions were mostly based on qualitative retrospective assessments of individuals’ beliefs about what led to sustainment success or failure, rather than based on statistical tests of their association [17–22].”

    From Using qualitative comparative analysis to uncover multiple pathways to program sustainment: implications for community-based youth substance misuse prevention (2022) · cites this paper as [22]

    The Methods > Qualitative study and Discussion (pages unavailable) describe retrospective interviews with eight health workers at two sites to assess perceived facilitators and barriers to sustainability. But this was a mixed-methods study with a planned sample of 876 patient records and statistical tests of ART-initiation outcomes (Methods > Quantitative study); it does not establish that most prior studies had small, homogeneous samples or relied mainly on qualitative assessments. (LLM, conf=0.84)

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Research works printed but not linked: 2

  1. [8]WHO. WHO consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations,2014 Geneva: 2015. 25996019
  2. [23]Semitala FC, Camlin CS. Understanding uptake of an intervention to accelerate antiretroviral therapy initiation in Uganda via qualitative inquiry. 2017;20(4). PMC5810312 29206357

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Authors
Katuramu, R., Kamya, M. R., Sanyu, N., Armstrong-Hough, M., & Semitala, F. C.
Affiliations
  • Infectious Diseases Research Collaboration (UG)
  • New York University (US)
Corresponding author
Semitala, Fred C.
ORCID
Venue
Implementation Science Communications
Publisher
Springer Science and Business Media LLC
Published
2020-03-30
Volume
1
Issue
1
Pages
37-37
ISSN
2662-2211 (ISSN-L)
DOI
10.1186/s43058-020-00025-5
PMC
PMC7427962
OpenAlex
W3032396853
Cited by
9
References
25
Citations by year
2025: 1 · 2023: 2 · 2022: 3 · 2021: 3
FWCI
0.26
Type
journal article
Language
en
Open access
Licence
Locations
  • Implementation Science Communications (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
Funders
Fogarty International Center (D43 TW010037)
Topics
  • Health Sciences › Medicine › Infectious Diseases › HIV/AIDS Research and Interventions
  • Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
  • Health Sciences › Medicine › Infectious Diseases › HIV/AIDS drug development and treatment
Keywords
antiretroviral therapy initiation, rapid ART initiation, implementation sustainability, HIV care, PRECEDE model, point-of-care CD4 testing, barriers to sustainability, health professions education, public health centers, Uganda, Mbarara District, health system capacity building, health workforce shortage

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