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Strengthening health systems at facility-level: feasibility of integrating antiretroviral therapy into primary health care services in lusaka, zambia.

Topp SM, Chipukuma JM, Giganti M, Mwango LK, Chiko LM, Tambatamba-Chapula B, Wamulume CS, Reid S - PLoS ONE (2010)

Bottom Line: Median OPD patient-provider contact time increased 110% (6.1 vs. 12.8 minutes; p<0.001) and decreased for ART patients by 23% (23 vs. 17.7 minutes; p<0.001).Integration enabled shared use of space and staffing that resulted in increased HIV case finding, a reduction in stigma associated with vertical ART services but resulted in an overall increase in patient waiting times.Further research is urgently required to assess long-term clinical outcomes and cost effectiveness in order to evaluate scalability and generalizability.

View Article: PubMed Central - PubMed

Affiliation: Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. stephanie.topp@cidrz.org

ABSTRACT

Introduction: HIV care and treatment services are primarily delivered in vertical antiretroviral (ART) clinics in sub-Saharan Africa but there have been concerns over the impact on existing primary health care services. This paper presents results from a feasibility study of a fully integrated model of HIV and non-HIV outpatient services in two urban Lusaka clinics.

Methods: INTEGRATION INVOLVED THREE KEY MODIFICATIONS: i) amalgamation of space and patient flow; ii) standardization of medical records and iii) introduction of routine provider initiated testing and counseling (PITC). Assessment of feasibility included monitoring rates of HIV case-finding and referral to care, measuring median waiting and consultation times and assessing adherence to clinical care protocols for HIV and non-HIV outpatients. Qualitative data on patient/provider perceptions was also collected.

Findings: Provider and patient interviews at both sites indicated broad acceptability of the model and highlighted a perceived reduction in stigma associated with integrated HIV services. Over six months in Clinic 1, PITC was provided to 2760 patients; 1485 (53%) accepted testing, 192 (13%) were HIV positive and 80 (42%) enrolled. Median OPD patient-provider contact time increased 55% (6.9 vs. 10.7 minutes; p<0.001) and decreased 1% for ART patients (27.9 vs. 27.7 minutes; p = 0.94). Median waiting times increased by 36 (p<0.001) and 23 minutes (p<0.001) for ART and OPD patients respectively. In Clinic 2, PITC was offered to 1510 patients, with 882 (58%) accepting testing, 208 (24%) HIV positive and 121 (58%) enrolled. Median OPD patient-provider contact time increased 110% (6.1 vs. 12.8 minutes; p<0.001) and decreased for ART patients by 23% (23 vs. 17.7 minutes; p<0.001). Median waiting times increased by 47 (p<0.001) and 34 minutes (p<0.001) for ART and OPD patients, respectively.

Conclusions: Integrating vertical ART and OPD services is feasible in the low-resource and high HIV-prevalence setting of Lusaka, Zambia. Integration enabled shared use of space and staffing that resulted in increased HIV case finding, a reduction in stigma associated with vertical ART services but resulted in an overall increase in patient waiting times. Further research is urgently required to assess long-term clinical outcomes and cost effectiveness in order to evaluate scalability and generalizability.

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Related in: MedlinePlus

Clinic 1 ART quality assurance indicators.
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pone-0011522-g006: Clinic 1 ART quality assurance indicators.

Mentions: Figures 6 and 7 summarize quarterly measurements for six indicators of adherence to ART protocol. In Clinic 1, the percentage of patients with baseline CD4 collected decreased from pre- to first quarter post-implementation (95.3%–88.5%, p = 0.01) but subsequently recovered with no difference between pre- and two-quarters post-implementation (95.3%–97%, p = 0.35). A decline in the percentage of patients with hemoglobin measured while on zidovudine was observed between pre- and two-quarters post-implementation (72.7%–60.3%, p = 0.02). For all other indicators in Clinic 1, no difference was measured. In Clinic 2, an increase in the percentage of delinquent patients was observed between pre- and first quarter post-implementation (6.6%–8.7%, p = 0.04), as well as pre- and second quarter post-implementation (6.6%–10.5%, p = 0.003). This is partially explained by the small numbers involved, as well as the unusually low rate of delinquency in the quarter preceding implementation. There was also a difference in percentage of patients with hemoglobin measured while on zidovudine between pre- and second quarter post-implementation (68.4%–60.6%, p = 0.04); no other indicators demonstrated significant change.


Strengthening health systems at facility-level: feasibility of integrating antiretroviral therapy into primary health care services in lusaka, zambia.

Topp SM, Chipukuma JM, Giganti M, Mwango LK, Chiko LM, Tambatamba-Chapula B, Wamulume CS, Reid S - PLoS ONE (2010)

Clinic 1 ART quality assurance indicators.
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC2903482&req=5

pone-0011522-g006: Clinic 1 ART quality assurance indicators.
Mentions: Figures 6 and 7 summarize quarterly measurements for six indicators of adherence to ART protocol. In Clinic 1, the percentage of patients with baseline CD4 collected decreased from pre- to first quarter post-implementation (95.3%–88.5%, p = 0.01) but subsequently recovered with no difference between pre- and two-quarters post-implementation (95.3%–97%, p = 0.35). A decline in the percentage of patients with hemoglobin measured while on zidovudine was observed between pre- and two-quarters post-implementation (72.7%–60.3%, p = 0.02). For all other indicators in Clinic 1, no difference was measured. In Clinic 2, an increase in the percentage of delinquent patients was observed between pre- and first quarter post-implementation (6.6%–8.7%, p = 0.04), as well as pre- and second quarter post-implementation (6.6%–10.5%, p = 0.003). This is partially explained by the small numbers involved, as well as the unusually low rate of delinquency in the quarter preceding implementation. There was also a difference in percentage of patients with hemoglobin measured while on zidovudine between pre- and second quarter post-implementation (68.4%–60.6%, p = 0.04); no other indicators demonstrated significant change.

Bottom Line: Median OPD patient-provider contact time increased 110% (6.1 vs. 12.8 minutes; p<0.001) and decreased for ART patients by 23% (23 vs. 17.7 minutes; p<0.001).Integration enabled shared use of space and staffing that resulted in increased HIV case finding, a reduction in stigma associated with vertical ART services but resulted in an overall increase in patient waiting times.Further research is urgently required to assess long-term clinical outcomes and cost effectiveness in order to evaluate scalability and generalizability.

View Article: PubMed Central - PubMed

Affiliation: Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. stephanie.topp@cidrz.org

ABSTRACT

Introduction: HIV care and treatment services are primarily delivered in vertical antiretroviral (ART) clinics in sub-Saharan Africa but there have been concerns over the impact on existing primary health care services. This paper presents results from a feasibility study of a fully integrated model of HIV and non-HIV outpatient services in two urban Lusaka clinics.

Methods: INTEGRATION INVOLVED THREE KEY MODIFICATIONS: i) amalgamation of space and patient flow; ii) standardization of medical records and iii) introduction of routine provider initiated testing and counseling (PITC). Assessment of feasibility included monitoring rates of HIV case-finding and referral to care, measuring median waiting and consultation times and assessing adherence to clinical care protocols for HIV and non-HIV outpatients. Qualitative data on patient/provider perceptions was also collected.

Findings: Provider and patient interviews at both sites indicated broad acceptability of the model and highlighted a perceived reduction in stigma associated with integrated HIV services. Over six months in Clinic 1, PITC was provided to 2760 patients; 1485 (53%) accepted testing, 192 (13%) were HIV positive and 80 (42%) enrolled. Median OPD patient-provider contact time increased 55% (6.9 vs. 10.7 minutes; p<0.001) and decreased 1% for ART patients (27.9 vs. 27.7 minutes; p = 0.94). Median waiting times increased by 36 (p<0.001) and 23 minutes (p<0.001) for ART and OPD patients respectively. In Clinic 2, PITC was offered to 1510 patients, with 882 (58%) accepting testing, 208 (24%) HIV positive and 121 (58%) enrolled. Median OPD patient-provider contact time increased 110% (6.1 vs. 12.8 minutes; p<0.001) and decreased for ART patients by 23% (23 vs. 17.7 minutes; p<0.001). Median waiting times increased by 47 (p<0.001) and 34 minutes (p<0.001) for ART and OPD patients, respectively.

Conclusions: Integrating vertical ART and OPD services is feasible in the low-resource and high HIV-prevalence setting of Lusaka, Zambia. Integration enabled shared use of space and staffing that resulted in increased HIV case finding, a reduction in stigma associated with vertical ART services but resulted in an overall increase in patient waiting times. Further research is urgently required to assess long-term clinical outcomes and cost effectiveness in order to evaluate scalability and generalizability.

Show MeSH
Related in: MedlinePlus