Evaluation of Facility-Based Individual Differentiated Service Delivery Among People Living with HIV in Nairobi, Kenya Open Access
Kinuthia, Rosemary (Spring 2022)
Published
Abstract
Introduction: It is challenging to maintain a high level of engagement for HIV care in regions with a high HIV burden due to health workforce shortages, making it very difficult to realize the goal of universal viral suppression. In response to global workforce shortages impacting access to HIV care, the World Health Organization recommends implementation of differentiated service delivery (DSD). DSD is a patient-centered approach to delivering HIV care and improving access to antiretroviral therapy for persons living with HIV who are established on ART. Out of the four DSD models, facility-based individual DSD is the least complex to implement. Thus, it has been widely implemented in sub-Saharan Africa, which bears the greatest HIV burden globally. This research aimed to study the impact of facility-based individual DSD.
Methods: This study used qualitative and quantitative research methods, including the analysis of retrospectively collected patient data abstracted from electronic medical records and interviews with health workers at a large HIV treatment facility in Nairobi, Kenya. Bivariate analysis was conducted to assess the association between facility-based individual DSD and viral suppression status among DSD-eligible patients who enrolled in DSD vs DSD-eligible patients who enrolled in standard care. In-depth semi-structured interviews with health workers explored their perceptions and experiences with the model. Qualitative descriptive methods were used to analyze interview data.
Results: A total of 814 participants were included in the analysis (41.5% male, 58.5% female). Majority were between 40-49 (37.3%) and 50-59 (38.3%) years of age. A pre-post McNemar’s test determined that among those who were eligible and enrolled in DSD, 94.6% maintained an undetectable viral load after 1 year (p= 0.078). A McNemar’s test looking post-enrollment viral load detection was conducted on 388 eligible matched pairs. The test determined that only 6 (1.6%) of the matched DSD pairs were detectable at the post visit, compared to only 3 (0.8%) of the matched non-DSD members pairs (p= 0.508). For Aim 2, a total of 30 HWs were interviewed. Participants primarily expressed their preference for facility-based DSD implementation over standard care, citing that it was beneficial to patients and health workers.
Conclusion: This study demonstrates the effectiveness of facility-based DSD in maintaining viral load suppression in patients and alleviating reduced HIV health workforce challenges in resource-limited settings. Findings will inform best-practices in HIV service delivery and facilitate the development of efficient models of care.
Table of Contents
Chapter 1: Research Protocol.....................................................................................................1
Introduction..............................................................................................................................2
Research Question and Study Aims.............................................................................................7
Conceptual Framework.............................................................................................................. 8
Methods...................................................................................................................................15
Study Design............................................................................................................................15
Setting ....................................................................................................................................15 Participants..............................................................................................................................16
Sampling Size and Power ..........................................................................................................17
Data Collection and Analysis.....................................................................................................19
Study Relevance........................................................................................................................20
Ethics and Dissemination...........................................................................................................21
Ethical Considerations ...............................................................................................................21
Informed Consent and Institutional Review Boards ..................................................................... 21
Confidentiality ..........................................................................................................................22
Outline of the Dissertation ........................................................................................................ 23
References................................................................................................................................. 24
Chapter 2: An Integrative Review of Facility-Based Individual Differentiated Service Delivery
Models for HIV Treatment in Sub-Saharan Africa ......................................................................30
Abstract ..................................................................................................................................... 31 Introduction............................................................................................................................... 33 Methods..................................................................................................................................... 36 Results....................................................................................................................................... 37
Discussion ................................................................................................................................. 45
Conclusion ................................................................................................................................ 48 References................................................................................................................................. 50
Chapter 3: Impact of Facility-Based Individual Differentiated Service Delivery on Viral
Suppression of HIV-Infected Persons in Nairobi, Kenya.............................................................71
Abstract .....................................................................................................................................72 Introduction............................................................................................................................... 75 Methods..................................................................................................................................... 79 Results....................................................................................................................................... 82
Discussion ................................................................................................................................. 90
Conclusion ................................................................................................................................ 93 References................................................................................................................................. 94
Chapter 4: Using Re-Aim to Examine Healthcare Workers’ Perspectives of Facility-Based
Individual Differentiated Service Delivery in Nairobi, Kenya .................................................101
Abstract ..................................................................................................................................102 Introduction............................................................................................................................104 Methods..................................................................................................................................108 Results....................................................................................................................................111
Discussion ..............................................................................................................................124 Conclusions.............................................................................................................................126 References...............................................................................................................................127
Chapter 5: Summary and Conclusions .....................................................................................135
Summary of Results..................................................................................................................136
Strengths and Limitations ........................................................................................................141
Research, Policy, and Clinical Implications ................................................................................142 Conclusions.............................................................................................................................143
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