Identifying models of HIV care and treatment service delivery in Tanzania, Uganda, and Zambia using cluster analysis and Delphi survey

Sharon Tsui, Julie A Denison, Caitlin E Kennedy, Larry W Chang, Olivier Koole, Kwasi Torpey, Eric Van Praag, Jason Farley, Nathan Ford, Leine Stuart, Fred Wabwire-Mangen, Sharon Tsui, Julie A Denison, Caitlin E Kennedy, Larry W Chang, Olivier Koole, Kwasi Torpey, Eric Van Praag, Jason Farley, Nathan Ford, Leine Stuart, Fred Wabwire-Mangen

Abstract

Background: Organization of HIV care and treatment services, including clinic staffing and services, may shape clinical and financial outcomes, yet there has been little attempt to describe different models of HIV care in sub-Saharan Africa (SSA). Information about the relative benefits and drawbacks of different models could inform the scale-up of antiretroviral therapy (ART) and associated services in resource-limited settings (RLS), especially in light of expanded client populations with country adoption of WHO's test and treat recommendation.

Methods: We characterized task-shifting/task-sharing practices in 19 diverse ART clinics in Tanzania, Uganda, and Zambia and used cluster analysis to identify unique models of service provision. We ran descriptive statistics to explore how the clusters varied by environmental factors and programmatic characteristics. Finally, we employed the Delphi Method to make systematic use of expert opinions to ensure that the cluster variables were meaningful in the context of actual task-shifting of ART services in SSA.

Results: The cluster analysis identified three task-shifting/task-sharing models. The main differences across models were the availability of medical doctors, the scope of clinical responsibility assigned to nurses, and the use of lay health care workers. Patterns of healthcare staffing in HIV service delivery were associated with different environmental factors (e.g., health facility levels, urban vs. rural settings) and programme characteristics (e.g., community ART distribution or integrated tuberculosis treatment on-site).

Conclusions: Understanding the relative advantages and disadvantages of different models of care can help national programmes adapt to increased client load, select optimal adherence strategies within decentralized models of care, and identify differentiated models of care for clients to meet the growing needs of long-term ART patients who require more complicated treatment management.

Keywords: Africa; Antiretroviral therapy; Cluster analysis; Delphi method; Human resources for health; Task sharing; Task shifting.

Conflict of interest statement

Ethics approval and consent to participate

All ART managers provided written informed consent prior to data collection, which was approved by seven Institutional Review Boards (IRB), including the US Centers for Disease Control and Prevention (CDC)‘s Human Research Protection Office, FHI 360’s Protection of Human Subjects Committee, Institute of Tropical Medicine Antwerp’s Universitair Ziekenhuis Antwerpen Ethics Committee, Tanzania’s Muhimbili University of Health and Allied Sciences Ethics Committee, Uganda’s National HIV/AIDS Research Committee, and Zambia’s Tropical Diseases Research Center Ethics Review Committee. The Massachusetts General Hospital’s Partners Human Research Committee ceded review to FHI 360. For the Delphi survey, the Johns Hopkins Bloomberg School of Public Health IRB determined that the survey did not require IRB oversight (DHHS regulations 45 CFR 46.102).

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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