Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
Department of Global Health, Boston University School of Public Health, Boston, MA, USA.
J Int AIDS Soc. 2020 Jun;23(6):e25544. doi: 10.1002/jia2.25544.
In 2014, the South African government adopted a differentiated service delivery (DSD) model in its "National Adherence Guidelines for Chronic Diseases (HIV, TB and NCDs)" (AGL) to strengthen the HIV care cascade. We describe the barriers and facilitators of the AGL implementation as experienced by various stakeholders in eight intervention and control sites across four districts.
Embedded within a cluster-randomized evaluation of the AGL, we conducted 48 in-depth interviews (IDIs) with healthcare providers, 16 IDIs with Department of Health and implementing partners and 24 focus group discussions (FGDs) with three HIV patient groups: new, stable and those not stable on treatment or not adhering to care. IDIs were conducted from August 2016 to August 2017; FGDs were conducted in January to February 2017. Content analysis was guided by the Consolidated Framework for Implementation Research. Findings were triangulated among respondent types to elicit barriers and facilitators to implementation.
New HIV patients found counselling helpful but intervention respondents reported sub-optimal counselling and privacy concerns as barriers to initiation. Providers felt insufficiently trained for this intervention and were confused by the simultaneous rollout of the Universal Test and Treat strategy. For stable patients, repeat prescription collection strategies (RPCS) were generally well received. Patients and providers concurred that RPCS reduced congestion and waiting times at clinics. There was confusion though, among providers and implementers, around implementation of RPCS interventions. For patients not stable on treatment, enhanced counselling and tracing patients lost-to-follow-up were perceived as beneficial to adherence behaviours but faced logistical challenges. All providers faced difficulties accessing data and identifying patients in need of tracing. Congestion at clinics and staff attitude were perceived as barriers preventing patients returning to care.
Implementation of DSD models at scale is complex but this evaluation identified several positive aspects of AGL implementation. The positive perception of RPCS interventions and challenges managing patients not stable on treatment aligned with results from the larger evaluation. While some implementation challenges may resolve with experience, ensuring providers and implementers have the necessary training, tools and resources to operationalize AGL effectively is critical to the overall success of South Africa's HIV control strategy.
2014 年，南非政府在其“慢性疾病（HIV、TB 和非传染性疾病）国家遵医嘱准则”（AGL）中采用了差异化服务提供（DSD）模式，以加强 HIV 护理级联。我们描述了在四个地区的八个干预和对照点的各种利益相关者在实施 AGL 方面遇到的障碍和促进因素。
在对 AGL 的一项集群随机评估中，我们对医疗保健提供者进行了 48 次深入访谈（IDIs），对卫生部和实施伙伴进行了 16 次 IDIs，并对三组 HIV 患者进行了 24 次焦点小组讨论（FGD）：新患者、稳定患者和那些治疗不稳定或不遵医嘱的患者。IDIs 于 2016 年 8 月至 2017 年 8 月进行；FGD 于 2017 年 1 月至 2 月进行。内容分析由实施研究综合框架指导。调查结果在受访者类型之间进行三角测量，以得出实施的障碍和促进因素。
新的 HIV 患者发现咨询很有帮助，但干预受访者报告说，咨询不足和隐私问题是启动治疗的障碍。提供者认为自己没有接受过这种干预的充分培训，并且对同时推出普遍检测和治疗策略感到困惑。对于稳定的患者，重复处方收集策略（RPCS）普遍受到欢迎。患者和提供者都认为 RPCS 减少了诊所的拥堵和等待时间。然而，提供者和实施者对 RPCS 干预的实施存在混淆。对于治疗不稳定的患者，增强咨询和跟踪失去随访的患者被认为有利于提高遵医嘱行为，但面临后勤挑战。所有提供者在获取数据和识别需要跟踪的患者方面都遇到了困难。诊所的拥堵和工作人员的态度被认为是阻止患者返回护理的障碍。
在大规模实施 DSD 模式是复杂的，但这项评估确定了 AGL 实施的几个积极方面。对 RPCS 干预的积极看法和管理治疗不稳定的患者的挑战与更大规模评估的结果一致。虽然一些实施挑战可能随着经验的增加而得到解决，但确保提供者和实施者拥有必要的培训、工具和资源来有效地实施 AGL，对南非 HIV 控制战略的整体成功至关重要。
