Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
Department of Public Health, Environments and Society, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK.
BMJ Glob Health. 2024 Aug 12;9(8):e015236. doi: 10.1136/bmjgh-2024-015236.
HIV testing and starting antiretroviral therapy (ART) are pivotal in treating people living with HIV (PLHIV) but sustaining PLHIV on treatment remains challenging. We assessed retention and attrition in community client-led antiretroviral distribution groups (CCLADs) in Uganda and identified positive deviant practices that foster long-term retention.
Using explanatory mixed methods, we collected longitudinal medical data from 65 health facilities across 12 districts in East Central Uganda. Quantitative phase, from 18 April 2021 to 30 May 2021, employed survival analysis and Cox regression to assess retention and identify attrition risk factors. Qualitative inquiry focused on four districts with high attrition from 11 August 2021 to 20 September 2021, where we identified nine health facilities exhibiting high retention in CCLADs. We purposively selected 50 clients for in-depth interviews (n=22) or focus group discussions (n=28). Using thematic analysis, we identified positive deviant practices. We integrated quantitative and qualitative findings into joint displays.
Involving 3055 PLHIV, the study showed retention rates of 97.5% at 6 months, declining to 89.7% at 96 months. Attrition risk factors were lower levels of care (health centre three (adjusted HR (aHR) 2.80, 95% CI 2.00 to 3.65) and health centre four (aHR 3.61, 95% CI 2.35 to 5.54)); being unemployed (aHR 2.21, 95% CI 1.00 to 4.84); enrolment year into CCLAD (aHR 23.93, 95% CI 4.66 to 123.05) and virological failure (aHR 3.41, 95% CI 2.51 to 4.63). Of 22 clients interviewed, 8 were positive deviants. Positive deviants were characterised by prolonged retention in CCLADs, improved clinical outcomes and practised uncommon behaviours that enabled them to find better solutions than their peers. Positive deviant practices included fostering family-like settings, offering financial or self-development advice, and promoting healthy lifestyles.
Findings underscore the importance of addressing factors contributing to attrition and leveraging positive deviant practices to optimise retention and long-term engagement in HIV care.
艾滋病毒检测和开始抗逆转录病毒治疗（ART）是治疗艾滋病毒感染者（PLHIV）的关键，但维持 PLHIV 的治疗仍然具有挑战性。我们评估了乌干达社区主导的抗逆转录病毒分发小组（CCLAD）中的保留和流失情况，并确定了促进长期保留的积极偏差实践。
使用解释性混合方法，我们从乌干达中东部 12 个区的 65 个卫生设施收集了纵向医疗数据。定量阶段从 2021 年 4 月 18 日至 5 月 30 日，采用生存分析和 Cox 回归评估保留率并确定流失风险因素。定性探究集中在四个流失率较高的地区，从 2021 年 8 月 11 日至 9 月 20 日，我们在那里确定了 9 个在 CCLAD 中保留率较高的卫生设施。我们有目的地选择了 50 名客户进行深入访谈（n=22）或焦点小组讨论（n=28）。使用主题分析，我们确定了积极的偏差实践。我们将定量和定性发现整合到联合展示中。
涉及 3055 名 PLHIV，研究显示 6 个月时的保留率为 97.5%，96 个月时降至 89.7%。流失风险因素包括护理水平较低（保健中心三（调整后的 HR（aHR）2.80，95%CI 2.00 至 3.65）和保健中心四（aHR 3.61，95%CI 2.35 至 5.54））；失业（aHR 2.21，95%CI 1.00 至 4.84）；CCLAD 入组年份（aHR 23.93，95%CI 4.66 至 123.05）和病毒学失败（aHR 3.41，95%CI 2.51 至 4.63）。在接受采访的 22 名客户中，有 8 人是积极偏差者。积极偏差者的特点是长期保留在 CCLAD 中，改善了临床结果，并采取了不常见的行为，使他们能够找到比同龄人更好的解决方案。积极偏差实践包括营造类似家庭的环境、提供财务或自我发展建议以及促进健康的生活方式。
研究结果强调了解决导致流失的因素和利用积极偏差实践的重要性，以优化 HIV 护理的保留和长期参与。
