A. What evidence are you proposing to translate into practice?
I am proposing to translate patient 'engagement' in HIV care into practice on Mfangano Island, Kenya. Sustained engagement in clinical care and thus consistent access to antiretrivoral therapy is essential for maintaining good clinical outcomes among those who are HIV-infected. The proposed intervention is a social network intervention designed to activate patient’s social networks to provide support for HIV care and treatment. This intervention provides social network groups with basic education on HIV biology and medication, as well as training on how to provide support for HIV treatment and prevention within the group and for the community at-large. After a series of training sessions, groups participate in voluntary HIV status disclosure within the group, such that each group member learns the HIV status of all other group members. In a community where the adult HIV prevalence is approximately 30%, this process often helps patients realize that they are not alone in dealing with HIV.
Justify that this evidence is “ready for translation.”
Engagement in care, defined as consistent attendance of scheduled appointments, is strongly associated with virologic suppression, an established surrogate for HIV-related morbidity and mortality. It is clear that attendance of clinic appointments, and thus refill of antiretroviral medications, is important for ensuring good clinical outcomes in the management of chronic HIV infection.
Identify a single, key behavior change target for your translational activity.
The behavioral target is attendance of clinic appointments. Barriers to appointment attendance, as documented in numerous studies, include financial (lacking money for transport, lacking help at work while absent), psychosocial (stigma, depression), physical (both feeling well and feeling sick).[1] The largest qualitative study to date evaluating facilitators of engagement in care identified social capital as a critical factor in maintaining good engagement.[2] Social capital serves both as a resource for overcoming financial or physical barriers and also a source of emotional support. The proposed intervention aims to formalize fostering of this social capital among existing social networks to promote sustained engagement in care.
Conduct a “gap analysis” of your target behavior. Look to diverse sources for “best guess” estimates if specific measures are not available.
In a quasi-experimental pilot study we conducted on Mfangano, 20% of patients in the control arm missed a clinic appointment by ≥90 days during 22-months of follow-up. A recent meta analysis estimates that retention in care may be as low as 70% among patients on antiretroviral therapy in sub-Saharan Africa.[3]
B. What is the quality (performance) gap?
Ideally, all patients should attend their scheduled clinic appointments. Even in cases where patients travel or are otherwise unable to make their appointment, alternate arrangements should be made to obtain needed medication refills. If 20% have gaps in care at baseline, this could be realistically reduced to 5%, leaving a gap of 15%.
C. What is the outcome gap?
unsuppressed viral load (strong surrogate), morbidity and mortality all result from poor engagement in HIV care
D. Is there evidence that changing performance will improve health (clinical outcomes)?
There is strong evidence that gaps in care increase the liklihood of developing medication resistance. Furthermore, gaps in care or permanent disengagement from care is associated with poor clinical outcomes. This suggests that minimizing these gaps will reduce both development of resistance and adverse health outcomes.
References:
1. Geng EH, Bangsberg DR, Musinguzi N, Emenyonu N, Bwana MB, et al. (2010) Understanding reasons for and outcomes of patients lost to follow-up in antiretroviral therapy programs in Africa through a sampling-based approach. Journal of acquired immune deficiency syndromes (1999) 53: 405-411.
2. Ware NC, Idoko J, Kaaya S, Biraro IA, Wyatt MA, et al. (2009) Explaining adherence success in sub-Saharan Africa: an ethnographic study. PLoS Med 6: e11.
3. Fox MP, Rosen S (2010) Patient retention in antiretroviral therapy programs up to three years on treatment in sub-Saharan Africa, 2007-2009: systematic review. Tropical medicine & international health : TM & IH 15 Suppl 1: 1-15.