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Can Self-Management Improve HIV Treatment Engagement, Adherence, and Retention? A Mixed Methods Evaluation in Tanzania and Uganda

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Abstract

This paper presents the evaluation results of a self-management support (SMS) initiative in Tanzania and Uganda, which used quality improvement to provide self-management counseling, nutritional support, and strengthened linkages to community-based services for highest-risk patients (those with malnutrition, missed appointments, poor adherence, high viral load, or low CD4 count). The evaluation assessed improvements in patient engagement, ART adherence, and retention. Difference-in-difference models used clinical data (n = 541 in Tanzania, 571 in Uganda) to compare SMS enrollees to people who would have met SMS eligibility criteria had they been at intervention sites. Interviews with health care providers explored experiences with the SMS program and were analyzed using codes derived deductively from the data. By end-line, SMS participants in Tanzania had significantly improved visit attendance (odds ratio 3.53, 95% confidence interval 2.15, 5.77); a non- significant improvement was seen in Uganda (odds ratio 1.62, 95% confidence interval 0.37, 7.02), which may reflect a dose–response relationship due to shorter program exposure there. Self-management can improve vulnerable patients’ outcomes—but maximum gains may require long implementation periods and accompanying system-level interventions. SMS interventions require long-term investment and should be contextualized in the systems and environments in which they operate.

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Acknowledgements

The authors express their gratitude for research assistance and support from: Canice Ahearn, Esther Fevrier, Diana Chamrad, Nigel Livesley, Lani Marquez, and Timothy Quick. The self-management support intervention and evaluation were funded by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) through the United States Agency for International Development (USAID) and implemented through the USAID Applying Science to Strengthen and Improve Systems Project managed by University Research Co., LLC under the terms of Cooperative Agreement Number AID-OAA-A-12-00101. Additionally, this analysis received support from Harvard Catalyst| The Harvard Clinical and Translational Science Center (National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health Award UL1 TR001102) and financial contributions from Harvard University and its affiliated academic healthcare centers. CM receives support from the Center for HIV Identification, Prevention, and Treatment Services (CHIPTS) NIMH grant P30MH58107; and from the NIH/National Center for Advancing Translational Science (NCATS) UCLA CTSI Grant Number KL2TR001882. The content is solely the responsibility of the authors and does not necessarily represent the official views of Harvard Catalyst, Harvard University and its affiliated academic healthcare centers, the National Institutes of Health, or USAID.

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Authors and Affiliations

  1. Department of Health Policy and Management, University of California Fielding School of Public Health, 650 Charles E Young Dr. S., Los Angeles, CA, 90095, USA

    Corrina Moucheraud

  2. USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project, University Research Co, LLC, Chevy Chase, MD, USA

    Amy F. Stern & Anisa Ismail

  3. USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project, University Research Co., LLC, Kampala, Uganda

    Tamara Nsubuga-Nyombi & Jude Ssensamba

  4. USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project, University Research Co., LLC, Dar es Salaam, Tanzania

    Monica M. Ngonyani & Jane Mvungi

Authors
  1. Corrina Moucheraud
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  2. Amy F. Stern
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  3. Anisa Ismail
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  4. Tamara Nsubuga-Nyombi
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  5. Monica M. Ngonyani
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  6. Jane Mvungi
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  7. Jude Ssensamba
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Correspondence to Corrina Moucheraud.

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Appendices

Appendices

Appendix 1

Interview Questions About SMS Program

  • Have you ever participated in any self-management activities? Give us your view about it.

  • Is there a “self-management” program at this facility?

  • If yes:

    • Who in the clinic participates in this program?

    • How does your facility implement this program?

    • Do you feel that the self-management tools and protocols your clinic is using are making a difference in your patients’ clinical outcomes? Why or why not?

  • If no:

    • Do you feel there is a role for increased patient self-management? Why or why not?

  • How can we make self-management services better and more acceptable in this facility?

  • Is there anything you would like to see done differently in this facility? If yes, what?

Codebook for Qualitative Data Analysis

  • Service delivery

    • Challenges to providing care

    • Impact of care on patients’ health—HIV

    • Impact of care on patients’ health—nutrition

    • Impact of care on patients’ empowerment

    • Perceived patient satisfaction with care

  • Self-management program

    • Benefits/role of the program

    • Drawbacks of the program

    • Program details

    • Suggestions for program improvement

    • Other comments about SMS

Appendix 2

Patient Outcomes, by Country and Site Type, Pre Versus Post Period

See Table 5.

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Moucheraud, C., Stern, A.F., Ismail, A. et al. Can Self-Management Improve HIV Treatment Engagement, Adherence, and Retention? A Mixed Methods Evaluation in Tanzania and Uganda. AIDS Behav 24, 1486–1494 (2020). https://doi.org/10.1007/s10461-019-02672-9

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  • DOI: https://doi.org/10.1007/s10461-019-02672-9

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