Suchergebnisse

IntroductionAs access to antiretroviral therapy (ART) increases, the success of treatment programmes depends on ensuring high patient retention in HIV care. We examined retention and attrition among adolescents in ART programmes across clinics operated by The AIDS Support Organization (TASO) in Uganda, which has operated both facility‐ and community‐based distribution models of ART delivery since 2004.MethodsUsing a retrospective cohort analysis of patient‐level clinical data, we examined attrition and retention in HIV care and factors associated with attrition among HIV‐positive adolescents aged 10–19 years who initiated ART at 10 TASO clinics between January 2006 and December 2011. Retention in care was defined as the proportion of adolescents who had had at least one facility visit within the six months prior to 1 June 2013, and attrition was defined as the proportion of adolescents who died, were lost to follow‐up, or stopped treatment. Descriptive statistics and Cox proportional hazards regression models were used to determine the levels of retention in HIV care and the factors associated with attrition following ART initiation.ResultsA total of 1228 adolescents began ART between 2006 and 2011, of whom 57% were female. The median duration in HIV care was four years (IQR=3–6 years). A total of 792 (65%) adolescents were retained in care over the five‐year period; 36 (3%) had died or transferred out and 400 (32%) were classified as loss to follow‐up. Factors associated with attrition included being older (adjusted hazard ratio (AHR)=1.38, 95% confidence interval (CI) 1.02–1.86), having a higher CD4 count (250+ cells/mm3) at treatment initiation (AHR=0.49, 95% CI 0.34–0.69) and HIV care site with a higher risk of attrition among adolescents in Gulu (AHR=2.26; 95% CI 1.27–4.02) and Masindi (AHR=3.30, 95% CI 1.87–5.84) and a lower risk of attrition in Jinja (AHR=0.24, 95% CI 0.08–0.70). Having an advanced WHO clinical stage at initiation was not associated with attrition.ConclusionsWe found an overall retention rate of 65%, which is comparable to rates achieved by TASO's adult patients and adolescents in other studies in Africa. Variations in the risk of attrition by TASO treatment site and by clinical and demographic characteristics suggest the need for early diagnosis of HIV infection, use of innovative approaches to reach and retain adolescents living with HIV in treatment and identifying specific groups, such as older adolescents, that are at high risk of dropping out of treatment for targeted care and support.

AbstractIntroductionDespite international commitment to achieving the end of HIV as a public health threat, progress is off‐track and existing gaps have been exacerbated by COVID‐19's collision with existing pandemics. Born out of models of political accountability and historical healthcare advocacy led by people living with HIV, community‐led monitoring (CLM) of health service delivery holds potential as a social accountability model to increase the accessibility and quality of health systems. However, the effectiveness of the CLM model in strengthening accountability and improving service delivery relies on its alignment with evidence‐based principles for social accountability mechanisms. We propose a set of unifying principles for CLM to support the impact on the quality and availability of health services.DiscussionBuilding on the social accountability literature, core CLM implementation principles are defined. CLM programmes include a community‐led and independent data collection effort, in which the data tools and methodology are designed by service users and communities most vulnerable to, and most impacted by, service quality. Data are collected routinely, with an emphasis on prioritizing and protecting respondents, and are then be used to conduct routine and community‐led advocacy, with the aim of increasing duty‐bearer accountability to service users. CLM efforts should represent a broad and collective community response, led independently by impacted communities, incorporating both data collection and advocacy, and should be understood as a long‐term approach to building meaningful engagement in systems‐wide improvements rather than discrete interventions.ConclusionsThe CLM model is an important social accountability mechanism for improving the responsiveness of critical health services and systems to communities. By establishing a collective understanding of CLM principles, this model paves the way for improved proliferation of CLM with fidelity of implementation approaches to core principles, rigorous examinations of CLM implementation approaches, impact assessments and evaluations of CLM's influence on service quality improvement.