Afya III: Rudi Kundini, Pamoja Kundini

Study overview

Use of antiretroviral therapy (ART) among people living with HIV (PLHIV) reduces mortality and lowers transmission; however, these benefits depend largely on viral suppression. Only 65% of PLHIV in eastern and southern Africa have viral suppression, which is a partial reflection of poor linkage, suboptimal adherence, and persistent disengagement from care. The World Health Organisation (WHO) estimates that adherence to long-term therapy of any kind in developed countries averages 50% and is lower in low-income settings. Lifelong ART success, including retention in care, is undermined by stigma, food insecurity, negative clinic experiences, anticipated or actual side effects, misinformation, asymptomatic infection, “treatment fatigue”, and myriad factors related to poverty.

Consequently, retention is a dynamic process, as PLHIV may default and re-engage in care numerous times over a lifetime. Some groups of PLHIV continually struggle to maintain continuity of care and/or viral suppression; these groups are the focus of our proposed study, and the primary endpoints for both objectives 1 and 2 are the viral suppression at 6 and 12 months.

Scope of work and objectives

This study is implemented in 32 health facilities (16 in each region, Geita and Kagera). In Geita, the facilities are Uyovu HC, Nyabugera Dispensary, Bwanga HC, Chato DH, Lwamgasa Dispensary, Katoro HC, Chikobe HC, Kasota HC, Nkome Dispensary, Ikunguigazi Dispensary, Bulugala HC, Masumbwe HC, Kasamwa HC, Geita RRH, Kharumwa HC, and Nzera DH. In Kagera, the sites are: Ndolage HC, Kaigara HC, Bukoba RRH, Bunazi HC, Mugana HC, St. Mary’s Isingiro, Kayanga HC, Murgwanza Hospital, Rulenge HC, Kimeya HC, Kanazi HC, Mabira Disp, Nyakanazi HC, Nyabusozi Disp, Biharamulo CDH and Nkwenda HC. Each facility has a target to enrol 20 clients (≥ 18 years old) who were lost to follow up whereby enrollment starting in August 2022, and we expect the VL collection phase to be completed by June 2024.

Ø  Objective 1: To evaluate the effectiveness of a home visit plus a one-time financial incentive on the proportion of out-of-care PLHIV with viral load suppression (<1000 copies/ml) at 6 months.

Ø  Objective 2: To evaluate the effectiveness of a short-term financial incentive program offered to in-care PLHIV who are predicted to be at high risk of disengaging from care using machine learning on durable viral load suppression (<1000 copies/ml) at 12 months:

Ø  Objective 3: Using a mixed-methods study, explore implementation successes and challenges and synthesise lessons learned to inform possible integration of incentive programs into the National AIDS Control Program for PLHIV who are out of care or at risk of disengaging. It will consist of quantitative and qualitative interviews with health facility staff, government stakeholders and PLHIV at participating sites. Consistent with a hybrid effectiveness-implementation study, we will triangulate Objective 1-2 results with Objective 3 findings about implementation to guide intervention optimisation and scale up, if effective.