Purpose: Immediate initiation of antiretroviral treatment following HIV infection is a cornerstone of the current HIV ‘universal test and treat’ approach. Delayed progress along the HIV care... Show morePurpose: Immediate initiation of antiretroviral treatment following HIV infection is a cornerstone of the current HIV ‘universal test and treat’ approach. Delayed progress along the HIV care continuum is thus framed as a major stumbling block in effective HIV epidemic control. Through examining the HIV care trajectories of people diagnosed with HIV in Shinyanga Region, Tanzania, we offer a critical interrogation of the HIV care continuum. Methods: Data are drawn from a social science study on the uptake of a ‘treat all’ model of HIV prevention and care conducted from 2018 to 2019. Methods included interviews with participants who tested positive (n = 30) and interviews (n = 25) with health staff involved in the testing campaigns.Findings: Exploring individuals’ care trajectories, we found that most participants followed pathways to care that do not easily align with the current emphasis on rapid, linear progress from testing to treatment initiation. Instead, participants’ trajectories from diagnosis to treatment happened on a different, non-linear time scale mediated through social relations and diverse communities of care. We thus conceptualize five pathways of linkage to care - virtuous/immediate, delayed testing, repeat testing, negotiated, and ‘failed’.Conclusion: Based on our findings we propose a community-centered HIV care continuum that exposes moments of potential connection with or rupture from the health system and centers the importance of social support structures and forms of relational labor involving broader communities of care. Show less
Okere, N.E.; Meta, J.; Maokola, W.; Martelli, G.; Praag, E. van; Naniche, D.; ... ; Hermans, S. 2022
Background: Differentiated service delivery (DSD) offers benefits to people living with HIV (improved access, peer support), and the health system (clinic decongestion, efficient service delivery).... Show moreBackground: Differentiated service delivery (DSD) offers benefits to people living with HIV (improved access, peer support), and the health system (clinic decongestion, efficient service delivery). ART clubs, 15–30 clients who usually meet within the community, are one of the most common DSD options. However, evidence about the quality of care (QoC) delivered in ART clubs is still limited.Materials and methods: We conducted a concurrent triangulation mixed-methods study as part of the Test & Treat project in northwest Tanzania. We surveyed QoC among stable clients and health care workers (HCW) comparing between clinics and clubs. Using a Donabedian framework we structured the analysis into three levels of assessment: structure (staff, equipment, supplies, venue), processes (time-spent, screenings, information, HCW-attitude), and outcomes (viral load, CD4 count, retention, self-worth).Results: We surveyed 629 clients (40% in club) and conducted eight focus group discussions, while 24 HCW (25% in club) were surveyed and 22 individual interviews were conducted. Quantitative results revealed that in terms of structure, clubs fared better than clinics except for perceived adequacy of service delivery venue (94.4% vs 50.0%, p = 0.013). For processes, time spent receiving care was significantly more in clinics than clubs (119.9 vs 49.9 minutes). Regarding outcomes, retention was higher in the clubs (97.6% vs 100%), while the proportion of clients with recent viral load <50 copies/ml was higher in clinics (100% vs 94.4%). Qualitative results indicated that quality care was perceived similarly among clients in clinics and clubs but for different reasons. Clinics were generally perceived as places with expertise and clubs as efficient places with peer support and empathy. In describing QoC, HCW emphasized structure-related attributes while clients focused on processes. Outcomes-related themes such as improved client health status, self-worth, and confidentiality were similarly perceived across clients and HCW.Conclusion: We found better structure and process of care in clubs than clinics with comparable outcomes. While QoC was perceived similarly in clinics and clubs, its meaning was understood differently between clients. DSD catered to the individual needs of clients, either technical care in the clinic or proximate and social care in the club. Our findings highlight that both clinic and DSD care are required as many elements of QoC were individually perceived. Show less
