This dissertation uses three types of routinely collected data from HIV care and treatment facilities in sub-Saharan Africa to investigate the association between the availability of adherence support and active outreach services on patient non-retention, loss to follow-up, and measured death after ART initiation. Following a literature review summarizing the state of knowledge concerning the influence of programmatic services on patient retention in care and survival, these relationships are first examined in an aggregate analysis of over 232,000 patients at 349 HIV care and treatment facilities initiating ART between January 2004 and December 2008. Key findings are that several adherence support and outreach services are associated with reduced rates of non-retention, loss to follow-up, and death. Specifically, facilities offering three or more adherence support services, written educational materials promoting ART adherence, one-on-one or group adherence counseling sessions, reminder tools, and food rations to promote ART adherence were associated with reduced non-retention and loss to follow-up, while facilities offering on-site support groups for HIV+ patients, peer educators, provision of reminder tools, and food rations to promote ART adherence were associated with reduced death rates. In sub-analyses investigating six- and 12-month retention after ART initiation, facilities offering three or more separate adherence support services, routine review of medication pickup and/or dedicated ART pharmacists, and active patient outreach to trace patients missing visits had lower non-retention. Taken together, this analysis provides evidence that program-level services found efficacious in experimental settings are also effective in operational settings. Next, a sub-analysis is conducted among facilities also providing electronic patient-level data to investigate similarities and differences in the association between adherence support and outreach services and patient non-retention, loss to follow-up, and measured death using aggregate vs. patient-level estimates of these outcomes, and to assess whether adjustment for patient-level differences between facilities change these measures of association. In multivariate analyses, clinics offering active patient outreach had lower rates of non-retention in both the ART cohort analysis and the patient-level analysis, and clinics offering food rations to promote ART adherence were associated with a lower risk of ascertained death in both the facility-level and patient-level analyses, but this association was diminished after adjustment for patient-level covariates. In contrast, various adherence counseling or support services were associated with lower non-retention in the ART cohort analyses but not in the patient-level data analyses. When compared with the results in the first paper, fewer associations were observed, suggesting either that the countries with patient-level databases are not representative of the entire range of HIV care and treatment facilities assessed in the first paper, and/or the specific facilities with electronic databases are more similar to each other than they are to facilities without electronic databases. Finally, the dissertation concludes with an investigation into the relationship between loss to follow-up and measured death. For this analysis, estimates of the death probability among patients lost to follow-up are created under varying assumptions (either assuming that the death probability among those lost to follow-up is equivalent to the death probability within various strata of covariates, or assuming that the probability of death is greater among patients lost to follow-up). Key findings from this analysis are that ratio comparisons of death rates between facilities offering different services are robust to changes in the death probability if patients lost to follow-up are assumed to have a similar probability of death, conditioned on covariates, as those not lost to follow-up, but that associations between facility services and death rates are masked under the scenario where the facility service is associated with loss to follow-up and the death probability is assumed to be higher, conditioned on covariates, then the death probability among patients not lost to follow-up.

The HIV care continuum captures the proportion of people who engage in various steps of the treatment cascade from the time of HIV diagnosis to the achievement of viral load suppression. Viral load suppression is the ultimate goal of HIV treatment as it is the best way to mitigate the spread of HIV and contain the epidemic. The best pathway to viral load suppression is not always clear. There are several factors that aid or hinder HIV patients from engaging in every step of the care continuum until they achieve and sustain viral load suppression. This dissertation aims to measure the underlying enablers of engagement in HIV care, relate them to potential barriers, and assess the effect of each enabler and barrier on future engagement in care and viral load suppression using data collected from people living with HIV (PLHIV) in Eswatini. Firstly, a systematic review was conducted to summarize the methodologies used to measure and analyze barriers and enablers of engagement in HIV care. A search of all peer-reviewed articles published in English globally since 1996 yielded a final selection of 228 articles. The vast majority of the studies were qualitative and descriptive, and there was a scarcity of quantitative studies utilizing predictive methods that can measure the effect of a barrier or enabler on future engagement in care. Secondly, an empirical analysis was conducted to assess the dimensionality (factor structure) of enablers of engagement in care using a sample largely representative of HIV patients in care in Eswatini. This analysis demonstrated the use of psychometric techniques that can capture underlying latent enablers. These techniques are useful for standardizing the measurements of enablers across studies and programs and can be used to predict future engagement in care. This analysis found financial and access enablers to be the most prominent underlying factors supporting engagement in care in Eswatini, suggesting that these should be an important consideration when designing interventions to retain HIV patients in care in resource-limited settings similar to Eswatini. Thirdly, in an additional empirical analysis, the latent enablers previously identified were used to select potential barriers and assess their effect on linkage to care, retention in care, and viral load suppression. The analysis also involved an assessment of the mediational pathway from the potential barriers to care to viral load suppression that goes through retention in care. Only perceived HIV stigma was related to any step of the care continuum, with low perceived stigma being marginally associated with less viral load suppression. Retention in care did not mediate the relationship between perceived stigma and viral load suppression. More psychometric studies are needed to standardize the measurement of underlying factors affecting engagement in HIV care. This dissertation demonstrated their utility by measuring latent enablers of engagement in care, assessing the downstream effects of the latent enablers and corresponding barriers, and assessing the mechanisms by which the barriers affect viral load suppression.

Adolescents and young adults represent a growing proportion of people living with HIV around the world and have worse outcomes than all other age groups. Retention along each step of the HIV care cascade is essential for optimal care, but importantly, achieving sustained adherence to antiretroviral therapy (ART) and subsequent viral suppression is necessary for decreasing morbidity and mortality and reducing further transmission. The overarching goal of this dissertation was to assess health-services interventions aimed at improving ART adherence among adolescents and young adults living with HIV, and prospectively evaluate one such intervention – point-of-care viral load testing – in a randomized control trial. First, a systematic review was conducted to assess and synthesize recent research on interventions aimed at improving ART adherence among adolescents and young adults living with HIV in a resource-limited setting. Evidence from the review indicated that comprehensive models of HIV care, re-structuring how HIV services were delivered to patients, which included increased monitoring of adolescents and young adults through home visits or case management in addition to standard clinical care improved ART adherence. Second, a randomized control trial was conducted to evaluate the implementation and effect of point-of-care viral load testing compared to standard laboratory-based testing. The trial had two primary objectives: 1) to assess the efficiency of point-of-care viral load testing, and 2) evaluate the effect of point-of-care viral load testing on health outcomes including ART adherence and viral suppression. The research protocol is described including study design, the point-of-care viral load testing intervention, analysis plan, and outcome definitions. Lastly, the results of this trial are reported which indicate that point-of-care viral load testing can be feasibly integrated into a low-resource, clinical setting. A majority of point-of-care viral load test results (81.8%; 148/181) were processed and returned the same day, with a mean time between blood collection and participant receipt of results of 2.7 hours (IQR: 2.5-3.2; range 1.7-6.0). Point-of-care viral load testing also appeared to improve the accuracy of reported ART adherence, an unanticipated finding. In the point-of-care arm, participants who reported sub-optimal ART adherence on any of 3 adherence questions were more likely to have a VL >1,000 copies/mL (OR: 6.57; 95% CI: 2.12-25.21), compared to participants in the standard arm among whom the association was weaker (OR: 2.62; 95% CI: 0.97-7.44). There was no difference in viral load outcomes between arms. Overall, this dissertation addresses gaps in our knowledge about interventions aimed at improving ART adherence among adolescents and young adults living with HIV. The key finding is that point-of-care viral load testing can simplify the viral load monitoring process and help clinicians accurately identify adolescents and young adults with a high viral load in order to provide enhanced adherence counseling or make clinical decisions regarding appropriate treatment options faster. Point-of-care viral load testing could be used in concert with other interventions which address additional barriers to ART adherence among adolescents and young adults such as forgetfulness, stigma, or lack of social support. As the public health field continues to focus on improving HIV outcomes among this vulnerable age group, these findings can guide the optimization of HIV services and the development of combination interventions which could increase the number of adolescents and young adults who achieve sustained ART adherence and viral suppression.

Submitted in fulfilment of the requirements for the Degree of Doctor in Public Management, Durban Universit of Technology, 2017. / HIV-AIDS has infected more than 37 million individuals globally and has resulted in approximately 35 million HIV-AIDS related deaths globally since its discovery 35 years ago. HIV-AIDS remains a global and local health crisis as, despite innovative and accessible HIV-AIDS prevention efforts, the disease continues to spread. UNAIDS estimated over 2 milliion new HIV-AIDS infections with 700 000 of these infections occurring in young African women in 2015, revealing that the burden of HIV-AIDS is far from over (UNAIDS, 2016). As more individuals become infected with HIV-AIDS, more infected individuals are living longer, productive lives due to the international rollout and scale-up of life-saving antiretroviral (ARV) therapy aimed at halting disease progression. In 16 years, the world has initiated over 16 million HIV-infected individuals onto ARV programmes across the world aimed at preserving first line drug effectiveness of treatment, less resistance and lower mortality and morbidity rates( UNAIDS, 2016). This number is set to double as countries across the globe take bold steps to provide ARV treatment for all, based on latest WHO guideline changes. The initiative of ARV roll out for all HIV-positive individuals globally, brings with it the challenges and complexities of infrastructure support, resource allocation, uninterrupted drug supply, global access and clinical training requirements for HIV-AIDS programmes across the globe. Quality management systems with monitoring and evaluation frameworks in particular play a pivotal role in planning, allocating and utilising resources for optimal health benefits.This research study reviews available data on the prevalence of quality management systems in HIV-AIDS healthcare and identifies gaps and smart practises towards recommendations for comprehensive global HIV-AIDS standards development. This research study aims to propose a conceptual monitoring and evaluation framework derived from quality management systems for management of HIV-AIDS private sector programmes that can be used in both public and private healthcare sectors through analysis of current conceptual frameworks in the HIV-AIDS healthcare and the HIV-AIDS programmes within the South African context of HIV-AIDS healthcare provision. / D

Innovative primary care models that deliver comprehensive primary care to address medical and social needs are an established means of improving health outcomes and reducing healthcare costs among persons living with chronic disease. Care management is one such approach that requires providers to monitor their respective patient panels and intervene on patients requiring care. Health information technology (IT) has been established as a critical component of care management and similar care models. While there exist a plethora of health IT systems for facilitating primary care, there is limited research on their ability to support care management and its emphasis on monitoring panels of patients with complex needs. In this dissertation, I advance the understanding of how computational methods can better support clinicians delivering care management, and use the management of human immunodeficiency virus (HIV) as an example scenario of use. The research described herein is segmented into 3 aims; the first was to understand the processes and barriers associated with care management and assess whether existing IT can support clinicians in this domain. The second and third aim focused on informing potential solutions to the technological shortcomings identified in the first aim. In the studies of the first aim, I conducted interviews and observations in two HIV primary care programs and analyzed the data generated to create a conceptual framework of population monitoring and identify challenges faced by clinicians in delivering care management. In the studies of the second aim, I used computational methods to advance the science of extracting from the patient record social and behavioral determinants of health (SBDH), which are not easily accessible to clinicians and represent an important barrier to care management. In the third aim, I conducted a controlled experimental evaluation to assess whether data visualization can improve clinician’s ability to maintain awareness of their patient panels.