Effect and Implementation Experience of Intensive Adherence Counseling in A Public Hiv Care Center in Uganda: A Mixed-methods Study

Abstract Background: Non-adherence to anti-retroviral therapy (ART) is responsible for up to 75% of the unsuppressed viral load among people living with HIV (PLWH) on ART. Intensive adherence counseling (IAC) is an intervention recommended by the World Health Organization to improve adherence. In 2016, the Ugandan Ministry of Health introduced IAC to improve viral load suppression. This study evaluated the effect and experiences of providing IAC in an urban HIV care center in Kampala, Uganda. Methods: This was a sequential explanatory mixed-method study that compared viral load suppression in the period with IAC intervention to a period without IAC at Kisenyi Health centre IV. Data were abstracted from patient files. The effect on viral load suppression of IAC and associated factors was analyzed using modified Poisson regression with robust standard errors. Using in-depth interviews and an inductive analysis approach in Atlas. ti, we also explored experiences of providing IAC among healthcare workers. Results: A total of 500 records were sampled: 249(49.8%) in the intervention period and 251(51.2%) in the pre-intervention period. The mean age of clients was 34.8 years (SD±12.8), and 326/500 (65.2%) were females. Majority were on a Lopinavir/ritonavir based regimen [314 (62.8%)], and the median duration on ART was 30.8 months (IQR: 12.5–51.7). Over the intervention period, all eligible clients received IAC [249/249 (100.0%)]. Of those, 143 (44.1%) achieved viral load suppression compared to 46 (26.3%) in the pre-intervention period. Receiving IAC significantly increased viral load suppression by 22% (aPR = 1.22, 95% CI: 1.01–1.47). Participants on Lopinavir/ritonavir-based regimen were less likely to suppress (aPR= 0.11, 95%CI: 0.08–0.15) than those on Efavirenz or Nevirapine based regimens. All the interviewed healthcare workers lauded IAC for improving ART adherence. However, non-disclosure, social-economic constraints, lack of a multidisciplinary team and work overload hindered adherence during IAC. Conclusions: The full potential of IAC in achieving viral suppression in this setting has not been reached, probably due to a combination of the health care system and patient-related factors. Provision of adequate IAC necessities and use of patient centered approach during IAC should be emphasized to obtain the maximum benefit of IAC .