REFERRAL NETWORK FACTORS AND HEALTH OUTCOMES AMONG HIV-POSITIVE WOMEN IN ETHIOPIA

Timely initiation, retention, adherence to antiretroviral therapy and improved quality of life among HIV-positive people are major goals of the UNAIDS Fast-Track or the 90-90-90 Initiative and the Ethiopian government. To contribute to these goals, MEASURE Evaluation implemented a referral network strengthening intervention in 2011-2012. The goal was to increase inter-organizational referrals, access to HIV services, adherence and quality of life among 1046 HIV-positive women receiving care from 51 providers in Addis Ababa, Ethiopia. Improvements in organizational network characteristics have been shown to improve health outcomes, yet pathways of these effects are poorly understood. Measurement invariance, a statistical property indicating that the same latent construct is being measured across groups, has also not been assessed. It is necessary for valid group comparisons of average latent outcome scores. The objective of this study was to assess measurement invariance of adherence and quality of life across patient groups. It also assessed the effects of the intervention, improved referrals and patient-related factors on treatment delay and adherence. In this pre-post quasi-experimental and interventional study, adherence and quality of life were measured using the Simplified Medication Adherence Questionnaire and the World Health Organization Quality of Life-BREF questionnaires respectively. Multiple group confirmatory factor analysis was used to evaluate measurement invariance of the latent outcomes. Structural equation modeling was used to evaluate the effects of the intervention on latent outcomes and direct and indirect effects between exogenous variables and the outcomes of interest. Findings suggest similarity in factor loadings, item intercepts and factor variances of observed responses for adherence (strong factorial invariance) but not quality of life (configural invariance) across intervention and control groups pre-and post-intervention. Patients in the intervention group were initiated on treatment 15 days earlier on average than those in control. The intervention had no effect on adherence. Quicker antiretroviral initiation improved adherence in the intervention site. Also, improved satisfaction increased adherence. Adherence scores can be compared across groups whereas those of quality of life cannot. Timely treatment initiation is a leverage facilitator of adherence. Referral network improvement is a necessary but insufficient factor for adherence, as depicted in the WHO’s adherence model.