Efeito de uma intervenção de cuidado centrada na pessoa no retorno e reengajamento sustentado após as interrupções do tratamento da atenção ao HIV na Zâmbia: Uma análise pós-hoc de um estudo randomizado de agrupamento escalonado

O que aconteceu

As más interações cliente-fornecedor levam ao reforço dos ciclos de interrupções do tratamento (TIs) dos cuidados com o HIV e medo do retorno, comprometendo a retenção sustentada. Demonstramos anteriormente um comportamento multicomponente de intervenção assistencial centrada na pessoa (PCC) visando ao trabalhador de saúde (HCW) melhorou a experiência do cliente e a retenção no cuidado ao HIV. Para entender mecanismos de retenção melhorada, avaliou-se o efeito da intervenção do PCC no retorno após IT e retenção sustentada após retorno em uma análise pós-hoc, hipotetizando-se que as atitudes mais amistosas do HCW possibilitam o reengajamento bem sucedido no cuidado.

O que encontraram

We implemented the PCC intervention at 24 clinics in Zambia in a stepped-wedge, cluster randomized trial from Aug 2019 to Nov 2021. Clinics were allocated into 4 groups (8 clinics in Groups 1 and 4, and 4 each in Groups 2 and 3) and randomly assigned to crossover from control to intervention every 6 months. Under control, clinics provided routine HIV care without additional support. Afterwards, clinics received the PCC intervention targeting caring aspects of HCW behavior with 1) training and coaching on PCC practices, 2) measurement and feedback of client experience (via exit interviews), and 3) small facility-level incentives. We examined individuals living with HIV who became >30 days late to a scheduled visit (i.e., TI), categorizing intervention exposure based on the last visit prior to TI. We used electronic health records to assess the effect of the PCC intervention on 1) return to HIV care after a TI, and 2) repeat TIs among those who returned. We used multistate analytic methods to estimate crude incidence of return and repeat TIs and prevalence of being in care at 1-year. We used shared frailty Cox proportional hazards and mixed-effects Poisson models to obtain formal comparisons that accounted for the stepped-wedge design. Individuals were censored at intervention crossover or database closure. During the study period, 128,910 clients (n = 69,671 control, n = 59,239 intervention) became >30 days late (64.3% female, median age 38y [IQR 31,45], median years in care 2.5y [IQR 0.6,6.7]). The PCC intervention increased incidence of return after TI at 12-months (72.3% intervention versus 67.7% control, crude risk difference [RD] +4.6% [CI 4.1,5.2], adjusted hazard ratio [aHR] 1.16 [CI 1.12,1.20]; p < 0.001). Among returners, the intervention decreased incidence of repeat TIs (44.3% versus 55.6%, RD -11.4% [CI -12.2,-10.6], aHR 0.50 [CI 0.45,0.55]; p < 0.001) and increased the proportion in care (with or without repeat TIs) (82.7% versus 73.4%, RD +9.3% [CI 8.6,10.0], adjusted risk ratio [aRR] 1.14 [CI 1.05,1.25]; p = 0.002) at 12-months after return. Overall, the PCC intervention increased the proportion in care 12-months after a TI from 51.5% to 60.1% (RD +8.7% [CI 8.0,9.3], aRR 1.19 [CI 1.05,1.35]; p = 0.008). Effect sizes were similar in direction and magnitude in multiple sensitivity analyses with varying precision. Limitations included post-hoc analysis and those associated with stepped-wedge design.

Trecho mantido em inglês: a tradução automática não passou na conferência de números.

Por que isso importa

A intervenção do PCC provavelmente melhorou as taxas de retorno aos cuidados após IT, manteve o reengajamento após o retorno e a retenção global entre indivíduos com IT. Estratégias voltadas para aspectos assistenciais do comportamento e experiência do cliente em RAS podem ajudar a diminuir as barreiras e enfrentar desafios persistentes com o reinício no cuidado.