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An EMR-Based Alert with Brief Provider-Led ART Adherence Counseling: Promising Results of the InfoPlus Adherence Pilot Study Among Haitian Adults with HIV Initiating ART

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Abstract

To promote HIV antiretroviral therapy (ART) outcomes in Haiti, we developed a culturally relevant intervention (InfoPlus Adherence) that combines an electronic medical record alert identifying patients at elevated risk of treatment failure and provider-delivered brief problem-solving counseling. We conducted a quasi-experimental mixed-methods study among 146 patients at two large ART clinics in Haiti with 728 historical controls. We conducted quantitative assessments of patients at baseline and intervention completion (6 months) as well as focus groups with health workers and exit interviews with patients. The primary quantitative outcome measures were HIV viral suppression according to medical record and ART adherence in terms of ≥ 90% for “proportion of days covered” (PDC) according to pharmacy dispensing data. Results indicated that the proportion of intervention patients with suppressed VL during the study/historical periods was 80.0%/86.0% and 76.8%/87.4% for controls. In a difference-in-differences (DID) analytic model, the adjusted relative risk for viral suppression with the intervention was 1.15 (95% CI 0.92–1.45, p = 0.21), representing favorable but non-significant association between the intervention and the trajectory of VL outcomes. PDC ≥ 90% during the study/historical periods was 30.9%/11.0% among intervention participants and 16.9%/19.4% among controls. In the adjusted DID model, the relative risk for of PDC ≥ 90% with the intervention was 4.00 (95% CI 1.91–8.38, p < 0.001), representing a highly favorable association between the intervention and the trajectory of PDC outcomes. Qualitative data affirmed acceptability of the intervention, although providers reported some challenges consistently implementing it. Future research is needed to demonstrate efficacy and explore optimal implementation strategies.

Resumen

Para promover los resultados del tratamiento antirretroviral (TAR) en Haití, desarrollamos una intervención culturalmente relevante (Adhesión InfoPlus) que combina una alerta del registro médico electrónico que identifica a los pacientes de alto riesgo de fracaso terapéutico con un breve asesoramiento brindado por el proveedor para la resolución de problemas. Realizamos un estudio cuasi-experimental de métodos mixtos entre 128 pacientes en dos clínicas grandes del TAR en Haití con 728 controles históricos. Llevamos a cabo evaluaciones cuantitativas de los pacientes al inicio, y a la realización de la intervención (6 meses), así como grupos de enfoque con personal de salud y entrevistas de salida con los pacientes. Las medidas de resultado cuantitativas primarias fueron la supresión viral del VIH de acuerdo con la historia clínica y la adherencia al tratamiento antirretroviral en términos de > = 90% para la "proporción de días cubiertos" (PDC) según los datos de dispensación de farmacia. Los resultados indicaron que la proporción de pacientes de intervención con supresión de la carga viral (CV) durante el estudio / períodos históricos fue 80.0% / 86.0% y 76.8% / 87.4% para los controles. En un modelo analítico de diferencias en diferencias (DID), el riesgo relativo ajustado por supresión viral con la intervención fue de 1,15 (IC 95%: 0,92 a 1,45; p = 0,21), lo que representa una asociación favorable pero no significativa entre la intervención y la trayectoria de los resultados del CV. PDC> = 90% durante el estudio / períodos históricos fue 30.9% / 11.0% entre los participantes de la intervención y 16.9% / 19.4% entre los controles. En el modelo DID ajustado, el riesgo relativo de PDC> = 90% con la intervención fue de 4.00 (IC 95%: 1.91-8.38; p <0.001), lo que representa una asociación altamente favorable entre la intervención y la trayectoria de los resultados de PDC. Los datos cualitativos afirmaron la aceptabilidad de la intervención, aunque los proveedores reportaron algunos desafíos con la implementación de manera consistente. Se necesita investigación futura para demostrar eficacia y estrategias óptimas de implementación.

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Acknowledgements

We gratefully acknowledge the participation of clinic patients as well as the assistance with recruitment from the clinic staff. This research was supported by NIH Grants #5R34MH112378 and AI027757.

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Authors and Affiliations

  1. Department of Global Health, International Training and Education Center for Health (I-TECH), University of Washington, Seattle, WA, USA

    Nancy Puttkammer & Tracy Sandifer

  2. Departments of Psychology and Global Health, University of Washington, 3909 Stevens Way NE, Campus, Box 351525, Seattle, WA, 98195-1525, USA

    Jane M. Simoni & Cameron Casey

  3. Centre Haïtien pour le Renforcement de Système de Santé (CHARESS), Port-au-Prince, Haiti

    Jean Marcxime Chéry, Witson Dervis, Jean Gabriel Balan & Jean Guy Honoré

  4. Hôpital Universitaire Justinien (HUJ), Cap Haitien, Haiti

    Jean Geto Dubé

  5. Hôpital Universitaire de l’Etat d’Haiti, Port-au-Prince, Haiti

    Guirlaine Calixte

  6. Programme National de Lutte contre le SIDA (PNLS), Ministère de la Santé Publique et de la Population (MSPP), Port-au-Prince, Haiti

    Ermane Robin & Kesner François

  7. Department of Health Services Policy & Practice, School of Public Health, Brown University, Providence, RI, USA

    Ira Wilson

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  1. Nancy Puttkammer
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Correspondence to Jane M. Simoni.

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Puttkammer, N., Simoni, J.M., Sandifer, T. et al. An EMR-Based Alert with Brief Provider-Led ART Adherence Counseling: Promising Results of the InfoPlus Adherence Pilot Study Among Haitian Adults with HIV Initiating ART. AIDS Behav 24, 3320–3336 (2020). https://doi.org/10.1007/s10461-020-02945-8

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