Increasing adherence to ART prescription policy at HIV treatment clinics through a quality improvement intervention

In urban areas, crowded HIV treatment facilities with long patient wait times can deter patients from attending their clinical appointments and picking up their medications, ultimately disrupting patient care and compromising patient retention and adherence. Since 2013, Zambia’s national antiretroviral treatment (ART) guidelines have recommended that stable patients be provided with prescriptions for up to three-months at a time. However, a formative assessment at the end of 2014 in 8 facilities in Zambia’s capital city, Lusaka, indicated that about half of stable patients were receiving antiretroviral drug (ARV) refills of two months or less, contributing to congestion in facilities.

In collaboration with the Ministry of Health, CHAI’s Demand-Driven Evaluations for Decision (3DE) program designed a quality improvement (QI) intervention to improve the operationalization of the three-month ARV refill policy. As part of the intervention, a policy memo was sent from the MOH to ART facilities in Lusaka District emphasizing the importance of adherence to the three-month refill policy. ARV supply forecasting support was provided that accounted for the anticipated short-term surge in ARV stock. A job aide was given to pharmacists that encouraged adherence to the refill policy. QI officers were designated at each facility and trained to complete a site readiness checklist and weekly checklist to trouble-shoot any challenges that arose and address them with the appropriate channels.

This intervention was rigorously tested using a cluster-randomized controlled trial design in sixteen facilities in Lusaka with the primary objective of examining the intervention’s impact on the proportion of stable patients receiving three-month refills. The intervention was successful in significantly increasing the proportion stable patients receiving three-month refills: there was a 15% mean difference in change among intervention sites compared to control sites from baseline to endline. Other results, though non-significant, suggested that the intervention reduced the average number of patient visits per day and decreased patient wait times. These results indicate that in ART facilities within urban Lusaka, district- and facility-level quality improvement activities can increase adherence to the three-month prescription refill policy outlined in the national HIV treatment guidelines. A more patient-centred service delivery schedule of three-month prescription refills for stable patients is a viable step towards reducing congestion in crowded clinics, improving the patient experience, improving retention and adherence, and ultimately improving clinical outcomes.

Read more about this evaluation in this policy brief and publication.