Improving the continuum of care monitoring in Brazilian HIV healthcare services: An implementation science approach

Abstract

Objective To evaluate the impact of an intervention improving the continuum of care monitoring (CCM) within HIV public healthcare services in São Paulo, Brazil, and implementing a clinical monitoring system. This system identified three patient groups prioritized for additional care engagement: (1) individuals diagnosed with HIV, but not receiving treatment (the treatment gap group); (2) individuals receiving treatment for >6 months with a detectable viral load (the virologic failure group); and (3) patients lost to follow-up (LTFU). Methods The implementation strategies included three training sessions, covering system logistics, case discussions, and development of maintenance goals. These strategies were conducted within 30 HIV public healthcare services (May 2019 to April 2020). After each training session, professionals shared their experiences with CCM at regional meetings. Before and after the intervention, providers were invited to answer 23 items from the normalization process theory questionnaire (online) to understand contextual factors. The mean item scores were compared using the Mann–Whitney U test. The RE-AIM implementation science framework (evaluating reach, effectiveness, adoption, implementation, and maintenance) was used to evaluate the integration of the CCM. Results In the study, 47 (19.3%) of 243 patients with a treatment gap initiated treatment, 456 (49.1%) of 928 patients with virologic failure achieved suppression, and 700 of 1552 (45.1%) LTFU patients restarted treatment. Strategies for the search and reengagement of patients were developed and shared. Providers recognized the positive effects of CCM on their work and how it modified existing activities (3.7 vs. 4.4, p<0.0001, and 3.9 vs. 4.1, p<0.05); 27 (90%) centers developed plans to sustain routine CCM. Conclusion Implementing CCM helped identify patients requiring more intensive attention. This intervention led to changes in providers’ perceptions of CCM and care and management processes, which increased the number of patients engaged across the care continuum and improved outcomes.