The Treatment of patients with AIDS in Home Health

Adherence to Antiretroviral Treatment (ART) in Home-Based Care
Introduction
UNAIDS HIV/AIDS statistics indicate that while HIV/AIDS morbidity has declined, the prevalence of AIDs has increased over the decades with 37 Million people living with HIV/AIDS globally (UNAIDS, 2019). Additionally, the introduction of antiretroviral treatment (ART) has solidified HIV/AIDS as a chronic disease. Effective management of HIV/AIDS entails adherence to antiretroviral treatment (ART) which has mainly been delivered in health center settings. ART is an integrated service provided by a multidisciplinary health team entailing nurses, physicians, health workers, and psychologist. Although the uptake of ART had increased by 46% in 2015, UNAIDS observes that the uptake remains low in resource-poor economies (UNAIDS, 2019). ART adherence is critical to optimize outcome which entails improved life quality and reduced morbidity (Wood et al., 2018), yet ART adherence remains a challenge among a large population of the patients.
World Health Organization (WHO) observes low resource setting, accessibility of palliative care for patients with a terminal illness is minimal (Wood et al., 2018). For example, Wesonga (2015) argues that due to limited health workers and limited health systems infrastructure, countries largely adopt curative interventions with minimal resource allocation to palliative care. The resource gap necessitates the adoption of alternative feasible and low-cost approaches to bridge the resource constraint. The increase in prevalence implies a strain to the formal inpatient programs health care facilities necessitating alternative palliative care practices. The Human Development Index for Swaziland identified that HIV/AIDS patients occupied half of the beds in Swaziland’s health facilities, a strain to the physical facilities and human resources (Wesonga, 2015). Another major drawback in health care in resource-poor economies is a low population of trained professionals. Moreover, barriers to accessing formal inpatient programs such as transport logistics constrain access to palliative care for HIV/AIDS patients (Wood et al., 2018).
Consequently, alternative palliative care practices such as Home Based Care (HBC) are gaining prominence. Similarly, shifting of palliative care from a professionally trained doctor to low-level caregivers such as nurses, and volunteer caregivers is inevitable to promote adherence to ART. The current study seeks to undertake a meta-analytic review of studies exploring the efficacy of task shifting in HIV/AIDS palliative care and the efficacy of Home-Based Care in promoting ART adherence.
Problem Statement
A critical component of HBC is task shifting from trained professionals such as medical doctors to lay health workers (Chishinga, et al., 2014). HBC entails decentralizing of ART and other palliative care services to centers closer to the patient by lay health workers. The decentralization entails the integration of home level follows up by the lay health workers breaking the structural impediments to health care. The task shifting entails a detour from a physician-led ART to a lay health worker ART. A systematic by Kredo et al, 2014) view on the shifting of the task by Selke et al., (2010) demonstrates that quality of palliative care doesn’t decline with the responsibility of palliative care shifting from physicians to non-physicians caregivers. Further, the review identified that task shifting didn’t increase HIV/AID morbidity. Task shifting in palliative health care has enabled build an ecosystem that effectively manages diseases in a pro-poor setting where are infrastructural and resource constraint (Chishinga, et al., 2014).
The shift, however, raises concern on the quality of care given the patient. There exists contradictory evidence on the adherence of HBC requirements by lay health workers. There exist insufficient evidence on the level of training sufficient for lay health workers to effectively administer HBC interventions. However, limited study exists to demonstrate the efficacy of HBC in relation to health systems, human resources, and financial resources. Moreover, existing studies have been conducted on small scale limiting the generalization of the efficacy of HBC in ART adherence. Therefore, there’s research need to establish evidence on the efficacy of HBC.
Wesonga (2015) argues that due to limited health workers and limited health systems infrastructure, countries largely adopt curative interventions with minimal resource allocation to palliative care. The resource gap necessitates the adoption of alternative feasible and low-cost approaches to bridge the resource constraint. The increase in prevalence implies a strain to the formal inpatient programs health care facilities necessitating alternative palliative care practices. The Human Development Index for Swaziland identified that HIV/AIDS patients occupied half of the beds in Swaziland’s health facilities, a strain to the physical facilities and human resources (Wesonga, 2015). Another major drawback in health care in resource-poor economies is a low population of trained professionals. Moreover, barriers to accessing formal inpatient programs such as transport logistics constrain access to palliative care for HIV/AIDS patients (Wood et al., 2018).
Consequently, alternative palliative care practices such as Home Based Care (HBC) are gaining prominence. Similarly, shifting of palliative care from a professionally trained doctor to low-level caregivers such as nurses, and volunteer caregivers is inevitable to promote adherence to ART. The current study seeks to undertake a meta-analytic review of studies exploring the efficacy of task shifting in HIV/AIDS palliative care and the efficacy of Home-Based Care in promoting ART adherence.
Literature Review
HBC entails caregiving to HIV/AIDS patients at home (Wesonga, 2015). The Committee on National Strategy for AIDS (CNSA) defines HBC as medical, social or palliative support offered to a patient at their residence (Wood et al., 2018). The WHO describes HBC as a form of care to the ill that entails palliative, physical spiritual and psychological activities offered at a home setting (Wood et al., 2018). HBC entails the multidisciplinary provision of service increasing delivery of antiretroviral treatment, medical care, and psychological support. HBC is related to symptom control as opposed to curative therapy which implies proximity to the patients is essential.
The practice of HBC entails decentralization of health care from centralized facilities to a residential setting that is geographically convenient to patients. According to Wood et al., (2018), the provision of HC can be undertaken by a variety of professionals including both qualified health care practitioners such as community health workers, volunteers and family members. HBC has been credited for its cost-effectiveness benefit since it entails the use of a relatively affordable workforce. Moreover, HBC aids in reducing stigma since the patient receives care in a familiar home setting as opposed to public health facilities (Chishinga, et al., 2014).
Compelling evidence largely indicates that HBC in HIV/AIDS management helps adherence of ART, reducing the prevalence of co-morbidities, malignancies and improved health outcomes which ultimately reduces morbidity (Chishinga, et al., 2014). According to Wood et al., (2018), HBC reduces exposure to hospital infectious diseases such as Tuberculosis among HIV/AIDS patients. Analyzing the delivery approach for antiretroviral, Selke et al., (2010) observed that patients receiving standard care clinic group reported a triple number of clinical visit compared to the patients receiving HBC implying HBC aids in decongesting clinical facilities.
According to Chishinga, et al., (2014), the advent and increasing prevalence of Home Based Care (HBC) have remarkably evolved palliative care of HIV/AIDs patients, substantially improving their life expectancy and quality of life. Evidence demonstrates increasing uptake of antiretroviral therapy (ART) when dispensed through HBC (Kameni et al., 2019). UNAIDS reports that the integration of HBC in the distribution of ART increased the ART enrolment to 15 Million by 2015 (UNAIDS, 2019) implying that HBC could increase ART adherence.
Accordingly, adopting initiatives that encourage voluntary community engagement in HBC is imperative to ensure sufficient human resource for sustainability. HBC offsets resources expenditure on inpatient programs for HIV/AIDS. HBC for HIV/AIDS entails multidimensional aspects including administering of ART, home-based testing, comorbidities treatment, psychological support and delivery of preventative interventions.
Proposed Solution
HBC is provided by typically relatives, friends or community volunteers who are by lesser extent supported by the health professionals. However, HBC takes a toll on the caregivers due to limited expertise, limited resources and frustration when they are unable to meet the needs of the patients. A systematic review by Wringe, et al., (2010) identifies that high expectations, stigmatization coupled with ill-equipping of HBC givers diminish their efficacy. The disappointment of patients due to rationing of ART supplies for example results to the receptiveness of support services by the HBC givers. According to Wringe, et al., (2010), HBC givers are inadequately trained which poses a risk to the lives of the HBC beneficiaries. Consequently, such psychological, and economic challenges constrain the efficacy of HBC.
To address the efficacy of HBC, its integration in the health insurance system is imperative. Although the HBC is relatively cost-effective relative to hospital-based care, it entails the use of financial resources by the caregiver. Incorporation in the insurance system ensures there are resources to sustain HBC. Moreover, it ensures that the patients continuously access their ART which is fundamental to maintain a bond between the HBC giver and the patient. Such an intervention would require a policy review at the national level.
A fundamental challenge to HBC is an inadequate skill set among the lay health workers. Caregiving entails risk to both the carer and the patient. For example, the carer is vulnerable to infectious diseases. Additionally, HBC is a multidimensional service that requires diverse skill sets and knowledge. Wesonga (2015) observed that HBC often receive minimal support from trained professionals which limits their effectiveness. According to Wringe et al., (2010) a systematic review, HBC volunteers reported having inadequate training which they argued could result to harm the patients. Incorporating frequent training of the HBC givers is essential to optimize HBC. HBC leaves the caregiver with burn out which could yield to psychological stress. Establishing a support group for the caregivers is therefore essential for continued emotional and psychological support.
A challenge of HBC is the geographical location of the caregiver and the location. Caregivers often have to commute to get to the patient which entails transportation cost. In addition, caregivers are breadwinners to their families. Engaging in in voluntary community HBC implies a loss of income or increased expenditure for the personnel. Fully integration of HBC would require government compensation for volunteer caregivers to sustain their expenditures and keep them motivated to optimally engage. Additionally, the provision of proper equipment to the caregivers would protect them from the risk associated with HBC.
The systematic review above entails analysis of randomized trials for ART adherence for HIV/AIDS patients. Understanding the efficiency of the two interventions is critical for policy decisions, resource allocation decisions and sustainability of ART.




References
Chishinga, N., Godfrey-Faussett, P., Fielding, K., & Ayles, H. (2014). Effect of home-based interventions on virologic outcomes in adults receiving antiretroviral therapy in Africa: a meta-analysis. BMC Public Health, 14(1). https://doi.org/10.1186/1471-2458-14-239
Selke, H. M., Kimaiyo, S., Sidle, J. E., Vedanthan, R., Tierney, W. M., Shen, C., Wools-Kaloustian, K. (2010). Task-Shifting of Antiretroviral Delivery From Health Care Workers to Persons Living With HIV/AIDS: Clinical Outcomes of a Community-Based Program in Kenya. JAIDS Journal of Acquired Immune Deficiency Syndromes, 55(4), 483. https://doi.org/10.1097/QAI.0b013e3181eb5edb
UNAIDS. (2019, 02 24). AIDSInfo. Retrieved from UNAIDS: http://aidsinfo.unaids.org./
Wesonga. (2015, June 29). Components, Practices, and Benefits of Home Based Care of HIV and AIDS Patients in Kenya: Butula Local Community’s Perspective. Retrieved February 24, 2019, from http://arjess.org/social-sciences-research/components-practices-and-benefits-of-home-based-care-of-hiv-and-aids-patients-in-kenya-butula-local-communitys-perspective/
Wringe, A., Cataldo, F., Stevenson, N., & Fakoya, A. (2010). Delivering comprehensive home-based care programmes for HIV: a review of lessons learned and challenges ahead in the era of antiretroviral therapy. Health Policy and Planning, 25(5), 352–362. https://doi.org/10.1093/heapol/czq005
Wood, E., Zani, B., Esterhuizen, T., & Young, T. (2018). Nurse-led home-based care for people with HIV/AIDS. BMC Health Service Research, 18:219.