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...…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.