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BMJ Open. 2012 Mar 15;2(2):e000195. doi: 10.1136/bmjopen-2011-000195. Print 2012.

Introduction and evaluation of a 'pre-ART care' service in Swaziland: an operational research study.

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1
Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.

Abstract

OBJECTIVE:

To implement and evaluate a formal pre-antiretroviral therapy (ART) care service at a district hospital in Swaziland.

DESIGN:

Operational research.

SETTING:

District hospital in Southern Africa.

PARTICIPANTS:

1171 patients with a previous diagnosis of HIV. A baseline patient group consisted of the first 200 patients using the service. Two follow-up groups were defined: group 1 was all patients recruited from April to June 2009 and group 2 was 200 patients recruited in February 2010.

INTERVENTION:

Introduction of pre-ART care-a package of interventions, including counselling; regular review; clinical staging; timely initiation of ART; social and psychological support; and prevention and management of opportunistic infections, such as tuberculosis.

PRIMARY AND SECONDARY OUTCOME MEASURES:

Proportion of patients assessed for ART eligibility, proportion of eligible patients who were started on ART and proportion receiving defined evidence-based interventions (including prophylactic co-trimoxazole and tuberculosis screening).

RESULTS:

Following the implementation of the pre-ART service, the proportion of patients receiving defined interventions increased; the proportion of patient being assessed for ART eligibility significantly increased (baseline: 59%, group 1: 64%, group 2: 76%; p=0.001); the proportion of ART-eligible patients starting treatment increased (baseline: 53%, group 1: 81%, group: 2, 81%; p<0.001) and the median time between patients being declared eligible for ART and initiation of treatment significantly decreased (baseline: 61 days, group 1: 39 days, group 2: 14 days; p<0.001).

CONCLUSIONS:

This intervention was part of a shift in the model of care from a fragmented acute care model to a more comprehensive service. The introduction of structured pre-ART was associated with significant improvements in the assessment, management and timeliness of initiation of treatment for patients with HIV.

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