Impact of immediate initiation of antiretroviral therapy on HIV patient satisfaction: a stepped-wedge cluster-randomized controlled trial.

Abstract

OBJECTIVES\nImmediate ART (or early access to ART for all, EAAA) is becoming a national policy in many countries in sub-Saharan Africa. It is plausible that the switch from delayed to immediate ART could either increase or decrease patient satisfaction with treatment. A decrease in patient satisfaction would likely have detrimental consequences for long-term retention and adherence, in addition to the value lost because of the worsening patient experience. We conducted a pragmatic stepped-wedge cluster-randomized controlled trial (SW-cRCT) to determine the causal impact of immediate treatment for HIV on patient satisfaction.\n\n\nDESIGN\nThis seven-step SW-cRCT took place in 14 public-sector healthcare facilities in Eswatini s Hhohho region, from September 2014 to August 2017.\n\n\nMETHODS\nDuring each step of the trial, we selected a random set of data collection days for each study facility. During these days, a random sample of HIV patients were selected for outcome assessment. In total, 2,629 patients provided data on their overall patient satisfaction and satisfaction with the following four domains of the patient experience using a 5-point Likert scale: wait time, consultation time, involvement in treatment decisions, and respectful treatment. Higher values on the Likert scale indicated lower patient satisfaction. We analyzed the data using a multilevel ordered logistic regression model with individuals at the first level and health facilities at the second (cluster) level.\n\n\nRESULTS\nThe proportional odds ratios comparing EAAA to control were 0.91 (95% CI: 0.66, 1.25) for overall patient satisfaction. For the specific domains of the patient experience, the impact of EAAA on satisfaction was 1.04 (95% CI: 0.61, 1.78) for wait time, 0.90 (95% CI: 0.62, 1.31) for involvement in treatment decisions, 0.86 (95% CI: 0.61, 1.20) for consultation time, and 1.35 (95% CI: 0.93, 1.96) for respectful treatment. These results were robust across a wide range of sensitivity analyses. Over time - and independent of EAAA - we observed a worsening trend for both overall patient satisfaction and for satisfaction within all four domains of the patient experience that we measured.\n\n\nCONCLUSIONS\nOur main findings support the policy change from delayed to immediate ART in sub-Saharan Africa. We find no impact of immediate (versus delayed) ART in public-sector health facilities in Eswatini on either overall patient satisfaction or on satisfaction with four specific domains of the patient experience. At the same time, we observed a strong secular trend of decreasing patient satisfaction in both the intervention and the control arm of the trial, which may be due to the generally increasing numbers of patients on ART. Further implementation research should identify approaches to ensure high patient satisfaction, as ART programs grow and mature.This trial was registered at ClinicalTrials.gov (NCT02909218).