title: Modifications to ART service delivery models by health facilities in Uganda in promotion of intervention sustainability: a mixed methods study.
abstract: In November 2015, WHO released new treatment guidelines recommending that all diagnosed as HIV positive be enrolled on antiretroviral therapy (ART). Sustaining and expanding ART scale-up programs in resource-limited settings will require adaptations and modifications to traditional ART delivery models to meet the rapid increase in demand. We identify modifications to ART service delivery models by health facilities in Uganda to sustain ART interventions over a 10-year period (2004-2014).
  
  
  
  A mixed methods approach involving two study phases was adopted. In the first phase, a survey of a nationally representative sample of health facilities (n = 195) in Uganda which were accredited to provide ART between 2004 and 2009 was conducted. The second phase involved semi-structured interviews (n = 18) with ART clinic managers of 6 of the 195 health facilities purposively selected from the first study phase. We adopted a thematic framework consisting of four categories of modifications (format, setting, personnel, and population).
  
  
  
  The majority of health facilities 185 (95%) reported making modifications to ART interventions between 2004 and 2014. Of the 195 health facilities, 157 (81%) rated the modifications made to ART as "major." Modifications to ART were reported under all the four themes. The quantitative and qualitative findings are integrated and presented under four themes. Format: Reducing the frequency of clinic appointments and pharmacy-only refill programs was identified as important strategies for decongesting ART clinics.
  
  
  
  Home-based care programs were introduced to reduce provider ART delivery costs. Personnel: Task shifting to non-physician cadre was reported in 181 (93%) of the health facilities.
  
  
  
  Visits to the ART clinic were rationalized in favor of the sub-population deemed to have more clinical need. Two health facilities focused on patients living nearer the health facilities to align with targets set by external donors.
  
  
  
  Over the study period, health facilities made several modifications ART interventions to improve fit with their resource-constrained settings thereby promoting long-term sustainability. Further research evaluating the effect of these modifications on patient outcomes and ART delivery costs is recommended. Our findings have implications for the sustainability of ART scale-up programs in Uganda and other resource-limited settings.
authors.affiliation: School of Public Health, Makerere University, Kampala, Uganda. zakumumpa@yahoo.com.
authors.forename: Henry
authors.initials: H
authors.lastname: Zakumumpa
authors.affiliation: Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA.
authors.forename: Sara
authors.initials: S
authors.lastname: Bennett
authors.affiliation: School of Public Health, Makerere University, Kampala, Uganda.
authors.forename: Freddie
authors.initials: F
authors.lastname: Ssengooba
mesh_terms: D000554:Ambulatory Care Facilities; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D003695:Delivery of Health Care / Q000379:methods*; D015658:HIV Infections / Q000188:drug therapy*; D006699:Home Care Services; D006801:Humans; D007407:Interviews as Topic; D014454:Uganda
chemical_list: D044966:Anti-Retroviral Agents
keywords: ART scale-up; Adaptation; Health services delivery; Health systems; Implementation; Resource-limited settings; Sustainability