Adherence support workers: a way to address human resource constraints in antiretroviral treatment programs in the public health setting in Zambia

Abstract

Background: In order to address staff shortages and improve adherence counseling for people on antiretroviral therapy (ART), the Zambia Prevention, Care and Treatment Partnership (ZPCT) developed an innovative strategy of training community volunteers to provide adherence support at the health facility and community levels. The objective of this study was to assess the effectiveness of these 'adherence support workers' (ASWs) in adherence counseling, treatment retention and addressing inadequate human resources at health facilities.

Methodology/principal findings: The study used quantitative and qualitative research techniques at five selected ART sites in four provinces in Zambia. Five hundred patients on ART were interviewed using a structured questionnaire to compare the quality of adherence counseling before and after the ASW scheme was introduced at the selected sites and between ASWs and HCWs after the introduction of ASWs. In addition, 3,903 and 4,972 electronic records of all new patients accessing antiretroviral therapy for the time period of 12 months before and 12 months after the introduction of ASWs respectively, were analyzed to assess loss to follow-up rates. Two focus group discussions with ASWs and health care workers (HCWs) were conducted in each clinic. Key informant interviews in the ART clinics were also conducted. There was a marked shift of workload from HCWs to ASWs without any compromise in the quality of counseling. Quality of adherence counseling by ASWs was comparable to HCWs after their introduction. The findings suggest that the deployment of ASWs helped reduce waiting times for adherence counseling. Loss to follow-up rates of new clients declined from 15% to 0% after the deployment of ASWs.

Conclusion: Adherence counseling tasks can be shifted to lay cadres like ASWs without compromising the quality of counseling. Follow-up of clients by ASWs within the community is necessary to improve retention of clients on ART.

Figure 1. Type of Cadres Providing Adherence Counseling Services.

This figure shows the type of cadres that were providing adherence counseling services before and after adherence support workers (ASWs) were deployed in the health facilities. Health Care Workers (HCWs) and other untrained staff such as data entry clerks, registration officers provided adherence counseling prior to the ASW intervention. After ASWs were introduced, they joined the above mentioned cadres in providing adherence counseling services.

Figure 2. Figure depicting the groups compared for Quality Measures.

Various quality measures for HCWs and ASWs were compared for clients who were counseled before and after ASWs were introduced in the facilities. Another comparison was conducted to compare ASWs and HCWs after the introduction of ASWs.