Combining Positive Deviance and Implementation Science to Improve Retention in HIV Care in South Africa
Abstract
SPECIFIC AIMS
In 2016, South Africa adopted the UNAIDS 90-90-90 goals of 90% of all people with HIV diagnosed, 90% of those with a positive HIV diagnosis on antiretroviral therapy (ART), and 90% of those on ART with undetectable HIV RNA by 2020. Despite notable increases in ART adherence and decreases in mortality,1 South Africa is not close to achieving the 90-90-90 goals, with only 60% of all PLWH having undetectable RNA as of 2017.2 Moreover, in the Western Cape (WC), the South African province where the proposed research will be conducted, the viral suppression rate (54.7%) is the second lowest in the country.2 Health care clinics face myriad challenges retaining people living with HIV (PWLH) in care long enough to maintain viral suppression. Structural-, organizational-, and individual-level patient barriers impede retention in care. 3-18 Nevertheless, a handful of health care clinics consistently have above average retention rates for PLWH.(cite ) Information about how some clinics are managing to succeed despite pervasive barriers could help improve retention rates in clinics that are not performing as well.
The proposed R34 study will combine a Positive Deviance (PD) approach to uncover unique strategies for addressing barriers to retention in care used by high-performing health care clinics in the Western Cape with well-studied implementation science methods for implementing and sustaining these strategies. Positive Deviance is an approach to studying ways in which a minority of individuals or organizations succeed despite facing barriers that typically hinder success. The approach begins with a ???discover??? phase in which intensive study is undertaken to uncover unique strategies of clinics with better outcomes than those facing similar challenges, followed by an implementation phase in which the strategies are implemented in clinics with poor outcomes.19-25 In the proposed study, ???deviants??? are clinics that are performing well, defined as having above average retention rates of PWLH in treatment 6 months after ART initiation.26
