Determinants of Appointment Spacing Model Acceptance Among People Living With HIV in Dessie City,Northeast Ethiopia: Case–Control Study

Abstract

Introduction

In Ethiopia, the appointment spacing model (ASM) has been adopted since 2017. However, a significant proportion of eligible people living with HIV (PLHIV) are not enrolling in this model. Hence, the aim of the study was to assess the determinants of ASM acceptance among PLHIV in Northeast Ethiopia.

Methods

An institution-based case–control study was conducted. Cases were PLHIV who were enrolled in ASM. Multivariable logistic regression analysis was used to identify the determinants of ASM acceptance at a p-value of <.05.

Results

A total of 305 PLHIV were participated in the study. Being female (Adjusted Odds Ratio (AOR) = 1.90; 95% CI: 1.07-3.35), rural residence (AOR = 3.27; 95% CI: 1.61-6.63), receiving ART over 5 years (AOR = 2.64; 95% CI: 1.32-5.25), HIV disclosure (AOR = 3.64; 95% CI: 1.57-8.41), and PLHIV who required 1 to 3 hours to reach the ART clinic (AOR = 0.33; 95% CI: 0.15-0.73) were associated with the ASM acceptance.

Conclusions

Sex, residence, duration on ART, HIV disclosure status, and time required to reach the ART clinic were found to be associated with the ASM acceptance.

Plain Language Summary Title

Improving clients’ engagement in the six-monthly HIV care program in Dessie city, Northeast Ethiopia

Plain Language Summary

This study examined which people living with HIV are engaged in a type of HIV care where the service is provided every 6 months. This study also examined what factors are associated with people living with HIV to engage in the six-monthly HIV care program designed for stable individuals. A survey was conducted at one hospital and three health centers in Dessie city by involving clients who were in the conventional HIV care and in the six-monthly HIV care program. Factors associated with engaging in the six-monthly HIV care program were identified. The study showed that females, living in rural area, receiving HIV drugs for over 5 years, disclosing HIV status, and time taken to reach the ART clinic were factors associated with patients’ involvement in the six-monthly HIV care program. Thus, these findings highlight that ART providers shall consider the socio-demographic and clinical profile of PLHIV while offering the six-monthly HIV service for eligible clients. Additionally, PLHIV would benefit from the six-monthly HIV care program if appropriate counseling is provided and all the potential barriers are addressed.

Introduction

HIV has continued as a global public health issue that has caused significant morbidity and mortality. Globally, about 39 million people were living with HIV, and Africa accounts for about 65% of the burden of the disease. ¹ However, new HIV infections and deaths have declined globally. ² In Ethiopia, about 600,000 people are living with HIV. ³ The disease has a wide regional variation, where Gambella, Addis Ababa, and Amhara regions contributed the highest burden. ⁴

Due to the availability of treatment, HIV becomes a chronic disease that enables patients to be clinically stable and live longer for many years. As a result, the differentiated service delivery (DSD) models have been introduced to accommodate the growing number of stable people living with HIV (PLHIV). ⁵ Stable PLHIV is defined as a client who has received anti-retroviral therapy (ART) for at least 6 months, has no current illnesses, has a good understanding of lifelong adherence, and has evidence of at least one suppressed viral load result. ⁶ DSD is a patient-centered approach that simplifies the HIV services across the cascade that serves the needs of people living with and vulnerable to HIV and optimizes the available resources in the healthcare systems. The World Health Organization (WHO) has recommended the use of the DSD models since 2016. Several countries in Sub-Saharan Africa (SSA) have adopted and scaled up the DSD models as part of their national health policy. ⁷

In general, DSD models for HIV treatment in stable PLHIV can be categorized into four models. These are individual models based at the healthcare facility, out-of-facility individual models, group models managed by health care providers, and group models managed by patients. For PLHIV who established on ART, a 3- to 6-month ART refill and clinical consultation is recommended. ⁸

Ethiopia has adopted various DSD models since 2017. ⁹ Appointment spacing model (ASM) has been implemented in the country, including in the study area, for stable adult PLHIV. In this care model, PLHIV will have a clinical review and ART refill at the healthcare facility every 6 months. In addition, enrolled PLHIV will have viral load tests yearly. ASM was found to be effective in stable PLHIV in improving adherence and associated with good treatment outcomes.^10–12 However, a considerable proportion of stable PLHIV are not engaging in the ASM. ¹³ Cross-sectional studies conducted in Northwest Ethiopia and Southern Ethiopia showed a 50% and 63% uptake of ASM, respectively.^14,15 A study finding in Southwest Ethiopia showed that the demographic and clinical factors are associated with the uptake of ASM. ¹⁶ A recent meta-analysis finding showed that the uptake of ASM in Ethiopia was estimated to be 48%. ¹⁷ However, the factors that determine the ASM acceptance were not well known in Ethiopia, including in the study area. Thus, unfolding the determinants of ASM acceptance will help to enhance clients’ engagement in the model. Hence, this study was aimed to assess the determinants of ASM acceptance among PLHIV in Dessie city, Northeast Ethiopia.

Methods

Study Design

An institution-based case–control study was employed to identify the determinants of ASM acceptance among PLHIV. This study was reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) for case–control studies ¹⁸ (Supplemental Material S1).

Study Period and Setting

The study was conducted from 2 to 30 August 2024 in HIV care-providing public health facilities found in Dessie city, Northeast Ethiopia. Dessie city is the zonal city of the South Wollo Zone and among the largest cities in the Amhara Regional State. It is located 400 km away from Addis Ababa (the capital city of Ethiopia) and 471 km away from Bahir Dar, the regional city of the Amhara Regional State.

In Dessie city, there is one comprehensive specialized hospital, one general hospital, eight public health centers, and three private hospitals. Dessie Comprehensive Specialized Hospital, Borumeda General Hospital, Segno Gebaye Health Center, Banbuawuha Health Center, and Dessie Health Center are among the public health facilities that provide comprehensive HIV care (offering HIV prevention, treatment, and support to the most vulnerable population) to the people of Dessie city and other people who come from surrounding zones and regions. The ASM has been implemented in all public health facilities of the city.

Population

The source population for cases were all PLHIV who enrolled in the ASM in public health facilities of Dessie city. Whereas, all PLHIV who were eligible but not enrolled in the ASM were the source population for controls. The study population for cases were all PLHIV who enrolled in the ASM during the data collection period in public health facilities of Dessie city. All PLHIV who were eligible but not enrolled in the ASM during the data collection period were the study population for controls.

Eligibility Criteria for ASM

Stable PLHIV are eligible to be enrolled in the ASM. Clients who have received ART for at least 6 months, have no current illnesses, have a good understanding of lifelong adherence, and have evidence of treatment success (at least one suppressed viral load result or CD4 > 20 °C/ml) are eligible for ASM. ⁶

Inclusion and Exclusion Criteria

Inclusion criteria for cases: All adult PLHIV (≥18 years) enrolled in the ASM were included in the study.

Inclusion criteria for controls: All adult PLHIV (≥18 years) who were on the conventional HIV care but eligible for the ASM were included in the study.

Exclusion criteria for cases: PLHIV who discontinued the ASM and were found enrolled in other differentiated ART delivery models, such as community-based models, were excluded from the study.

Exclusion criteria for controls: PLHIV who enrolled in the other differentiated ART delivery models, such as community-based models, were excluded from the study.

Sample Size and Sampling Technique

The sample size was calculated using Epi-Info Version 7 based on the following assumptions: a proportion of 16% urban residents among ASM attendants and the odds ratio of 2.61 taken from a previous study. ¹⁶ With a 95% confidence interval (CI), 80% power, and a case-to-control ratio of 1:3. With this information, the sample size was 291 (97 cases and 194 controls). After adding a 10% non-response rate, the total sample size becomes 305, of which 102 were cases and 203 were controls.

The following steps were held to select the study participants. Of all public health facilities that provide the ASM in Dessie city, four healthcare facilities (one hospital and three health centers) were selected using a simple random sampling technique. In the selected health facilities, the total number of PLHIV who enrolled in the ASM (cases) was estimated from the facilities’ ART registration. Similarly, the number of PLHIV who were eligible to be enrolled in the ASM but continued receiving the conventional HIV care (controls) was estimated. Both the cases and controls were clinically stable clients who were established on ART. Then, the monthly total of ASM-enrolled clients and those in conventional care was estimated by taking the previous 6 months’ client flow from the ART registration. Thus, the expected number of cases and controls during the study period (for 1 month) was estimated, and it was used as a sampling frame. Then, proportional allocation was made in each healthcare facility based on the estimated number of cases and controls. Finally, a systematic sampling approach (every fourth client) was used to select the study participants by taking the data collection period into consideration (Figure 1).

Figure 1.

A schematic presentation of the sampling procedure for assessing the determinants of the ASM acceptance among PLHIV in Dessie city, Northeast Ethiopia.

Data Collection Tool

An interviewer-administered structured questionnaire was adapted by reviewing previous literatures.^16,19,20 In addition, a document review of the patent's chart was used to collect pertinent clinical HIV-related data using a data extraction tool. In particular, the type of ART regimens that the PLHIV are receiving and the number of years since patients initiating ART were taken from the patients’ charts. The data collection contains the socio-demographic characteristics of participants and the clinical profiles of PLHIV (Supplemental Material S2). The questionnaire was pretested by taking 5% of the total sample size in the Kutaber Health Center to assess its clarity and validity and minor modifications were made before the data collection.

Study Variables

In this study, the outcome of interest was ASM acceptance. Sex, age, marital status, educational level, residence, occupation, religion, ethnicity, and housing status were among the independent variables. In addition, duration on ART, current ART regimen, availability of a unique drug storage place at home, client's means of transportation to the ART clinic, average time required to reach the ART clinic, and HIV disclosure status were the independent variables.

Operational Definitions

Cases: In this study, cases were PLHIV who enrolled in the ASM.

Controls: PLHIV who were on conventional HIV care, eligible to be enrolled in the ASM but not enrolled.

Data Quality Assurance

Data quality was ensured by undertaking the following measures. The questionnaire was initially developed in English and translated into the Amharic language by bilingual public health experts. The translated version was then back-translated into English by an independent translator who was blinded to the original data collection tool. The original and back-translated versions of the questionnaire were compared, and any discrepancy was resolved through discussion to ensure conceptual similarity. Five data collectors and two supervisors were trained for 2 days regarding the objective of the study, ethical issues, and how to conduct the data collection. The data extraction tool for the clinical profile of patients was developed from the national ART guideline chronic follow-up form. In addition, the data collection tool was pretested by taking 5% of the total sample size in Kutaber Health Center, which is found in Dessie Zuria District, and minor modifications were made, including improving question sequencing before the data collection.

Ethical Approval and Consent to Participate

The ethical approval for this study was obtained from the Ethical Review Committee of the College of Medicine and Health Sciences of Wollo University (approval no. WU CMHS 4024/20/2024) on 07/20/2024. In addition, permission letters were obtained from the selected healthcare facilities. A written informed consent was waived by the ethical review committee, as the study had no risk to participants and involved medical record reviews. Instead, informed verbal consent was approved by the ethical review committee. Thus, the study participants were informed about the purpose and importance of the study, and data collection was initiated after obtaining informed verbal consent from each participant. To ensure confidentiality, all data were de-identified using unique study codes, and no personal identifiers were included. The paper-based questionnaire was stored in a locked cabinet, and the electronic data was stored on password-protected computers, which are accessible only to the research team, and the data was used only for the research purpose.

Data Processing and Analysis

Data was coded and entered using Epi-info Version 7 statistical software and then exported to SPSS Version 23 for further statistical analysis. Appropriate descriptive statistics were used to analyze the data. Frequency, percentage, and tables were utilized to summarize the data. Age data was missed in three of the study participants, and it was imputed under the assumption of missing at random. Thus, a single imputation approach was used and performed using SPSS. Multivariable logistic regression analysis was employed to identify the determinants of ASM acceptance. In bivariable analysis, variables that had a p-value of less than .2 were entered into the multivariable logistic analysis model. In addition, prior evidence from the literature and biological plausibility was also considered in the multivariable analysis. A multicollinearity test was conducted using tolerance and variance inflation factor (VIF). No interaction terms were included in the final model. A multivariable logistic regression model was employed, and the model goodness-of-fit was assessed using the Hosmer–Lemeshow test. Adjusted odds ratios (AORs) with 95% CIs were reported, and statistical significance was set at a p-value of less than .05.

Results

Socio-Demographic Characteristics of Study Participants

A total of 305 eligible PLHIV (102 cases and 203 controls) were invited to participate in the study, and none declined participation, with 100% response rate. The mean age of cases was 35.6 (SD ± 13.2 years), and that of controls was 38.7 years (SD ± 15.4 years). In this study, 36.3% of cases and 41.9% of controls were found in the age group of 36 to 45 years. About 55.9% of cases and 46.8% of controls had completed secondary school. About 65.7% of cases and about 47.8% of controls were females. In this study, 70.6% of the cases and 85.7% of the controls were living in the urban area. Moreover, 61.8% of the cases and 54.2% of the controls were living in their private house (Table 1).

Table 1.

Bivariable and Multivariable Analyses of Factors Associated With ASM Acceptance Among PLHIV in Dessie City, Northeast Ethiopia, 2024 (n = 305).

Variables	Cases (N = 102)	Control (N = 203)	COR (95% CI)	AOR (95% CI)	P-Value
	n (%)	n (%)
Sex
Female	67 (65.7)	97 (47.8)	2.09 (1.27-3.42)	1.90 (1.07-3.35)	.026
Male	35 (34.3)	106 (52.2)	1	1
Age (in years)
18-35	23 (22.5)	64 (31.5)	0.46 (0.24-0.86)	0.54 (0.26-1.13)	.104
36-45	37 (36.3)	85 (41.9)	0.56 (0.32-0.97)	0.60 (0.32-1.15)	.129
≥46	42 (41.2)	54 (26.6)	1	1
Highest level of education
No formal education	15 (14.7)	20 (9.9)	1	1
Elementary school	19 (18.6)	38 (18.7)	0.66 (0.28-1.58)	1.05 (0.38-2.89)	.916
Secondary school	57 (55.9)	95 (46.8)	0.80 (0.38-1.68)	0.78 (0.32-1.90)	.597
College and above	11 (10.8)	50 (24.6)	0.29 (0.11-0.74)	0.40 (0.13-1.18)	.099
Residence
Rural	30 (29.4)	29 (14.3)	2.50 (1.40-4.46)	3.27 (1.61-6.63)	.001
Urban	72 (70.6)	174 (85.7)	1	1
Housing status
Private	63 (61.8)	110 (54.2)	1.36 (0.84-2.22)	1.76 (0.98-3.16)	.056
Rent	39 (38.2)	93 (45.8)	1	1
Duration on ART
≤5 years	16 (15.7)	63 (31.0)	1	1
>5 years	86 (84.3)	140 (69.0)	2.41 (1.31-4.45)	2.64 (1.32-5.25)	.006
Do you have unique place to keep ART at home?
Yes	77 (75.5)	130 (64.0)	1.73 (1.01-2.95)	1.82 (0.98-3.36)	.056
No	25 (24.5)	73 (36.0)	1	1
Means of transportation to the ART clinic
On foot	34 (33.3)	46 (22.7)	1.70 (1.01-2.89)	1.23 (0.65-2.32)	.516
Using taxi/bus	68 (66.7)	157 (77.3)	1	1
Average time required to reach the ART clinic
<1 h	23 (22.5)	28 (13.8)	1	1
1-3 h	45 (44.2)	123 (60.6)	0.44 (0.23-0.85)	0.33 (0.15-0.73)	.006
>3 h	34 (33.3)	52 (25.6)	0.79 (0.39-1.60)	0.62 (0.27-1.43)	.266
HIV disclosure status
Disclosed	93 (91.2)	150 (73.9)	3.65 (1.72-7.74)	3.64 (1.57-8.41)	.003
Not disclosed	9 (8.8)	53 (26.1)	1	1

COR, crude odds ratio; AOR, adjusted odds ratio; CI, confidence interval.

1 stands for reference.

Clinical Characteristics of Study Participants

In this study, 84.3% of the cases and 69% of the controls were on ART for more than 5 years. Three-fourths of the cases and about 64% of the controls had a unique place to keep their ART at home. Regarding means of transportation to the ART clinic, about one-third of the cases and 22.7% of the controls had reported that they travel on foot. On average, 44.2% of the cases and 60.6% of the controls required about 1 to 3 hours to reach the ART clinics. Moreover, the majority of the study participants (91.2% of the cases and 73.9% of the controls) had disclosed their HIV status (Table 1).

Factors Associated With Appointment Spacing Model Acceptance

Multicollinearity was checked using tolerance and VIF, and it revealed the absence of multicollinearity among the variables, as all the VIF values were <10 and tolerance were found to be close to one. A total of 15 variables were tested in the bivariable logistic regression analysis. In bivariable logistic regression analysis, sex, age, residence, educational status, housing status, duration on ART, having had a unique place to keep ART at home, means of transportation to the ART clinic, average time required to reach the ART clinic, and HIV disclosure status had a p-value of <.2 and were entered in the multivariable logistic regression analysis.

In the multivariable analysis, sex, residence, duration on ART, HIV disclosure status, and average time required to reach the ART clinic were found to be significantly associated with ASM acceptance. The Hosmer–Lemeshow statistic showed that the model is considered a good fit to the data (p = .328). Being female (AOR = 1.90; 95% CI: 1.07-3.35), rural residence (AOR = 3.27; 95% CI: 1.61-6.63), being on ART for >5 years (AOR = 2.64; 95% CI: 1.32-5.25), those who disclosed their HIV status (AOR = 3.64; 95% CI: 1.57-8.41), and patients who required 1 to 3 hours to reach the ART clinic (AOR = 0.33; 95% CI: 0.15-0.73) were significantly associated with ASM acceptance (Table 1).

Discussion

Significant progress has been made in HIV care and treatment, particularly in resource-limited countries. WHO recommended the use of multi-month dispensing and clinical consultation for stable PLHIV since 2016, and several countries in SSA are implementing this package of care as part of their national policy for adults who are established on ART. ¹⁰ ASM is an HIV care model in which clients will have a clinical consultation and ART refill schedules every 6 months, and it has been implemented in Ethiopia since 2017. However, all eligible clients are not enrolling in this DSD model. Hence, this study was aimed to assess the determinants of ASM acceptance among PLHIV. In this study, sex, residence, duration on ART, average time required to reach the ART clinic, and HIV disclosure status were found to be significantly associated with ASM acceptance.

Our study showed that females were 1.9 times more likely (AOR = 1.90; 95% CI: 1.07-3.35) to accept the ASM than males. This finding was in line with a study reported in Uganda, where being female was positively associated with the uptake of the community client-led ART delivery model. ²¹ This could be related to the higher workload of females than males. In Ethiopia, particularly in the study area, women have more duties than men. They could have limited time to visit the healthcare facilities more frequently. Thus, they might prefer to engage in the ASM by taking advantage of saving time and limited clinical visits.

In this study, rural residents were 3.27 times (AOR = 3.27; 95% CI: 1.61-6.63) more likely to accept ASM than urban residents. This finding was in line with a study conducted in Southwest Ethiopia. ¹⁶ This could be related to the proximity of ART-providing healthcare facilities for clients who are living in urban areas as compared to facilities that are located in rural areas. Due to the long distance between their home and the ART clinic and transportation costs at every clinical visit, clients in rural areas may accept this type of DSD model. The amount of distance between the healthcare facility and the clients’ home showed significant association with DSD acceptance.^14,15,22 However, our finding contradicted a study finding from Tanzania, where urban residence was positively associated with the uptake of the multi-month dispensing model. ²² This could be related to the easy availability and accessibility of information regarding innovative approaches in urban areas.

In our study, the average time required to reach the ART clinic was significantly associated with ASM acceptance. The ASM acceptance was found to be reduced by 67% in PLHIV who required 1 to 3 hours to reach the ART clinic compared to those who took less than 1 hour (AOR = 0.33; 95% CI: 0.15-0.73). This might indicate that the burden for transportation still exists, and each clinical visit still is costly and requires exhausting traveling.

In our study, PLHIV who received ART for over 5 years were about 2.64 times (AOR = 2.64; 95% CI: 1.32-5.25) more likely to accept ASM than clients who received ART for ≤5 years. This finding was similar to a study conducted in Southwest Ethiopia. ¹⁶ Moreover, longer duration on ART was positively associated with the uptake of DSD models.^14,15,21

Moreover, our study showed that PLHIV who disclosed their HIV status were 3.64 times (AOR = 3.64; 95% CI: 1.57-8.41) more likely to accept ASM as compared to those who did not disclose their HIV status. However, the wide CI showed that this estimate has limited precision and should be interpreted cautiously. In ASM-based care, clients will receive ART for 6 months, and if they didn’t disclose their HIV status, ASM acceptance could be challenging related to storing the drug and privacy. PLHIV who disclosed their HIV status also have optimal ART adherence and care engagement, which enables them to obtain social support from their families. Strong social support is important in DSD-enrolled clients to make HIV care more effective.^14,15,23,24

Following the new WHO guideline, specific populations like children, adolescents, pregnant and breastfeeding women, and key populations become eligible to be enrolled in the DSD models besides stable adult clients. ²⁵ DSD is patient-centered care that depends on the needs of clients and their preferences. Although PLHIV are expected to be involved in deciding their preferred model, ART providers have a great influence in deciding the DSD models. ²⁶ In Mozambique, ART providers showed high preference for the fast-track ART refill and the three-monthly ART dispensing models but showed less preference for the community-based models. ²⁷

Strength and Limitations of the Study

The strength of this study was the use of a case–control study design to identify the potential factors associated with ASM acceptance. It provides valuable insights on the determinants of ASM acceptance in similar settings. However, this study also has limitations that the readers should consider. There could be recall and social desirability bias as we used self-reported data from the respondents. This study assessed only stable PLHIV who were established on ART, and the findings may not be generalized to all types of PLHIV. A systematic random approach was applied using client flow as a sampling frame, and selection bias may have occurred if the clinical follow-up of clients had hidden patterns. Although multivariable analysis was performed, residual confounding from unmeasured variables cannot be ruled out. Moreover, this study didn’t assess the facility-level factors that could influence ASM acceptance besides the patient-level factors.

Conclusions

In our study, being female, rural residence, longer duration on ART, disclosing HIV status, and average time required to reach the ART clinic were found to be significantly associated with ASM acceptance. Thus, ART providers shall consider the socio-demographic and clinical profile of patients while offering ASM for stable PLHIV. Future study is required to identify the facility-level factors that could have association with the ASM acceptance.

Supplemental Material

sj-docx-1-jia-10.1177_23259582261433148 - Supplemental material for Determinants of Appointment Spacing Model Acceptance Among People Living With HIV in Dessie City, Northeast Ethiopia: Case–Control Study

Supplemental material, sj-docx-1-jia-10.1177_23259582261433148 for Determinants of Appointment Spacing Model Acceptance Among People Living With HIV in Dessie City, Northeast Ethiopia: Case–Control Study by Ehetenesh Berihun, Hawa Wolie, Missale Kasahun, Silewondim Mekonen, Meron Birhanu, Mulugeta Ashagrie, Sisay Gedamu and Abebe Dires in Journal of the International Association of Providers of AIDS Care (JIAPAC)

Supplemental Material

sj-doc-2-jia-10.1177_23259582261433148 - Supplemental material for Determinants of Appointment Spacing Model Acceptance Among People Living With HIV in Dessie City, Northeast Ethiopia: Case–Control Study

Supplemental material, sj-doc-2-jia-10.1177_23259582261433148 for Determinants of Appointment Spacing Model Acceptance Among People Living With HIV in Dessie City, Northeast Ethiopia: Case–Control Study by Ehetenesh Berihun, Hawa Wolie, Missale Kasahun, Silewondim Mekonen, Meron Birhanu, Mulugeta Ashagrie, Sisay Gedamu and Abebe Dires in Journal of the International Association of Providers of AIDS Care (JIAPAC)