Implementation of clinic-based modified-directly observed therapy (m-DOT) for ART; experiences in Mombasa, Kenya

Abstract

The effectiveness of modified-directly observed therapy (m-DOT), an adherence support intervention adapted from TB DOTS programmes, has been documented. Describing the implementation process and acceptability of this intervention is important for scaling up, replication in other settings and future research.

In a randomised trial in Mombasa, Kenya, patients were assigned to m-DOT or standard of care for 24 weeks. m-DOT entailed twice weekly visits to a health centre for medication collection, ongoing adherence counselling and nurse-observed pill ingestion. Community health workers (CHWs) traced non-attendees, observing pill taking at participant's home. Using process indicators and a semi-structured questionnaire, implementation of m-DOT was evaluated among 94 participants who completed 24 weeks m-DOT (81%; 94/116).

Two-thirds of m-DOT recipients were female (64%; 74/116) and a mean 37 years (SD = 7.8). Selection of the m-DOT observation site was determined by proximity to home for 73% (69/94), with the remainder choosing sites near their workplace, or due to perceived high-quality services. A median 42 of 48 scheduled m-DOT visits (IQR = 28–45) were attended. Most found m-DOT is very useful (87%; 82/94) and had positive attitudes to the services. A high proportion received CHWs home visits (96%; 90/94) and looked forward to these. Use of CHWs and several satellite observation sites facilitated provision of services closer to patient's homes. A substantial number, however, thought 24 weeks of m-DOT was too long (43%; 42/94).

Our experience suggests that m-DOT services could be implemented widely and are acceptable if delivered with adequate attention to coordination, provision of a broad set of interventions, shifting tasks to less-specialised workers and integration within the health system. m-DOT programmes should utilise existing resources while simultaneously expanding capacity within communities and the public sector. These findings could be used to inform replication of such services and to improve the design of m-DOT in future studies.

Keywords:

• HIV
• adherence
• modified-directly observed therapy
• antiretroviral therapy
• Kenya

Acknowledgements

We thank the Ministry of Health, Government of Kenya for their support. Also, sincere thanks to the adherence research team: Jerry Okal, Lillian Mutunga, Jacinta Mutegi, Nicodemus Kisengese, Agnes Rinyiru, Gerald Kimondo and Rebbecca Isemele for their commendable contributions to the study. Our thanks to Dr. John Adungosi of Family Health International and to Jedida Wachira of Management Sciences for Health. We also acknowledge the staff at Coast Provincial General Hospital, Port Reitz District Hospital, Bomu Medical Centre, Magongo Health Centre, Likoni Health Centre and Bamburi Health Centre and the Community Health Workers for their active participation. Lastly, we thank all study participants for their invaluable contribution. Sponsorship: Financial support for this study was provided by the President's Emergency Plan for AIDS Relief through the Office of HIV/AIDS, Bureau of Global Health, US Agency for International Development (USAID), through the Population Council's Horizons Program cooperative agreement of Award No. HRN-A-00-97-00012-00. The opinions expressed herein are those of the authors and do not necessarily reflect the views of USAID.