Understanding factors that facilitate effective uptake and integration of health interventions in South African primary health care clinics
Although antiretroviral therapy (ART) has been established as a highly successful HIV prevention tool and despite international calls to prioritize programs that will ensure HIV diagnosis, ART prescription, and viral suppression,1 only a small number of programs to improve ART uptake, retention in care, and adherence to medication have been successfully integrated into health systems. Two issues have hindered translation of efficacious programming into national policy in countries like South Africa with large HIV epidemics: first, relatively few efficacious programs exist2 , and second, moving a proven successful program from the context of a randomized trial into scaled programming in public clinics is far from straightforward.3,4 Health systems often do not have the material or human resources, training needed, systems set in place, or sufficient buy-in from staff to uptake interventions, particularly in low income, high HIV prevalence countries where clinics are overextended with the growing number of patients initiating and remaining on ART. Typically these, and other, challenges to broad scale up relate to costs, operational constraints, quality concerns, and service delivery problems. 4 Successful translation of research to practice requires careful consideration and an approach that can facilitate the rapid uptake of relevant skills and incorporation of intervention protocols into the routine delivery of care across the healthcare workforce.
The field of implementation science (IS) has begun to shed some light on why some successful interventions have not translated into programmatic successes, noting numerous factors that can impede uptake of interventions in actual clinical practice.5 A growing number of IS frameworks outlining processes for successful implementation have been proposed, few, however, have been formally evaluated and fewer focus specifically on translating interventions into clinical practice in resource poor settings. Those that do exist have large numbers of constructs and few established measurement tools, which makes their incorporation in research designs more challenging. In this application, my mentors and I propose to complete formative work that will position us to build on current IS frameworks and work towards a more focused Implementation Science model for the rapid uptake of new HIV interventions and services in low resource clinical environments. We ultimately plan to use the new model to develop and test health system supports to facilitate rapid incorporation of proveneffective interventions. This can only be done by conferring with service providers and policy makers to better understand both successful and unsuccessful past experiences in translating research to practice, and exploring what aspects of translational work were not given adequate attention and can be fortified in IS models moving forward.
To facilitate this research agenda, we will build on international research scientist Dr. van Heerden’s experience working on intervention research in local clinics in the high HIV prevalence Province of Kwa-Zulu Natal and also leverage a peer navigation (PN) intervention developed by proposal mentors, Drs Lippman and Steward, 6 that was shown to be effective in a recent cluster-randomized trial (trial registration: NCT02417233) in South African primary care clinics7 but has not yet been taken up as routine practice outside of the research context. The PN is an ideal intervention to use as a test case when developing IS-related theory and practice to promote translation of findings. The research will be conducted in the Msunduzi Municipality, KwaZulu Natal South Africa where the HSRC has a clinical research infrastructure and partnerships with local clinics.