
==== Front
BMC Infect Dis
BMC Infect Dis
BMC Infectious Diseases
1471-2334
BioMed Central London

39271975
9888
10.1186/s12879-024-09888-8
Research
Adherence of healthcare providers to Enhanced Adherence Counseling (EAC) intervention protocol in West Amhara Public Health Facilities, Northwest Ethiopia, 2023: mixed method evaluation
Belete Amare 1
Teshale Getachew getateshale1221@gmail.com

2
Yalew Andualem 2
Delie Endalkachew 2
Getu Gebrie 3
Atnafu Asmamaw 2
1 https://ror.org/00b2nf889 grid.463120.2 0000 0004 0455 2507 Gondar Branch Office, Amhara Regional Health Bureau, CDC project, Gondar, Ethiopia
2 https://ror.org/0595gz585 grid.59547.3a 0000 0000 8539 4635 Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
3 https://ror.org/0595gz585 grid.59547.3a 0000 0000 8539 4635 Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
13 9 2024
13 9 2024
2024
24 9772 1 2024
5 9 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Background

In Ethiopia, there were an estimated 670,906 people living with the Human Immune Virus (HIV). Implementing an HIV test and treat strategy and rapid scale-up of anti-retroviral treatment (ART) provided health facilities increased the number of the number of people living with HIV/AIDS. In the same way, the expansion of viral load monitoring in these health facilities and poor adherence to ART increase the number of high-viral load (HVL) patients. To alleviate this problem, the World Health Organization (WHO) recommended EAC intervention for HVL patients. Therefore, the aim of this research was to determine the level of healthcare providers’ adherence to the EAC intervention protocol and explore barriers and facilitators of the intervention in West Amhara, Northwest Ethiopia.

Method

Descriptive cross-sectional study design with concurrent mixed-method evaluation was employed. The adherence dimension, with its sub-dimensions of content, coverage, frequency, and duration of the EAC intervention, was used with sixteen indicators. A total of 20 high-case-load public health facilities and 173 HVL patients were included in our study. Quantitative data was entered into Epi Info and exported to SPSS version 25 for analysis. Descriptive statistics are analyzed in terms of frequencies, percentages, variances, and means and presented as narrations, frequency tables, graphs, and charts. Qualitative data were transcribed, translated, coded, and analyzed thematically using Open Code version 4.0 software. The qualitative findings were used to triangulate the quantitative findings.

Result

The average adherence level of health care providers (HCPs) to the EAC intervention protocol was 55.3%, from which content, coverage, frequency, and duration of the intervention contributed 70.3%, 86.3%, 36.9%, and 27.7%, respectively. Most of the intervention contents were delivered during the session, but none of the providers developed a patient adherence plan at the end of the session. All HVL patients were linked and enrolled in the EAC intervention. But only 6% of them were tested for repeat VL.

Conclusion

The average adherence level of HCPs to the EAC intervention protocol was very inadequate. The main gap identified was difficulties in completing the EAC intervention sessions based on schedules. Implementing adherence improvement strategies, assigning an adequate number of EAC providers in ART and Prevention of Mother-to-Child Transmission (PMTCT) clinics, and allowing sufficient time during EAC sessions are important.

Keywords

Adherence
High viral load
EAC
Amhara
Ethiopia
issue-copyright-statement© BioMed Central Ltd., part of Springer Nature 2024
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pmcIntroduction

In Ethiopia, there were an estimated 670,906 people living with HIV, with an incidence rate of 36,990 per year among all ages and sexes. Although the age-standardized AIDS mortality rate declined very fast after 2005, nearly 20,000 AIDS-related deaths were predicted in 2023/24 in Ethiopia [1].

Implementing HIV test and treat strategy and rapid scale-up of ART providing health facilities led to large number of people living with HIV on ART [2, 3]. The expansion of viral load monitoring in these health facilities, in turn, led to the detection of an increased number of HVL patients. Poor adherence is also another reason to increase the number of HVL patients [3–6]. As a solution, WHO has recommended EAC intervention for HVL patients and [7] following this WHO recommendation, countries has adopted and implemented EAC intervention.

EAC is a structured and targeted adherence counseling intervention for HVL patients after the client has been on ART for at least 6 months and before they are diagnosed with treatment failure. It includes assessing the adherence rate, exploring barriers, and supporting HVL patients to find solutions [4, 7]. EAC intervention is given for all HVL patients monthly for 3–6 months to identify adherence barriers [4]. HVL patients should have at least 3 months’ good adherence record to repeat the VL test. A repeated VL test result > 1000 copies/ml is one of the indicators to switch an HIV patient from 1st line ART to 2nd or 3rd line ART in EAC, but HIV patients with a repeated VL test result of £1000 copies/ml will be discharged from EAC intervention and stay at 1st line ART (Fig. 1).

Fig. 1 Algorithm of VL monitoring and EAC intervention [4]

Based on WHO recommendations, Ethiopia has implemented EAC interventions since 2017 [4]. Studies conducted in West Gojjam [8] and North Wollo [9] Ethiopia showed only 51.73% and 60.4% viral re-suppression was achieved after EAC sessions respectively. Both findings were lower than the WHO minimum target [3].

Studies suggest that the content of an intervention is its active ingredient as it primarily determines implementation success or failure. These studies noted that the inability to deliver the content of an intervention affects the extent to which full implementation is attained [10–12]. Programs are less effective when study participants do not receive the intended contents [13].In addition to the content of the intervention, the coverage of the intervention services has an effect on attaining the program’s expected results. An epidemiological study in Ethiopia showed that around 51% of HVL patients had defaulted on their EAC intervention before their repeated VL testing [14]. Incomplete delivery and poor coverage makes the intervention ineffective [15].Although the EAC implementation guidelines recommended that all HVL patients receive their EAC sessions on a monthly basis, they didn’t attend due to different challenges like the inaccessibility of health facilities, current peace and security problems in the country, and the limited number of EAC rooms [16]. EAC is designed to provide it services for 3 months, after which a HVL patients are being on ART regimen or switched to next regimen [4].But studies showed that the median time to start the first EAC session after HVL detection was 8 weeks, 33.2% of participants started the first EAC session 4–8 weeks after HVL detection, and around 13% of HVL patients did not start EAC sessions up to 3 months [9]. The same study in Ethiopia showed that only 46.8% of HVL patients completed EAC sessions within the recommended time duration, and 27.2% completed EAC sessions after 6 months of initiation of EAC sessions [9].

Therefore, this evaluation study determined the level of healthcare providers’ adherence to the EAC intervention protocol and program design in terms of intervention content, frequency, coverage, and duration and explored the intervention barriers and facilitators (Fig. 2).

Fig. 2 Conceptual framework for implementation fidelity of EAC intervention in West Amhara public health facilities, Northwest Ethiopia Adapted from Carroll et al. [10] and Hasson [54]

Methods and materials

Evaluation area and period

This evaluation study was conducted in 20 public HFs in West Amhara, Ethiopia, from February to July 2023. West Amhara includes seven town administrations: Debark, Gondar, Debre-Tabor, Bahir Dar, Injibara, Finote Selam, Debre-Markos, and eight zones: North Gondar, Central Gondar, South Gondar, West Gondar, West Gojjam, Awi, and East Gojjam. Based on a population estimation of 2021/22, it had a total population of 13,889,807 [17]. One hundred seventy-eight (178) public health facilities have been providing ART services in West Amhara in 2022/23.

Evaluation design and method

Descriptive cross-sectional study design with concurrent mixed method evaluation was employed. This study design aims to measure and describe healthcare providers’ adherence to EAC intervention protocol accurately and systematically and for better understanding of the intervention gaps. Using mixed method approach provides complimentary and more comprehensive evidences and for better understanding of EAC intervention. It can increase confidence and validity of the findings.

Variables and measurement

After discussion and reaching consensus with stakeholders, adherence dimension with its sub dimensions of content, coverage, frequency and duration of EAC intervention with sixteen indicators were used. Indicators for each sub dimensions were adopted from Ethiopia national EAC intervention guideline, routine monthly key performance indicator (KPI) as well as from other WHO, CDC, PEPFAR and ICAP documets [4, 18–21]. Sub dimensions and indicators also wieghted based on their level of importance for the program and stakeholders’ agreement. Accordingly, a total of 16 indicators were used in the four sub-dimensions.

Content indicators

Number of EAC sessions for which patient adherence rate was assessed.

Number of EAC sessions for which patient adherence barriers were assessed.

Number of EAC sessions with EAC provider motivated and assisted HVL patients to identify solutions for their challenges.

Number of EAC sessions with patient adherence plan was prepared.

Coverage indicators

Percentage of HVL patients initiated first EAC session.

Percentage of HVL patients received second EAC session.

Percentage of HVL patients received third EAC session.

Percentage of HVL patients tested for repeat VL.

Frequency indicators19

Percentage of HVL patients who got 2nd EAC session one month after first EAC session.

Percentage of HVL patients who got 3rd EAC session one month after second EAC session.

Percentage of HVL patients who tested for repeat VL one month after third EAC session.

Duration indicators

Time to first EAC session in days from VL result received.

Time to second EAC session in days from first EAC session.

Time to third EAC session in days from second EAC session.

Time to repeat VL collection in days from third EAC session.

EAC session duration in minutes during direct EAC session observation.

Populations and sampling

In Amhara region, there were 178 ART providing health facilities. Thus, based on sampling manual for facility surveys recommendation [22] and feasibility issues of the study, we took 11% of the health facilities and these facilities were selected purposively; based on their relative high-case-load. Since all HVL patients enrolled in the EAC intervention in the selected health facilities during our study period were only 173, census was done for all cases (Table 1).

Table 1 Selected health facilities for evaluating implementation fidelity of EAC intervention in West Amhara public health facilities, Northwest Ethiopia, 2022

S. No	HF Name	# HVL patients	S.No	HF Name	# HVL patients	
1	GUCSH	11	11	Debark GH	19	
2	Gondar HC	15	12	Debark HC	4	
3	Azezo HC	3	13	Finote-Selam GH	7	
4	Maraki HC	3	14	Burie HC	6	
5	Teda HC	3	15	Dangila HC	3	
6	Debre-tabor SH	3	16	Debre-Markos SH	19	
7	Felegehiwot SH	29	17	Debre-Markos HC	12	
8	Bahirdar HC	7	18	Abima HC	4	
9	Han HC	6	19	Koladiba HC	8	
10	Abay HC	4	20	Maksegnit HC	4	
	Grand Total = 173	

Besides, EAC providers, ART focal persons, EAC registrations and selected patients’ chart in the selected public health facilities were also our study population. Based on USAID recommendation [23], we conducted 32 randomly selected EAC session observations from 14 purposively selected public HFs. The health facilities used for observation were selected based on their relative performance on ART program (4, 4, 5 low, high and averagely performed facilities) and their performance status was obtained from their routine performance reports. The numbers of observation sessions were determined by the level saturation.

A total of 23 in-depth interviews with randomly selected HVL patients and 20 key informant interviews with purposively selected individuals (ART focal) from each selected health facilities were also conducted.

Data collection tool and field work

HVL patients’ charts and EAC register (logbooks) extraction tools, observation checklists, in-depth interview and KII tools adopted from EAC intervention guideline and other related literatures [4, 24, 25]. These tools were translated to Amharic (local language) and retranslated to English to check its consistency and validity for easily understanding. A senior research expert was involved during the tool adaptation and translation (mentioned in the acknowledgment) process.

We recruited four bachelor degree holder data collectors and two MSc holder supervisors and provided two days training. Both quantitative and qualitative data were collected simultaneously analyzed separately and integrated in result and discussion section.

Data management and analysis

Quantitative data were checked daily for its consistency and completeness, entered into Epi Info and exported to SPSS version 25 for analysis. Descriptive statistics like frequency distribution, central tendency and dispersion analysis was conducted and findings presented in terms of narrations, frequency tables, percentages, means, graphs and charts. Qualitative data were transcribed, translated, coded and analyzed schematically by using Open Code version 4.0 software. The qualitative findings were used to triangulate the quantitative results.

Matrix of analysis and judgment

The matrix of analysis and judgment were developed with full involvement of stakeholders. The weight of sub-dimensions under adherence dimension and the respective indicators were given depending on their level of relevance and stakeholders’ consensus. The sum of all sub-dimensions was attributed to the adherence of the program. Therefore, by convention the stakeholders gave the weight for content 30%, frequency 25%, coverage 20% and duration 25%.Finally, the healthcare providers’ adherence was judged by the average score of these sub-dimensions and we categorized it as very adequate(95–100%), adequate (80–94%), inadequate (60–79%) and very inadequate (< 60% ) [26–28].

Results

A total of 173 HVL patients’ EAC follow up forms and 21 EAC logbook reviews, 32 direct EAC session observations, 23 in-depth interviews and 21 key informant interviews were done. Six hospitals and fifteen health centers were included in our study. From 173 HVL patients whose document reviewed, 84 (49%) were females and 89 (51%) were males, 150 (87%) were on 1st line and 23 (13%) were on 2nd line ART drugs, 79 (45.7%) had VL count between 1,001 and 10,000 copies/ml and 94 (54.3%) were above 10,000 copies/ml when they enrolled to EAC. All HVL participants had no documented mental illness. Most of HVL patients 133 (76.9%) were tested for their viral load due to their annual schedule and almost all patients’ test was done and ART started with in the same health facility. Majority 140 (80.9%) of HVL participants’ first VL test result was in the range of 1,001 to 50,000 viruses per cubic centimeter. While the remaining 17 (9.8%) and 16 (9.2%) of HVL participants’ first VL test result was in the range 50,001 to 100,000 and greater than 100,000 viruses per cubic centimeter respectively.

Content of EAC intervention

Among 32 direct observation EAC sessions, none of the healthcare provides developed or assisted to develop patient adherence plan for HVL participants at end of the session and only 59.4% (19) of the healthcare providers asked and assessed about the storage of patients’ ARV drugs (Table 2).

Table 2 Measuring the content of EAC intervention in West Amhara public health facilities, Northwest Ethiopia, 2023 (n = 32 observations)

S.No.	Contents of EAC intervention	Yes	No	
1.	Assessed adherence rate	28 (87.5%)	4 (12.5%)	
2.	Assessed ARV dosage	32 (100%)	0 (0%)	
3.	Assessed ARV timing	32 (100%)	0 (0%)	
4.	Assessed ARV storage	19 (59.4%)	13 (40.6%)	
5.	Assessed ARV side effects	31 (96.9%)	1 (3.1%)	
6.	Screened mental health	32 (100%)	0 (0%)	
7.	discussed about reducing alcohol or substance use	32 (100%)	0 (0%)	
8.	discussedabout dis-closing to family membres (for support)	32 (100%)	0 (0%)	
9.	Discussed about condom use	32 (100%)	0 (0%)	
10.	Motivated and assisted patient to identify solutions for identified barriers	32 (100%)	0 (0%)	
11.	Developed assisted individualized adherence plan	0 (0%)	32 (100%)	
Most of the intervention contents were delivered during the session and key informant interviews also revealed that.

Health care workers counseled me on different issues like avoiding alcohol, timely taking ARV medicationsby using phone alarming, storing ARV drugs in dry places, using condom during intercourse and eating timely balanced diet. To tell the truth, I can not totally avoid alcohol. This is really challengig even I tried many times.

[43 years old male RVI patient ]

Our observation finding also revealed that none of the observed EAC sessions adherence plan were prepared. The average content of EAC intervention was 70.3% and it was judged as adequate (Table 3).

Table 3 Judgment matrix about content of EAC intervention in West Amhara public health facilities, Northwest Ethiopia, 2023

S.No.	Indicators	Expected	Observed	Achaived	Judgment	
1	Number of EAC sessions adherence rate assessed	32	28	87.5%	Adequate	
2	Number of EAC sessions adherence barriers assessed	32	30	93.7%	Adequate	
3	Number of EAC sessions EAC provider motivated and assisted HVL patients to identify solutions	32	32	100%	Very adequate	
4	Number of EAC sessions adherence plan prepared	32	0	0%	Very inadequate	
	Average content sub dimension	128	90	70.3%	Adequate	

Coverage of EAC intervention

All HVL patients included in our study were linked and enrolled to EAC intervention. Among these, 164 (94.8%) received first EAC intervention, 146 (84.4%) received second EAC intervention and 107 (61.8%) received EAC intervention for the third time. Seven HVL patients’ viral load test result were received during our data collection period and six of them were below 50 copies per ml while the remaining one was > 1,000 copies per ml. Nine participants in six HFs did not receive any EAC session within the three months.

About 39 charts had no EAC follow up forms and there was no EAC session recorded for 20 (11.6%) HVL patients’ charts despite EAC form were attached. There was no EAC session registered in EAC logbooks for nine (5%) of HVL patients. Numbers of EAC sessions registered in EAC follow up forms and EAC logbooks were also different (Table 4).

Table 4 EAC sessions registered in EAC follow up forms versus EAC logbooks in West Amhara public HFs, Northwest Ethiopia, 2023

S.N.	# EAC sessions registered	EAC follow up form	EAC logbook	
1	# HVL patients with no EAC session registered	59 (34%)	9 (5%)	
2	# HVL patients with only one EAC session registered	17 (9.8%)	18 (10.5	
2	# HVL patients with only two EAC sessions registered	32 (18.5)	39 (22.5)	
4	# HVL patients with three EAC sessions registered	65 (37.5%)	107 (61.8)	
	Total	173	173	

Among the HVL patients who tested for repeat VL test after completing the three EAC sessions, 6 (60%) had undetectable VL result and remained in their first line ART but one result remained HVL and not yet switched to 2nd line regimen. The remaining three tests were not returned to the HFs from viral load testing laboratories. Among all 173 HVL patients, only 10 (6%) were tested for repeat VL and163 (94%) didn’t complete EAC sessions.

Qualitative findings suggest that poor patient adherence, HVL patients’ workload and distance from health facilities are some of the challenges for EAC intervention.I have been working in private organization. Working environment in the organization is very busy throughout the day. Because of this, frequently, coming to my follow up hospital to receive EAC session as well as medication refill was difficult for me. For example, I was on field last month and I did not receive last month EAC session but I took medication from other nearby health facility.

(37 years old male RVI patient).

The coverage of EAC intervention was measured by five indicators and it was 86.3% which was judged as adequate (Table 5).

Table 5 Coverage of EAC intervention in West Amhara public health facilities, Northwest Ethiopia, 2022

S.
No.	Indicators	E	O	W	S	A	JP	
1	% HVL patients initiated 1st EAC session	173	164	173	164	94.8%	Satisfactory	
2	% HVL patients received 2nd EAC session	164	146	164	146	89%	Satisfactory	
3	% HVL patients received 3rd EAC session	146	107	146	107	73.3%	Inadequate	
	Total coverage dimension	483	417	483	417	86.3%	Satisfactory	
Note: E: expected, W: weight, O: observed, S: Score ((observed X weight)/Expected), A: Achievement in percentage ((S/W) * 100), JP: Judgment Parameter

Frequency of EAC intervention

Mean time between EAC session one and EAC session two was 33.94 days while from EAC two to EAC three was 31.57 days. The mean time to complete three EAC session (from EAC one to repeat VL collection) was 84 days (Table 6).

Table 6 Frequency of EAC intervention in West Amhara public health facilities, Northwest Ethiopia,2023

Indicators	# of EAC sessions	Minimum
Days	Maximum
Days	Mean	Std. Deviation	
# days from VL result received to EAC 1	164	0	87	16.3	23.5	
#days from EAC1 to EAC 2	146	10	91	33.9	11.5	
# days from EAC 2 to EAC 3	107	17	62	31.6	6.1	
# days to do repeat VL after EAC3	10	1	37	25.4	10.4	
# days from VL received to repeat VL test	10	70	98	86.6	8.7	
# Days from VL received to EAC 3	107	39	114	69.21	13.5	
#Days from EAC1 to repeat VL collection	10	62	93	84.00	9.7	

Over burdening with other activities and poor adherence of patients to EAC intervention are some of the barriers to conduct regular EAC session schedules and ARV refill.“I have received adequate counseling in the first month of EAC session but, sometimes, there are things that come in and affect me to take EAC sessions monthly and regularly. For example, the EAC session had strict schedule, when I went for social reasons in my parents and relatives for few days, I missed the sessions. I knew this would really lead to high viral load test results”.

(42 years old female RVI patients).

Poor commitment of some HVL patients for adjustable and minor reasons were also considered as other barriers to conduct the session based on schedule.

“From my observation, some HVL patients were not truly committed to their counseling session due to different easily adjustable and very minor reasons. Receiving counseling session is lifesaving and the benefit is more than anything else. They did know this but simply they gave less attention. We will work focusing on these patients”.

[31 years HCP serving in ART clinic for more than 7 years]

Overall, only 36.9% EAC intervention sessions were conducted based on their schedule and this was judged as very inadequate based on our judgment parameter (Table 7).

Table 7 Frequency indicator and judgment of EAC intervention in West Amhara public health facilities, Northwest Ethiopia, 2023

S. No.	Indicators	E	O	W	S	A	JP	
1	% of HVL patients who got 2nd EAC session one month after EAC 1	146	49	146	49	33.6%	Very inadequate	
2	% of HVL patients who got 3rd EAC session one month after EAC 2	107	45	107	45	42.1%	Very inadequate	
3	% of HVL patients who tested for repeat VL one month after EAC 3	10	3	10	3	30%	Very inadequate	
	Total frequency sub dimension	263	97	263	97	36.9%	Very inadequate	
Note: E: expected, W: weight, O: observed, S: Score ((observed X weight)/Expected), A: Achievement in percentage ((S/W) * 100), JP: Judgment Parameter

Duration of EAC intervention

Based on our research findings, Turnaround Time (TaT) for 1st VL was 16 days while mean time to start first EAC after receiving HVL result was 16.3 days which was late from the recommended time (7days). Despite late engagement to EAC first session after receiving HVL result, the mean time to complete three EAC sessions was 84 days which (Table 8).

Table 8 Mean and median time of EAC intervention in West Amhara public health facilities, Northwest Ethiopia, 2023

Indicators	# HVL pts in EAC sessions	Mean	Std. Deviation	
Time to EAC 1 in days from receiving HVL result	164	16.3	23.5	
Time to EAC 2 in days from EAC 1	146	33.9	11.5	
Time to EAC 3 in days from EAC 2	107	31.6	6.1	
Time to repeat VL test in days from EAC 3	10	25.4	10.4	
Time to repeat VL collection in days from EAC 1	10	84.0	8.7	
Time duration in minutes for one EAC session	437	22.84	9.1	

More than half of HVL patients 95 (54.9%) at 1st EAC session received their 1st EAC session within recommended period (within 7 days) but only 28.3% and 26% of HVL patients were received their 2nd and 3rd EAC sessionsbased on recommended time (within 1 month) respectively. About one-fifth of HVL patients have started EAC sessions after more than one month of HVL result received. Similarly, 10% of HVL patients didn’t start EAC session up to 2 months.

In addition, mean time in minutes took for one EAC session during our session observation was 23 min (ranged from 9 to 59 min). EAC providers could not be able to give EAC sessions according to the protocol due to workload. A key informat intereview also revealed this:At this health facility, we are working as EAC providers as well as ART refillers, we have to counsel new ART clients, those who were lost to follow up and those with poor adherence. This leaves very little time for HVL patients’ EAC session.

[27 years old male HCP with 5 years work experience

Our finding showed that EAC session was given according to the standard duration for only 27.7% HVL patients (Table 9).

Table 9 Judgment for duration of EAC intervention in West Amhara public health facilities, Northwest Ethiopia, 2023. (n = 173)

S.No	Indicators	Within recommended time frame	Later to recommended time frame	Not took at all	Achieved	Judgment	
1	Time to EAC 1 from HVL result received	95	69 (9)	9	54.9%	Very inadequate	
2	Time to EAC 2 from EAC 1	49	97 (27)	27	28.3%	Very inadequate	
3	Time to EAC 3 from EAC 2	45	62 (66)	66	26.0%	Very inadequate	
4	Time to repeat VL test from EAC 3	3	7(163)	163	1.7%	Very inadequate	
	Average achievement of duration sub dimension		27.7%	Very inadequate	

Based on the above four adherence sub-dimensions measured, the average adherance level of HCPs to the EAC intervention protocol was 55.3%, from which content, coverage, frequency, and duration of the intervention contributed 70.3%, 86.3%, 36.9%, and 27.7%, respectively, and were judged as very inadequate.

Discussion

This study determined the adherence of EAC providers to the intervention protocol and explored barriers and facilitators of the intervention. Accordingly, the average adherence level of HCPs to the EAC intervention protocol was 55.3%. Our observation findings revealed that most of the EAC intervention contents were delivered to the target beneficiaries. The finding was in line with EAC intervention protocol expectations [7, 29]. But it was less than a similar study in Indonesia [30]. His difference may be due to the fact that the fact that our data collection method was direct observation of EAC sessions, while the Indonesian study used self-reports of participants, which increased the intended results. This evidence was supported by Hanssen et al. [31]ho found that observational measures are more reliable and have higher validity than self-reports by implementers or participants.

Our session observation and chart review also showed that preparing the next adherence plan for HVL patients was not implemented in all study health facilities. However, the EAC intervention protocol recommends that HVL patients receive all the core contents of the of the EAC session. Similarly, studies suggest that the content of an intervention is its active ingredient, as it primarily determines implementation success or failure. These studies noted that the inability to deliver the content of an intervention affects the extent to which full implementation is attained [10–12].In addition, we found that some study health facilities did not document some performed activities properly in EAC follow-up charts and EAC logbooks.

All HVL patients were linked and enrolled to EAC intervention. The finding was similar to a study in Nigeria [32] where 100% HVL patients were linked to EAC sessions. The finding was alsohigher than a study in Uganda [33]. The difference may be due to the fact that our study includes facilities found in urban sites while the Ugandian study was in rural health facilities, which is characterized by transport inaccessibility to attend the EAC sessions. It was also greater than studies conducted in Zimbabwe [34], Uganda [35], Kenya [36], Nigeria [37] and Lesotho [38].

Among those HVL patients who enrolled in EAC intervention, 94.7% of HVL patients received their first EAC session. This EAC intervention coverage was in line with the EAC intervention protocol, which stated that it is satisfactory if more than 80% of HVL patients receive the first EAC session. In our study, the coverage of the EAC intervention was found to be greater than in other studies in Uganda [39], Uganda [40], Zimbabwe [34], India [41], Swaziland [42] and Lesotho [43]. The reason for this variation might be due to the measurement difference where some studies took one EAC session, some others took two EAC sessions, and the and the other remaining studies took three EAC sessions to calculate EAC intervention coverage.

Most HVL patients who were eligible for EAC intervention sessions two and three got the session, and the findings were greater than the study findings in Uganda [40], Zambiya [44], Zimbabwe [34], Swaziland [45] and India [41]. But, it was lower than study in Zimbabwe [34] and in Kenya [36]. Those who did not receive any EAC session in our study was 5.2% and this was lower than a study in Swaziland [42], Zimbabwe [34], Uganda [33] and Lesotho [43]. The reason for this variation might be due to measurement differences, and the EAC intervention got more attention recently in our study than in earlier other studies. Our qualitative findings also revealed that HVL patrients were challenged to be fully engaged in the EAC sessions due to an inconvenient schedule, difficulty avoiding alcohol consumption, and fear of stigma. This finding was supported by other previous studies [46].

The proportion of HVL patients that completed EAC sessions and achieved VL re-suppression following EAC in our study was better than the protocol set by WHO and a study in North Wollo zone of Ethiopia [9]. The difference could be because our study didn’t include children where as the Wollo study included children. Children are known to have low VL resuppression. Our finding was also greater than a study in Lesotho [38], four West african countries [47], meta analysis studies [48] and Kenya [36].

Findings from the qualitative analysis showed that HVL patients’ work-related problems and the far distance from their house to health facilities were some barriers to attending EAC sessions. Similarly, it was very difficult for EAC providers, adherence case managers, and adherence supporters to address the socio-economic constraints of HVL patients. They had linked a few clients, especially vulnerable children, to some projects such as ANPPCAN for nutritional support, but these institutions cannot take on all the clients due to resource constraints. This finding was supported by a qualitative study done in Uganda [49].

Our study showed only one third of HVL patients received three EAC sessions on a monthly basis. This finding was lower than a recommendation set by the intervention protocol, which stated that all HVL patients have to receive their EAC sessions on a monthly basis. Our finding was also lower than a study in Nairob [36]. This might be because in Kenya providers used phone alarms to remind the session schedules.

Participants reported that there were barriers like disclosing their HIV positive status to others and social and family-related barriers that negatively affected taking their EAC sessions monthly and regularly. Despite this, our key informant said that some HVL patients were not committed to their EAC session follow-up for adjustable and minor reasons. Findings from the qualitative analysis also justified the fact that the majority of HVL patients reasoned that the monthly visits of health facilities for EAC sessions usually resulted in stigma against to them.

Only one fourth of EAC sessions were delivered for recommenended duration. EAC sessions took place for a very short duration (mean of 23 min) despite to EAC intervention protocol which states that one EAC session has to be given for at least 30–45 min. Our finding was also less than a study conducted in New York [50] but greater than a study in South Africa [51]. Increasing the length of time for each sessions may increase the adherance rate and was supported by a randomized controlled trial study in New York [50], where each additional counseling hour was associated with a 20% increase in post-counseling adherence rate.

In our study, the time to start EAC sessions after the HVL result was received was late as compared to the intervention protocol. However, our finding was better than a study conducted in Lesotho [38]. About one-fifth of HVL patients have started EAC sessions after more than one month of HVL results. Similarly, 10% of HVL patients didn’t start an EAC session for up to 2 months. But this finding was better than a study in northern Wollo, Ethiopia [9]. The difference might be due to the fact that in some of our study sites, the CDC started to send an alarm to the targets’ cell phones to remind them of the session schedules.

Despite the fact that over two-thirds of HVL patients started the third EAC session, only 6% of them completed the recommended three repeat VL tests within the protocol time frame. This finding was less than studies done in northern Wollo, Ethiopia [9], Nigeria [37] and south Africa [52]. The reason for our lower finding could be that the study period in our study was only three months, whereas in other studies it was longer.

In our study, we found that the mean time from the third EAC session to the repeat VL was earlier than the protocol. This finding was also slightly earlier than the study in the north Wollo zone of Ethiopia [9]. Our finding indicated that only around one-third of HVL patients gave samples for repeat VL tests in accordance with the protocol within 30 days. This finding was lower than a study in Tanzania [53]. After having three consecutive good adherences to EAC sessions, the repeat VL has to be tested to check whether the first HVL is suppressed or not. The recommendation in the protocol stated that this repeat VL sample has to be collected within 30 days after the third EAC session given.

Our qualitative finding indicated that providers’ workload was found to be a barrier to attending the sessions. They reported that they were overwhelmed with workload and may not be able to give EAC sessions according to the intervention protocol.

Our document review clearly showed the registerees were incomplete, which implies that they did not review client records very thoroughly and often sent HVL patients by refilling their ARV only but missed conducting the sessions.

Strength and limitation of the evaluation

This study was done using a mixed-methods approach and multiple data sources like in-depth interviews, key informant interviews, document reviews, and observation of EAC sessions, which increased the validity of the findings. The study also included multiple health facilities with the maximum effort to address high-case-load facilities in the region. However, the study is descriptive, which couldn’t show a cause-and-effect relationship and unable to infer for the general population. Hawthorne effect during observation, which may increase the observation findings, was also the other limitation.

Conclusion

The overall adherence level of HCPs to the EAC intervention protocol was 55.3%, which was judged to be very inadequate. The main gap identified was difficulties in completing the EAC intervention sessions based on schedules. The findings also showed that a lack of transport fees, a lack of EAC session rooms, HVL patients work and social-related issues, a lack of commitment of HVL patients to the schedule, and an inadequate number of EAC providers in ART and PMTCT clinics were the barriers to poor adherence.

The regional health bureau shall implement adherence improvement strategies like providing ongoing monitoring and feedback, training, and follow-up for EAC providers and supporting their work. Health facilities have to assign an adequate number of EAC providers in ART and PMTCT clinics and create suitable rooms for counseling sessions, and HCPs should allow sufficient time during EAC sessions to explore individual-level barriers and facilitators.

Acknowledgements

We are very grateful to University of Gondar for its technical support. We would also like to thank all health facilities included in our study all participants for their information and commitment. We would like to give our deepest gratitude to Professor Amsalu Feleke for their comments, suggestions and help to improve our research quality and finally our appreciation extended to the data collectors for their unreserved contribution.

Author contributions

All authors contributed to the preparation of the manuscript. AB and GT designed the study, wrote proposal, collected and analyzed the data. AY, ED, GG and AA revised the analysis. AB and GT prepared the manuscript. All authors approved the manuscript.

Funding

There is no specific fund for this research work.

Data availability

Data is provided within the manuscript or supplementary information files.

Declarations

Ethical consideration

Ethical clearance was obtained from the Institutional Review Board (IRB) of the University of Gondar, College of Medicine and Health Sciences, Institute of Public Health (ref. №: IPH/2119/2014). After a brief explanation of the study objective and purpose, informed consent was obtained from each participant. Participants were also informed that participation is voluntary, and they had the right to withdraw from the study at any time during the data collection. Furthermore, all data obtained from participants were kept confidential and used for this study only. The study was also conducted according to Helsinki declarations.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Abbreviations

AIDS Acquired Immune Deficiency Syndrome

ANPPCAN African Network for the Prevention and Protection against Child Abuse and Neglect

ART Antiretroviral Therapy

ARV Antiretroviral

CDC Centers for Disease Control and Prevention

EAC Enhanced Adherence Counseling

HC Health Center

HF Health Facility

HIV Human Immunodeficiency Virus

HVL High Viral Load

PLHIV People Living with Human Immunodeficiency Virus

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Amare Belete and Getachew Teshale have equal contribution.
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