A multi-method study of HIV care quality in Zambia

The expansion of HIV treatment to over 19.8 million people in sub-Saharan Africa has placed immense pressure on health systems. As chronic disease management evolves, service quality and patient experience remain essential, as people value not only convenient services but also respectful, kind providers. Although service delivery coverage has been a research priority, less attention has focussed on how patient-provider interactions and health-system foundations affect long-term retention in care. My thesis used quantitative methods to assess a person-centred care (PCC) intervention and measure patient experience and quality gaps across HIV services in Zambia I co-led a stepped-wedge, cluster randomized trial evaluating a PCC intervention across 24 clinics in Lusaka Province, collaborating with a multidisciplinary team. The intervention included healthcare worker training, client experience assessments with feedback, and targeted performance incentives. Results indicated a dramatic reduction in poor client experiences, from 23.3% to 3.5%, and improved 15-month retention, especially among first-time ART initiators. However, there was no statistically significant effect on viral suppression. A parallel analysis compared patient experience responses in exit interviews and among trained exit clients (TECs) across 16 clinics. TECs who received pre-visit training reported higher odds of negative experiences, such as feeling unwelcome (aPR 1.71, 95% CI: 1.20, 2.44) and witnessing rude provider behaviour (aPR 2.28, CI: 1.63, 3.19). TECs demonstrated potential as a low-cost option for regular service quality monitoring and could be integrated into broader community-led monitoring systems to improve accountability and patient-centred improvement. Finally, I examined viral load (VL) monitoring among 7,916 ART patients with elevated VL. At 6 months, 72.2% had returned to the clinic; at 12 months, 70.1% had a repeat VL, with 16.6% experiencing treatment interruption and 11.4% returning without repeat VL. Re-suppression rates were higher for patients on tenofovir disoproxil fumarate/lamivudine or emtricitabine/dolutegravir TDF/XTC/DTG (TLD) (85.0%) than tenofovir disoproxil fumarate/lamivudine or emtricitabine/efavirenz TDF/XTC/EFV (TLE) (58.2%), highlighting the need for timely monitoring and regimen switches These results demonstrate that putting patients’ experiences at the forefront through person-centred care, supportive provider relationships, and responsive clinical practices is essential for achieving high-quality HIV care. Building on this work, similar multi-component PCC interventions could be adapted and tested in other high-burden settings to understand which elements are most transferable and cost-effective. Sustaining gains will require embedding patient-experience measurement into routine monitoring systems, aligning incentives and supervision with PCC principles, and ensuring timely access to optimal regimens and VL testing so that clinical quality keeps pace with improvements in experience and retention.