Putting the ‘care’ back in healthcare: Friendly health providers can improve outcomes for PLHIV
Healthcare is about more than just diagnosing illnesses and prescribing treatments – it’s also about creating meaningful connections. For people living with HIV (PLHIV), the experience of care—how they are treated by health workers—can greatly affect their health outcomes. A groundbreaking study conducted by researchers in Zambia and supported by Midwest D-CFAR director Elvin Geng and member Aaloke Mody (both are on faculty at the WashU School of Medicine), tested a new way to make HIV care more person-centered by focusing on respect, kindness, and better communication from healthcare workers. The results, which were recently published in the Lancet HIV journal, show that fostering positive provider-patient relationships can significantly improve not only the client experience but also then increases retention in care and reduces missed appointments.
Kombatende Sikombe presenting at the 2023 AcademyHealth Dissemination and Implementation Science in Health Conference in Arlington, Virginia. (PHOTO: April Houston).
The lead author of the Lancet article is Kombatende Sikombe from the Centre for Infectious Disease Research in Zambia (CIDRZ). Sikombe explained that the idea for this new study came from previous research, where the team asked people living with HIV who were not seeing a health provider regularly what it would take for them to come back into care. “In our formative work, we learned that people actually liked being with nice providers and were willing to travel long distances to see one,” he said. Although other barriers to care were also reported by the participants, the CIDRZ team decided that focusing on the barriers created by the health system itself and inside the clinic was paramount. “Rude provider behavior was something that we thought could be addressed immediately,” Sikombe said. “We aimed to identify and implement strategies that could provide a more holistic, person-centered approach to HIV care.”
Person-centered care (PCC) is about putting people’s needs, preferences, and experiences at the heart of healthcare. While previous research has concentrated on making services easier to access, this study uniquely focused on the interpersonal side of care. The intervention targeted healthcare workers’ behaviors to create a warmer, more supportive environment for clients.
Study design and intervention
The study took place in 24 HIV clinics in Zambia between August 2019 and November 2021. Clinics were divided into four groups, with the PCC intervention introduced to one group every six months using a stepped-wedge, cluster-randomized design. The intervention included:
Training and coaching: Healthcare workers were initially trained in best practices for communication and client interaction and then receiving ongoing coaching over the course of the study
Feedback loops: Client experiences were systematically measured through trained exit surveys—similar to “secret shopper” approaches—and then fed back to clinics to see how client experiences were changing over time.
Performance-based incentives: Small rewards to the clinic motivated staff to sustain positive changes.
The researchers evaluated the impact of the intervention by analyzing client experience surveys, missed appointments, retention in care, and viral suppression.
Key findings
Improved client experiences: The proportion of visits rated as poor (a score of ≤8 on a 12-point survey) dropped by 85% after six months or more of the intervention. Before the intervention, 23.3% of visits were rated poor. After six months, only 3.5% of visits were rated poor.
Fewer missed appointments: Missed visits decreased from 25.3% before the intervention to 21.5% after six months or more.
Better retention in care: Retention at 15 months improved from 80.2% in the control group to 83.6% in the intervention group, with even greater gains among clients who had never been on an antiretroviral therapy regimen before.
Viral suppression: There was no effect on viral suppression in a smaller nested subcohort of participants.
Why it works
The study highlighted that the attention to kindness, such as greeting clients warmly or listening to their concerns, had the greatest effects among those who were having the worst client experiences and groups that have traditionally not done as well, such as those new to treatment or those returning to care after a lapse in treatment. These groups often face greater stigma and challenges, making respectful interactions particularly impactful.
“We hope this study demonstrates that person-centered care in HIV services can be delivered in routine settings in low- and middle-income countries,” Sikombe explained. “Our ultimate goal is to see a global shift towards more empathetic, inclusive, and effective HIV care, leading to better health outcomes and improved quality of life for people living with HIV.”
A key success factor was helping healthcare workers understand and use their discretion to accommodate clients as much as possible. For example, instead of reprimanding a patient for coming on the wrong day, staff were encouraged to address their needs with empathy.
Implications for public health
This study provides a practical roadmap for implementing PCC in resource-limited settings. It demonstrated that respectful, client-focused care can complement existing strategies like fast-track medication pick-up. “A lot of attention in public health has focused on the care delivery structures, but the healthcare workers delivering care within these structures are just as important of a piece. This study highlights that attention to supporting them and their behaviors is an essential and complementary part of the solution to delivering person-centered care in public health programs” explained Dr. Mody. By focusing on improving the client-provider relationship, the approach centers the client and offers a scalable way to enhance health outcomes without overburdening the system.
The intervention’s design—integrating training, data feedback, and incentives to target healthcare worker behaviors—can also readily be applied to other healthcare areas, such as maternal and child health, where disrespectful treatment is a known barrier to care.
"This study shows that investing in the human side of health care—how clients feel treated and cared for—can significantly improve outcomes,” highlighted Dr. Geng. “In the U.S., where retention in HIV care remains a challenge for many, particularly among marginalized communities, these findings highlight the potential for person-centered care approaches to foster trust, engagement, and continuity in treatment."
Looking ahead
The study’s success underscores the importance of integrating PCC strategies into national healthcare policies. CIDRZ is at the forefront of these efforts and has partnered with the International AIDS Society to train advocates to identify service delivery gaps in their communities and develop action plans to overcome these challenges using PCC approaches. Their team, including Drs. Geng and Mody, recently launched the “Person-Centered approaches to Viremia: Connection, Rapport, and Engagement (P-CoRE)” study, which aims to understand the primary pathways leading to viremia and to design and test effective solutions.
By training healthcare workers to prioritize kindness and respect, we can improve not only HIV care but also services in other fields. As public health systems worldwide strive to become more patient-centered, Zambia’s example offers a blueprint for creating more compassionate and effective care environments.
For more details on this study and its methods, read the full article in the Lancet HIV.
Written by April Houston