Background: Long patient wait time is reported as an operational barrier to retention in HIV care in resource limited settings. Patients may perceive waiting several hours to see a clinician for only a few minutes as an unacceptable opportunity cost. The SEARCH HIV test-and-treat cluster randomized trial (NCT:01864603) in 32 rural Ugandan and Kenyan communities is implementing a “streamlined” HIV care delivery model in government supported clinics that aims to reduce wait times to address this problem.
Methods: We examined differences in patient wait time before and during clinical visits conducted under “streamlined” and standard government HIV clinic care. Components of streamlined HIV care aimed at reducing wait time included:
(1) nurse-driven triage for patient evaluation;
(2) 3-month ART refills (vs. 1 or 2 month) for stable patients; and
(3) consolidation of services at encounter (ART, phlebotomy, medication dispensing).
We conducted a time-and-motion study of patient clinical visits. We compared mean patient wait time before and during clinical visits among SEARCH study patients with CD4 >500 cells/uL (n=119), SEARCH patients with CD4 < 500 cells/uL (n=234) and other government clinic patients (n=745).
Results: Mean visit length was over one hour shorter among SEARCH patients with CD4 >500 cells/uL and SEARCH patients with CD4 < 500 cells/ uL compared to other government clinic patients, even though mean time with providers was similar between groups (see Table). This difference was due to wait times that were >30 minutes shorter both before and during visits. Time spent receiving health education, HIV care, laboratory services, medication dispensing and other services did not differ between patient groups.

 SEARCH Patients CD4>=500 (hours:minutes) mean (SD)SEARCH Patients CD4<500 (hours:minutes) mean (SD)Other government clinic patients (hours:minutes) mean (SD)
Total visit length1:08 (1:02)1:13 (1:03)2:35 (1:33)
Wait time before visit0:21 (0:36)0:28 (0:43)1:13 (1:13)
Wait time during visit0:19 (0:30)0:23 (0:35)0:58 (1:00)
Time receiving services0:27 (0:24)0:22 (0:20)0:24 (0:29)
--Health education<0:01 (0:03)0:01 (0:07)0:08 (0:21)
--HIV care0:18 (0:18)0:12 (0:11)0:08 (0:13)
--Laboratory services0:03 (0:09)0:01 (0:08)0:01 (0:08)
--Medication dispensing0:01 (0:02)0:03 (0:07)0:04 (0:10)
--Other0:03 (0:09)0:03 (0:09)<0:01 (0:05)
[Mean wait time and time receiving services by patient types]

Conclusions: Streamlined HIV care delivery led to shortened wait times both before and during HIV clinic visits. These efficiency improvements may contribute towards improved retention in HIV care.