Behavioral Risk Identification and Decision Guidance for Engagement (BRIDGE): Research protocol for an evaluation of an HIV treatment retention toolkit for the early treatment period

Background Interruptions in HIV care pose a major challenge to achieving HIV control goals in many countries, with 30% of clients who initiate antiretroviral therapy (ART) in South Africa experiencing an interruption of >28 days during their first six months on treatment. South Africa introduced revised guidelines in 2023 to improve outcomes during this early treatment period, but guideline compliance remains incomplete and gaps in the support provided to both clients and providers to optimize service delivery and health outcomes. Protocol BRIDGE (Behavioral Risk Identification and Decision Guidance for Engagement) is a mixed-methods evaluation of a package of light-touch, low-cost interventions aimed at improving the experiences of both clients and providers of care, increasing compliance with the 2023 guidelines, supporting clients to remain in care, and ultimately reducing the incidence of missed visits during the early treatment period. Components of the BRIDGE Retention Toolkit include an intervention navigator to help clients self-assess areas of vulnerability for disengagement from care and identify appropriate interventions; client roadmap to explain the treatment journey for the early treatment period; WhatsApp-based counseling tool for clients; guideline reference for providers; and tracing job aids. The tookit will be piloted at 6-8 public sector primary health facilities for a one-month period. The primary outcome will be the probability of returning less than 28 days late for the next scheduled clinic visit, assessed using electronic medical record data for the pilot and comparison sites. Pilot outcomes will be compared to both their own probabilities prior to the pilot and to probabilities from comparable non-pilot facilities. Implementation outcomes to be assessed using qualitative interview data from both clients and providers will include reach, implementation fidelity, adoption (uptake), costs, feasibility, appropriateness, and acceptability. Discussion The evaluation will assess the implementation and preliminary effectiveness of a set of interventions designed to improve client outcomes during the early HIV treatment period. If some or all of the BRIDGE tools are found to be helpful and/or are associated with a reduction in missed clinic visits, they will comprise a readily scalable and affordable intervention to help address a major barrier in large-scale HIV treatment programs.