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

This paper outlines the research protocol for BRIDGE, a mixed-methods evaluation of a low-cost toolkit designed to improve HIV treatment retention and guideline compliance during the critical early treatment period in South Africa by piloting interventions at public health facilities to assess their feasibility, implementation outcomes, and preliminary effectiveness in reducing missed clinic visits.

The Gist

Imagine you've just started a very important journey to get healthy. You've been given a map and a compass (your HIV medication), but the first few months of the trip are the most dangerous. Many people get lost, turn around, or just stop walking because the path is confusing, they forget where they're going, or they feel overwhelmed.

In South Africa, about 30% of people who start HIV treatment stop coming to the clinic during their first six months. This is a huge problem because if you stop the treatment, the virus can come back.

The BRIDGE study is like a team of friendly guides trying to build a "safety net" to help people stay on this journey. They aren't building a new highway; they are just fixing the potholes and putting up better signs on the road that already exists.

Here is how they are doing it, explained simply:

The Problem: The "Early Treatment" Fog

When you first start HIV treatment, the rules are strict. You have to visit the clinic often, take your pills every day, and get blood tests. It's like learning to drive a car while someone is yelling instructions at you from the passenger seat.

• Patients are confused: "Do I have to come back every month forever? What if I miss a day? What happens if I get sick?"
• Doctors and Nurses are busy: They have hundreds of patients, and sometimes they forget to tell patients about new, easier rules that the government just made.

The Solution: The "Retention Toolkit"

The BRIDGE team created a "toolkit" (a box of helpful items) to make the journey clearer and less scary. Think of it as a survival kit for the first six months of treatment. It has five main tools:

1. The "Risk Navigator" (The Self-Check Map):

   • What it is: A simple checklist handed to patients.
   • The Analogy: Imagine a GPS that asks, "Are you worried about money? Do you have trouble remembering to take your pills?" If you check a box, the GPS immediately says, "Okay, here is a solution: We can give you a pillbox, or a social worker can help you with transport." It helps patients find their own problems and the clinic's solutions.

2. The "Client Roadmap" (The Visual Journey):

   • What it is: A colorful brochure showing the future.
   • The Analogy: Instead of a boring list of rules, this is a comic strip or a map showing the whole trip. It says, "You come here now, then in 3 months you get a blood test, and if you're doing well, you can come back in 6 months instead of 3." It shows patients that the trip gets easier over time, so they don't feel trapped.

3. The "WhatsApp Health Coach" (The Digital Friend):

   • What it is: A free app on WhatsApp.
   • The Analogy: Imagine having a wise, friendly nurse in your pocket who is awake 24/7. If you are scared at 2 AM or forgot to take your meds, you can text the "Coach." It answers questions, sends reminders, and even lets you talk to a real human if things get serious. It's like having a personal trainer for your health, but via text message.

4. The "Guideline Poster" (The Cheat Sheet for Doctors):

   • What it is: A big poster in the doctor's office.
   • The Analogy: Doctors are busy and can't read a 100-page rulebook while a patient is waiting. This poster is like a "cheat sheet" taped to the wall. It reminds the doctor, "Oh right, the new rule says if the patient's blood test is good, we can wait 6 months before the next visit." It helps the staff follow the latest, easiest rules.

5. The "Tracing Tools" (The Safety Net for Lost Travelers):

   • What it is: A checklist and a sticky note for the clinic staff.
   • The Analogy: If a patient misses an appointment, the clinic tries to call them. But often, they call the wrong number because the patient moved and didn't update their file. This tool is a reminder for the receptionist: "Every time someone walks in, ask for their phone number again!" It also gives the staff a step-by-step guide on how to call lost patients effectively, so they don't give up too easily.

How They Are Testing It

The researchers are going to 6 to 8 clinics in South Africa for one month. They will give these tools to the staff and see what happens.

• The Goal: To see if fewer people miss their appointments.
• The Method: They will look at the clinic's computer records to count how many people showed up on time compared to before the tools were used.
• The Feedback: They will also talk to the patients and the doctors to ask, "Did this help? Was it annoying? Did you actually use it?"

Why This Matters

If these simple, low-cost tools work, they could be used in thousands of clinics across Africa and the world. They don't require expensive new machines or more doctors; they just require better communication and a little bit of organization.

In short: The BRIDGE study is trying to turn a confusing, scary maze into a clear, well-lit path so that people living with HIV can stay healthy and reach their destination.

Technical Summary

Based on the provided research protocol, here is a detailed technical summary of the BRIDGE (Behavioral Risk Identification and Decision Guidance for Engagement) study.

1. Problem Statement

Despite significant advancements in HIV treatment in South Africa, disengagement from care during the early treatment period (the first six months after ART initiation) remains a critical barrier to achieving viral suppression and national HIV control goals.

• Prevalence: Approximately 30% of clients initiating ART in South Africa experience an interruption of care (>28 days) within their first six months.
• Risk: The probability of missing a scheduled visit approaches 9% immediately after initiation.
• Root Causes: Disengagement is driven by a complex interplay of factors:
  • Client-level: Lack of treatment literacy, fear of lifelong monthly visits, stigma, side effects, and logistical/financial constraints.
  • Provider/Facility-level: Incomplete compliance with 2023 revised guidelines, lack of time for counseling, and insufficient tools for risk stratification.
  • Systemic: A "one-size-fits-all" model that fails to transition clients to differentiated service delivery (DSD) models quickly enough.
• Guideline Gap: Although the South African National Department of Health (NDOH) revised guidelines in 2023 to reduce visit frequency (from 11 to 6 visits in year one) and accelerate DSD enrollment, facility-level compliance remains incomplete.

2. Methodology

The BRIDGE study is a mixed-methods evaluation of a "light-touch, low-cost" retention toolkit designed to improve care experiences and adherence during the first six months of ART.

• Study Design:

  • Type: Pilot evaluation of a retention toolkit.
  • Setting: 6–8 public sector primary health clinics (PHCs) in Gauteng, KwaZulu-Natal, and/or Mpumalanga provinces.
  • Duration: A one-month pilot implementation period (anticipated April–May 2026).
  • Comparison: Outcomes will be compared against:
    1. The same facilities' performance in the 6 months prior to the pilot.
    2. Comparable non-pilot facilities within the SENTINEL network.

• Intervention Components (The BRIDGE Toolkit):
  The toolkit consists of five co-designed components aimed at clients and providers:

  1. Intervention Navigator: A handout/poster allowing clients to self-assess vulnerabilities (e.g., stigma, transport issues) and map them to specific clinic interventions.
  2. Client Roadmap: A visual tri-fold brochure explaining the treatment journey, including when to expect DSD enrollment and how to handle missed visits.
  3. WhatsApp Health Coach: Integration of an existing AI-powered chatbot (by Population Services International) providing 24/7 confidential counseling, reminders, and triage via WhatsApp.
  4. Guideline Reference Poster: A laminated desk reference summarizing 2023 guidelines (e.g., viral load timing, DSD eligibility) to aid provider compliance.
  5. Tracing Support Tools: A job aid for tracing staff and a "contact update sticker" for receptionists to ensure client contact details are verified at every visit, not just initiation.

• Data Collection:

  • Quantitative: Electronic Medical Record (EMR) data from TIER.Net for up to 30,000 clients (15k pilot, 15k comparison).
  • Qualitative:
    • Telephone interviews with ~80 clients (exposed to the toolkit).
    • In-person interviews with ~40 providers (nurses, counselors).

• Analysis Plan:

  • Primary Clinical Outcome: Probability of returning $\le$28 days late for the next scheduled visit.
  • Implementation Outcomes: Reach, fidelity, adoption, cost, feasibility, appropriateness, and acceptability (based on Proctor et al. framework).
  • Statistical Approach: Calculation of crude relative risk and risk differences with 95% confidence intervals.

3. Key Contributions

• Co-Design Approach: The toolkit was developed collaboratively with NDOH officials, facility staff, and clients to ensure relevance and feasibility within resource-constrained settings.
• Bridging the Guideline Gap: Specifically targets the implementation lag of the 2023 NDOH guidelines by providing visual aids and decision support for providers.
• Low-Cost Scalability: The intervention relies on existing infrastructure (WhatsApp, paper handouts, posters) and requires minimal additional budget or staff time, making it highly scalable.
• Hybrid Intervention Model: Combines human-centric tools (roadmaps, navigators) with digital health (AI chatbot) to address both information gaps and behavioral barriers.

4. Results

• Status: As this document is a research protocol (preprint posted March 2026), no empirical results are yet available.
• Anticipated Outcomes: The study aims to determine if the toolkit reduces the rate of missed visits and to assess the feasibility of widespread adoption.
• Limitations Acknowledged: The authors note that the short pilot duration (1 month) may limit the ability to detect long-term behavioral changes and that small sample sizes may reduce statistical power to detect small effect sizes.

5. Significance

• Public Health Impact: If effective, the BRIDGE toolkit offers a scalable solution to a major bottleneck in South Africa's HIV response: early treatment interruption. Reducing interruptions in the first six months is critical for achieving viral suppression.
• Policy Relevance: The findings will directly inform the South African Department of Health on how to operationalize the 2023 guidelines and improve service delivery models.
• Global Applicability: The "light-touch" nature of the intervention makes it a potential model for other low-resource settings facing similar challenges with ART retention and guideline implementation.
• Implementation Science: The study contributes to the evidence base on how to effectively translate clinical guidelines into routine practice through simple, behavioral-focused tools.

Conclusion: The BRIDGE study represents a pragmatic, evidence-based attempt to solve the "early treatment drop-off" crisis in South Africa. By focusing on low-cost, high-impact behavioral tools, it seeks to bridge the gap between policy (2023 guidelines) and practice, potentially offering a blueprint for improving HIV retention globally.