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Chau LB, Hoa DM, Hoang NM, Anh ND, Nuong NT. Linkage between HIV diagnosis and care: Understanding the role of gender in a Northern Province in Vietnam. Health Care Women Int 2017; 39:429-441. [PMID: 29068776 DOI: 10.1080/07399332.2017.1390752] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Early linkage to HIV care is associated significantly with improved patient outcomes and reduced the risk of HIV transmission. However, delays between HIV diagnosis and registering for care have prevailed in Vietnam. The aim of researchers in this study is to examine linkages to care for individuals newly diagnosed with HIV in 2014, especially to highlight the impact of gender upon these linkages in a Northern Province of Ninh Binh. We collected secondary data of all 125 eligible HIV positive people diagnosed in 2014 and conducted a gender-based descriptive analysis of their registration to care within 6 months. Nineteen in-depth interviews and two focus group discussions were completed. We found that women accounted for one-third of newly diagnosed cases (42/125), but initiated HIV treatment at an earlier stage of HIV disease than men (65% women at stage 1, 2 versus 31% in men). Stigma and discrimination was greater among women while inadequate awareness of treatment was greater for men. Dissatisfaction with HIV testing and counseling and no or passive referral to treatment were other barriers for both the genders for enrolling in care services after diagnosis.
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Affiliation(s)
- Le Bao Chau
- a Health Management Training Institute, Hanoi University of Public Health , Hanoi , Vietnam
| | - Do Mai Hoa
- a Health Management Training Institute, Hanoi University of Public Health , Hanoi , Vietnam
| | - Nguyen Minh Hoang
- a Health Management Training Institute, Hanoi University of Public Health , Hanoi , Vietnam
| | - Nguyen Duy Anh
- b Hanoi Obstetric and Gynecology Hospital , Hanoi , Vietnam
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202
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Factors Associated With Poor Linkage to HIV Care in South Africa: Secondary Analysis of Data From the Thol'impilo Trial. J Acquir Immune Defic Syndr 2017; 76:453-460. [PMID: 28961678 DOI: 10.1097/qai.0000000000001550] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Poor linkage to HIV care is impeding achievement of the Joint United Nations Programme on HIV and AIDS (UNAIDS) 90-90-90 targets. This study aims to identify risk factors for poor linkage-to-care after HIV counseling and testing, thereby informing strategies to achieve 90-90-90. SETTING The Thol'impilo trial was a large randomized controlled trial performed between 2012 and 2015 in South Africa, comparing different strategies to improve linkage-to-care among adults aged ≥18 years who tested HIV-positive at mobile clinic HIV counseling and testing. METHODS In this secondary analysis, sociodemographic factors associated with time to linkage-to-care were identified using Cox regression. RESULTS Of 2398 participants, 61% were female, with median age 33 years (interquartile range: 27-41) and median CD4 count 427 cells/mm (interquartile range: 287-595). One thousand one hundred one participants (46%) had clinic verified linkage-to-care within 365 days of testing HIV-positive. In adjusted analysis, younger age [≤30 vs >40 years: adjusted hazard ratio (aHR): 0.58, 95% CI: 0.50 to 0.68; 31-40 vs >40 years: aHR: 0.81, 95% CI: 0.70 to 0.94, test for trend P < 0.001], being male (aHR: 0.86, 95% CI: 0.76 to 0.98, P = 0.028), not being South African (aHR: 0.79, 95% CI: 0.66 to 0.96, P = 0.014), urban district (aHR: 0.82, 95% CI: 0.73 to 0.93, P = 0.002), being employed (aHR: 0.81, 95% CI: 0.72 to 0.92, P = 0.001), nondisclosure of HIV (aHR: 0.63, 95% CI: 0.56 to 0.72, P < 0.001), and having higher CD4 counts (test for trend P < 0.001) were all associated with decreased hazard of linkage-to-care. CONCLUSION Linkage-to-care was low in this relatively large cohort. Increasing linkage-to-care requires innovative, evidence-based interventions particularly targeting individuals who are younger, male, immigrant, urban, employed, and reluctant to disclose their HIV status.
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Effect of frequency of clinic visits and medication pick-up on antiretroviral treatment outcomes: a systematic literature review and meta-analysis. J Int AIDS Soc 2017; 20:21647. [PMID: 28770599 PMCID: PMC6192466 DOI: 10.7448/ias.20.5.21647] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Introduction: Expanding and sustaining antiretroviral therapy (ART) coverage may require simplified HIV service delivery strategies that concomitantly reduce the burden of care on the health system and patients while ensuring optimal outcomes. We conducted a systematic review to assess the impact of reduced frequency of clinic visits and drug dispensing on patient outcomes. Methods: As part of the development process of the World Health Organization antiretroviral (ARV) guidelines, we systematically searched medical literature databases for publications up to 30 August 2016. Information was extracted on trial characteristics, patient characteristics and the following outcomes: mortality, morbidity, treatment adherence, retention, patient and provider acceptability, cost and patients exiting the programme. When feasible, conventional pairwise meta‐analyses were conducted. Results and discussion: Of 6443 identified citations, 21 papers, pertaining to 16 studies, were included in this review, with 11 studies contributing to analyses. Although analyses were feasible, they were limited by the sparse evidence base, despite the importance of the research area, and relatively low quality. Comparative analyses of eight studies reporting on frequency of clinic visits showed that less frequent clinic visits led to higher odds of being retained in care (odds ratio [OR]: 1.90; 95% CI: 1.21–2.99). No differences were found with respect to viral failure, morbidity or mortality; however, most estimates were favourable to reduced clinic visits. Reduced frequency of ARVs pick‐ups showed a trend towards better retention (OR: 1.93; 95% CI: 0.62–6.04). Strategies using community support tended to have better outcomes; however, their implementation varied, particularly by location. External validity may be questionable. Conclusions: Our systematic review suggests that reduction of clinical visits (and likely ARVs pick‐ups) may improve clinical outcomes, and that they are a viable option to relieve health systems and reduce burden of care for PLHIV. Strategies aimed at reducing clinic visits or drug refill services should focus on stable patients who are virally suppressed, tolerant to their drug regimen and fully adherent. These strategies may be critical to the current changes taking place in HIV treatment policy; thus, due to the data limitations, further high quality research is needed to inform policy and programmatic interventions.
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Chipungu J, Bosomprah S, Zanolini A, Thimurthy H, Chilengi R, Sharma A, Holmes CB. Understanding linkage to care with HIV self-test approach in Lusaka, Zambia - A mixed method approach. PLoS One 2017; 12:e0187998. [PMID: 29149194 PMCID: PMC5693414 DOI: 10.1371/journal.pone.0187998] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 10/30/2017] [Indexed: 11/18/2022] Open
Abstract
Introduction HIV self-testing (HIVST) is a novel approach designed to assist in achieving the goal of at least 90% of the population that learn their HIV status. A self-test user with a positive test is required to visit a clinic to link into HIV care, yet little is known about patient preferences for linkage strategies. We examined the intention to link to care amongst potential HIVST users and the suitability of three linkage to care strategies in Lusaka Province, Zambia. Methods We conducted a representative cross sectional survey of 1,617 individuals aged 16–49 years old in Lusaka Province. Participants were shown a video of the HIVST. Data on intention to link to care and preferred linkage to care strategies—text message, phone call and home visits were collected. Eight focus group discussions were held concurrently with survey respondents to understand their preferences between the three linkage to care strategies. Results Of 1617 enrolled, 60% were women, 40% were men, with an average age of 27years (IQR = 22, 35). More men than women had at least secondary education (84% vs 77%) and were either employed or self-employed (67% vs. 41%). 85% (95%CI = 83 to 86) of participants said they would link to care within the first week of a positive self-test. Income >2,000 Kwacha (USD 200) per month versus income < 2,000 Kwacha (Adjusted odds ratio (AOR) = 0.59; 95%CI: 0.40 to 0.88; p = 0.009) and never versus prior HIV testers (AOR = 0.54; 95%CI: 0.32 to 0.91; p = 0.020) were associated with reduced odds of intention to link to care. 53% (95%CI = 50 to 55) preferred being prompted to link to care by home visits compared to phone call (30%) or SMS (17%). Conclusion We found almost nine out of ten potential HIVST users in the general population intend to link to care shortly after a positive test, and preferred home visits or phone calls to facilitate linkage, rather than SMS. Also, higher income earners and those who never tested for HIV were associated with reduced odds of intention to link to care. Policy guidelines and implementation strategies for HIVST should be responsive to patient preferences for linkage to care strategies to achieve the continuum of HIV care.
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Affiliation(s)
- Jenala Chipungu
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
- * E-mail:
| | - Samuel Bosomprah
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
- Department of Biostatistics, School of Public Health, University of Ghana, Accra, Ghana
| | - Arianna Zanolini
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
- American Institutes for Research, Lusaka, Zambia
| | - Harsha Thimurthy
- Gilling’s School of Public Health, University of North Carolina at Chapel Hill, North Carolina, Chapel Hill, United States of America
| | - Roma Chilengi
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Anjali Sharma
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Charles B. Holmes
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
- School of Medicine, Johns Hopkins University, Baltimore, United States of America
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Kulkarni S, Tymejczyk O, Gadisa T, Lahuerta M, Remien RH, Melaku Z, El-Sadr W, Elul B, Nash D, Hoffman S. "Testing, Testing": Multiple HIV-Positive Tests among Patients Initiating Antiretroviral Therapy in Ethiopia. J Int Assoc Provid AIDS Care 2017; 16:546-554. [PMID: 29117777 DOI: 10.1177/2325957417737840] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Repeat HIV testing after receiving a positive result has never been studied systematically and may give insight into reasons for delayed linkage to care. Among 831 adults in 6 secondary facilities in Oromia, Ethiopia, who completed an interviewer-administered structured questionnaire within 2 weeks of initiating antiretroviral therapy in 2012 to 2013, 110 (13.2%) reported having retested after an HIV-positive result. The odds of repeat (versus single) HIV-positive testing were higher among those who had doubted their HIV status (adjusted odds ratio [AOR]ref=nodoubt = 6.5; 95% confidence interval [CI]: 3.7-11.4) and those who initially tested at another facility, whether another secondary facility (AOR ref=studyfacility = 22.7; 95% CI: 11.0-46.9) or a lower-level facility (AORref=studyfacility = 19.1; 95% CI: 10.5-34.5). The odds of repeat (versus single) HIV-positive testing were lower among those who initially tested because of symptoms (AORref=not a reason = 0.40; 95% CI: 0.24-0.66). Median time between initial diagnosis and enrollment in care was 12.3 versus 1.0 month for repeat and single HIV-positive testers, respectively ( P < .001). Repeat HIV-positive testing-not a rare occurrence-appears to stem from doubt, seeking care at a facility other than where diagnosed, and testing for a reason other than having symptoms. Because repeat HIV-positive testing is associated with delay in linkage to care, providers should be aware of this potential when counseling those who test HIV positive.
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Affiliation(s)
- Sarah Kulkarni
- 1 CUNY Graduate School of Public Health and Health Policy, New York, NY, USA.,2 CUNY Institute of Implementation Science in Population Health, New York, NY, USA
| | - Olga Tymejczyk
- 1 CUNY Graduate School of Public Health and Health Policy, New York, NY, USA.,2 CUNY Institute of Implementation Science in Population Health, New York, NY, USA
| | - Tsigereda Gadisa
- 3 ICAP-Columbia University, Mailman School of Public Health, New York, NY, USA
| | - Maria Lahuerta
- 3 ICAP-Columbia University, Mailman School of Public Health, New York, NY, USA
| | - Robert H Remien
- 4 HIV Center for Clinical and Behavioral Studies, New York, NY, USA
| | - Zenebe Melaku
- 3 ICAP-Columbia University, Mailman School of Public Health, New York, NY, USA
| | - Wafaa El-Sadr
- 3 ICAP-Columbia University, Mailman School of Public Health, New York, NY, USA.,5 Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Batya Elul
- 3 ICAP-Columbia University, Mailman School of Public Health, New York, NY, USA.,5 Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Denis Nash
- 1 CUNY Graduate School of Public Health and Health Policy, New York, NY, USA.,2 CUNY Institute of Implementation Science in Population Health, New York, NY, USA.,4 HIV Center for Clinical and Behavioral Studies, New York, NY, USA.,5 Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Susie Hoffman
- 4 HIV Center for Clinical and Behavioral Studies, New York, NY, USA.,5 Mailman School of Public Health, Columbia University, New York, NY, USA
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McNairy ML, Lamb MR, Gachuhi AB, Nuwagaba-Biribonwoha H, Burke S, Mazibuko S, Okello V, Ehrenkranz P, Sahabo R, El-Sadr WM. Effectiveness of a combination strategy for linkage and retention in adult HIV care in Swaziland: The Link4Health cluster randomized trial. PLoS Med 2017; 14:e1002420. [PMID: 29112963 PMCID: PMC5675376 DOI: 10.1371/journal.pmed.1002420] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 09/29/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Gaps in the HIV care continuum contribute to poor health outcomes and increase HIV transmission. A combination of interventions targeting multiple steps in the continuum is needed to achieve the full beneficial impact of HIV treatment. METHODS AND FINDINGS Link4Health, a cluster-randomized controlled trial, evaluated the effectiveness of a combination intervention strategy (CIS) versus the standard of care (SOC) on the primary outcome of linkage to care within 1 month plus retention in care at 12 months after HIV-positive testing. Ten clusters of HIV clinics in Swaziland were randomized 1:1 to CIS versus SOC. The CIS included point-of-care CD4+ testing at the time of an HIV-positive test, accelerated antiretroviral therapy (ART) initiation for treatment-eligible participants, mobile phone appointment reminders, health educational packages, and noncash financial incentives. Secondary outcomes included each component of the primary outcome, mean time to linkage, assessment for ART eligibility, ART initiation and time to ART initiation, viral suppression defined as HIV-1 RNA < 1,000 copies/mL at 12 months after HIV testing among patients on ART ≥6 months, and loss to follow-up and death at 12 months after HIV testing. A total of 2,197 adults aged ≥18 years, newly tested HIV positive, were enrolled from 19 August 2013 to 21 November 2014 (1,096 CIS arm; 1,101 SOC arm) and followed for 12 months. The median participant age was 31 years (IQR 26-39), and 59% were women. In an intention-to-treat analysis, 64% (705/1,096) of participants at the CIS sites achieved the primary outcome versus 43% (477/1,101) at the SOC sites (adjusted relative risk [RR] 1.52, 95% CI 1.19-1.96, p = 0.002). Participants in the CIS arm versus the SOC arm had the following secondary outcomes: linkage to care regardless of retention at 12 months (RR 1.08, 95% CI 0.97-1.21, p = 0.13), mean time to linkage (2.5 days versus 7.5 days, p = 0.189), retention in care at 12 months regardless of time to linkage (RR 1.48, 95% CI 1.18-1.86, p = 0.002), assessment for ART eligibility (RR 1.20, 95% CI 1.07-1.34, p = 0.004), ART initiation (RR 1.16, 95% CI 0.96-1.40, p = 0.12), mean time to ART initiation from time of HIV testing (7 days versus 14 days, p < 0.001), viral suppression among those on ART for ≥6 months (RR 0.97, 95% CI 0.88-1.07, p = 0.55), loss to follow-up at 12 months after HIV testing (RR 0.56, 95% CI 0.40-0.79, p = 0.002), and death (N = 78) within 12 months of HIV testing (RR 0.80, 95% CI 0.46-1.35, p = 0.41). Limitations of this study include a small number of clusters and the inability to evaluate the incremental effectiveness of individual components of the combination strategy. CONCLUSIONS A combination strategy inclusive of 5 evidence-based interventions aimed at multiple steps in the HIV care continuum was associated with significant increase in linkage to care plus 12-month retention. This strategy offers promise of enhanced outcomes for HIV-positive patients. TRIAL REGISTRATION ClinicalTrials.gov NCT01904994.
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Affiliation(s)
- Margaret L. McNairy
- ICAP at Columbia University, New York, New York, United States of America
- Department of Medicine, Weill Cornell Medical College, New York, New York, United States of America
- * E-mail:
| | - Matthew R. Lamb
- ICAP at Columbia University, New York, New York, United States of America
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Averie B. Gachuhi
- ICAP at Columbia University, New York, New York, United States of America
| | - Harriet Nuwagaba-Biribonwoha
- ICAP at Columbia University, New York, New York, United States of America
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Sean Burke
- ICAP at Columbia University, New York, New York, United States of America
| | | | - Velephi Okello
- Ministry of Health, Kingdom of Swaziland, Mbabane, Swaziland
| | - Peter Ehrenkranz
- Bill and Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Ruben Sahabo
- ICAP at Columbia University, New York, New York, United States of America
| | - Wafaa M. El-Sadr
- ICAP at Columbia University, New York, New York, United States of America
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, United States of America
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Elul B, Lamb MR, Lahuerta M, Abacassamo F, Ahoua L, Kujawski SA, Tomo M, Jani I. A combination intervention strategy to improve linkage to and retention in HIV care following diagnosis in Mozambique: A cluster-randomized study. PLoS Med 2017; 14:e1002433. [PMID: 29136001 PMCID: PMC5685437 DOI: 10.1371/journal.pmed.1002433] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 10/10/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Concerning gaps in the HIV care continuum compromise individual and population health. We evaluated a combination intervention strategy (CIS) targeting prevalent barriers to timely linkage and sustained retention in HIV care in Mozambique. METHODS AND FINDINGS In this cluster-randomized trial, 10 primary health facilities in the city of Maputo and Inhambane Province were randomly assigned to provide the CIS or the standard of care (SOC). The CIS included point-of-care CD4 testing at the time of diagnosis, accelerated ART initiation, and short message service (SMS) health messages and appointment reminders. A pre-post intervention 2-sample design was nested within the CIS arm to assess the effectiveness of CIS+, an enhanced version of the CIS that additionally included conditional non-cash financial incentives for linkage and retention. The primary outcome was a combined outcome of linkage to care within 1 month and retention at 12 months after diagnosis. From April 22, 2013, to June 30, 2015, we enrolled 2,004 out of 5,327 adults ≥18 years of age diagnosed with HIV in the voluntary counseling and testing clinics of participating health facilities: 744 (37%) in the CIS group, 493 (25%) in the CIS+ group, and 767 (38%) in the SOC group. Fifty-seven percent of the CIS group achieved the primary outcome versus 35% in the SOC group (relative risk [RR]CIS vs SOC = 1.58, 95% CI 1.05-2.39). Eighty-nine percent of the CIS group linked to care on the day of diagnosis versus 16% of the SOC group (RRCIS vs SOC = 9.13, 95% CI 1.65-50.40). There was no significant benefit of adding financial incentives to the CIS in terms of the combined outcome (55% of the CIS+ group achieved the primary outcome, RRCIS+ vs CIS = 0.96, 95% CI 0.81-1.16). Key limitations include the use of existing medical records to assess outcomes, the inability to isolate the effect of each component of the CIS, non-concurrent enrollment of the CIS+ group, and exclusion of many patients newly diagnosed with HIV. CONCLUSIONS The CIS showed promise for making much needed gains in the HIV care continuum in our study, particularly in the critical first step of timely linkage to care following diagnosis. TRIAL REGISTRATION ClinicalTrials.gov NCT01930084.
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Affiliation(s)
- Batya Elul
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, New York, United States of America
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, United States of America
- * E-mail:
| | - Matthew R. Lamb
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, New York, United States of America
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Maria Lahuerta
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, New York, United States of America
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | | | - Laurence Ahoua
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Stephanie A. Kujawski
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Maria Tomo
- Center for Collaboration in Health, Maputo, Mozambique
| | - Ilesh Jani
- Instituto Nacional de Saúde, Maputo, Mozambique
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Ford N, Ball A, Baggaley R, Vitoria M, Low-Beer D, Penazzato M, Vojnov L, Bertagnolio S, Habiyambere V, Doherty M, Hirnschall G. The WHO public health approach to HIV treatment and care: looking back and looking ahead. THE LANCET. INFECTIOUS DISEASES 2017; 18:e76-e86. [PMID: 29066132 DOI: 10.1016/s1473-3099(17)30482-6] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 07/20/2017] [Accepted: 07/25/2017] [Indexed: 11/18/2022]
Abstract
In 2006, WHO set forth its vision for a public health approach to delivering antiretroviral therapy. This approach has been broadly adopted in resource-poor settings and has provided the foundation for scaling up treatment to over 19·5 million people. There is a global commitment to end the AIDS epidemic as a public health threat by 2030 and, to support this goal, there are opportunities to adapt the public health approach to meet the ensuing challenges. These challenges include the need to improve identification of people with HIV infection through expanded approaches to testing; further simplify and improve treatment and laboratory monitoring; adapt the public health approach to concentrated epidemics; and link HIV testing, treatment, and care to HIV prevention. Implementation of these key public health principles will bring countries closer to the goals of controlling the HIV epidemic and providing universal health coverage.
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Affiliation(s)
- Nathan Ford
- Department of HIV and Global Hepatitis Programme, World Health Organization, Geneva, Switzerland.
| | - Andrew Ball
- Department of HIV and Global Hepatitis Programme, World Health Organization, Geneva, Switzerland
| | - Rachel Baggaley
- Department of HIV and Global Hepatitis Programme, World Health Organization, Geneva, Switzerland
| | - Marco Vitoria
- Department of HIV and Global Hepatitis Programme, World Health Organization, Geneva, Switzerland
| | - Daniel Low-Beer
- Department of HIV and Global Hepatitis Programme, World Health Organization, Geneva, Switzerland
| | - Martina Penazzato
- Department of HIV and Global Hepatitis Programme, World Health Organization, Geneva, Switzerland
| | - Lara Vojnov
- Department of HIV and Global Hepatitis Programme, World Health Organization, Geneva, Switzerland
| | - Silvia Bertagnolio
- Department of HIV and Global Hepatitis Programme, World Health Organization, Geneva, Switzerland
| | - Vincent Habiyambere
- Department of HIV and Global Hepatitis Programme, World Health Organization, Geneva, Switzerland
| | - Meg Doherty
- Department of HIV and Global Hepatitis Programme, World Health Organization, Geneva, Switzerland
| | - Gottfried Hirnschall
- Department of HIV and Global Hepatitis Programme, World Health Organization, Geneva, Switzerland
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McLean E, Renju J, Wamoyi J, Bukenya D, Ddaaki W, Church K, Zaba B, Wringe A. 'I wanted to safeguard the baby': a qualitative study to understand the experiences of Option B+ for pregnant women and the potential implications for 'test-and-treat' in four sub-Saharan African settings. Sex Transm Infect 2017; 93:sextrans-2016-052972. [PMID: 28736391 PMCID: PMC5739848 DOI: 10.1136/sextrans-2016-052972] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 03/24/2017] [Accepted: 04/03/2017] [Indexed: 11/04/2022] Open
Abstract
Objective To explore what influences on engagement with Option B+ in four sub-Saharan African settings. Methods In-depth interviews were conducted in 2015, with 22 HIV-positive women who had been pregnant since Option B+ was available, and 15 healthcare workers (HCWs) involved in HIV service delivery. Participants were purposely selected from four health and demographic surveillance sites in Malawi, Tanzania and Uganda. A thematic content analysis was conducted to investigate what influenced engagement with Option B+. Results Feeling ‘ready’ was key to pregnant women accepting antiretroviral treatment (ART) on the same day as diagnosis at antenatal clinic; this was influenced by previous knowledge of HIV-positive status, interactions with HCWs and relationship with their partners. The desire to protect their unborn infant was the main issue that motivated women to initiate treatment, temporarily over-riding barriers to starting ART. Many HCWs recognised that pressurising women into starting ART may lead them to stop treatment following delivery. However, their own responsibility to protect the infant sometimes drove HCWs to use strong persuasive techniques to initiate pregnant women onto ART as early as possible, occasionally causing women to disengage. Conclusions Protecting the baby superseded feelings of unpreparedness for lifelong ART and may explain poor retention observed in Option B+ programmes. Women may benefit from more time to accept their status, and counselling on the long-term value of ART beyond the pregnancy and breastfeeding period. Strategies to promote readiness for same-day initiation of lifelong treatment are urgently needed, and may provide important lessons for universal test-and-treat implementation.
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Affiliation(s)
- Estelle McLean
- Malawi Epidemiology and Intervention Research Unit, Karonga, Malawi.,Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Jenny Renju
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Joyce Wamoyi
- National Institute for Medical Research, Mwanza, Tanzania
| | - Dominic Bukenya
- Medical Research Council/Uganda Virus Research Institute Research Unit on AIDS, Entebbe, Uganda
| | | | - Kathryn Church
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Basia Zaba
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Alison Wringe
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
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Strategies to Accelerate HIV Care and Antiretroviral Therapy Initiation After HIV Diagnosis: A Randomized Trial. J Acquir Immune Defic Syndr 2017; 75:540-547. [PMID: 28471840 DOI: 10.1097/qai.0000000000001428] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Determine the effectiveness of strategies to increase linkage to care after testing HIV positive at mobile HIV testing in South Africa. DESIGN Unmasked randomized controlled trial. METHODS Recruitment of adults testing HIV positive and not currently in HIV care occurred at 7 mobile HIV counseling and testing units in urban, periurban, and rural South Africa with those consenting randomized 1:1:1:1 into 1 of 4 arms. Three strategies were compared with standard of care (SOC): point-of-care CD4 count testing (POC CD4), POC CD4 plus longitudinal strengths-based counseling (care facilitation; CF), and POC CD4 plus transport reimbursement (transport). Participants were followed up telephonically and through clinic records and analyzed with an intention-to-treat analysis. RESULTS From March 2013 to October 2014, 2558 participants were enrolled, of whom 160 were excluded postrandomization. Compared with the SOC arm where 298 (50%) reported having entered care, linkage to care was 319 (52%) for POC CD4, hazard ratio (HR) 1.0 [95% confidence interval (CI): 0.89 to 1.2, P = 0.6]; 331 (55%) for CF, HR: 1.1 (95% CI: 0.84 to 1.3, P = 0.2); and 291 (49%) for transport, HR 0.97 (95% CI: 0.83 to 1.1, P = 0.7). Linkage to care verified with clinical records that occurred for 172 (29%) in the SOC arm; 187 (31%) in the POC CD4 arm, HR: 1.0 (95% CI: 0.86 to 1.3, P = 0.6); 225 (38%) in the CF arm, HR: 1.4 (95% CI: 1.1 to 1.7, P = 0.001); and 180 (31%) in the transport arm, HR: 1.1 (95% CI: 0.88 to 1.3, P = 0.5). CONCLUSIONS CF improved verified linkage to care from 29% to 38%.
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Dorward J, Garrett N, Quame-Amaglo J, Samsunder N, Ngobese H, Ngomane N, Moodley P, Mlisana K, Schaafsma T, Donnell D, Barnabas R, Naidoo K, Abdool Karim S, Celum C, Drain PK. Protocol for a randomised controlled implementation trial of point-of-care viral load testing and task shifting: the Simplifying HIV TREAtment and Monitoring (STREAM) study. BMJ Open 2017; 7:e017507. [PMID: 28963304 PMCID: PMC5623564 DOI: 10.1136/bmjopen-2017-017507] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 08/28/2017] [Accepted: 08/29/2017] [Indexed: 01/17/2023] Open
Abstract
INTRODUCTION Achieving the Joint United Nations Programme on HIV and AIDS 90-90-90 targets requires models of HIV care that expand antiretroviral therapy (ART) coverage without overburdening health systems. Point-of-care (POC) viral load (VL) testing has the potential to efficiently monitor ART treatment, while enrolled nurses may be able to provide safe and cost-effective chronic care for stable patients with HIV. This study aims to demonstrate whether POC VL testing combined with task shifting to enrolled nurses is non-inferior and cost-effective compared with laboratory-based VL monitoring and standard HIV care. METHODS AND ANALYSIS The STREAM (Simplifying HIV TREAtment and Monitoring) study is an open-label, non-inferiority, randomised controlled implementation trial. HIV-positive adults, clinically stable at 6 months after ART initiation, will be recruited in a large urban clinic in South Africa. Approximately 396 participants will be randomised 1:1 to receive POC HIV VL monitoring and potential task shifting to enrolled nurses, versus laboratory VL monitoring and standard South African HIV care. Initial clinic follow-up will be 2-monthly in both arms, with VL testing at enrolment, 6 months and 12 months. At 6 months (1 year after ART initiation), stable participants in both arms will qualify for a differentiated care model involving decentralised ART pickup at community-based pharmacies. The primary outcome is retention in care and virological suppression at 12 months from enrolment. Secondary outcomes include time to appropriate entry into the decentralised ART delivery programme, costs per virologically suppressed patient and cost-effectiveness of the intervention compared with standard care. Findings will inform the scale up of VL testing and differentiated care in HIV-endemic resource-limited settings. ETHICS AND DISSEMINATION Ethical approval has been granted by the University of KwaZulu-Natal Biomedical Research Ethics Committee (BFC296/16) and University of Washington Institutional Review Board (STUDY00001466). Results will be presented at international conferences and published in academic peer-reviewed journals. TRIAL REGISTRATION NCT03066128; Pre-results.
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Affiliation(s)
- Jienchi Dorward
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Nigel Garrett
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Justice Quame-Amaglo
- Department of Global Health, Schools of Medicine and Public Health, University of Washington, Seattle, Washington, USA
| | - Natasha Samsunder
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Hope Ngobese
- Prince Cyril Zulu Communicable Disease Clinic, Durban Municipality, Durban, KwaZulu-Natal, South Africa
| | - Noluthando Ngomane
- Prince Cyril Zulu Communicable Disease Clinic, Durban Municipality, Durban, KwaZulu-Natal, South Africa
| | - Pravikrishnen Moodley
- Department of Virology, Inkosi Albert Luthuli Central Hospital, Durban, KwaZulu-Natal, South Africa
| | - Koleka Mlisana
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
- National Health Laboratory Service, Durban, KwaZulu-Natal, South Africa
| | - Torin Schaafsma
- Department of Global Health, Schools of Medicine and Public Health, University of Washington, Seattle, Washington, USA
| | - Deborah Donnell
- Department of Global Health, Schools of Medicine and Public Health, University of Washington, Seattle, Washington, USA
| | - Ruanne Barnabas
- Department of Global Health, Schools of Medicine and Public Health, University of Washington, Seattle, Washington, USA
- Department of Medicine, School of Medicine, University of Washington, Seattle, Washington, USA
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, USA
| | - Kogieleum Naidoo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
- MRC-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Salim Abdool Karim
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
- MRC-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
- Department of Epidemiology, Columbia University, New York City, USA
| | - Connie Celum
- Department of Global Health, Schools of Medicine and Public Health, University of Washington, Seattle, Washington, USA
- Department of Medicine, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Paul K Drain
- Department of Global Health, Schools of Medicine and Public Health, University of Washington, Seattle, Washington, USA
- Department of Medicine, School of Medicine, University of Washington, Seattle, Washington, USA
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, USA
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Chawla S, Shringarpure K, Modi B, Sharma R, Rewari BB, Shah AN, Verma PB, Dongre AR, Kumar AMV. Why are HIV-infected people not started on antiretroviral therapy? A mixed-methods study from Gujarat, India. Public Health Action 2017; 7:183-192. [PMID: 29201653 DOI: 10.5588/pha.16.0108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 05/24/2017] [Indexed: 12/20/2022] Open
Abstract
Setting: Five purposively selected antiretroviral therapy (ART) centres in Gujarat, India. Objectives: To assess the proportion of ART-eligible people living with the human immunodeficiency virus (PLHIV) who were not initiated on ART within 2 months of being recorded as eligible, to identify factors associated with non-initiation and to explore reasons from the provider's perspective. Design: We used a mixed-methods design (triangulation) of 1) a quantitative phase involving record reviews and cohort analysis (Poisson regression) of PLHIV registered during April 2014-March 2015, and 2) a qualitative phase involving one-to-one interviews with 25 providers. Results: Of 2079 ART-eligible PLHIV, 339 (16%) were not started on ART within 2 months. PLHIV with CD4 counts of <350 cells/μl and patients who were labourers, hospitalised, bedridden or registered with certain ART centres were more likely not to be initiated on ART. Qualitative results were categorised into two broad themes: government health system- and patient-related challenges, which validated and complemented the quantitative findings. Conclusion: Several patient subgroups at greater risk of ART non-initiation were identified, along with reasons for risk; this has important programme implications for achieving the UNAIDS 90-90-90 goal, and particularly the second 90 component of having 90% of diagnosed PLHIV start ART.
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Affiliation(s)
- S Chawla
- Gujarat State AIDS Control Society, Health and Family Welfare Department, Government of Gujarat, Ahmedabad, India
| | - K Shringarpure
- Department of Community Medicine, Government Medical College and SSG Hospital, Vadodara, India
| | - B Modi
- Department of Community Medicine, Gujarat Medical Education and Research Society (GMERS) Medical College, Gandhinagar, India
| | - R Sharma
- Department of Community Medicine, GMERS Medical College, Sola, Ahmedabad, India
| | - B B Rewari
- World Health Organization India Country Office, New Delhi, India
| | - A N Shah
- Department of Medicine, BJ Medical College and Civil Hospital, Ahmedabad, India
| | - P B Verma
- Gujarat State AIDS Control Society, Health and Family Welfare Department, Government of Gujarat, Ahmedabad, India.,Department of Community Medicine, Gujarat Medical Education and Research Society (GMERS) Medical College, Gandhinagar, India
| | - A R Dongre
- Department of Community Medicine, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India
| | - A M V Kumar
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India.,The Union, Paris, France
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Mujugira A, Baeten JM, Kidoguchi L, Haberer J, Celum C, Donnell D, Ngure K, Bukusi EA, Mugo N, Asiimwe S, Odoyo J, Tindimwebwa E, Bulya N, Katabira E, Heffron R, for the Partners Demonstration Proj. High levels of viral suppression among East African HIV-infected women and men in serodiscordant partnerships initiating antiretroviral therapy with high CD4 counts and during pregnancy. AIDS Res Hum Retroviruses 2017. [PMID: 28899162 DOI: 10.1089/aid.2017.0020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND People who are asymptomatic and feel healthy, including pregnant women, may be less motivated to initiate ART or achieve high adherence. We assessed whether ART initiation, and viral suppression 6, 12 and 24-months after ART initiation, were lower in HIV-infected members of serodiscordant couples who initiated during pregnancy or with higher CD4 counts. METHODS We used data from the Partners Demonstration Project, an open-label study of the delivery of integrated PrEP and ART (at any CD4 count) for HIV prevention among high-risk HIV serodiscordant couples in Kenya and Uganda. Differences in viral suppression (HIV RNA <400 copies/ml) among people initiating ART at different CD4 count levels (≤350, 351-500, and >500 cells/mm3) and during pregnancy were estimated using Poisson regression. RESULTS Of 865 HIV-infected participants retained after becoming eligible for ART during study follow-up, 95% initiated ART. Viral suppression 24-months after ART initiation was high overall (97%), and comparable among those initiating ART at CD4 counts >500, 351-500 and ≤350 cells/mm3 (96% vs 97% vs 97%; relative risk [RR] 0.98; 95% CI: 0.93-1.03 for CD4 >500 vs <350 and RR 0.99; 95% CI: (0.93-1.06) for CD4 351-500 vs ≤350). Viral suppression was as likely among women initiating ART primarily to prevent perinatal transmission as ART initiation for other reasons (p=0.9 at 6 months and p=0.5 at 12 months). CONCLUSIONS Nearly all HIV-infected partners initiating ART were virally suppressed by 24 months, irrespective of CD4 count or pregnancy status. These findings suggest that people initiating ART at high CD4 counts or due to pregnancy can adhere to ART as well as those starting treatment with symptomatic HIV disease or low CD4 counts.
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Affiliation(s)
- Andrew Mujugira
- Department of Global Health, University of Washington, Seattle, Washington
| | - Jared M. Baeten
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
- Department of Medicine, University of Washington, Seattle, Washington
| | - Lara Kidoguchi
- Department of Global Health, University of Washington, Seattle, Washington
| | | | - Connie Celum
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
- Department of Medicine, University of Washington, Seattle, Washington
| | - Deborah Donnell
- Department of Global Health, University of Washington, Seattle, Washington
| | - Kenneth Ngure
- Department of Global Health, University of Washington, Seattle, Washington
- School of Public Health, Jomo Kenyatta University of Agriculture and Technology, Juja, Kenya
| | - Elizabeth A. Bukusi
- Department of Global Health, University of Washington, Seattle, Washington
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Nelly Mugo
- Department of Global Health, University of Washington, Seattle, Washington
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Josephine Odoyo
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Nulu Bulya
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Elly Katabira
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Renee Heffron
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
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Naidoo K, Hassan-Moosa R, Yende-Zuma N, Govender D, Padayatchi N, Dawood H, Adams RN, Govender A, Chinappa T, Abdool-Karim S, Abdool-Karim Q. High mortality rates in men initiated on anti-retroviral treatment in KwaZulu-Natal, South Africa. PLoS One 2017; 12:e0184124. [PMID: 28902869 PMCID: PMC5597205 DOI: 10.1371/journal.pone.0184124] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 08/18/2017] [Indexed: 12/20/2022] Open
Abstract
In attaining UNAIDS targets of 90-90-90 to achieve epidemic control, understanding who the current utilizers of HIV treatment services are will inform efforts aimed at reaching those not being reached. A retrospective chart review of CAPRISA AIDS Treatment Program (CAT) patients between 2004 and 2013 was undertaken. Of the 4043 HIV-infected patients initiated on ART, 2586 (64.0%) were women. At ART initiation, men, compared to women, had significantly lower median CD4+ cell counts (113 vs 131 cells/mm3, p <0.001), lower median body mass index (BMI) (21.0 vs 24.2 kg/m2, p<0.001), higher mean log viral load (5.0 vs 4.9 copies/ml, p<0.001) and were significantly older (median age: 35 vs. 32 years, p<0.001). Men had higher mortality rates compared to women, 6.7 per 100 person-years (p-y), (95% CI: 5.8-7.8) vs. 4.4 per 100 p-y, (95% CI: 3.8-5.0); mortality rate ratio: 1.54, (95% CI: 1.27-1.87), p <0.001. Age-standardised mortality rate was 7.9 per 100 p-y (95% CI: 4.1-11.7) for men and 5.7 per 100 p-y (95% CI: 2.7 to 8.6) for women (standardised mortality ratio: 1.38 (1.15 to 1.70)). Mean CD4+ cell count increases post-ART initiation were lower in men at all follow-up time points. Men presented later in the course of their HIV disease for ART initiation with more advanced disease and experienced a higher mortality rate compared to women.
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Affiliation(s)
- Kogieleum Naidoo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, KwaZulu-Natal, South Africa
- MRC-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Razia Hassan-Moosa
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, KwaZulu-Natal, South Africa
| | - Nonhlanhla Yende-Zuma
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, KwaZulu-Natal, South Africa
- MRC-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Dhineshree Govender
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, KwaZulu-Natal, South Africa
| | - Nesri Padayatchi
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, KwaZulu-Natal, South Africa
- MRC-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Halima Dawood
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, KwaZulu-Natal, South Africa
| | - Rochelle Nicola Adams
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, KwaZulu-Natal, South Africa
| | - Aveshen Govender
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, KwaZulu-Natal, South Africa
| | - Tilagavathy Chinappa
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, KwaZulu-Natal, South Africa
| | - Salim Abdool-Karim
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, KwaZulu-Natal, South Africa
- MRC-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
- Mailman School of Public Health, Department of Epidemiology, Columbia University, New York, New York, United States of America
| | - Quarraisha Abdool-Karim
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, KwaZulu-Natal, South Africa
- Mailman School of Public Health, Department of Epidemiology, Columbia University, New York, New York, United States of America
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Spatial patterns of HIV prevalence and service use in East Zimbabwe: implications for future targeting of interventions. J Int AIDS Soc 2017; 20:21409. [PMID: 28364568 PMCID: PMC5467609 DOI: 10.7448/ias.20.1.21409] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Focusing resources for HIV control on geographic areas of greatest need in countries with generalized epidemics has been recommended to increase cost-effectiveness. However, socioeconomic inequalities between areas of high and low prevalence could raise equity concerns and have been largely overlooked. We describe spatial patterns in HIV prevalence in east Zimbabwe and test for inequalities in accessibility and uptake of HIV services prior to the introduction of spatially-targeted programmes. METHODS 8092 participants in an open-cohort study were geo-located to 110 locations. HIV prevalence and HIV testing and counselling (HTC) uptake were mapped with ordinary kriging. Clusters of high or low HIV prevalence were detected with Kulldorff statistics, and the socioeconomic characteristics and sexual risk behaviours of their populations, and levels of local HIV service availability (measured in travel distance) and uptake were compared. Kulldorff statistics were also determined for HTC, antiretroviral therapy (ART), and voluntary medical male circumcision (VMMC) uptake. RESULTS One large and one small high HIV prevalence cluster (relative risk [RR] = 1.78, 95% confidence interval [CI] = 1.53-2.07; RR = 2.50, 95% CI = 2.08-3.01) and one low-prevalence cluster (RR = 0.70, 95% CI = 0.60-0.82) were detected. The larger high-prevalence cluster was urban with a wealthier population and more high-risk sexual behaviour than outside the cluster. Despite better access to HIV services, there was lower HTC uptake in the high-prevalence cluster (odds ratio [OR] of HTC in past three years: OR = 0.80, 95% CI = 0.66-0.97). The low-prevalence cluster was predominantly rural with a poorer population and longer travel distances to HIV services; however, uptake of HIV services was not reduced. CONCLUSION High-prevalence clusters can be identified to which HIV control resources could be targeted. To date, poorer access to HIV services in the poorer low-prevalence areas has not resulted in lower service uptake, whilst there is significantly lower uptake of HTC in the high-prevalence cluster where health service access is better. Given the high levels of risky sexual behaviour and lower uptake of HTC services, targeting high-prevalence clusters may be cost-effective in this setting. If spatial targeting is introduced, inequalities in HIV service uptake may be avoided through mobile service provision for lower prevalence areas.
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Gueler A, Vanobberghen F, Rice B, Egger M, Mugglin C. The HIV Care Cascade from HIV diagnosis to viral suppression in sub-Saharan Africa: a systematic review and meta-regression analysis protocol. Syst Rev 2017; 6:172. [PMID: 28841910 PMCID: PMC5574086 DOI: 10.1186/s13643-017-0562-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 08/10/2017] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND In 2014, UNAIDS announced the 90-90-90 treatment targets to curb the HIV epidemic by 2020: 90% of people living with HIV know their HIV status, 90% of people who know their HIV status access treatment and 90% of people on treatment have suppressed viral loads. Monitoring and evaluation are needed to track linkage and retention throughout the continuum of care. We propose a systematic review and meta-regression to identify the different methodological approaches used to define the steps in the HIV care cascade in sub-Saharan Africa (SSA), where most people with HIV live, and to assess the proportion of participants retained at each step. METHODS We will include cohort and cross-sectional studies published between 2004 and 2016 that report on the HIV care cascade among adults in SSA. The PubMed, Embase and CINAHL databases will be searched. Two reviewers will independently screen titles and abstracts, assess the full texts for eligibility and extract data. Disagreements will be resolved by consensus or consultation with a third reviewer. We will assess the number and proportion of individuals retained in the HIV care cascade from HIV diagnosis to linkage to care, engagement in pre-ART care, initiation of ART, retention on ART, and viral suppression. The data will be analysed using random effects meta-regression analysis. Publication bias will be assessed by funnel plots. DISCUSSION This review will contribute to a better understanding of the HIV care cascade in SSA. It will help programs identify gaps and approaches to improve care and treatment for people living with HIV and reduce HIV transmission. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017055863.
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Affiliation(s)
- Aysel Gueler
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Finkenhubelweg 11, 3012 Bern, Switzerland
| | - Fiona Vanobberghen
- Population Studies Group, Dept of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Brian Rice
- Measurement & Surveillance of HIV Epidemics Consortium, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
| | - Matthias Egger
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Finkenhubelweg 11, 3012 Bern, Switzerland
- Centre for Infectious Disease Epidemiology and Research (CIDER), School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Observatory 7925, Cape Town, South Africa
| | - Catrina Mugglin
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Finkenhubelweg 11, 3012 Bern, Switzerland
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Oluoch P, Orwa J, Lugalia F, Mutinda D, Gichangi A, Oundo J, Karama M, Nganga Z, Galbraith J. Application of psychosocial models to Home-Based Testing and Counseling (HBTC) for increased uptake and household coverage in a large informal urban settlement in Kenya. Pan Afr Med J 2017; 27:285. [PMID: 29187954 PMCID: PMC5660906 DOI: 10.11604/pamj.2017.27.285.10104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 08/04/2017] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Home Based Testing and Counselling (HBTC) aims at reaching individuals who have low HIV risk perception and experience barriers which prevent them from seeking HIV testing and counseling (HTC) services. Saturating the community with HTC is needed to achieve the ambitious 90-90-90 targets of knowledge of HIV status, ARV treatment and viral suppression. This paper describes the use of health belief model and community participation principles in HBTC to achieve increased household coverage and HTC uptake. METHODS This cross sectional survey was done between August 2009 and April 2011 in Kibera slums, Nairobi city. Using three community participation principles; defining and mobilizing the community, involving the community, overcoming barriers and respect to cultural differences and four constructs of the health belief model; risk perception, perceived severity, perceived benefits of changed behavior and perceived barriers; we offered HTC services to the participants. Descriptive statistics were used to describe socio-demographic characteristics, calculate uptake and HIV prevalence. RESULTS There were 72,577 individuals enumerated at the start of the program; 75,141 residents were found during service delivery. Of those, 71,925 (95.7%) consented to participate, out of which 71,720 (99.7%) took the HIV test. First time testers were (39%). The HIV prevalence was higher (6.4%) among repeat testers than first time testers (4.0%) with more women (7.4%) testing positive than men (3.6%) and an overall 5.5% slum prevalence. CONCLUSION This methodology demonstrates that the use of community participation principles combined with a psychosocial model achieved high HTC uptake, coverage and diagnosed HIV in individuals who believed they are HIV free. This novel approach provides baseline for measuring HTC coverage in a community.
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Affiliation(s)
- Patricia Oluoch
- Division of Global HIV/AIDS and Tuberculosis (DGHT), Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
| | - James Orwa
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Fillet Lugalia
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - David Mutinda
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Anthony Gichangi
- Division of Global HIV/AIDS and Tuberculosis (DGHT), Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
| | - Joseph Oundo
- United States Army Medical Research Unit (USAMRU) Kericho, Kenya
| | - Mohamed Karama
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Zipporah Nganga
- Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Jennifer Galbraith
- Division of Global HIV/AIDS and Tuberculosis (DGHT), Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
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Decroo T, Telfer B, Dores CD, White RA, Santos ND, Mkwamba A, Dezembro S, Joffrisse M, Ellman T, Metcalf C. Effect of Community ART Groups on retention-in-care among patients on ART in Tete Province, Mozambique: a cohort study. BMJ Open 2017; 7:e016800. [PMID: 28801427 PMCID: PMC5629627 DOI: 10.1136/bmjopen-2017-016800] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES Estimate the effect of participation in Community ART Groups (CAG) versus individual care on retention-in-care (RIC) on antiretroviral therapy (ART). DESIGN Retrospective cohort study. SETTING High levels of attrition (death or loss-to-follow-up (LTFU) combined) on ART indicate that delivery models need to adapt in sub-Saharan Africa. In 2008, patients more than 6 months on ART began forming CAG, and took turns to collect ART refills at the health facility, in Tete Province, Mozambique,. PARTICIPANTS 2406 adult patients, retained in care for at least 6 months after starting ART, during the study period (date of CAG introduction at the health facility-30 April 2012). METHODS Data up to 30 April 2012 were collected from patient records at eight health facilities. Survival analysis was used to compare RIC among patients in CAG and patients in individual care, with joining a CAG treated as an irreversible time-dependent variable. Multivariable Cox regression was used to estimate the effect of CAG on RIC, adjusted for age, sex and health facility type and stratified by calendar cohort. RESULTS 12-month and 24-monthRIC from the time of eligibility were, respectively, 89.5% and 82.3% among patients in individual care and 99.1% and 97.5% among those in CAGs (p<0.0001). CAG members had a greater than fivefold reduction in risk of dying or being LTFU (adjusted HR: 0.18, 95% CI 0.11 to 0.29). CONCLUSIONS Among patients on ART, RIC was substantially better among those in CAGs than those in individual care. This study confirms that patient-driven ART distribution through CAGs results in higher RIC among patients who are stable on ART.
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Affiliation(s)
- Tom Decroo
- Mission Mozambique, Médecins Sans Frontières, Operational Center Brussels, Tete, Mozambique
| | - Barbara Telfer
- Mission Mozambique, Médecins Sans Frontières, Operational Center Brussels, Tete, Mozambique
| | - Carla Das Dores
- Direcção Provincial de Saúde, Ministério da Saude de Moçambique, Tete, Moçambique
| | - Richard A White
- Department of Infectious Disease Epidemiology and Modelling, Norwegian Institute of Public Health, Oslo, Norway
| | - Natacha Dos Santos
- Mission Mozambique, Médecins Sans Frontières, Operational Center Brussels, Tete, Mozambique
| | - Alec Mkwamba
- Mission Mozambique, Médecins Sans Frontières, Operational Center Brussels, Tete, Mozambique
| | - Sergio Dezembro
- Mission Mozambique, Médecins Sans Frontières, Operational Center Brussels, Tete, Mozambique
| | - Mariano Joffrisse
- Mission Mozambique, Médecins Sans Frontières, Operational Center Brussels, Tete, Mozambique
| | - Tom Ellman
- Southern Africa Medical Unit, South Africa, Médecins Sans Frontières, Operational Center Brussels, Cape Town, South Africa
| | - Carol Metcalf
- Southern Africa Medical Unit, South Africa, Médecins Sans Frontières, Operational Center Brussels, Cape Town, South Africa
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Feasibility and Acceptability of Health Communication Interventions Within a Combination Intervention Strategy for Improving Linkage and Retention in HIV Care in Mozambique. J Acquir Immune Defic Syndr 2017; 74 Suppl 1:S29-S36. [PMID: 27930609 PMCID: PMC5147034 DOI: 10.1097/qai.0000000000001208] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Challenges to ensuring timely linkage to and retention in HIV care are well documented. Combination intervention strategies can be effective in improving the HIV care continuum. Data on feasibility and acceptability of intervention types within intervention packages are limited. METHODS The Engage4Health study assessed the effectiveness of a combination intervention strategy to increase linkage and retention among adults newly diagnosed with HIV in Mozambique. The study included 2 health communication interventions-modified delivery of pre-antiretroviral therapy (pre-ART) counseling sessions and SMS reminders-and 3 structural interventions-point-of-care CD4 testing after diagnosis, accelerated ART initiation, and noncash financial incentives. We used a process evaluation framework to assess dose delivered-extent each intervention was delivered as planned-and dose received-participant acceptability-of health communication versus structural interventions in the effectiveness study to understand associated benefits and challenges. Data sources included study records, participant interviews, and clinical data. RESULTS For dose delivered of health communication interventions, 98% of eligible clients received pre-ART counseling and 90% of participants received at least one SMS reminder. For structural interventions, 74% of clients received CD4 testing and 53% of eligible participants initiated ART within 1 month. Challenges for structural interventions included facility-level barriers, staffing limitations, and machine malfunctions. For dose received, participants reported pre-ART counseling and CD4 testing as the most useful interventions for linkage and financial incentives as the least useful for linkage and retention. DISCUSSION Findings demonstrate that health communication interventions can be feasibly and acceptably integrated with structural interventions to create combination intervention strategies.
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Effective Interpersonal Health Communication for Linkage to Care After HIV Diagnosis in South Africa. J Acquir Immune Defic Syndr 2017; 74 Suppl 1:S23-S28. [PMID: 27930608 PMCID: PMC5147038 DOI: 10.1097/qai.0000000000001205] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background: Early in the global response to HIV, health communication was focused toward HIV prevention. More recently, the role of health communication along the entire HIV care continuum has been highlighted. We sought to describe how a strategy of interpersonal communication allows for precision health communication to influence behavior regarding care engagement. Methods: We analyzed 1 to 5 transcripts from clients participating in longitudinal counseling sessions from a communication strategy arm of a randomized trial to accelerate entry into care in South Africa. The counseling arm was selected because it increased verified entry into care by 40% compared with the standard of care. We used thematic analysis to identify key aspects of communication directed specifically toward a client's goals or concerns. Results: Of the participants, 18 of 28 were female and 21 entered HIV care within 90 days of diagnosis. Initiating a communication around client-perceived consequences of HIV was at times effective. However, counselors also probed around general topics of life disruption—such as potential for child bearing—as a technique to direct the conversation toward the participant's needs. Once individual concerns and needs were identified, counselors tried to introduce clinical care seeking and collaboratively discuss potential barriers and approaches to overcome to accessing that care. Conclusions: Through the use of interpersonal communication messages were focused on immediate needs and concerns of the client. When effectively delivered, it may be an important communication approach to improve care engagement.
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221
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Hickey MD, Odeny TA, Petersen M, Neilands TB, Padian N, Ford N, Matthay Z, Hoos D, Doherty M, Beryer C, Baral S, Geng EH. Specification of implementation interventions to address the cascade of HIV care and treatment in resource-limited settings: a systematic review. Implement Sci 2017; 12:102. [PMID: 28784155 PMCID: PMC5547499 DOI: 10.1186/s13012-017-0630-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 07/17/2017] [Indexed: 01/23/2023] Open
Abstract
Background The global response to HIV has started over 18 million persons on life-saving antiretroviral therapy (ART)—the vast majority in low- and middle-income countries (LMIC)—yet substantial gaps remain: up to 40% of persons living with HIV (PLHIV) know their status, while another 30% of those who enter care are inadequately retained after starting treatment. Identifying strategies to enhance use of treatment is urgently needed, but the conceptualization and specification of implementation interventions is not always complete. We sought to assess the completeness of intervention reporting in research to advance uptake of treatment for HIV globally. Methods We carried out a systematic review to identify interventions targeting the adult HIV care cascade in LMIC dating from 1990 to 2017. We identified components of each intervention as “intervention types” to decompose interventions into common components. We grouped “intervention types” into a smaller number of more general “implementation approaches” to aid summarization. We assessed the reporting of six intervention characteristics adapted from the implementation science literature: the actor, action, action dose, action temporality, action target, and behavioral target in each study. Findings In 157 unique studies, we identified 34 intervention “types,” which were empirically grouped into six generally understandable “approaches.” Overall, 42% of interventions defined the actor, 64% reported the action, 41% specified the intervention “dose,” 43% reported action temporality, 61% defined the action target, and 69% reported a target behavior. Average completeness of reporting varied across approaches from a low of 50% to a high of 72%. Dimensions that involved conceptualization of the practices themselves (e.g., actor, dose, temporality) were in general less well specified than consequences (e.g., action target and behavioral target). Implications The conceptualization and Reporting of implementation interventions to advance treatment for HIV in LMIC is not always complete. Dissemination of standards for reporting intervention characteristics can potentially promote transparency, reproducibility, and scientific accumulation in the area of implementation science to address HIV in low- and middle-income countries. Electronic supplementary material The online version of this article (doi:10.1186/s13012-017-0630-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Matthew D Hickey
- Division of General Internal Medicine, San Francisco General Hospital, Department of Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA
| | | | - Maya Petersen
- Department of Biostatistics and Epidemiology, School of Public Health, University of California, Berkeley, CA, USA
| | - Torsten B Neilands
- Center for AIDS Prevention Studies, Department of Medicine, UCSF, San Francisco, CA, USA
| | - Nancy Padian
- Department of Biostatistics and Epidemiology, School of Public Health, University of California, Berkeley, CA, USA
| | - Nathan Ford
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | | | - David Hoos
- Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Meg Doherty
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Chris Beryer
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Stefan Baral
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Elvin H Geng
- Division of ID HIV and Global Medicine, San Francisco General Hospital, Department of Medicine, UCSF, Building 80, 6th Floor, 1001 Potrero Avenue, San Francisco, CA, 94110, USA.
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Andriamandimby SF, Olive MM, Shimakawa Y, Rakotomanana F, Razanajatovo IM, Andrianinarivomanana TM, Ravalohery JP, Andriamamonjy S, Rogier C, Héraud JM. Prevalence of chronic hepatitis B virus infection and infrastructure for its diagnosis in Madagascar: implication for the WHO's elimination strategy. BMC Public Health 2017; 17:636. [PMID: 28778194 PMCID: PMC5544978 DOI: 10.1186/s12889-017-4630-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 07/25/2017] [Indexed: 12/18/2022] Open
Abstract
Background WHO developed a global strategy to eliminate hepatitis B by 2030 and set target to treat 80% of people with chronic hepatitis B virus (HBV) infection eligible for antiviral treatment. As a first step to achieve this goal, it is essential to conduct a situation analysis that is fundamental to designing national hepatitis plans. We therefore estimated the prevalence of chronic HBV infection, and described the existing infrastructure for HBV diagnosis in Madagascar. Methods We conducted a stratified multi-stage serosurvey of hepatitis B surface antigen (HBsAg) in adults aged ≥18 years using 28 sentinel surveillance sites located throughout the country. We obtained the list of facilities performing HBV testing from the Ministry of Health, and contacted the person responsible at each facility. Results A total of 1778 adults were recruited from the 28 study areas. The overall weighted seroprevalence of HBsAg was 6.9% (95% CI: 5.6–8.6). Populations with a low socio-economic status and those living in rural areas had a significantly higher seroprevalence of HBsAg. The ratio of facilities equipped to perform HBsAg tests per 100,000 inhabitants was 1.02 in the capital city of Antananarivo and 0.21 outside the capital. There were no facilities with the capacity to perform HBV DNA testing or transient elastography to measure liver fibrosis. There are only five hepatologists in Madagascar. Conclusion Madagascar has a high-intermediate level of endemicity for HBV infection with a severely limited capacity for its diagnosis and treatment. Higher HBsAg prevalence in rural or underprivileged populations underlines the importance of a public health approach to decentralize the management of chronic HBV carriers in Madagascar by using simple and low-cost diagnostic tools. Electronic supplementary material The online version of this article (doi:10.1186/s12889-017-4630-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Marie-Marie Olive
- Virology Unit, Institut Pasteur of Madagascar, Antananarivo, Madagascar.,UPR AGIRs, CIRAD Montpellier, Montpellier, France
| | - Yusuke Shimakawa
- Unité d'Epidémiologie des Maladie Emergentes, Institut Pasteur, Paris, France
| | | | | | | | | | | | - Christophe Rogier
- Direction centrale du service de santé des armées Parcelle, Paris, France
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223
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Katz IT, Maughan-Brown B. Improved life expectancy of people living with HIV: who is left behind? Lancet HIV 2017; 4:e324-e326. [PMID: 28501496 PMCID: PMC5828160 DOI: 10.1016/s2352-3018(17)30086-3] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 03/23/2017] [Accepted: 04/12/2017] [Indexed: 01/06/2023]
Affiliation(s)
- Ingrid T Katz
- Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA; Massachusetts General Hospital, Center for Global Health, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - Brendan Maughan-Brown
- Southern Africa Labour and Development Research Unit, University of Cape Town, South Africa
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224
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Ma PHX, Chan ZCY, Loke AY. The Socio-Ecological Model Approach to Understanding Barriers and Facilitators to the Accessing of Health Services by Sex Workers: A Systematic Review. AIDS Behav 2017. [PMID: 28631228 DOI: 10.1007/s10461-017-1818-2] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Inequities in accessing health care persist among sex workers. The purpose of the review is to understand the health-seeking behaviours of sex workers and their access to health care services with socio-ecological model. Of 3852 citations screened, 30 met the inclusion criteria for this review. The access that sex workers have to health services is a complex issue. A wide range of barriers and facilitators at multiple levels could influence sex workers' utilization of health care services, such as health or service information, stigma, social support, quality of health care, available, accessible and affordable services, healthcare policy. Health services or future intervention studies should take into account the facilitators and barriers identified in this review to improve the health services utilization and health of sex workers, as part of the effort to protect the right of humans to health.
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225
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Tomita A, Vandormael AM, Cuadros D, Slotow R, Tanser F, Burns JK. Proximity to healthcare clinic and depression risk in South Africa: geospatial evidence from a nationally representative longitudinal study. Soc Psychiatry Psychiatr Epidemiol 2017; 52:1023-1030. [PMID: 28299376 PMCID: PMC5534383 DOI: 10.1007/s00127-017-1369-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 02/22/2017] [Indexed: 10/20/2022]
Abstract
Proximity to primary healthcare facilities may be a serious barrier to accessing mental health services in resource-limited settings. In this study, we examined whether the distance to the primary healthcare clinic (PHCC) was associated with risk of depression in KwaZulu-Natal Province, South Africa. Depressive symptoms and household coordinates data were accessed from the nationally representative South African National Income Dynamics Study. Distances between households and their nearest PHCCs were calculated and mixed-effects logistic regression models fitted to the data. Participants residing <6 km from a PHCC (aOR = 0.608, 95% CI 0.42-0.87) or 6-14.9 km (aOR = 0. 612, 95% CI 0.44-0.86) had a lower depression risk compared to those residing ≥15 km from the nearest PHCC. Distance to the PHCC was independently associated with increased depression risk, even after controlling for key socioeconomic determinants. Minimizing the distance to PHCC through mobile health clinics and technology could improve mental health.
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Affiliation(s)
- Andrew Tomita
- College of Health Sciences, University of KwaZulu-Natal, Private Bag X7, Durban, South Africa. .,Africa Health Research Institute, University of KwaZulu-Natal, Durban, South Africa.
| | - Alain M. Vandormael
- College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa,Africa Health Research Institute, University of KwaZulu-Natal, Durban, South Africa
| | - Diego Cuadros
- Department of Geography, University of Cincinnati, Cincinnati, U.S.A
| | - Rob Slotow
- School of Life Sciences, University of KwaZulu-Natal, Durban, South Africa,Department of Genetics, Evolution & Environment, University College, London, United Kingdom
| | - Frank Tanser
- Africa Health Research Institute, University of KwaZulu-Natal, Durban, South Africa,Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa,School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Jonathan K. Burns
- Department of Psychiatry, University of KwaZulu-Natal, Durban, South Africa,Institute for Health Research, University of Exeter, Exeter, United Kingdom
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Kiene SM, Kalichman SC, Sileo KM, Menzies NA, Naigino R, Lin CD, Bateganya MH, Lule H, Wanyenze RK. Efficacy of an enhanced linkage to HIV care intervention at improving linkage to HIV care and achieving viral suppression following home-based HIV testing in rural Uganda: study protocol for the Ekkubo/PATH cluster randomized controlled trial. BMC Infect Dis 2017; 17:460. [PMID: 28673251 PMCID: PMC5494823 DOI: 10.1186/s12879-017-2537-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 06/09/2017] [Indexed: 01/05/2023] Open
Abstract
Background Though home-based human immunodeficiency virus (HIV) counseling and testing (HBHCT) is implemented in many sub-Saharan African countries as part of their HIV programs, linkage to HIV care remains a challenge. The purpose of this study is to test an intervention to enhance linkage to HIV care and improve HIV viral suppression among individuals testing HIV positive during HBHCT in rural Uganda. Methods The PATH (Providing Access To HIV Care)/Ekkubo Study is a cluster-randomized controlled trial which compares the efficacy of an enhanced linkage to HIV care intervention vs. standard-of-care (paper-based referrals) at achieving individual and population-level HIV viral suppression, and intermediate outcomes of linkage to care, receipt of opportunistic infection prophylaxis, and antiretroviral therapy initiation following HBHCT. Approximately 600 men and women aged 18-59 who test HIV positive during district-wide HBHCT in rural Uganda will be enrolled in this study. Villages (clusters) are pair matched by population size and then randomly assigned to the intervention or standard-of-care arm. Study teams visit households and participants complete a baseline questionnaire, receive HIV counseling and testing, and have blood drawn for HIV viral load and CD4 testing. At baseline, standard-of-care arm participants receive referrals to HIV care including a paper-based referral and then receive their CD4 results via home visit 2 weeks later. Intervention arm participants receive an intervention counseling session at baseline, up to three follow-up counseling sessions at home, and a booster session at the HIV clinic if they present for care. These sessions each last approximately 30 min and consist of counseling to help clients: identify and reduce barriers to HIV care engagement, disclose their HIV status, identify a treatment supporter, and overcome HIV-related stigma through links to social support resources in the community. Participants in both arms complete interviewer-administered questionnaires at six and 12 months follow-up, HIV viral load and CD4 testing at 12 months follow-up, and allow access to their medical records. Discussion The findings of this study can inform the integration of a potentially cost-effective approach to improving rates of linkage to care and HIV viral suppression in HBHCT. If effective, this intervention can improve treatment outcomes, reduce mortality, and through its effect on individual and population-level HIV viral load, and decrease HIV incidence. Trial registration NCT02545673
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Affiliation(s)
- Susan M Kiene
- Division of Epidemiology and Biostatistics, Graduate School of Public Health, San Diego State University, 5500 Campanile Drive (MC-4162), San Diego, CA, 92182, USA.
| | - Seth C Kalichman
- Department of Psychology, University of Connecticut, Storrs, CT, USA
| | - Katelyn M Sileo
- Division of Epidemiology and Biostatistics, Graduate School of Public Health, San Diego State University, San Diego, CA, USA
| | - Nicolas A Menzies
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Rose Naigino
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda
| | - Chii-Dean Lin
- Department of Mathematics and Statistics, San Diego State University, San Diego, CA, USA
| | - Moses H Bateganya
- Formerly: Department of Global Health, University of Washington, Seattle, WA, USA
| | | | - Rhoda K Wanyenze
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda
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Low-Beer D, Beusenberg M, Hayashi C, Calleja T, Marsh K, Mamahit A, Babovic T, Hirnschall G. Monitoring HIV Treatment and the Health Sector Cascade: From Treatment Numbers to Impact. AIDS Behav 2017; 21:15-22. [PMID: 28401415 PMCID: PMC5515963 DOI: 10.1007/s10461-017-1754-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Although not originally part of the MDGs, HIV treatment has been at the center of global HIV reporting since 2003, marked by achievement of the target of 15 million people receiving treatment before 2015 and 18.2 million (16.1–19.0 million) by mid 2016. Monitoring of treatment has been strengthened with harmonized partner reporting and accountability with regular, annual reports. Beyond treatment numbers, increasingly measures of treatment adherence, retention and outcomes have been reported though with varying quality and completeness. However, with the sustainable development goals (SDGs), monitoring treatment is changing in three important ways. First, treatment monitoring is shifting from numbers to coverage and gaps in a cascade of services to achieve universal access. Secondly, this requires greater emphasis on disaggregated, individual level patient and case monitoring systems, which can better support linkage, retention and chronic, long term care. Thirdly, the prevention, testing and treatment cascade with a clear results chain, links treatment numbers to impact, in terms of reduced viral load, mortality and incidence. This agenda will require a greater contribution of routine impact evaluation alongside monitoring, with treatment seen as part of a cascade of services to ensure impact on mortality and incidence. In conclusion, the shift from monitoring treatment numbers to treatment linked to universal access to prevention, testing and treatment and impact on mortality and incidence, will be critical to monitor, evaluate, and improve HIV programs as part of the SDGs.
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Choko AT, Kumwenda MK, Johnson CC, Sakala DW, Chikalipo MC, Fielding K, Chikovore J, Desmond N, Corbett EL. Acceptability of woman-delivered HIV self-testing to the male partner, and additional interventions: a qualitative study of antenatal care participants in Malawi. J Int AIDS Soc 2017; 20:21610. [PMID: 28691442 PMCID: PMC5515040 DOI: 10.7448/ias.20.1.21610] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 06/07/2017] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION In the era of ambitious HIV targets, novel HIV testing models are required for hard-to-reach groups such as men, who remain underserved by existing services. Pregnancy presents a unique opportunity for partners to test for HIV, as many pregnant women will attend antenatal care (ANC). We describe the views of pregnant women and their male partners on HIV self-test kits that are woman-delivered, alone or with an additional intervention. METHODS A formative qualitative study to inform the design of a multi-arm multi-stage cluster-randomized trial, comprised of six focus group discussions and 20 in-depth interviews, was conducted. ANC attendees were purposively sampled on the day of initial clinic visit, while men were recruited after obtaining their contact information from their female partners. Data were analysed using content analysis, and our interpretation is hypothetical as participants were not offered self-test kits. RESULTS Providing HIV self-test kits to pregnant women to deliver to their male partners was highly acceptable to both women and men. Men preferred this approach compared with standard facility-based testing, as self-testing fits into their lifestyles which were characterized by extreme day-to-day economic pressures, including the need to raise money for food for their household daily. Men and women emphasized the need for careful communication before and after collection of the self-test kits in order to minimize the potential for intimate partner violence although physical violence was perceived as less likely to occur. Most men stated a preference to first self-test alone, followed by testing as a couple. Regarding interventions for optimizing linkage following self-testing, both men and women felt that a fixed financial incentive of approximately USD$2 would increase linkage. However, there were concerns that financial incentives of greater value may lead to multiple pregnancies and lack of child spacing. In this low-income setting, a lottery incentive was considered overly disappointing for those who receive nothing. Phone call reminders were preferred to short messaging service. CONCLUSIONS Woman-delivered HIV self-testing through ANC was acceptable to pregnant women and their male partners. Feedback on additional linkage enablers will be used to alter pre-planned trial arms.
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Affiliation(s)
- Augustine Talumba Choko
- TB/HIV Theme, Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Moses Kelly Kumwenda
- TB/HIV Theme, Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- College of Medicine, University of Malawi, Blantyre, Malawi
| | | | - Doreen Wongera Sakala
- TB/HIV Theme, Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Maria Chifuniro Chikalipo
- College of Medicine, University of Malawi, Blantyre, Malawi
- University of Malawi, Kamuzu College of Nursing, Blantyre, Malawi
| | - Katherine Fielding
- Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Jeremiah Chikovore
- HIV/AIDS, Sexually Transmitted Infections & TB, Human Sciences Research Council, Durban, South Africa
| | - Nicola Desmond
- TB/HIV Theme, Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Department of Clinical Research, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Elizabeth Lucy Corbett
- TB/HIV Theme, Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
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Abstract
Supplemental Digital Content is available in the text Objective: Age-disparate sexual relationships with older men may drive high rates of HIV acquisition in young women in sub-Saharan Africa, but evidence is limited. We investigate the association between age-disparate relationships and HIV incidence in Manicaland, Zimbabwe. Design: A general-population open-cohort study (six surveys) (1998–2013). Methods: A total of 3746 young women aged 15–24 years participated in consecutive surveys and were HIV-negative at the beginning of intersurvey periods. Last sexual partner age difference and age-disparate relationships [intergenerational (≥10 years age difference) and intragenerational (5–9 years) versus age-homogeneous (0–4 years)] were tested for associations with HIV incidence in Cox regressions. A proximate determinants framework was used to explore factors possibly explaining variations in the contribution of age-disparate relationships to HIV incidence between populations and over time. Results: About 126 HIV infections occurred over 8777 person-years (1.43 per 100 person-years; 95% confidence interval = 1.17–1.68). Sixty-five percent of women reported partner age differences of at least 5 years. Increasing partner age differences were associated with higher HIV incidence [adjusted hazard ratio (aHR) = 1.05 (1.01–1.09)]. Intergenerational relationships tended to increase HIV incidence [aHR = 1.78 (0.96–3.29)] but not intragenerational relationships [aHR = 0.91 (0.47–1.76)]. Secondary education was associated with reductions in intergenerational relationships [adjusted odds ratio (aOR) = 0.49 (0.36–0.68)]. Intergenerational relationships were associated with partners having concurrent relationships [aOR = 2.59 (1.81–3.70)], which tended to increase HIV incidence [aHR = 1.74 (0.96–3.17)]. Associations between age disparity and HIV incidence did not change over time. Conclusion: Sexual relationships with older men expose young women to increased risk of HIV acquisition in Manicaland, which did not change over time, even with introduction of antiretroviral therapy.
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Relationship Between Time to Initiation of Antiretroviral Therapy and Treatment Outcomes: A Cohort Analysis of ART Eligible Adolescents in Zimbabwe. J Acquir Immune Defic Syndr 2017; 74:390-398. [PMID: 28002183 PMCID: PMC5321111 DOI: 10.1097/qai.0000000000001274] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Supplemental Digital Content is Available in the Text. Background: Age-specific retention challenges make antiretroviral therapy (ART) initiation in adolescents difficult, often requiring a lengthy preparation process. This needs to be balanced against the benefits of starting treatment quickly. The optimal time to initiation duration in adolescents is currently unknown. Objective: To assess the effect of time to ART initiation on mortality and loss to follow-up (LTFU) among treatment eligible adolescents. Methods: We conducted a retrospective cohort analysis among 1499 ART eligible adolescents aged ≥10 to <19 years registered in a public sector HIV program in Bulawayo, Zimbabwe, between 2004 and 2011. Hazard ratios (HR) for mortality and LTFU were calculated for different time to ART durations using multivariate Cox regression models. Results: Median follow-up duration was 1.6 years. Mortality HRs of patients who initiated at 0 to ≤7 days, >14 days to ≤1 month, >1 to ≤2 months, >2 months, and before initiation were 1.59, 1.19, 1.56, 1.08, and 0.94, respectively, compared with the reference group of >7 to ≤14 days. LTFU HRs were 1.02, 1.07, 0.85, 0.97, and 3.96, respectively. Among patients not on ART, 88% of deaths and 85% of LTFU occurred during the first 3 months after becoming ART eligible, but only 37% and 29% among adolescents on ART, respectively. Conclusions: Neither mortality or LTFU was associated with varying time to ART. The initiation process can be tailored to the adolescents' needs and individual life situations without risking to increase poor treatment outcomes. Early mortality was high despite rapid ART initiation, calling for earlier rather than faster initiation through HIV testing scale-up.
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231
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Keane J, Pharr JR, Buttner MP, Ezeanolue EE. Interventions to Reduce Loss to Follow-up During All Stages of the HIV Care Continuum in Sub-Saharan Africa: A Systematic Review. AIDS Behav 2017; 21:1745-1754. [PMID: 27578001 DOI: 10.1007/s10461-016-1532-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The continuum of care for successful HIV treatment includes HIV testing, linkage, engagement in care, and retention on antiretroviral therapy (ART). Loss to follow-up (LTFU) is a significant disruption to this pathway and a common outcome in sub-Saharan Africa. This review of literature identified interventions that have reduced LTFU in the HIV care continuum. A search was conducted utilizing terms that combined the disease state, stages of the HIV care continuum, interventions, and LTFU in sub-Saharan Africa and articles published between January 2010 and July 2015. Thirteen articles were included in the final review. Use of point of care CD4 testing and community-supported programs improved linkage, engagement, and retention in care. There are few interventions directed at LTFU and none that span across the entire continuum of HIV care. Further research could focus on devising programs that include a series of interventions that will be effective through the entire continuum.
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Mooney AC, Gottert A, Khoza N, Rebombo D, Hove J, Suárez AJ, Twine R, MacPhail C, Treves-Kagan S, Kahn K, Pettifor A, Lippman SA. Men's Perceptions of Treatment as Prevention in South Africa: Implications for Engagement in HIV Care and Treatment. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2017; 29:274-287. [PMID: 28650225 PMCID: PMC6686680 DOI: 10.1521/aeap.2017.29.3.274] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
While South Africa provides universal access to treatment, HIV testing and antiretroviral therapy (ART) uptake remains low, particularly among men. Little is known about community awareness of the effects of treatment on preventing transmission, and how this information might impact HIV service utilization. This qualitative study explored understandings of treatment as prevention (TasP) among rural South African men. Narratives emphasized the know value of ART for individual health, but none were aware of its preventive effects. Many expressed that preventing transmission to partners would incentivize testing, earlier treatment, and adherence in the absence of symptoms, and could reduce the weight of a diagnosis. Doubts about TasP impacts on testing and care included enduring risks of stigma and transmission. TasP information should be integrated into clinic-based counseling for those utilizing services, and community-based education for broader reach. Pairing TasP information with alternative testing options may increase engagement among men reluctant to be seen at clinics.
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Affiliation(s)
- Alyssa C Mooney
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | | | - Nomhle Khoza
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | | | - Jennifer Hove
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Aimée Julien Suárez
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill
| | - Rhian Twine
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Catherine MacPhail
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- School of Health, University of New England, New South Wales, Australia
| | - Sarah Treves-Kagan
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco
- Department of Health Behavior, Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Audrey Pettifor
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill
| | - Sheri A Lippman
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco
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Hall BJ, Sou KL, Beanland R, Lacky M, Tso LS, Ma Q, Doherty M, Tucker JD. Barriers and Facilitators to Interventions Improving Retention in HIV Care: A Qualitative Evidence Meta-Synthesis. AIDS Behav 2017; 21:1755-1767. [PMID: 27582088 PMCID: PMC5332336 DOI: 10.1007/s10461-016-1537-0] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Retention in HIV care is vital to the HIV care continuum. The current review aimed to synthesize qualitative research to identify facilitators and barriers to HIV retention in care interventions. A qualitative evidence meta-synthesis utilizing thematic analysis. Prospective review registration was made in PROSPERO and review procedures adhered to PRISMA guidelines. Nineteen databases were searched to identify qualitative research conducted with individuals living with HIV and their caregivers. Quality assessment was conducted using CASP and the certainty of the evidence was evaluated using CERQual. A total of 4419 citations were evaluated and 11 were included in the final meta-synthesis. Two studies were from high-income countries, 3 from middle-income countries, and 6 from low-income countries. A total of eight themes were identified as facilitators or barriers for retention in HIV care intervention: (1) Stigma and discrimination, (2) Fear of HIV status disclosure, (3) task shifting to lay health workers, (4) Human resource and institutional challenges, (5) Mobile Health (mHealth), (6) Family and friend support, (7) Intensive case management, and, (8) Relationships with caregivers. The current review suggests that task shifting interventions with lay health workers were feasible and acceptable. mHealth interventions and stigma reduction interventions appear to be promising interventions aimed at improving retention in HIV care. Future studies should focus on improving the evidence base for these interventions. Additional research is needed among women and adolescents who were under-represented in retention interventions.
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Affiliation(s)
- Brian J Hall
- Global and Community Mental Health Research Group, Department of Psychology, University of Macau, E21-3040, Avenida da Universidade, Taipa, Macau (SAR), People's Republic of China.
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Ka-Lon Sou
- Global and Community Mental Health Research Group, Department of Psychology, University of Macau, E21-3040, Avenida da Universidade, Taipa, Macau (SAR), People's Republic of China
| | - Rachel Beanland
- HIV/AIDS Department, World Health Organization, Geneva, Switzerland
| | - Mellanye Lacky
- University of North Carolina Chapel Hill Project-China, No. 2 Lujing Road, Guangzhou, 510095, People's Republic of China
| | - Lai Sze Tso
- University of North Carolina Chapel Hill Project-China, No. 2 Lujing Road, Guangzhou, 510095, People's Republic of China
| | - Qingyan Ma
- University of North Carolina Chapel Hill Project-China, No. 2 Lujing Road, Guangzhou, 510095, People's Republic of China
- Guangzhou Eighth People's Hospital, Guangzhou, People's Republic of China
| | - Meg Doherty
- HIV/AIDS Department, World Health Organization, Geneva, Switzerland
| | - Joseph D Tucker
- University of North Carolina Chapel Hill Project-China, No. 2 Lujing Road, Guangzhou, 510095, People's Republic of China
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234
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Peeling RW, Ford N. Reprising the role of CD4 cell count in HIV programmes. Lancet HIV 2017; 4:e377-e378. [PMID: 28579226 DOI: 10.1016/s2352-3018(17)30096-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 05/08/2017] [Indexed: 11/24/2022]
Affiliation(s)
- Rosanna W Peeling
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
| | - Nathan Ford
- World Health Organization, Geneva, Switzerland
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Rosen S, Fox MP, Larson BA, Brennan AT, Maskew M, Tsikhutsu I, Bii M, Ehrenkranz PD, Venter WDF. Simplified clinical algorithm for identifying patients eligible for immediate initiation of antiretroviral therapy for HIV (SLATE): protocol for a randomised evaluation. BMJ Open 2017; 7:e016340. [PMID: 28554939 PMCID: PMC5726128 DOI: 10.1136/bmjopen-2017-016340] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION African countries are rapidly adopting guidelines to offer antiretroviral therapy (ART) to all HIV-infected individuals, regardless of CD4 count. For this policy of 'treat all' to succeed, millions of new patients must be initiated on ART as efficiently as possible. Studies have documented high losses of treatment-eligible patients from care before they receive their first dose of antiretrovirals (ARVs), due in part to a cumbersome, resource-intensive process for treatment initiation, requiring multiple clinic visits over a several-week period. METHODS AND ANALYSIS The Simplified Algorithm for Treatment Eligibility (SLATE) study is an individually randomised evaluation of a simplified clinical algorithm for clinicians to reliably determine a patient's eligibility for immediate ART initiation without waiting for laboratory results or additional clinic visits. SLATE will enrol and randomise (1:1) 960 adult, HIV-positive patients who present for HIV testing or care and are not yet on ART in South Africa and Kenya. Patients randomised to the standard arm will receive routine, standard of care ART initiation from clinic staff. Patients randomised to the intervention arm will be administered a symptom report, medical history, brief physical exam and readiness assessment. Patients who have positive (satisfactory) results for all four components of SLATE will be dispensed ARVs immediately, at the same clinic visit. Patients who have any negative results will be referred for further clinical investigation, counselling, tests or other services prior to being dispensed ARVs. After the initial visit, follow-up will be by passive medical record review. The primary outcomes will be ART initiation ≤28 days and retention in care 8 months after study enrolment. ETHICS AND DISSEMINATION Ethics approval has been provided by the Boston University Institutional Review Board, the University of the Witwatersrand Human Research Ethics Committee (Medical) and the KEMRI Scientific and Ethics Review Unit. Results will be published in peer-reviewed journals and made widely available through presentations and briefing documents. TRIAL REGISTRATION NCT02891135.
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Affiliation(s)
- Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Matthew P Fox
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Bruce A Larson
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Alana T Brennan
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mhairi Maskew
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Isaac Tsikhutsu
- Kenya Medical Research Institute/Walter Reed Project HIV Program, Kericho, Kenya
| | - Margaret Bii
- Kenya Medical Research Institute/Walter Reed Project HIV Program, Kericho, Kenya
| | | | - WD Francois Venter
- Wits Reproductive Health and HIV Institute, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Assefa Y, Gilks CF, Lynen L, Williams O, Hill PS, Tolera T, Malvia A, Van Damme W. Performance of the Antiretroviral Treatment Program in Ethiopia, 2005-2015: strengths and weaknesses toward ending AIDS. Int J Infect Dis 2017; 60:70-76. [PMID: 28533167 DOI: 10.1016/j.ijid.2017.05.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 05/11/2017] [Accepted: 05/11/2017] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Ethiopia is one of the countries which has scaled up antiretroviral treatment (ART) over the past decade. This study reviews the performance of the ART program in Ethiopia during the past decade, and identifies successes and weaknesses toward ending AIDS in the country. METHODS A review and synthesis of data was conducted using multiple data sources: reports from all health facilities in Ethiopia to the Federal Ministry of Health, HIV/AIDS estimates and projections, and retrospective cohort and cross-sectional studies conducted between 2005/6 and 2014/15. FINDINGS The ART program has been successful over several critical areas: (1) ART coverage improved from 4% to 54%; (2) the median CD4 count/mm3 at the time of ART initiation increased from 125 in 2005/6 to 231 in 2012/13; (3) retention in care after 12 months on ART has increased from 82% to 92%. In spite of these successes, important challenges also remain: (1) ART coverage is not equitable: among regions (5.6%-93%), between children (25%) and adults (60%), and between female (54%) and male patients (69%); (2) retention in care is variable among regions (83%-94%); and, (3) the shift to second-line ART is slow and low (0·58%). INTERPRETATION The findings suggest that the ART program should sustain the successes and reflect on the shortcomings toward the goal of ending AIDS. It is important to capitalize on and calibrate the interventions and approaches utilized to scale up ART in the past. Analysis of the treatment cascade, in order to pinpoint the gaps and identify appropriate solutions, is commendable in this regard.
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Affiliation(s)
- Yibeltal Assefa
- The University of Queensland, School of Public Health, Brisbane, Australia; Ethiopian Public Health Institute, Addis Ababa, Ethiopia.
| | - Charles F Gilks
- The University of Queensland, School of Public Health, Brisbane, Australia
| | - Lutgarde Lynen
- Institute of Tropical Medicine, Department of Clinical Sciences, Antwerp, Belgium
| | - Owain Williams
- The University of Queensland, School of Public Health, Brisbane, Australia
| | - Peter S Hill
- The University of Queensland, School of Public Health, Brisbane, Australia
| | - Taye Tolera
- Federal Ministry of Health, Addis Ababa, Ethiopia
| | | | - Wim Van Damme
- Institute of Tropical Medicine, Department of Public Health, Antwerp, Belgium
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Implementation and Operational Research: Impact of Nurse-Targeted Care on HIV Outcomes Among Immunocompromised Persons: A Before-After Study in Uganda. J Acquir Immune Defic Syndr 2017; 72:e32-6. [PMID: 27003494 DOI: 10.1097/qai.0000000000001002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Improving HIV outcomes among severely immunocompromised HIV-infected persons who have increased morbidity and mortality remains an important issue in sub-Saharan Africa. We sought to evaluate the impact of targeted clinic-based nurse care on antiretroviral therapy (ART) initiation and retention among severely immunocompromised HIV-infected persons. METHODS The study included ART-naive patients with CD4 counts <100 cells per microliter registered in seven urban clinics in Kampala, Uganda. Data were retrospectively collected on patients enrolled from July to December 2011 (routine care cohort). Between July 2012 and September 2013, 1 additional nurse per clinic was hired (nurse counselor cohort) to identify new patients, expedite ART initiation, and trace those who were lost to follow-up. We compared time to ART initiation and 6-month retention in care between cohorts and used a generalized linear model to estimate the relative risk of retention. RESULTS The study included 258 patients in the routine care cohort and 593 in the nurse counselor cohort. The proportion of patients who initiated ART increased from 190 (73.6%) in the routine care cohort to 506 (85.3%) in the nurse counselor cohort (P < 0.001). At 6 months, 62% of the routine care cohort were retained in care versus 76% in the nurse counselor cohort (P = 0.001). A 21% increase in the likelihood of retention in the nurse counselor cohort (relative risk: 1.21, 95% CI: 1.09 to 1.34) compared with the routine care cohort was observed. CONCLUSIONS Implementation of targeted nurse-led care of severely immunocompromised HIV-infected patients in public outpatient health care facilities resulted in decreased time to ART initiation and increased retention.
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238
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Abstract
OBJECTIVE The aim of this study was to identify the range and frequency of patient-reported barriers and facilitators to antiretroviral treatment (ART) adherence in sub-Saharan Africa (SSA). DESIGN Studies from 2005 to 2016 were identified by searching 10 electronic databases and through additional hand and web-searching. METHODS Inclusion criteria were HIV-positive adults taking ART based in any SSA country, qualitative study or quantitative survey and included at least one patient-reported barrier or facilitator to ART adherence. Exclusion criteria were only including data from treatment-naive patients initiating ART, only single-dose treatment, participants residing outside of SSA and reviews. RESULTS After screening 11 283 records, 154 studies (161 papers) were included in this review. Forty-three barriers and 30 facilitators were reported across 24 SSA countries. The most frequently identified barriers across studies were forgetting (n = 76), lack of access to adequate food (n = 72), stigma and discrimination (n = 68), side effects (n = 67) and being outside the house or travelling (n = 60). The most frequently identified facilitators across studies were social support (n = 60), reminders (n = 55), feeling better or healthier after taking ART (n = 35), disclosing their HIV status (n = 26) and having a good relationship with a health provider (n = 22). CONCLUSION This review addresses the gap in knowledge by collating all the patient-reported barriers and facilitators to ART adherence in SSA. Current barriers measures need to be adapted or new tools developed to include the wide variety of factors identified. The factors that have the greatest impact need to be isolated so interventions are developed that reduce the barriers and enhance the facilitators.
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Determinants of time from HIV infection to linkage-to-care in rural KwaZulu-Natal, South Africa. AIDS 2017; 31:1017-1024. [PMID: 28252526 DOI: 10.1097/qad.0000000000001435] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To estimate time from HIV infection to linkage-to-care and its determinants. Linkage-to-care is usually assessed using the date of HIV diagnosis as the starting point for exposure time. However, timing of diagnosis is likely endogenous to linkage, leading to bias in linkage estimation. DESIGN We used longitudinal HIV serosurvey data from a large population-based HIV incidence cohort in KwaZulu-Natal (2004-2013) to estimate time of HIV infection. We linked these data to patient records from a public-sector HIV treatment and care program to determine time from infection to linkage (defined using the date of the first CD4 cell count). METHODS We used Cox proportional hazards models to estimate time from infection to linkage and the effects of the following covariates on this time: sex, age, education, food security, socioeconomic status, area of residence, distance to clinics, knowledge of HIV status, and whether other household members have initiated antiretroviral therapy. RESULTS We estimated that it would take an average of 4.9 years for 50% of HIV seroconverters to be linked to care (95% confidence intervals: 4.2-5.7). Among all cohort members who were linked to care, the median CD4 cell count at linkage was 350 cells/μl (95% confidence interval: 330-380). Men and participants aged less than 30 years were found to have the slowest rates of linkage-to-care. Time to linkage became shorter over calendar time. CONCLUSION Average time from HIV infection to linkage-to-care is long and needs to be reduced to ensure that HIV treatment-as-prevention policies are effective. Targeted interventions for men and young individuals have the largest potential to improve linkage rates.
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Sanga ES, Lerebo W, Mushi AK, Clowes P, Olomi W, Maboko L, Zarowsky C. Linkage into care among newly diagnosed HIV-positive individuals tested through outreach and facility-based HIV testing models in Mbeya, Tanzania: a prospective mixed-method cohort study. BMJ Open 2017; 7:e013733. [PMID: 28404611 PMCID: PMC5541440 DOI: 10.1136/bmjopen-2016-013733] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Revised: 02/18/2017] [Accepted: 02/27/2017] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE Linkage to care is the bridge between HIV testing and HIV treatment, care and support. In Tanzania, mobile testing aims to address historically low testing rates. Linkage to care was reported at 14% in 2009 and 28% in 2014. The study compares linkage to care of HIV-positive individuals tested at mobile/outreach versus public health facility-based services within the first 6 months of HIV diagnosis. SETTING Rural communities in four districts of Mbeya Region, Tanzania. PARTICIPANTS A total of 1012 newly diagnosed HIV-positive adults from 16 testing facilities were enrolled into a two-armed cohort and followed for 6 months between August 2014 and July 2015. 840 (83%) participants completed the study. MAIN OUTCOME MEASURES We compared the ratios and time variance in linkage to care using the Kaplan-Meier estimator and Log rank tests. Cox proportional hazards regression models to evaluate factors associated with time variance in linkage. RESULTS At the end of 6 months, 78% of all respondents had linked into care, with differences across testing models. 84% (CI 81% to 87%, n=512) of individuals tested at facility-based site were linked to care compared to 69% (CI 65% to 74%, n=281) of individuals tested at mobile/outreach. The median time to linkage was 1 day (IQR: 1-7.5) for facility-based site and 6 days (IQR: 3-11) for mobile/outreach sites. Participants tested at facility-based site were 78% more likely to link than those tested at mobile/outreach when other variables were controlled (AHR=1.78; 95% CI 1.52 to 2.07). HIV status disclosure to family/relatives was significantly associated with linkage to care (AHR=2.64; 95% CI 2.05 to 3.39). CONCLUSIONS Linkage to care after testing HIV positive in rural Tanzania has increased markedly since 2014, across testing models. Individuals tested at facility-based sites linked in significantly higher proportion and modestly sooner than mobile/outreach tested individuals. Mobile/outreach testing models bring HIV testing services closer to people. Strategies to improve linkage from mobile/outreach models are needed.
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Affiliation(s)
- Erica Samson Sanga
- NIMR-Mbeya Medical Research Centre (MMRC), Mbeya, Tanzania
- School of Public Health, University of Western Cape, Cape Town, South Africa
| | - Wondwossen Lerebo
- School of Public Health, University of Western Cape, Cape Town, South Africa
- School of Public Health, Mekelle University, Mekelle, Ethiopia
| | - Adiel K Mushi
- National Institute for Medical Research (NIMR), Dar es Salaam, Tanzania
| | - Petra Clowes
- NIMR-Mbeya Medical Research Centre (MMRC), Mbeya, Tanzania
- Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich (LMU), Munich, Germany
| | | | - Leonard Maboko
- NIMR-Mbeya Medical Research Centre (MMRC), Mbeya, Tanzania
| | - Christina Zarowsky
- School of Public Health, University of Western Cape, Cape Town, South Africa
- University of Montreal Hospital Research Centre and School of Public Health, Université de Montréal, Montreal, Quebec, Canada
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Abstract
Matthew Fox and Sydney Rosen discuss a cascade of HIV care adapted to WHO-recommended antiretroviral therapy irrespective of CD4 cell count.
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Affiliation(s)
- Matthew P. Fox
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- * E-mail:
| | - Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Mulqueeny DM, Taylor M. Patients' recommendations for a patient-centred public antiretroviral therapy programme in eThekwini, KwaZulu-Natal. South Afr J HIV Med 2017; 18:677. [PMID: 29568623 PMCID: PMC5843240 DOI: 10.4102/sajhivmed.v18i1.677] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 01/20/2017] [Indexed: 11/06/2022] Open
Abstract
Background The South African antiretroviral therapy (ART) programme, which is in its second decade of existence, includes many successes and challenges. This study provides patients’ recommendations to address the challenges they currently experience at four antiretroviral (ARV) clinics based in urban public hospitals in order to provide a patient-centred service. Objectives To use patients’ recommendations to develop intervention strategies to improve patients’ experiences of the public ART programme. Method A three-stage, sequential, mixed-method study was implemented. Stage 1 recruited five patients from the four sites to formulate and test a structured questionnaire prior to data collection. Stage 2 recruited a stratified random sample of 400 patients (100 from each hospital) to complete the administered structured questionnaire. Stage 3 purposively selected 12 patients (three from each of the four sites) to participate in in-depth audio-recorded interviews using an interview schedule. Results The 412 patients prioritised six recommendations, which are as follows: waiting areas should be enclosed to protect patients from the elements (rain, sun, lightening, wind and cold); patients should not have to return their files to the main hospital or ARV clinic themselves; stable patients should collect their ARV drugs every three months; pharmacy opening and closing times should be revised to suit patients’ needs; HIV-positive patient representatives should be elected at each ARV clinic to address patients’ concerns and/or challenges to ensure that the programme could be more patient-centred and ARV clinic operating times should be extended to open later during weekdays and over weekends. Conclusion Patients living with HIV have a valuable contribution to make in assessing service delivery and making recommendations to create a patient-centred healthcare environment, which will feasibly increase their adherence to ART.
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Affiliation(s)
| | - Myra Taylor
- School of Nursing and Public Health, University of KwaZulu-Natal, South Africa
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Gesesew HA, Tesfay Gebremedhin A, Demissie TD, Kerie MW, Sudhakar M, Mwanri L. Significant association between perceived HIV related stigma and late presentation for HIV/AIDS care in low and middle-income countries: A systematic review and meta-analysis. PLoS One 2017; 12:e0173928. [PMID: 28358828 PMCID: PMC5373570 DOI: 10.1371/journal.pone.0173928] [Citation(s) in RCA: 138] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 02/28/2017] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Late presentation for human immunodeficiency virus (HIV) care is a major impediment for the success of antiretroviral therapy (ART) outcomes. The role that stigma plays as a potential barrier to timely diagnosis and treatment of HIV among people living with HIV/AIDS (acquired immunodeficiency syndrome) is ambivalent. This review aimed to assess the best available evidence regarding the association between perceived HIV related stigma and time to present for HIV/AIDS care. METHODS Quantitative studies conducted in English language between 2002 and 2016 that evaluated the association between HIV related stigma and late presentation for HIV care were sought across four major databases. This review considered studies that included the following outcome: 'late HIV testing', 'late HIV diagnosis' and 'late presentation for HIV care after testing'. Data were extracted using a standardized Joanna Briggs Institute (JBI) data extraction tool. Meta- analysis was undertaken using Revman-5 software. I2 and chi-square test were used to assess heterogeneity. Summary statistics were expressed as pooled odds ratio with 95% confidence intervals and corresponding p-value. RESULTS Ten studies from low- and middle- income countries met the search criteria, including six (6) and four (4) case control studies and cross-sectional studies respectively. The total sample size in the included studies was 3,788 participants. Half (5) of the studies reported a significant association between stigma and late presentation for HIV care. The meta-analytical association showed that people who perceived high HIV related stigma had two times more probability of late presentation for HIV care than who perceived low stigma (pooled odds ratio = 2.4; 95%CI: 1.6-3.6, I2 = 79%). CONCLUSIONS High perceptions of HIV related stigma influenced timely presentation for HIV care. In order to avoid late HIV care presentation due the fear of stigma among patients, health professionals should play a key role in informing and counselling patients on the benefits of early HIV testing or early entry to HIV care. Additionally, linking the systems and positive case tracing after HIV testing should be strengthened.
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Affiliation(s)
- Hailay Abrha Gesesew
- Epidemiology, Jimma University, Jimma, Ethiopia
- Public Health, Flinders University, Adelaide, Australia
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Czaicki NL, Holmes CB, Sikazwe I, Bolton C, Savory T, wa Mwanza M, Moyo C, Padian NS, Geng EH. Nonadherence to antiretroviral therapy among HIV-infected patients in Zambia is concentrated among a minority of patients and is highly variable across clinics. AIDS 2017; 31:689-696. [PMID: 28225707 DOI: 10.1097/qad.0000000000001347] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The distribution of adherence to antiretroviral therapy (ART) can indicates whether barriers are concentrated or more distributed. We quantified the medication possession ratio (MPR) and characterized the distribution of medication nonpossession in a network of clinics in Zambia to identify 'hotspots' and predictors of poorer adherence. METHODS We analyzed a population of adults on ART for more than 3 months who made at least one clinic visit between 1 January 2013 and 28 February 2015. Pharmacy refill and clinical information were obtained through the electronic medical record system used in routine care. We constructed a Lorenz curve to visualize the distribution of poor adherence and used a multilevel logistic regression model to examine factors associated with MPR. RESULTS Among 131 767 patients in 56 clinics [64% women, median age 34 years (interquartile range (IQR) 29-41), median CD4 cell count at ART initiation 351 cells/μl (IQR 220-517)], the median MPR was 85.8% (IQR 70.8-96.8). During months 7-12 on ART, 45.6% of patients had 100% MPR and 10.5% accounted for 50% of medication nonpossession. Across clinics, median MPR ranged from 49.1 to 98.5, and clinic accounted for 12% of the variability in adherence after adjusting for individual and clinic-level characteristics. CONCLUSION A small fraction of patients account for the majority of days of medication nonpossession. Further characterization of these subpopulations is needed to target interventions. Clinic also accounted for much variability in MPR. Health systems interventions targeting clinic 'hot spots' may represent an efficient use of resources to improve ART adherence.
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Building the evidence base for stigma and discrimination-reduction programming in Thailand: development of tools to measure healthcare stigma and discrimination. BMC Public Health 2017; 17:245. [PMID: 28284184 PMCID: PMC5346237 DOI: 10.1186/s12889-017-4172-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Accepted: 03/04/2017] [Indexed: 12/25/2022] Open
Abstract
Background HIV-related stigma and discrimination (S&D) are recognized as key impediments to controlling the HIV epidemic. S&D are particularly detrimental within health care settings because people who are at risk of HIV and people living with HIV (PLHIV) must seek services from health care facilities. Standardized tools and monitoring systems are needed to inform S&D reduction efforts, measure progress, and monitor trends. This article describes the processes followed to adapt and refine a standardized global health facility staff S&D questionnaire for the context of Thailand and develop a similar questionnaire measuring health facility stigma experienced by PLHIV. Both questionnaires are currently being used for the routine monitoring of HIV-related S&D in the Thai healthcare system. Methods The questionnaires were adapted through a series of consultative meetings, pre-testing, and revision. The revised questionnaires then underwent field testing, and the data and field experiences were analyzed. Results Two brief questionnaires were finalized and are now being used by the Department of Disease Control to collect national routine data for monitoring health facility S&D: 1) a health facility staff questionnaire that collects data on key drivers of S&D in health facilities (i.e., fear of HIV infection, attitudes toward PLHIV and key populations, and health facility policy and environment) and observed enacted stigma and 2) a brief PLHIV questionnaire that captures data on experienced discriminatory practices at health care facilities. Conclusions This effort provides an example of how a country can adapt global S&D measurement tools to a local context for use in national routine monitoring. Such data helps to strengthen the national response to HIV through the provision of evidence to shape S&D-reduction programming. Electronic supplementary material The online version of this article (doi:10.1186/s12889-017-4172-4) contains supplementary material, which is available to authorized users.
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Tucker JD, Tso LS, Hall B, Ma Q, Beanland R, Best J, Li H, Lackey M, Marley G, Rich ZC, Sou KL, Doherty M. Enhancing Public Health HIV Interventions: A Qualitative Meta-Synthesis and Systematic Review of Studies to Improve Linkage to Care, Adherence, and Retention. EBioMedicine 2017; 17:163-171. [PMID: 28161401 PMCID: PMC5360566 DOI: 10.1016/j.ebiom.2017.01.036] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Revised: 01/25/2017] [Accepted: 01/25/2017] [Indexed: 12/21/2022] Open
Abstract
Although HIV services are expanding, few have reached the scale necessary to support universal viral suppression of individuals living with HIV. The purpose of this systematic review was to summarize the qualitative evidence evaluating public health HIV interventions to enhance linkage to care, antiretroviral drug (ARV) adherence, and retention in care. We searched 19 databases without language restrictions. The review collated data from three separate qualitative evidence reviews addressing each of the three outcomes along the care continuum. 21,738 citations were identified and 24 studies were included in the evidence review. Among low and middle-income countries in Africa, men living with HIV had decreased engagement in interventions compared to women and this lack of engagement among men also influenced the willingness of their partners to engage in services. Four structural issues (poverty, unstable housing, food insecurity, lack of transportation) mediated the feasibility and acceptability of public health HIV interventions. Individuals living with HIV identified unmet mental health needs that interfered with their ability to access HIV services. Persistent social and cultural factors contribute to disparities in HIV outcomes across the continuum of care, shaping the context of service delivery among important subpopulations.
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Affiliation(s)
- Joseph D Tucker
- University of North Carolina Project-China, Guangzhou, China; Institute for Global Health and Infectious Diseases at UNC-Chapel Hill, Chapel Hill, USA.
| | - Lai Sze Tso
- University of North Carolina Project-China, Guangzhou, China.
| | - Brian Hall
- Global and Community Mental Health Research Group, Department of Psychology, University of Macau, Macau, China; Johns Hopkins Bloomberg School of Public Health, Department of Health, Behavior and Society, Baltimore, MD, USA.
| | - Qingyan Ma
- University of North Carolina Project-China, Guangzhou, China.
| | - Rachel Beanland
- HIV Department, World Health Organization, Geneva, Switzerland.
| | - John Best
- School of Medicine, University of California, San Francisco, San Francisco, USA.
| | - Haochu Li
- University of North Carolina Project-China, Guangzhou, China
| | - Mellanye Lackey
- Eccles Health Sciences Library, University of Utah, Salt Lake City, UT, USA.
| | - Gifty Marley
- University of North Carolina Project-China, Guangzhou, China.
| | - Zachary C Rich
- University of North Carolina Project-China, Guangzhou, China.
| | - Ka-Lon Sou
- University of North Carolina Project-China, Guangzhou, China.
| | - Meg Doherty
- HIV Department, World Health Organization, Geneva, Switzerland.
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Lippman SA, Pettifor A, Rebombo D, Julien A, Wagner RG, Kang Dufour MS, Kabudula CW, Neilands TB, Twine R, Gottert A, Gómez-Olivé FX, Tollman SM, Sanne I, Peacock D, Kahn K. Evaluation of the Tsima community mobilization intervention to improve engagement in HIV testing and care in South Africa: study protocol for a cluster randomized trial. Implement Sci 2017; 12:9. [PMID: 28095904 PMCID: PMC5240325 DOI: 10.1186/s13012-016-0541-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Accepted: 12/27/2016] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND HIV transmission can be decreased substantially by reducing the burden of undiagnosed HIV infection and expanding early and consistent use of antiretroviral therapy (ART). Treatment as prevention (TasP) has been proposed as key to ending the HIV epidemic. To activate TasP in high prevalence countries, like South Africa, communities must be motivated to know their status, engage in care, and remain in care. Community mobilization (CM) has the potential to significantly increase uptake testing, linkage to and retention in care by addressing the primary social barriers to engagement with HIV care-including poor understanding of HIV care; fear and stigma associated with infection, clinic attendance and disclosure; lack of social support; and gender norms that deter men from accessing care. METHODS/DESIGN Using a cluster randomized trial design, we are implementing a 3-year-theory-based CM intervention and comparing gains in HIV testing, linkage, and retention in care among individuals residing in 8 intervention communities to that of individuals residing in 7 control communities. Eligible communities include 15 villages within a health and demographic surveillance site (HDSS) in rural Mpumalanga, South Africa, that were not exposed to previous CM efforts. CM activities conducted in the 8 intervention villages map onto six mobilization domains that comprise the key components for community mobilization around HIV prevention. To evaluate the intervention, we will link a clinic-based electronic clinical tracking system in all area clinics to the HDSS longitudinal census data, thus creating an open, population-based cohort with over 30,000 18-49-year-old residents. We will estimate the marginal effect of the intervention on individual outcomes using generalized estimating equations. In addition, we will evaluate CM processes by conducting baseline and endline surveys among a random sample of 1200 community residents at each time point to monitor intervention exposure and community level change using validated measures of CM. DISCUSSION Given the known importance of community social factors with regard to uptake of testing and HIV care, and the lack of rigorously evaluated community-level interventions effective in improving testing uptake, linkage and retention, the proposed study will yield much needed data to understand the potential of CM to improve the prevention and care cascade. Further, our work in developing a CM framework and domain measures will permit validation of a CM conceptual framework and process, which should prove valuable for community programming in Africa. TRIAL REGISTRATION NCT02197793 Registered July 21, 2014.
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Affiliation(s)
- Sheri A Lippman
- Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco, 550 16th Street, 3rd Floor, San Francisco, 94158-2549, CA, USA.
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, 27 St Andrews Road, Parktown 2193, Johannesburg, South Africa.
| | - Audrey Pettifor
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, 27 St Andrews Road, Parktown 2193, Johannesburg, South Africa
- Gillings School of Global Public Health, University of North Carolina, 135 Dauer Dr., Chapel Hill, 27599, NC, USA
| | - Dumisani Rebombo
- Sonke Gender Justice, 4th Floor Westminster House, 122 Longmarket Street, 8001, Cape Town, South Africa
| | - Aimée Julien
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, 27 St Andrews Road, Parktown 2193, Johannesburg, South Africa
- Gillings School of Global Public Health, University of North Carolina, 135 Dauer Dr., Chapel Hill, 27599, NC, USA
| | - Ryan G Wagner
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, 27 St Andrews Road, Parktown 2193, Johannesburg, South Africa
- Umeå Centre for Global Health Research, Division of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, 90187, Umeå, Sweden
| | - Mi-Suk Kang Dufour
- Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco, 550 16th Street, 3rd Floor, San Francisco, 94158-2549, CA, USA
| | - Chodziwadziwa Whiteson Kabudula
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, 27 St Andrews Road, Parktown 2193, Johannesburg, South Africa
- Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel Street London WC1E 7HT, London, UK
| | - Torsten B Neilands
- Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco, 550 16th Street, 3rd Floor, San Francisco, 94158-2549, CA, USA
| | - Rhian Twine
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, 27 St Andrews Road, Parktown 2193, Johannesburg, South Africa
| | - Ann Gottert
- Gillings School of Global Public Health, University of North Carolina, 135 Dauer Dr., Chapel Hill, 27599, NC, USA
| | - F Xavier Gómez-Olivé
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, 27 St Andrews Road, Parktown 2193, Johannesburg, South Africa
| | - Stephen M Tollman
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, 27 St Andrews Road, Parktown 2193, Johannesburg, South Africa
| | - Ian Sanne
- Clinical HIV Research Unit, Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Helen Joseph Hospital, Perth Road, Westdene, 2092, Johannesburg, South Africa
| | - Dean Peacock
- Sonke Gender Justice, 4th Floor Westminster House, 122 Longmarket Street, 8001, Cape Town, South Africa
- Division of Social and Behavioural Sciences, School of Public Health, University of Cape Town, Falmouth Rd, Observatory 7925, Cape Town, South Africa
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, 27 St Andrews Road, Parktown 2193, Johannesburg, South Africa
- Umeå Centre for Global Health Research, Division of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, 90187, Umeå, Sweden
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Tsai AC, Hatcher AM, Bukusi EA, Weke E, Lemus Hufstedler L, Dworkin SL, Kodish S, Cohen CR, Weiser SD. A Livelihood Intervention to Reduce the Stigma of HIV in Rural Kenya: Longitudinal Qualitative Study. AIDS Behav 2017; 21:248-260. [PMID: 26767535 DOI: 10.1007/s10461-015-1285-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The scale-up of effective treatment has partially reduced the stigma attached to HIV, but HIV still remains highly stigmatized throughout sub-Saharan Africa. Most studies of anti-HIV stigma interventions have employed psycho-educational strategies such as information provision, counseling, and testimonials, but these have had varying degrees of success. Theory suggests that livelihood interventions could potentially reduce stigma by weakening the instrumental and symbolic associations between HIV and premature morbidity, economic incapacity, and death, but this hypothesis has not been directly examined. We conducted a longitudinal qualitative study among 54 persons with HIV participating in a 12-month randomized controlled trial of a livelihood intervention in rural Kenya. Our study design permitted assessment of changes over time in the perspectives of treatment-arm participants (N = 45), as well as an understanding of the experiences of control arm participants (N = 9, interviewed only at follow-up). Initially, participants felt ashamed of their seropositivity and were socially isolated (internalized stigma). They also described how others in the community discriminated against them, labeled them as being "already dead," and deemed them useless and unworthy of social investment (perceived and enacted stigma). At follow-up, participants in the treatment arm described less stigma and voiced positive changes in confidence and self-esteem. Concurrently, they observed that other community members perceived them as active, economically productive, and contributing citizens. None of these changes were noted by participants in the control arm, who described ongoing and continued stigma. In summary, our findings suggest a theory of stigma reduction: livelihood interventions may reduce internalized stigma among persons with HIV and also, by targeting core drivers of negative attitudes toward persons with HIV, positively change attitudes toward persons with HIV held by others. Further research is needed to formally test these hypotheses, assess the extent to which these changes endure over the long term, and determine whether this class of interventions can be implemented at scale.
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Lippman SA, Neilands TB, MacPhail C, Peacock D, Maman S, Rebombo D, Twine R, Selin A, Leslie HH, Kahn K, Pettifor A. Community Mobilization for HIV Testing Uptake: Results From a Community Randomized Trial of a Theory-Based Intervention in Rural South Africa. J Acquir Immune Defic Syndr 2017; 74 Suppl 1:S44-S51. [PMID: 27930611 PMCID: PMC5147031 DOI: 10.1097/qai.0000000000001207] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND HIV testing uptake in South Africa is below optimal levels. Community mobilization (CM) may increase and sustain demand for HIV testing, however, little rigorous evidence exists regarding the effect of CM interventions on HIV testing and the mechanisms of action. METHODS We implemented a theory-driven CM intervention in 11 of 22 randomly-selected villages in rural Mpumalanga Province. Cross-sectional surveys including a community mobilization measure were conducted before (n = 1181) and after (n = 1175) a 2-year intervention (2012-2014). We assessed community-level intervention effects on reported HIV testing using multilevel logistic models. We used structural equation models to explore individual-level effects, specifically whether intervention assignment and individual intervention exposure were associated with HIV testing through community mobilization. RESULTS Reported testing increased equally in both control and intervention sites: the intervention effect was null in primary analyses. However, the hypothesized pathway, CM, was associated with higher HIV testing in the intervention communities. Every standard deviation increase in village CM score was associated with increased odds of reported HIV testing in intervention village participants (odds ratio: 2.6, P = <0.001) but not control village participants (odds ratio: 1.2, P = 0.53). Structural equation models demonstrate that the intervention affected HIV testing uptake through the individual intervention exposure received and higher personal mobilization scores. CONCLUSIONS There was no evidence of community-wide gains in HIV testing due to the intervention. However, a significant intervention effect on HIV testing was noted in residents who were personally exposed to the intervention and who evidenced higher community mobilization. Research is needed to understand whether CM interventions can be diffused within communities over time.
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Affiliation(s)
- Sheri A. Lippman
- Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco, San Francisco, CA
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Torsten B. Neilands
- Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco, San Francisco, CA
| | - Catherine MacPhail
- School of Health, University of New England, Armidale, New South Wales, Australia
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Dean Peacock
- Sonke Gender Justice, Cape Town, South Africa
- School of Public Health, University of Cape Town, South Africa
| | - Suzanne Maman
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Dumisani Rebombo
- Sonke Gender Justice, Cape Town, South Africa
- School of Public Health, University of Cape Town, South Africa
| | - Rhian Twine
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Amanda Selin
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Hannah H. Leslie
- Division of Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, CA; and
| | - Kathleen Kahn
- Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco, San Francisco, CA
- Umeå Centre for Global Health Research, Division of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Audrey Pettifor
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Neduzhko O, Postnov O, Perehinets I, DeHovitz J, Joseph M, Odegaard D, Kaplan R, Kiriazova T. Factors Associated with Delayed Enrollment in HIV Medical Care among HIV-Positive Individuals in Odessa Region, Ukraine. J Int Assoc Provid AIDS Care 2016; 16:168-173. [PMID: 28034344 PMCID: PMC5363501 DOI: 10.1177/2325957416686194] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
In Ukraine, about one-third of identified HIV-positive individuals are not connected to care. We conducted a cross-sectional survey (n = 200) among patients registered at Odessa AIDS centers in October to December 2011. Factors associated with delayed enrollment in HIV care (>3 months since positive HIV test) were evaluated using logistic regression. Among study participants (mean age 35 ± 8.2 years, 47.5% female, 42.5% reported history of injecting drugs), 55% delayed HIV care enrollment. Odds of delayed enrollment were higher for those with lower educational attainment (adjusted odds ratio [aOR]: 2.65, 95% confidence interval [CI]: 1.04-6.76), not feeling ill (aOR: 2.98, 95% CI: 1.50-5.93), or not having time to go to the AIDS center (aOR: 3.89, 95% CI: 1.39-10.89); injection drug use was not associated with delayed enrollment. Programs linking HIV-positive individuals to specialized care should address enrollment barriers and include education on HIV care benefits and case management for direct linkage to care. HIV testing and treatment should be coupled to ensure a continuum of care.
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Affiliation(s)
| | - Oleksandr Postnov
- 2 Ukrainian I. I. Mechnikov Research Anti-Plague Institute, Odessa, Ukraine
| | | | - Jack DeHovitz
- 4 Department of Medicine, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Michael Joseph
- 5 Department of Epidemiology and Biostatistics, SUNY Downstate School of Public Health, Brooklyn, NY, USA
| | - David Odegaard
- 4 Department of Medicine, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Robert Kaplan
- 6 Department of English, Stony Brook University, Stony Brook, NY, USA
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