251
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Breger TL, Newman JE, Mfangam Molu B, Akam W, Balimba A, Atibu J, Kiumbu M, Azinyue I, Hemingway-Foday J, Pence BW. Self-disclosure of HIV status, disclosure counseling, and retention in HIV care in Cameroon. AIDS Care 2016; 29:838-845. [PMID: 28024412 DOI: 10.1080/09540121.2016.1271390] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Poor retention in care is common among HIV-positive adults in sub-Saharan Africa settings and remains a key barrier to HIV management. We quantify the associations of disclosure of HIV status and referral to disclosure counseling with successful retention in care using data from three Cameroon clinics participating in the Phase 1 International epidemiologic Databases to Evaluate AIDS Central Africa cohort. Of 1646 patients newly initiating antiretroviral therapy between January 2008 and January 2011, 43% were retained in care following treatment initiation. Self-disclosure of HIV status to at least one person prior to treatment initiation was associated with a minimal increase in the likelihood of being retained in care (risk ratio [RR] = 1.14; 95% confidence interval (CI): 0.94, 1.38). However, referral to disclosure counseling was associated with a moderate increase in retention (RR = 1.37; 95% CI: 1.21, 1.55) and was not significantly modified by prior disclosure status (p = .3). Our results suggest that while self-disclosure may not significantly improve retention among patients receiving care at these Cameroon sites, counseling services may play an important role regardless of prior disclosure status.
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Affiliation(s)
- Tiffany L Breger
- a Department of Epidemiology , University of North Carolina at Chapel Hill , Chapel Hill , NC , USA
| | | | | | | | | | - Joseph Atibu
- f Ecole de Santé Publique , Kinshasa , Democratic Republic of the Congo
| | - Modeste Kiumbu
- f Ecole de Santé Publique , Kinshasa , Democratic Republic of the Congo
| | | | | | - Brian W Pence
- a Department of Epidemiology , University of North Carolina at Chapel Hill , Chapel Hill , NC , USA
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252
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Kakuhikire B, Suquillo D, Atuhumuza E, Mushavi R, Perkins JM, Venkataramani AS, Weiser SD, Bangsberg DR, Tsai AC. A livelihood intervention to improve economic and psychosocial well-being in rural Uganda: Longitudinal pilot study. SAHARA J 2016; 13:162-9. [PMID: 27619011 PMCID: PMC5642427 DOI: 10.1080/17290376.2016.1230072] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
HIV and poverty are inextricably intertwined in sub-Saharan Africa. Economic and livelihood intervention strategies have been suggested to help mitigate the adverse economic effects of HIV, but few intervention studies have focused specifically on HIV-positive persons. We conducted three pilot studies to assess a livelihood intervention consisting of an initial orientation and loan package of chickens and associated implements to create poultry microenterprises. We enrolled 15 HIV-positive and 22 HIV-negative participants and followed them for up to 18 months. Over the course of follow-up, participants achieved high chicken survival and loan repayment rates. Median monthly income increased, and severe food insecurity declined, although these changes were not statistically significant (P-values ranged from 0.11 to 0.68). In-depth interviews with a purposive sample of three HIV-positive participants identified a constellation of economic and psychosocial benefits, including improved social integration and reduced stigma.
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Affiliation(s)
- Bernard Kakuhikire
- MBA, is Senior Lecturer and Director of the Institute of Management Sciences, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Diego Suquillo
- MIB, is a resident tutor at Quincy House, Harvard College, Cambridge, MA, USA
| | - Elly Atuhumuza
- MSc, is a study coordinator at the Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Jessica M. Perkins
- PhD, MPH, is a postdoctoral research fellow in the Chester M. Pierce, MD Division of Global Psychiatry, Massachusetts General Hospital, Boston, Boston, MA, USA
| | | | - Sheri D. Weiser
- MD, MPH, is Associate Professor of Medicine, University of California at San Francisco, San Francisco, CA, USA
| | - David R. Bangsberg
- MD, MPH, is Founding Dean, Oregon Health Sciences University-Portland State University School of Public Health, Portland, OR, USA
| | - Alexander C. Tsai
- MD, is Assistant Professor of Psychiatry at Harvard Medical School, Boston, MA, USA
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253
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Amanyire G, Semitala FC, Namusobya J, Katuramu R, Kampiire L, Wallenta J, Charlebois E, Camlin C, Kahn J, Chang W, Glidden D, Kamya M, Havlir D, Geng E. Effects of a multicomponent intervention to streamline initiation of antiretroviral therapy in Africa: a stepped-wedge cluster-randomised trial. Lancet HIV 2016; 3:e539-e548. [PMID: 27658873 PMCID: PMC5408866 DOI: 10.1016/s2352-3018(16)30090-x] [Citation(s) in RCA: 114] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 06/29/2016] [Accepted: 06/30/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND In Africa, up to 30% of HIV-infected patients who are clinically eligible for antiretroviral therapy (ART) do not start timely treatment. We assessed the effects of an intervention targeting prevalent health systems barriers to ART initiation on timing and completeness of treatment initiation. METHODS In this stepped-wedge, non-blinded, cluster-randomised controlled trial, 20 clinics in southwestern Uganda were randomly assigned in groups of five clinics every 6 months to the intervention by a computerised random number generator. This procedure continued until all clinics had crossed over from control (standard of care) to the intervention, which consisted of opinion-leader-led training and coaching of front-line health workers, a point-of-care CD4 cell count testing platform, a revised counselling approach without mandatory multiple pre-initiation sessions, and feedback to the facilities on their ART initiation rates and how they compared with other facilities. Treatment-naive, HIV-infected adults (aged ≥18 years) who were clinically eligible for ART during the study period were included in the study population. The primary outcome was ART initiation 14 days after first clinical eligibility for ART. This study is registered with ClinicalTrials.gov, number NCT01810289. FINDINGS Between April 11, 2013, and Feb 2, 2015, 12 024 eligible patients visited one of the 20 participating clinics. Median CD4 count was 310 cells per μL (IQR 179-424). 3753 of 4747 patients (weighted proportion 80%) in the intervention group had started ART by 2 weeks after eligibility compared with 2585 of 7066 patients (38%) in the control group (risk difference 41·9%, 95% CI 40·1-43·8). Vital status was ascertained in a random sample of 208 patients in the intervention group and 199 patients in the control group. Four deaths (2%) occurred in the intervention group and five (3%) occurred in the control group. INTERPRETATION A multicomponent intervention targeting health-care worker behaviour increased the probability of ART initiation 14 days after eligibility. This intervention consists of widely accessible components and has been tested in a real-world setting, and is therefore well positioned for use at scale. FUNDING National Institute of Allergy and Infectious Diseases (NIAID) and the President's Emergency Fund for AIDS Relief (PEPFAR).
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Affiliation(s)
| | | | | | | | | | - Jeanna Wallenta
- University of California San Francisco, San Francisco, CA, USA
| | | | - Carol Camlin
- University of California San Francisco, San Francisco, CA, USA
| | - James Kahn
- University of California San Francisco, San Francisco, CA, USA
| | - Wei Chang
- University of California San Francisco, San Francisco, CA, USA
| | - David Glidden
- University of California San Francisco, San Francisco, CA, USA
| | | | - Diane Havlir
- University of California San Francisco, San Francisco, CA, USA
| | - Elvin Geng
- University of California San Francisco, San Francisco, CA, USA.
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254
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Katirayi L, Chouraya C, Kudiabor K, Mahdi MA, Kieffer MP, Moland KM, Tylleskar T. Lessons learned from the PMTCT program in Swaziland: challenges with accepting lifelong ART for pregnant and lactating women - a qualitative study. BMC Public Health 2016; 16:1119. [PMID: 27776495 PMCID: PMC5078916 DOI: 10.1186/s12889-016-3767-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 10/13/2016] [Indexed: 11/25/2022] Open
Abstract
Background Swaziland has one of the highest HIV prevalence rates in sub-Saharan Africa, 26 % of the adult population is infected with HIV. The prevalence is highest among pregnant women, at 41.1 %. According to Swaziland’s prevention of mother-to-child transmission (PMTCT) guidelines, approximately 50 % of pregnant women are eligible for antiretroviral therapy (ART) by CD4 criteria (<350 cells/ml). Studies have shown that most mother-to-child transmission and postnatal deaths occur among women who are eligible for ART. Therefore, ensuring that ART eligible women are initiated on ART is critical for PMTCT and for mother and baby survival. This study provides insight into the challenges of lifelong ART initiation among pregnant women under Option A in Swaziland. We believe that these challenges and lessons learned from initiating women on lifelong ART under Option A are relevant and important to consider during implementation of Option B+. Methods HIV-positive, treatment-eligible, postpartum women and nurses were recruited within maternal and child health (MCH) units using convenience and purposive sampling. Participants came from both urban and rural areas. Focus group discussions (FGDs) and structured interviews using a short answer questionnaire were conducted to gain an understanding of the challenges experienced when initiating lifelong ART. Seven FGDs (of 5–11 participants) were conducted, four FGDs with nurses, two FGDs with women who initiated ART, and one FGD with women who did not initiate ART. A total of 83 interviews were conducted; 50 with women who initiated ART and 33 with women who did not initiate. Data collection with the women was conducted in the local language of SiSwati and data collection with the nurses was done in English. FGDs were audio-recorded and simultaneously transcribed and translated into English. Analysis was conducted using thematic analysis. Transcripts were coded by two researchers in the qualitative software program MAXqda v.10. Thematic findings were illustrated using verbatim quotes which were selected on the basis of being representative of a specific theme. The short-answer interview questionnaire included specific questions about the different steps in the woman’s experience initiating ART; therefore the responses for each question were analyzed separately. Results Findings from the study highlight women feeling overwhelmed by the lifetime commitment of ART, feeling “healthy” when asked to initiate ART, preference for short-course prophylaxis and fear of side effects (body changes). Also, the preference for nurses to determine on an individual basis the number of counseling appointments a woman needs before initiating ART, more information about HIV and ART needed at the community level, and the need to educate men about HIV and ART. Conclusion Women face a myriad of challenges initiating lifelong ART. Understanding women’s concerns will aid in developing effective counseling messages, designing appropriate counseling structures, understanding where additional support is needed in the process of initiating ART, and knowing who to target for community level messages.
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Affiliation(s)
- Leila Katirayi
- Elizabeth Glaser Pediatric AIDS Foundation, 1140 Connecticut Ave NW, Suite 200, Washington DC, 20036, USA. .,Center for International Health, University of Bergen, Bergen, Norway.
| | | | | | - Mohammed Ali Mahdi
- Elizabeth Glaser Pediatric AIDS Foundation, 1140 Connecticut Ave NW, Suite 200, Washington DC, 20036, USA
| | - Mary Pat Kieffer
- Elizabeth Glaser Pediatric AIDS Foundation, 1140 Connecticut Ave NW, Suite 200, Washington DC, 20036, USA
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255
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Pham MD, Agius PA, Romero L, McGlynn P, Anderson D, Crowe SM, Luchters S. Performance of point-of-care CD4 testing technologies in resource-constrained settings: a systematic review and meta-analysis. BMC Infect Dis 2016; 16:592. [PMID: 27769181 PMCID: PMC5073828 DOI: 10.1186/s12879-016-1931-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 10/13/2016] [Indexed: 01/02/2023] Open
Abstract
Background Point-of-care (POC) CD4 testing increases patient accessibility to assessment of antiretroviral therapy eligibility. This review evaluates field performance in low and middle-income countries (LMICs) of currently available POC CD4 technologies. Methods Eight electronic databases were searched for field studies published between January 2005 and January 2015 of six POC CD4 platforms: PointCare NOW™, Alere Pima™ CD4, Daktari™ CD4 Counter, CyFlow® CD4 miniPOC, BD FACSPresto™, and MyT4™ CD4. Due to limited data availability, meta-analysis was conducted only for diagnostic performance of Pima at a threshold of 350 cells/μl, applying a bivariate multi-level random-effects modelling approach. A covariate extended model was also explored to test for difference in diagnostic performance between capillary and venous blood. Results Twenty seven studies were included. Published field study results were found for three of the six POC CD4 tests, 24 of which used Pima. For Pima, test failure rates varied from 2 to 23 % across study settings. Pooled sensitivity and specificity were 0.92 (95 % CI = 0.88–0.95) and 0.87 (95 % CI = 0.85–0.88) respectively. Diagnostic performance by blood sample type (venous vs. capillary) revealed non-significant differences in sensitivity (0.94 vs 0.89) and specificity (0.86 vs 0.87), respectively in the extended model (Wald χ2(2) = 4.77, p = 0.09). Conclusions POC CD4 testing can provides reliable results for making treatment decision under field conditions in low-resource settings. The Pima test shows a good diagnostic performance at CD4 cut-off of 350 cells/μl. More data are required to evaluate performance of POC CD4 testing using venous versus capillary blood in LMICs which might otherwise influence clinical practice. Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-1931-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Minh D Pham
- Burnet Institute, 85 Commercial Road, Melbourne, VIC, 3004, Australia. .,Department of Epidemiology and Preventive Medicine, Faculty of Medicine Nursing and Health Science, Monash University, Melbourne, Australia.
| | - Paul A Agius
- Burnet Institute, 85 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Lorena Romero
- The Alfred Hospital, The Ian Potter Library, Melbourne, VIC, Australia
| | - Peter McGlynn
- Department of Epidemiology and Preventive Medicine, Faculty of Medicine Nursing and Health Science, Monash University, Melbourne, Australia
| | - David Anderson
- Burnet Institute, 85 Commercial Road, Melbourne, VIC, 3004, Australia.,Department of Immunology, Faculty of Medicine Nursing and Health Science, Monash University, Melbourne, Australia
| | - Suzanne M Crowe
- Burnet Institute, 85 Commercial Road, Melbourne, VIC, 3004, Australia.,Department of Infectious Diseases, The Alfred Hospital and Monash University, Melbourne, Australia
| | - Stanley Luchters
- Burnet Institute, 85 Commercial Road, Melbourne, VIC, 3004, Australia.,Department of Epidemiology and Preventive Medicine, Faculty of Medicine Nursing and Health Science, Monash University, Melbourne, Australia.,Department of Obstetrics and Gynecology, International Centre for Reproductive Health, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
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256
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Hoffman S, Exner TM, Lince-Deroche N, Leu CS, Phillip JL, Kelvin EA, Gandhi AD, Levin B, Singh D, Mantell JE, Blanchard K, Ramjee G. Immediate Blood Draw for CD4+ Cell Count Is Associated with Linkage to Care in Durban, South Africa: Findings from Pathways to Engagement in HIV Care. PLoS One 2016; 11:e0162085. [PMID: 27706150 PMCID: PMC5051894 DOI: 10.1371/journal.pone.0162085] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 08/17/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Timely linkage to care by newly-diagnosed HIV+ individuals remains a significant challenge to achieving UNAIDS 90-90-90 goals. Current World Health Organization (WHO) guidelines recommend initiating anti-retroviral treatment (ART) regardless of CD4+ count, with priority given to those with CD4+ <350 cells/μl. We evaluated the impact of not having a day-of-diagnosis CD4+ count blood draw, as recommended by South African guidelines, on time to linkage, using data from a prospective cohort study. METHODS Individuals (N = 2773) were interviewed prior to HIV counseling and testing at three public sector primary care clinics in the greater Durban area; 785 were newly-diagnosed and eligible for the cohort study; 459 (58.5%) joined and were followed for eight months with three structured assessments. Linkage to care, defined as returning to clinic for CD4+ count results, and day-of-diagnosis blood draw were self-reported. RESULTS Overall, 72.5% did not have a day-of-diagnosis CD4+ count blood draw, and 19.2% of these never returned. Compared with a day-of-diagnosis blood draw, the adjusted hazard ratio of linkage (AHRlinkage) associated with not having day-of-diagnosis blood draw was 0.66 (95%CI: 0.51, 0.85). By 4 months, 54.8% of those without day-of-diagnosis blood draw vs. 75.2% with one were linked to care (chi-squared p = 0.004). Of those who deferred blood draw, 48.3% cited clinic-related and 51.7% cited personal reasons. AHRlinkage was 0.60 (95%CI: 0.44, 0.82) for clinic-related and 0.53 (95%CI: 0.38, 0.75) for personal reasons relative to having day-of-diagnosis blood draw. CONCLUSIONS Newly-diagnosed HIV+ individuals who did not undergo CD4+ count blood draw on the day they were diagnosed-regardless of the reason for deferring-had delayed linkage to care relative to those with same-day blood draw. To enhance prompt linkage to care even when test and treat protocols are implemented, all diagnostic testing required before ART initiation should be performed on the same day as HIV testing/diagnosis. This may require modifying clinic procedures to enable overnight blood storage if same-day draws cannot be performed, and providing additional counseling to encourage newly-diagnosed individuals to complete day-of-diagnosis testing. Tracking HIV+ individuals via clinic registries should commence immediately from diagnosis to reduce these early losses to care.
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Affiliation(s)
- Susie Hoffman
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, 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
| | - Theresa M. Exner
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia University, New York, New York, United States of America
| | | | - Cheng-Shiun Leu
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia University, New York, New York, United States of America
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Jessica L. Phillip
- South African Medical Research Council, HIV Prevention Research Unit, Durban, South Africa
| | - Elizabeth A. Kelvin
- Epidemiology & Biostatistics Program, CUNY Graduate School of Public Health and Health Policy, City University of New York, New York, New York, United States of America
| | - Anisha D. Gandhi
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia University, New York, New York, United States of America
| | - Bruce Levin
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia University, New York, New York, United States of America
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Dinesh Singh
- South African Medical Research Council, HIV Prevention Research Unit, Durban, South Africa
| | - Joanne E. Mantell
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia University, New York, New York, United States of America
| | - Kelly Blanchard
- Ibis Reproductive Health, Cambridge, Massachusetts, United States of America
| | - Gita Ramjee
- South African Medical Research Council, HIV Prevention Research Unit, Durban, South Africa
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257
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Changing HIV treatment eligibility under health system constraints in sub-Saharan Africa: investment needs, population health gains, and cost-effectiveness. AIDS 2016; 30:2341-50. [PMID: 27367487 PMCID: PMC5017264 DOI: 10.1097/qad.0000000000001190] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [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 Objective: We estimated the investment needs, population health gains, and cost-effectiveness of different policy options for scaling-up prevention and treatment of HIV in the 10 countries that currently comprise 80% of all people living with HIV in sub-Saharan Africa (Ethiopia, Kenya, Malawi, Mozambique, Nigeria, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe). Design: We adapted the established STDSIM model to capture the health system dynamics: demand-side and supply-side constraints in the delivery of antiretroviral treatment (ART). Methods: We compared different scenarios of supply-side (i.e. health system capacity) and demand-side (i.e. health seeking behavior) constraints, and determined the impact of changing guidelines to ART eligibility at any CD4+ cell count within these constraints. Results: Continuing current scale-up would require US$178 billion by 2050. Changing guidelines to ART at any CD4+ cell count is cost-effective under all constraints tested in the model, especially in demand-side constrained health systems because earlier initiation prevents loss-to-follow-up of patients not yet eligible. Changing guidelines under current demand-side constraints would avert 1.8 million infections at US$208 per life-year saved. Conclusion: Treatment eligibility at any CD4+ cell count would be cost-effective, even under health system constraints. Excessive loss-to-follow-up and mortality in patients not eligible for treatment can be avoided by changing guidelines in demand-side constrained systems. The financial obligation for sustaining the AIDS response in sub-Saharan Africa over the next 35 years is substantial and requires strong, long-term commitment of policy-makers and donors to continue to allocate substantial parts of their budgets.
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258
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Conroy AA, Tsai AC, Clark GM, Boum Y, Hatcher AM, Kawuma A, Hunt PW, Martin JN, Bangsberg DR, Weiser SD. Relationship Power and Sexual Violence Among HIV-Positive Women in Rural Uganda. AIDS Behav 2016; 20:2045-53. [PMID: 27052844 DOI: 10.1007/s10461-016-1385-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Gender-based power imbalances place women at significant risk for sexual violence, however, little research has examined this association among women living with HIV/AIDS. We performed a cross-sectional analysis of relationship power and sexual violence among HIV-positive women on anti-retroviral therapy in rural Uganda. Relationship power was measured using the Sexual Relationship Power Scale (SRPS), a validated measure consisting of two subscales: relationship control (RC) and decision-making dominance. We used multivariable logistic regression to test for associations between the SRPS and two dependent variables: recent forced sex and transactional sex. Higher relationship power (full SRPS) was associated with reduced odds of forced sex (AOR = 0.24; 95 % CI 0.07-0.80; p = 0.020). The association between higher relationship power and transactional sex was strong and in the expected direction, but not statistically significant (AOR = 0.47; 95 % CI 0.18-1.22; p = 0.119). Higher RC was associated with reduced odds of both forced sex (AOR = 0.18; 95 % CI 0.06-0.59; p < 0.01) and transactional sex (AOR = 0.38; 95 % CI 0.15-0.99; p = 0.048). Violence prevention interventions with HIV-positive women should consider approaches that increase women's power in their relationships.
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Affiliation(s)
- Amy A Conroy
- Center for AIDS Prevention Studies, Department of Medicine, University of California - San Francisco, 550 16th Street 3rd Floor, San Francisco, CA, USA.
| | - Alexander C Tsai
- Center for Global Health, Massachusetts General Hospital, Boston, USA
| | - Gina M Clark
- Department of Psychiatry, Kaiser Permanente, San Franscisco, USA
| | - Yap Boum
- Faculty of Medicine, Mbarara University of Science & Technology, Mbarara, Uganda
| | - Abigail M Hatcher
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Division of HIV/AIDS, Department of Medicine, University of California - San Francisco, San Francisco, USA
| | - Annet Kawuma
- Faculty of Medicine, Mbarara University of Science & Technology, Mbarara, Uganda
| | - Peter W Hunt
- Division of HIV/AIDS, Department of Medicine, University of California - San Francisco, San Francisco, USA
| | - Jeffrey N Martin
- Department of Epidemiology, University of California - San Francisco, San Francisco, USA
| | - David R Bangsberg
- Center for Global Health, Massachusetts General Hospital, Boston, USA
- Department of Medicine, Harvard University, Boston, USA
| | - Sheri D Weiser
- Division of HIV/AIDS, Department of Medicine, University of California - San Francisco, San Francisco, USA
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259
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Franse CB, Kayigamba FR, Bakker MI, Mugisha V, Bagiruwigize E, Mitchell KR, Asiimwe A, Schim van der Loeff MF. Linkage to HIV care before and after the introduction of provider-initiated testing and counselling in six Rwandan health facilities. AIDS Care 2016; 29:326-334. [PMID: 27539782 DOI: 10.1080/09540121.2016.1220475] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
HIV testing and counselling forms the gateway to the HIV care and treatment continuum. Therefore, the World Health Organization recommends provider-initiated testing and counselling (PITC) in countries with a generalized HIV epidemic. Few studies have investigated linkage-to-HIV-care among out-patients after PITC. Our objective was to study timely linkage-to-HIV-care in six Rwandan health facilities (HFs) before and after the introduction of PITC in the out-patient departments (OPDs). Information from patients diagnosed with HIV was abstracted from voluntary counselling and testing, OPD and laboratory registers of six Rwandan HFs during three-month periods before (March-May 2009) and after (December 2009-February 2010) the introduction of PITC in the OPDs of these facilities. Information on patients' subsequent linkage-to-pre-antiretroviral therapy (ART) care and ART was abstracted from ART clinic registers of each HF. To triangulate the findings from HF routine, a survey was held among patients to assess reasons for non-enrolment. Of 635 patients with an HIV diagnosis, 232 (36.5%) enrolled at the ART clinic within 90 days of diagnosis. Enrolment among out-patients decreased after the introduction of PITC (adjusted odds ratio, 2.0; 95% confidence interval, 1.0-4.2; p = .051). Survey findings showed that retesting for HIV among patients already diagnosed and enrolled into care was not uncommon. Patients reported non-acceptance of disease status, stigma and problems with healthcare services as main barriers for enrolment. Timely linkage-to-HIV-care was suboptimal in this Rwandan study before and after the introduction of PITC; the introduction of PITC in the OPD may have had a negative impact on linkage-to-HIV-care. Healthier patients tested through PITC might be less ready to engage in HIV care. Fear of HIV stigma and mistrust of test results appear to be at the root of these problems.
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Affiliation(s)
- Carmen B Franse
- a Royal Tropical Institute, KIT Biomedical Research , Amsterdam , The Netherlands
| | | | - Mirjam I Bakker
- a Royal Tropical Institute, KIT Biomedical Research , Amsterdam , The Netherlands
| | - Veronicah Mugisha
- c ICAP, Mailman School of Public Health, Columbia University , Kigali , Rwanda
| | | | | | - Anita Asiimwe
- f College of Medicine and Health Sciences , University of Rwanda , Kigali , Rwanda
| | - Maarten F Schim van der Loeff
- g Amsterdam Institute of Global Health and Development (AIGHD) , Amsterdam , The Netherlands.,h Center for Infection and Immunity Amsterdam (CINIMA), AMC , Amsterdam , The Netherlands.,i Public Health Service of Amsterdam (GGD) , Amsterdam , The Netherlands
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260
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Rachlis B, Bakoyannis G, Easterbrook P, Genberg B, Braithwaite RS, Cohen CR, Bukusi EA, Kambugu A, Bwana MB, Somi GR, Geng EH, Musick B, Yiannoutsos CT, Wools-Kaloustian K, Braitstein P. Facility-Level Factors Influencing Retention of Patients in HIV Care in East Africa. PLoS One 2016; 11:e0159994. [PMID: 27509182 PMCID: PMC4980048 DOI: 10.1371/journal.pone.0159994] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 07/12/2016] [Indexed: 12/25/2022] Open
Abstract
Losses to follow-up (LTFU) remain an important programmatic challenge. While numerous patient-level factors have been associated with LTFU, less is known about facility-level factors. Data from the East African International epidemiologic Databases to Evaluate AIDS (EA-IeDEA) Consortium was used to identify facility-level factors associated with LTFU in Kenya, Tanzania and Uganda. Patients were defined as LTFU if they had no visit within 12 months of the study endpoint for pre-ART patients or 6 months for patients on ART. Adjusting for patient factors, shared frailty proportional hazard models were used to identify the facility-level factors associated with LTFU for the pre- and post-ART periods. Data from 77,362 patients and 29 facilities were analyzed. Median age at enrolment was 36.0 years (Interquartile Range: 30.1, 43.1), 63.9% were women and 58.3% initiated ART. Rates (95% Confidence Interval) of LTFU were 25.1 (24.7–25.6) and 16.7 (16.3–17.2) per 100 person-years in the pre-ART and post-ART periods, respectively. Facility-level factors associated with increased LTFU included secondary-level care, HIV RNA PCR turnaround time >14 days, and no onsite availability of CD4 testing. Increased LTFU was also observed when no nutritional supplements were provided (pre-ART only), when TB patients were treated within the HIV program (pre-ART only), and when the facility was open ≤4 mornings per week (ART only). Our findings suggest that facility-based strategies such as point of care laboratory testing and separate clinic spaces for TB patients may improve retention.
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Affiliation(s)
- Beth Rachlis
- The Ontario HIV Treatment Network, Toronto, Canada.,Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Giorgos Bakoyannis
- Department of Biostatistics, Richard Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, United States of America
| | | | - Becky Genberg
- Department of Health Services, Brown University, Providence, Rhode Island, United States of America
| | - Ronald Scott Braithwaite
- Department of Population Health, School of Medicine, New York University, New York, New York, United States of America
| | - Craig R Cohen
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Elizabeth A Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Mwebesa Bosco Bwana
- Department of Internal Medicine, Mbarara University of Science & Technology, Mbarara, Uganda
| | | | - Elvin H Geng
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Beverly Musick
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Constantin T Yiannoutsos
- Department of Biostatistics, Richard Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, United States of America
| | - Kara Wools-Kaloustian
- Division of Infectious Diseases, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Paula Braitstein
- Academic Model Providing Access To Healthcare (AMPATH), Eldoret, Kenya.,Department of Medicine, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya.,Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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261
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Genberg BL, Naanyu V, Wachira J, Hogan JW, Sang E, Nyambura M, Odawa M, Duefield C, Ndege S, Braitstein P. Linkage to and engagement in HIV care in western Kenya: an observational study using population-based estimates from home-based counselling and testing. Lancet HIV 2016; 2:e20-6. [PMID: 25621303 DOI: 10.1016/s2352-3018(14)00034-4] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Few population-based studies exist on the HIV care continuum in sub-Saharan Africa. We aimed to describe engagement in care in all adults with an existing diagnosis of HIV and to assess the time to and predictors of linkage and engagement in adults newly diagnosed via home-based counselling and testing (HBCT) in a high-prevalence setting in western Kenya. METHODS Data were derived from AMPATH (Academic Model Providing Access to Healthcare), which has provided HIV care in western Kenya since 2001 and the HBCT programme, which has been operating since 2007. After a widespread HBCT programme in Bunyala subcounty from December, 2009, to February, 2011, we reviewed electronic medical records to identify uptake of care in individuals (aged 13 years or older) with previously known (self-reported) infection and new (identified at HBCT) HIV diagnoses as of June 1, 2014. We defined engagement in HIV care as an initial encounter with an HIV care provider. We used Cox regression analysis to examine the predictors of engagement in care for newly diagnosed individuals. FINDINGS Of the 3482 adults with HIV identified at HBCT, 2122 (61%) had previously been diagnosed with HIV, of whom 1778 (84%) had had at least one clinical encounter within AMPATH. 993 (73%) of the 1360 individuals with new diagnoses at HBCT were registered in the electronic medical records, although only 209 (15%) had seen a clinician over a median of 3·4 years since diagnosis. The median time to engagement in the newly diagnosed individuals was 60 days (IQR 10–411). INTERPRETATION Creative and innovative strategies are needed to support people to engage with care when they are newly diagnosed with HIV through population-based case-finding initiatives. FUNDING US President’s Emergency Plan for AIDS Relief (PEPFAR), Abbott Laboratories, the Purpleville Foundation, the Global Business Coalition, the US National Institute of Mental Health, and the Bill & Melinda Gates Foundation.
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262
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Interventions to improve the rate or timing of initiation of antiretroviral therapy for HIV in sub-Saharan Africa: meta-analyses of effectiveness. J Int AIDS Soc 2016; 19:20888. [PMID: 27507249 PMCID: PMC4978859 DOI: 10.7448/ias.19.1.20888] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 06/06/2016] [Accepted: 07/05/2016] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION As global policy evolves toward initiating lifelong antiretroviral therapy (ART) regardless of CD4 count, initiating individuals newly diagnosed with HIV on ART as efficiently as possible will become increasingly important. To inform progress, we conducted a systematic review of pre-ART interventions aiming to increase ART initiation in sub-Saharan Africa. METHODS We searched PubMed, Embase and the ISI Web of Knowledge from 1 January 2008 to 1 March 2015, extended in PubMed to 25 May 2016, for English language publications pertaining to any country in sub-Saharan Africa and reporting on general adult populations. We included studies describing interventions aimed at increasing linkage to HIV care, retention in pre-ART or uptake of ART, which reported ART initiation as an outcome. We synthesized the evidence on causal intervention effects in meta-analysis of studies belonging to distinct intervention categories. RESULTS AND DISCUSSION We identified 22 studies, which evaluated 25 interventions and included data on 45,393 individual patients. Twelve of twenty-two studies were observational. Rapid/point-of-care (POC) CD4 count technology (seven interventions) (relative risk, RR: 1.26; 95% confidence interval, CI: 1.02-1.55), interventions within home-based testing (two interventions) (RR: 2.00; 95% CI: 1.36-2.92), improved clinic operations (three interventions) (RR: 1.36; 95% CI: 1.25-1.48) and a package of patient-directed services (three interventions) (RR: 1.54; 95% CI: 1.20-1.97) were all associated with increased ART initiation as was HIV/TB service integration (three interventions) (RR: 2.05; 95% CI: 0.59-7.09) but with high imprecision. Provider-initiated testing (three interventions) was associated with reduced ART initiation (RR: 0.91; 95% CI: 0.86-0.97). Counselling and support interventions (two interventions) (RR 1.08; 95% CI: 0.94-1.26) had no impact on ART initiation. Overall, the evidence was graded as low or moderate quality using the GRADE criteria. CONCLUSIONS The literature on interventions to increase uptake of ART is limited and of mixed quality. POC CD4 count and improving clinic operations show promise. More implementation research and evaluation is needed to identify how best to offer treatment initiation in a manner that is both efficient for service providers and effective for patients without jeopardizing treatment outcomes.
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263
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Pham MD, Agius PA, Romero L, McGlynn P, Anderson D, Crowe SM, Luchters S. Acceptability and feasibility of point-of-care CD4 testing on HIV continuum of care in low and middle income countries: a systematic review. BMC Health Serv Res 2016; 16:343. [PMID: 27484023 PMCID: PMC4971709 DOI: 10.1186/s12913-016-1588-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Accepted: 07/27/2016] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND CD4 testing is, and will remain an important part of HIV treatment and care in low and middle income countries (LMICs). We report the findings of a systematic review assessing acceptability and feasibility of POC CD4 testing in field settings. METHODS Electronic databases were searched for studies published in English between 2005 and 2015 that describe POC CD4 platforms. Studies conducted in LMICs and under field conditions outside a laboratory environment were eligible. Qualitative and descriptive data analysis was used to present the findings. RESULTS Twelve studies were included, 11 of which were conducted in sub-Saharan countries and used one POC CD4 test (The Alere Pima CD4). Patients reported positively regarding the implementation of POC CD4 testing at primary health care and community level with ≥90 % of patients accepting the test across various study settings. Health service providers expressed preference toward POC CD4 testing as it is easy-to-use, efficient and satisfied patients' needs to a greater extent as compared to conventional methods. However, operational challenges including preference toward venous blood rather than finger-prick sampling, frequent device failures and operator errors, quality of training for test operators and supervisors, and increased staff workload were also identified. CONCLUSIONS POC CD4 testing seems acceptable and feasible in LIMCs under field conditions. Further studies using different POC CD4 tests available on the market are required to provide critical data to support countries in selection and implementation of appropriate POC CD4 technologies.
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Affiliation(s)
- Minh D Pham
- Burnet Institute, Melbourne, VIC, Australia.
- Department of Epidemiology and Preventive Medicine, Faculty of Medicine Nursing and Health Science, Monash University, Melbourne, Australia.
| | | | - Lorena Romero
- The Alfred Hospital, The Ian Potter Library, Melbourne, VIC, Australia
| | - Peter McGlynn
- Department of Epidemiology and Preventive Medicine, Faculty of Medicine Nursing and Health Science, Monash University, Melbourne, Australia
| | - David Anderson
- Burnet Institute, Melbourne, VIC, Australia
- Department of Immunology, Faculty of Medicine Nursing and Health Science, Monash University, Melbourne, Australia
| | - Suzanne M Crowe
- Burnet Institute, Melbourne, VIC, Australia
- Department of Infectious Diseases, The Alfred hospital Melbourne, Melbourne, Australia
- Monash School of Medicine, Faculty of Medicine Nursing and Health Science, Monash University, Melbourne, Australia
| | - Stanley Luchters
- Burnet Institute, Melbourne, VIC, Australia
- Department of Epidemiology and Preventive Medicine, Faculty of Medicine Nursing and Health Science, Monash University, Melbourne, Australia
- International Centre for Reproductive Health, Department of Obstetrics and Gynecology, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
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264
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Rosen S, Fox MP, Larson BA, Sow PS, Ehrenkranz PD, Venter F, Manabe YC, Kaplan J, Models for Accelerating Treatment Initiation (MATI) Technical Consultation. Accelerating the Uptake and Timing of Antiretroviral Therapy Initiation in Sub-Saharan Africa: An Operations Research Agenda. PLoS Med 2016; 13:e1002106. [PMID: 27505444 PMCID: PMC4978457 DOI: 10.1371/journal.pmed.1002106] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Sydney Rosen and colleagues describe an operations research agenda to accelerating uptake of HIV treatment initiation.
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Affiliation(s)
- 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
- * E-mail:
| | - Matthew P. Fox
- 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
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Bruce A. Larson
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Papa Salif Sow
- Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
- Department of infectious Diseases, University of Dakar, Dakar, Senegal
| | - Peter D. Ehrenkranz
- Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - 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
| | - Yukari C. Manabe
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Jonathan Kaplan
- Independent investigator, Atlanta, Georgia, United States of America
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265
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Hoffmann CJ, Mabuto T, McCarthy K, Maulsby C, Holtgrave DR. A Framework to Inform Strategies to Improve the HIV Care Continuum in Low- and Middle-Income Countries. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2016; 28:351-364. [PMID: 27427929 DOI: 10.1521/aeap.2016.28.4.351] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Reasons for attrition along the HIV care continuum are well described. However, improving patient engagement in care has been a challenge. New approaches to understanding and responding to reasons for attrition are required. Here, with a focus on low- and middle-income countries, we propose a framework that brings together an explanatory model with social ecological levels. Individual action may be based on a conscious or unconscious balance between perceived value and perceived costs. When the balance between value and cost favors value, engagement in care can be expected. Value and cost may be mediated by levels of the individual, interpersonal interactions, the clinic experience, community, society, and policy. We encourage the use of a framework for developing strategies to improve the care continuum and believe that this framework provides a rigorous approach.
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Affiliation(s)
- Christopher J Hoffmann
- Johns Hopkins University School of Medicine and Bloomberg School of Public Health, Baltimore, Maryland
- Aurum Institute, Johannesburg, South Africa
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266
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Assessment of linkages from HIV testing to enrolment and retention in HIV care in Central Mozambique. J Int AIDS Soc 2016; 19:20846. [PMID: 27443273 PMCID: PMC4956731 DOI: 10.7448/ias.19.5.20846] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 04/22/2016] [Accepted: 05/02/2016] [Indexed: 12/30/2022] Open
Abstract
Introduction Effectiveness of the rapid expansion of antiretroviral therapy (ART) throughout sub-Saharan Africa is highly dependent on adequate enrolment and retention in HIV care. However, the measurement of both has been challenging in these settings. This study aimed to assess enrolment and retention in HIV care (pre-ART and ART) among HIV-positive adults in Central Mozambique, including identification of barriers and facilitators. Methods We assessed linkages to and retention in HIV care using a mixed quantitative and qualitative approach in six districts of Manica and Sofala provinces. We analyzed routine district and health facility monthly reports and HIV care registries from April 2012 to March 2013 and used single imputation and trimmed means to adjust for missing values. In eight health facilities in the same districts and period, we assessed retention in HIV care among 795 randomly selected adult patient charts (15 years and older). We also conducted 25 focus group discussions and 53 in-depth interviews with HIV-positive adults, healthcare providers and community members to identify facilitators and barriers to enrolment and retention in HIV care. Results Overall, 46% of the monthly HIV testing reports expected at the district level were missing, compared to 6.4% of the pre-ART registry reports. After adjustment for missing values, we estimated that the aggregate numbers of adults registered in pre-ART was 75% of the number of persons tested HIV-positive in the six districts. In the eight health facilities, 40% of the patient charts for adults enrolled in pre-ART and 44% in ART were missing. Of those on ART for whom charts were found, retention in treatment within 90 and 60 days prior to the study team visit was 34 and 25%, respectively. Combining these multiple data sources, the overall estimated retention was 18% in our sample. Individual-level factors were perceived to be key influences to enrolment in HIV care, while health facility and structural-level factors were perceived to be key influences of retention. Conclusions Efforts to increase linkages to and retention in HIV care should address individual, health facility, and structural-level factors in Central Mozambique. However, their outcomes cannot be reliably assessed without improving the quality of routine health information systems.
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267
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Lessons learned and study results from HIVCore, an HIV implementation science initiative. J Int AIDS Soc 2016. [DOI: 10.7448/ias.19.5.21261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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268
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Kulkarni S, Hoffman S, Gadisa T, Melaku Z, Fantehun M, Yigzaw M, El-Sadr W, Remien R, Tymejczyk O, Nash D, Elul B. Identifying Perceived Barriers along the HIV Care Continuum: Findings from Providers, Peer Educators, and Observations of Provider-Patient Interactions in Ethiopia. J Int Assoc Provid AIDS Care 2016; 15:291-300. [PMID: 26173944 PMCID: PMC4713361 DOI: 10.1177/2325957415593635] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Increasing the proportion of HIV-positive individuals who link promptly to and are retained in care remains challenging in sub-Saharan Africa, but little evidence is available from the provider perspective. In 4 Ethiopian health facilities, we (1) interviewed providers and peer educators about their perceptions of service delivery- and patient-level barriers and (2) observed provider-patient interactions to characterize content and interpersonal aspects of counseling. In interviews, providers and peer educators demonstrated empathy and identified nonacceptance of HIV status, anticipated stigma from unintended disclosure, and fear of antiretroviral therapy as patient barriers, and brusque counseling and insufficient counseling at provider-initiated testing sites as service delivery-related. However, observations from the same clinics showed that providers often failed to elicit patients' barriers to retention, making it unlikely these would be addressed during counseling. Training is needed to improve interpersonal aspects of counseling and ensure providers elicit and address barriers to HIV care experienced by patients.
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Affiliation(s)
- Sarah Kulkarni
- Department of Epidemiology and Biostatistics, City University of New York School of Public Health, New York, NY, USA
| | - Susie Hoffman
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, New York, NY, USA Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Tsigereda Gadisa
- International Center for AIDS Care and Treatment Programs, Columbia University, Mailman School of Public Health, New York, NY, USA
| | - Zenebe Melaku
- International Center for AIDS Care and Treatment Programs, Columbia University, Mailman School of Public Health, New York, NY, USA
| | - Mesganaw Fantehun
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Muluneh Yigzaw
- International Center for AIDS Care and Treatment Programs, Columbia University, Mailman School of Public Health, New York, NY, USA
| | - Wafaa El-Sadr
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA International Center for AIDS Care and Treatment Programs, Columbia University, Mailman School of Public Health, New York, NY, USA
| | - Robert Remien
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, New York, NY, USA
| | - Olga Tymejczyk
- Department of Epidemiology and Biostatistics, City University of New York School of Public Health, New York, NY, USA
| | - Denis Nash
- Department of Epidemiology and Biostatistics, City University of New York School of Public Health, New York, NY, USA HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, New York, NY, USA Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Batya Elul
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
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Gaida R, Truter I, Grobler C. Incidence of neuropsychiatric side effects of efavirenz in HIV-positive treatment-naïve patients in public-sector clinics in the Eastern Cape. South Afr J HIV Med 2016; 17:452. [PMID: 29568611 PMCID: PMC5843017 DOI: 10.4102/sajhivmed.v17i1.452] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 05/16/2016] [Indexed: 01/02/2023] Open
Abstract
Background It is acknowledged that almost half of patients initiated on efavirenz will experience at least one neuropsychiatric side effect. Objectives The aim was to determine the incidence and severity of neuropsychiatric side effects associated with efavirenz use in five public-sector primary healthcare clinics in the Eastern Cape. Method The study was a prospective drug utilisation study. A total of 126 medical records were reviewed to obtain the required information. After baseline assessment, follow-up reviews were conducted at 4 weeks, 12 weeks and 24 weeks from 2014 to 2015. Results The participant group was 74.60% female (n = 94), and the average age was 37.57±10.60 years. There were no neuropsychiatric side effects recorded for any patient. After the full follow-up period, there were a total of 49 non-adherent patients and one patient had demised. A non-adherent patient was defined as a patient who did not return to the clinic for follow-up assessment and medication refills 30 days or more after the appointed date. Some patients (n = 11) had sent a third party to the clinic to collect their antiretroviral therapy (ART). The clinic pharmacy would at times dispense a two-month supply of medication resulting in the patient presenting only every two months. Conclusion Further pharmacovigilance studies need to be conducted to determine the true incidence of these side effects. Healthcare staff must be encouraged to keep complete records to ensure meaningful patient assessments. Patients being initiated on ART need to personally attend the clinic monthly for at least the first 6 months of treatment. Clinic staff should receive regular training concerning ART, including changes made to guidelines as well as reminders of side effects experienced.
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Affiliation(s)
- Razia Gaida
- Department of Pharmacy, Nelson Mandela Metropolitan University, South Africa
| | - Ilse Truter
- Department of Pharmacy, Nelson Mandela Metropolitan University, South Africa.,Drug Utilisation Research Unit, Nelson Mandela Metropolitan University, South Africa
| | - Christoffel Grobler
- Department of Pharmacy, Nelson Mandela Metropolitan University, South Africa
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270
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Skhosana M, Reddy S, Reddy T, Ntoyanto S, Spooner E, Ramjee G, Ngomane N, Coutsoudis A, Kiepiela P. PIMA™ point-of-care testing for CD4 counts in predicting antiretroviral initiation in HIV-infected individuals in KwaZulu-Natal, Durban, South Africa. South Afr J HIV Med 2016; 17:444. [PMID: 29568605 PMCID: PMC5843260 DOI: 10.4102/sajhivmed.v17i1.444] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Accepted: 03/22/2016] [Indexed: 12/22/2022] Open
Abstract
Introduction Limited information is available on the usefulness of the PIMA™ analyser in predicting antiretroviral treatment eligibility and outcome in a primary healthcare clinic setting in disadvantaged communities in KwaZulu-Natal, South Africa. Materials and methods The study was conducted under the eThekwini Health Unit, Durban, KwaZulu-Natal. Comparison of the enumeration of CD4+ T-cells in 268 patients using the PIMA™ analyser and the predicate National Health Laboratory Services (NHLS) was undertaken during January to July 2013. Bland-Altman analysis to calculate bias and limits of agreement, precision and levels of clinical misclassification at various CD4+ T-cell count thresholds was performed. Results There was high precision of the PIMA™ control bead cartridges with low and normal CD4+ T-cell counts using three different PIMA™ analysers (%CV < 5). Under World Health Organization (WHO) guidelines (≤ 500 cells/mm3), the sensitivity of the PIMA™ analyser was 94%, specificity 78% and positive predictive value (PPV) 95%. There were 24 (9%) misclassifications, of which 13 were false-negative in whom the mean bias was 149 CD4+ T-cells/mm3. Most (87%) patients returned for their CD4 test result but only 67% (110/164) of those eligible (≤ 350 cells/mm3) were initiated on antiretroviral therapy (ART) with a time to treatment of 49 days (interquartile range [IQR], 42–64 days). Conclusion There was adequate agreement between PIMA™ analyser and predicate NHLS CD4+ T-cell count enumeration (≤ 500 cells/mm3) in adult HIV-positive individuals. The high PPV, sensitivity and acceptable specificity of the PIMA™ analyser technology lend it as a reliable tool in predicting eligibility and rapid linkage to care in ART programmes.
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Affiliation(s)
- Mandisa Skhosana
- Department of Paediatrics and Child Health, University of KwaZulu-Natal, South Africa.,Medical Research Council of South Africa, HIV Prevention Research Unit, South Africa
| | - Shabashini Reddy
- Medical Research Council of South Africa, HIV Prevention Research Unit, South Africa
| | - Tarylee Reddy
- Medical Research Council of South Africa, Biostatistics Unit, South Africa
| | - Siphelele Ntoyanto
- Medical Research Council of South Africa, HIV Prevention Research Unit, South Africa
| | - Elizabeth Spooner
- Department of Paediatrics and Child Health, University of KwaZulu-Natal, South Africa.,Medical Research Council of South Africa, HIV Prevention Research Unit, South Africa
| | - Gita Ramjee
- Medical Research Council of South Africa, HIV Prevention Research Unit, South Africa
| | | | - Anna Coutsoudis
- Department of Paediatrics and Child Health, University of KwaZulu-Natal, South Africa
| | - Photini Kiepiela
- Medical Research Council of South Africa, HIV Prevention Research Unit, South Africa
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271
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Tso LS, Best J, Beanland R, Doherty M, Lackey M, Ma Q, Hall BJ, Yang B, Tucker JD. Facilitators and barriers in HIV linkage to care interventions: a qualitative evidence review. AIDS 2016; 30:1639-53. [PMID: 27058350 PMCID: PMC4889545 DOI: 10.1097/qad.0000000000001101] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To synthesize qualitative evidence on linkage to care interventions for people living with HIV. DESIGN Systematic literature review. METHODS We searched 19 databases for studies reporting qualitative evidence on linkage interventions. Data extraction and thematic analysis were used to synthesize findings. Quality was assessed using the Critical Appraisal Skills Programme tool and certainty of evidence was evaluated using the Confidence in the Evidence from Reviews of Qualitative Research approach. RESULTS Twenty-five studies from 11 countries focused on adults (24 studies), adolescents (eight studies), and pregnant women (four studies). Facilitators included community-level factors (i.e., task shifting, mobile outreach, integrated HIV, and primary services, supportive cessation programs for substance users, active referrals, and dedicated case management teams), and individual-level factors (encouragement of peers/family and positive interactions with healthcare providers in transitioning into care). One key barrier for people living with HIV was perceived inability of providers to ensure confidentiality as part of linkage to care interventions. Providers reported difficulties navigating procedures across disparate facilities and having limited resources for linkage to care interventions. CONCLUSION Our findings extend the literature by highlighting the importance of task-shifting, mobile outreach, integrated HIV, and primary care services. Both community and individual-level factors may increase the feasibility and acceptability of HIV linkage to care interventions. These findings may inform policies to increase the reach of HIV services available in communities.
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Affiliation(s)
- Lai Sze Tso
- aUniversity of North Carolina Project-China, Guangzhou, ChinabInstitute for Global Health and Infectious Diseases at UNC-Chapel Hill, Chapel Hill, North Carolina, USAcGuangdong Provincial Center for STD Control, Guangzhou, ChinadSchool of Medicine, University of California, San Francisco, California, USAeHIV/AIDS Department World Health Organization, Geneva SwitzerlandfUniversity of Utah, Salt Lake City, Utah, USAgGuangzhou Eighth People's Hospital, Guangzhou, ChinahDepartment of Psychology, Global and Community Mental Health Research Group, University of Macau, Macau, ChinaiDepartment of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Ying R, Sharma M, Celum C, Baeten JM, van Rooyen H, Hughes JP, Garnett G, Barnabas RV. Home testing and counselling to reduce HIV incidence in a generalised epidemic setting: a mathematical modelling analysis. Lancet HIV 2016; 3:e275-82. [PMID: 27240790 PMCID: PMC4927306 DOI: 10.1016/s2352-3018(16)30009-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Revised: 03/14/2016] [Accepted: 03/16/2016] [Indexed: 01/02/2023]
Abstract
BACKGROUND Home HIV testing and counselling (HTC) achieves high levels of HIV testing and linkage to care. Periodic home HTC, particularly targeted to those with high HIV viral load, might facilitate expansion of antiretroviral therapy (ART) coverage. We used a mathematical model to assess the effect of periodic home HTC programmes on HIV incidence in KwaZulu-Natal, South Africa. METHODS We developed a dynamic HIV transmission model with parameters, primary cost data, and measures of viral suppression collected from a prospective study of home HTC in KwaZulu-Natal. In our model, we assumed home HTC took place every 5 years with ART initiation for people with CD4 counts of 350 cells per μL or less. For individuals with CD4 counts of more than 350 cells per μL, we compared increasing ART coverage for those with 350-500 cells per μL with initiating treatment for those who have viral loads of more than 10 000 copies per mL. FINDINGS Maintaining the presently observed level of 36% viral suppression in HIV-positive people, HIV incidence decreases by 33·8% over 10 years. Home HTC every 5 years with linkage to care with ART initiation at CD4 counts of 350 cells per μL or less reduces HIV incidence by 40·6% over 10 years. Expansion of ART to people with CD4 counts of more than 350 cells per μL who also have a viral load of 10 000 copies per mL or more decreases HIV incidence by 51·6%, and this was the most cost-effective strategy for prevention of HIV infections at US$2960 per infection averted. Expansion of ART eligibility CD4 counts of 350-500 cells per μL is cost-effective at $900 per quality-adjusted life-year gained. Following health economic guidelines, expansion of ART use to individuals who have viral loads of more than 10 000 copies per mL among those with CD4 counts of more than 350 cells per μL was cost-effective to reduce HIV-related morbidity. INTERPRETATION Our results show that province-wide home HTC every 5 years can be a cost-effective strategy to increase ART coverage and reduce HIV burden. Expanded ART initiation criteria that includes individuals with high viral load will improve the effectiveness of home HTC in linking individuals to ART who are at high risk of transmitting HIV, thereby preventing morbidity and onward transmission. FUNDING National Institutes of Health.
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Affiliation(s)
- Roger Ying
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Monisha Sharma
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA
| | - Connie Celum
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA
| | - Jared M Baeten
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA
| | - Heidi van Rooyen
- Human Sciences Research Council, Sweetwaters, KwaZulu-Natal, South Africa
| | - James P Hughes
- Department of Biostatistics, University of Washington, Seattle, WA, USA; Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | | | - Ruanne V Barnabas
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA; Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.
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273
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Velen K, Lewis JJ, Charalambous S, Page-Shipp L, Popane F, Churchyard GJ, Hoffmann CJ. Household HIV Testing Uptake among Contacts of TB Patients in South Africa. PLoS One 2016; 11:e0155688. [PMID: 27195957 PMCID: PMC4873208 DOI: 10.1371/journal.pone.0155688] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 05/03/2016] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND In high HIV prevalence settings, offering HIV testing may be a reasonable part of contact tracing of index tuberculosis (TB) patients. We evaluated the uptake of HIV counselling and testing (HCT) among household contacts of index TB patients and the proportion of newly diagnosed HIV-infected persons linked into care as part of a household TB contact tracing study. METHODS We recruited index TB patients at public health clinics in two South African provinces to obtain consent for household contact tracing. During scheduled household visits we offered TB symptom screening to all household members and HCT to individuals ≥14years of age. Factors associated with HCT uptake were investigated using a random effects logistic regression model. RESULTS & DISCUSSION Out of 1,887 listed household members ≥14 years old, 984 (52%) were available during a household visit and offered HCT of which 108 (11%) self-reported being HIV infected and did not undergo HCT. Of the remaining 876, a total of 304 agreed to HCT (35%); 26 (8.6%) were newly diagnosed as HIV positive. In multivariable analysis, factors associated with uptake of HCT were prior testing (odds ratio 1.6; 95% confidence interval [CI]: 1.1-2.3) and another member in the household testing (odds ratio 2.4; 95% CI: 1.7-3.4). Within 3 months of testing HIV-positive, 35% reported initiating HIV care. CONCLUSION HCT as a component of household TB contact tracing reached individuals without prior HIV testing, however uptake of HIV testing was poor. Strategies to improve HIV testing in household contacts should be evaluated.
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Affiliation(s)
- Kavindhran Velen
- The Aurum Institute, Johannesburg, South Africa
- The School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - James J. Lewis
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Salome Charalambous
- The Aurum Institute, Johannesburg, South Africa
- The School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | | | | | - Gavin J. Churchyard
- The Aurum Institute, Johannesburg, South Africa
- The School of Public Health, University of Witwatersrand, Johannesburg, South Africa
- London School of Hygiene and Tropical Medicine, London, United Kingdom
- Advancing Care and Treatment for TB and HIV, MRC Collaborating Centre of Excellence, Johannesburg, South Africa
| | - Christopher J. Hoffmann
- The Aurum Institute, Johannesburg, South Africa
- The School of Public Health, University of Witwatersrand, Johannesburg, South Africa
- Johns Hopkins University School of Medicine, Baltimore, United States of America
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274
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Vojnov L, Markby J, Boeke C, Harris L, Ford N, Peter T. POC CD4 Testing Improves Linkage to HIV Care and Timeliness of ART Initiation in a Public Health Approach: A Systematic Review and Meta-Analysis. PLoS One 2016; 11:e0155256. [PMID: 27175484 PMCID: PMC4866695 DOI: 10.1371/journal.pone.0155256] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 04/26/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND CD4 cell count is an important test in HIV programs for baseline risk assessment, monitoring of ART where viral load is not available, and, in many settings, antiretroviral therapy (ART) initiation decisions. However, access to CD4 testing is limited, in part due to the centralized conventional laboratory network. Point of care (POC) CD4 testing has the potential to address some of the challenges of centralized CD4 testing and delays in delivery of timely testing and ART initiation. We conducted a systematic review and meta-analysis to identify the extent to which POC improves linkages to HIV care and timeliness of ART initiation. METHODS We searched two databases and four conference sites between January 2005 and April 2015 for studies reporting test turnaround times, proportion of results returned, and retention associated with the use of point-of-care CD4. Random effects models were used to estimate pooled risk ratios, pooled proportions, and 95% confidence intervals. RESULTS We identified 30 eligible studies, most of which were completed in Africa. Test turnaround times were reduced with the use of POC CD4. The time from HIV diagnosis to CD4 test was reduced from 10.5 days with conventional laboratory-based testing to 0.1 days with POC CD4 testing. Retention along several steps of the treatment initiation cascade was significantly higher with POC CD4 testing, notably from HIV testing to CD4 testing, receipt of results, and pre-CD4 test retention (all p<0.001). Furthermore, retention between CD4 testing and ART initiation increased with POC CD4 testing compared to conventional laboratory-based testing (p = 0.01). We also carried out a non-systematic review of the literature observing that POC CD4 increased the projected life expectancy, was cost-effective, and acceptable. CONCLUSIONS POC CD4 technologies reduce the time and increase patient retention along the testing and treatment cascade compared to conventional laboratory-based testing. POC CD4 is, therefore, a useful tool to perform CD4 testing and expedite result delivery.
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Affiliation(s)
- Lara Vojnov
- Clinton Health Access Initiative, Boston, MA, United States of America
| | | | - Caroline Boeke
- Clinton Health Access Initiative, Boston, MA, United States of America
| | - Lindsay Harris
- Clinton Health Access Initiative, Boston, MA, United States of America
| | - Nathan Ford
- World Health Organization, Geneva, Switzerland
| | - Trevor Peter
- Clinton Health Access Initiative, Boston, MA, United States of America
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275
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Orlando S, Diamond S, Palombi L, Sundaram M, Shear Zimmer L, Marazzi MC, Mancinelli S, Liotta G. Cost-Effectiveness and Quality of Care of a Comprehensive ART Program in Malawi. Medicine (Baltimore) 2016; 95:e3610. [PMID: 27227921 PMCID: PMC4902345 DOI: 10.1097/md.0000000000003610] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The aim of this study is to assess the cost-effectiveness of a holistic, comprehensive human immunodeficiency virus (HIV) treatment Program in Malawi.Comprehensive cost data for the year 2010 have been collected at 30 facilities from the public network of health centers providing antiretroviral treatment (ART) throughout the country; two of these facilities were operated by the Disease Relief through Excellent and Advanced Means (DREAM) program.The outcomes analysis was carried out over five years comparing two cohorts of patients on treatment: 1) 2387 patients who started ART in the two DREAM centers during 2008, 2) patients who started ART in Malawi in the same year under the Ministry of Health program.Assuming the 2010 cost as constant over the five years the cost-effective analysis was undertaken from a health sector and national perspective; a sensitivity analysis included two hypothesis of ART impact on patients' income.The total cost per patient per year (PPPY) was $314.5 for the DREAM protocol and $188.8 for the other Malawi ART sites, with 737 disability adjusted life years (DALY) saved among the DREAM program patients compared with the others. The Incremental Cost-Effectiveness Ratio was $1640 per DALY saved; it ranged between $896-1268 for national and health sector perspective respectively. The cost per DALY saved remained under $2154 that is the AFR-E-WHO regional gross domestic product per capita threshold for a program to be considered very cost-effective.HIV/acquired immune deficiency syndrome comprehensive treatment program that joins ART with laboratory monitoring, treatment adherence reinforcing and Malnutrition control can be very cost-effective in the sub-Saharan African setting.
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Affiliation(s)
- Stefano Orlando
- From the Dream programme - Community of Sant'Egidio (SO), Clinton Health Access Initiative (SD, LSZ), Department of Public Health, University of Tor Vergata, Rome, Italy (LP, SM, GL), Bill and Melinda Gates Foundation (MS), and LUMSA University, Rome, Italy (MCM)
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276
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Culbert GJ, Bazazi AR, Waluyo A, Murni A, Muchransyah AP, Iriyanti M, Finnahari, Polonsky M, Levy J, Altice FL. The Influence of Medication Attitudes on Utilization of Antiretroviral Therapy (ART) in Indonesian Prisons. AIDS Behav 2016; 20:1026-38. [PMID: 26400080 PMCID: PMC4805506 DOI: 10.1007/s10461-015-1198-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Negative attitudes toward HIV medications may restrict utilization of antiretroviral therapy (ART) in Indonesian prisons where many people living with HIV (PLH) are diagnosed and first offered ART. This mixed-method study examines the influence of medication attitudes on ART utilization among HIV-infected Indonesian prisoners. Randomly-selected HIV-infected male prisoners (n = 102) completed face-to-face in-depth interviews and structured surveys assessing ART attitudes. Results show that although half of participants utilized ART, a quarter of those meeting ART eligibility guidelines did not. Participants not utilizing ART endorsed greater concerns about ART efficacy, safety, and adverse effects, and more certainty that ART should be deferred in PLH who feel healthy. In multivariate analyses, ART utilization was independently associated with more positive ART attitudes (AOR = 1.09, 95 % CI 1.03-1.16, p = 0.002) and higher internalized HIV stigma (AOR = 1.03, 95 % CI 1.00-1.07, p = 0.016). Social marketing of ART is needed to counteract negative ART attitudes that limit ART utilization among Indonesian prisoners.
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Affiliation(s)
- Gabriel J Culbert
- Department of Health Systems Science, University of Illinois at Chicago, College of Nursing, 845 S. Damen Ave., Chicago, IL, 60612, USA.
- Center for HIV/AIDS Nursing Research, Faculty of Nursing, Universitas Indonesia, Depok, Indonesia.
- Section of Infectious Diseases, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA.
- Centre of Excellence for Research in AIDS (CERiA), University of Malaya, Kuala Lumpur, Malaysia.
| | - Alexander R Bazazi
- Section of Infectious Diseases, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
- Centre of Excellence for Research in AIDS (CERiA), University of Malaya, Kuala Lumpur, Malaysia
| | - Agung Waluyo
- Center for HIV/AIDS Nursing Research, Faculty of Nursing, Universitas Indonesia, Depok, Indonesia
| | - Astia Murni
- Directorate General of Corrections, Indonesian Ministry of Law and Human Rights, Jakarta, Indonesia
| | | | - Mariska Iriyanti
- Center for HIV/AIDS Nursing Research, Faculty of Nursing, Universitas Indonesia, Depok, Indonesia
| | - Finnahari
- Directorate General of Corrections, Indonesian Ministry of Law and Human Rights, Jakarta, Indonesia
| | - Maxim Polonsky
- Section of Infectious Diseases, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Judith Levy
- Department of Health Policy & Administration, University of Illinois at Chicago School of Public Health, Chicago, IL, USA
| | - Frederick L Altice
- Section of Infectious Diseases, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
- Centre of Excellence for Research in AIDS (CERiA), University of Malaya, Kuala Lumpur, Malaysia
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Initiating Antiretroviral Therapy for HIV at a Patient's First Clinic Visit: The RapIT Randomized Controlled Trial. PLoS Med 2016; 13:e1002015. [PMID: 27163694 PMCID: PMC4862681 DOI: 10.1371/journal.pmed.1002015] [Citation(s) in RCA: 237] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 03/22/2016] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND High rates of patient attrition from care between HIV testing and antiretroviral therapy (ART) initiation have been documented in sub-Saharan Africa, contributing to persistently low CD4 cell counts at treatment initiation. One reason for this is that starting ART in many countries is a lengthy and burdensome process, imposing long waits and multiple clinic visits on patients. We estimated the effect on uptake of ART and viral suppression of an accelerated initiation algorithm that allowed treatment-eligible patients to be dispensed their first supply of antiretroviral medications on the day of their first HIV-related clinic visit. METHODS AND FINDINGS RapIT (Rapid Initiation of Treatment) was an unblinded randomized controlled trial of single-visit ART initiation in two public sector clinics in South Africa, a primary health clinic (PHC) and a hospital-based HIV clinic. Adult (≥18 y old), non-pregnant patients receiving a positive HIV test or first treatment-eligible CD4 count were randomized to standard or rapid initiation. Patients in the rapid-initiation arm of the study ("rapid arm") received a point-of-care (POC) CD4 count if needed; those who were ART-eligible received a POC tuberculosis (TB) test if symptomatic, POC blood tests, physical exam, education, counseling, and antiretroviral (ARV) dispensing. Patients in the standard-initiation arm of the study ("standard arm") followed standard clinic procedures (three to five additional clinic visits over 2-4 wk prior to ARV dispensing). Follow up was by record review only. The primary outcome was viral suppression, defined as initiated, retained in care, and suppressed (≤400 copies/ml) within 10 mo of study enrollment. Secondary outcomes included initiation of ART ≤90 d of study enrollment, retention in care, time to ART initiation, patient-level predictors of primary outcomes, prevalence of TB symptoms, and the feasibility and acceptability of the intervention. A survival analysis was conducted comparing attrition from care after ART initiation between the groups among those who initiated within 90 d. Three hundred and seventy-seven patients were enrolled in the study between May 8, 2013 and August 29, 2014 (median CD4 count 210 cells/mm3). In the rapid arm, 119/187 patients (64%) initiated treatment and were virally suppressed at 10 mo, compared to 96/190 (51%) in the standard arm (relative risk [RR] 1.26 [1.05-1.50]). In the rapid arm 182/187 (97%) initiated ART ≤90 d, compared to 136/190 (72%) in the standard arm (RR 1.36, 95% confidence interval [CI], 1.24-1.49). Among 318 patients who did initiate ART within 90 d, the hazard of attrition within the first 10 mo did not differ between the treatment arms (hazard ratio [HR] 1.06; 95% CI 0.61-1.84). The study was limited by the small number of sites and small sample size, and the generalizability of the results to other settings and to non-research conditions is uncertain. CONCLUSIONS Offering single-visit ART initiation to adult patients in South Africa increased uptake of ART by 36% and viral suppression by 26%. This intervention should be considered for adoption in the public sector in Africa. TRIAL REGISTRATION ClinicalTrials.gov NCT01710397, and South African National Clinical Trials Register DOH-27-0213-4177.
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278
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Labhardt ND, Ringera I, Lejone TI, Masethothi P, Thaanyane T, Kamele M, Gupta RS, Thin K, Cerutti B, Klimkait T, Fritz C, Glass TR. Same day ART initiation versus clinic-based pre-ART assessment and counselling for individuals newly tested HIV-positive during community-based HIV testing in rural Lesotho - a randomized controlled trial (CASCADE trial). BMC Public Health 2016; 16:329. [PMID: 27080120 PMCID: PMC4832467 DOI: 10.1186/s12889-016-2972-6] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 03/19/2016] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Achievement of the UNAIDS 90-90-90 targets in Sub-Sahara Africa is challenged by a weak care-cascade with poor linkage to care and retention in care. Community-based HIV testing and counselling (HTC) is widely used in African countries. However, rates of linkage to care and initiation of antiretroviral therapy (ART) in individuals who tested HIV-positive are often very low. A frequently cited reason for non-linkage to care is the time-consuming pre-ART assessment often requiring several clinic visits before ART-initiation. METHODS This two-armed open-label randomized controlled trial compares in individuals tested HIV-positive during community-based HTC the proposition of same-day community-based ART-initiation to the standard of care pre-ART assessment at the clinic. Home-based HTC campaigns will be conducted in catchment areas of six clinics in rural Lesotho. Households where at least one individual tested HIV positive will be randomized. In the standard of care group individuals receive post-test counselling and referral to the nearest clinic for pre-ART assessment and counselling. Once they have started ART the follow-up schedule foresees monthly clinic visits. Individuals randomized to the intervention group receive on the spot point-of-care pre-ART assessment and adherence counselling with the proposition to start ART that same day. Once they have started ART, follow-up clinic visits will be less frequent. First primary outcome is linkage to care (individual presents at the clinic at least once within 3 months after the HIV test). The second primary outcome is viral suppression 12 months after enrolment in the study. We plan to enrol a minimum of 260 households with 1:1 allocation and parallel assignment into both arms. DISCUSSION This trial will show if in individuals tested HIV-positive during community-based HTC campaigns the proposition of same-day ART initiation in the community, combined with less frequent follow-up visits at the clinic could be a pragmatic approach to improve the care cascade in similar settings. TRIAL REGISTRATION NCT02692027 , registered February 21, 2016.
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Affiliation(s)
- Niklaus Daniel Labhardt
- />Clinical Research Unit, Medical Services and Diagnostics, Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051 Basel, Switzerland
- />University of Basel, Basel, Switzerland
| | - Isaac Ringera
- />SolidarMed, Swiss Organization for Health in Africa, Premium House #224, Kingsway, P.O.Box 0254, Maseru West, 105 Lesotho
| | - Thabo Ishmael Lejone
- />SolidarMed, Swiss Organization for Health in Africa, Premium House #224, Kingsway, P.O.Box 0254, Maseru West, 105 Lesotho
| | - Phofu Masethothi
- />SolidarMed, Swiss Organization for Health in Africa, Premium House #224, Kingsway, P.O.Box 0254, Maseru West, 105 Lesotho
| | - T’sepang Thaanyane
- />SolidarMed, Swiss Organization for Health in Africa, Premium House #224, Kingsway, P.O.Box 0254, Maseru West, 105 Lesotho
| | - Mashaete Kamele
- />SolidarMed, Swiss Organization for Health in Africa, Premium House #224, Kingsway, P.O.Box 0254, Maseru West, 105 Lesotho
| | - Ravi Shankar Gupta
- />District Health Management Team Butha-Buthe, Ministry of Health of Lesotho, Butha-Buthe, Lesotho
| | - Kyaw Thin
- />Research Coordination Unit, Room Number 326, Ministry of Health of Lesotho, Maseru, Lesotho
| | - Bernard Cerutti
- />Faculty of Medicine, UDREM, University of Geneva, 1 Rue Michel Servet, 1211 Geneva, Switzerland
| | - Thomas Klimkait
- />Department of Biomedicine – Petersplatz, Molecular Virology, University of Basel, Basel, Switzerland
| | - Christiane Fritz
- />SolidarMed, Swiss Organization for Health in Africa, Premium House #224, Kingsway, P.O.Box 0254, Maseru West, 105 Lesotho
| | - Tracy Renée Glass
- />Clinical Research Unit, Medical Services and Diagnostics, Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051 Basel, Switzerland
- />University of Basel, Basel, Switzerland
- />Biostatistics Department, Epidemiology and Public Health Unit, Swiss Tropical and Public Health Institute, Socinstrasse 57, P.O. Box 4002, Basel, Switzerland
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Moyo F, Chasela C, Brennan AT, Ebrahim O, Sanne IM, Long L, Evans D. Treatment outcomes of HIV-positive patients on first-line antiretroviral therapy in private versus public HIV clinics in Johannesburg, South Africa. Clin Epidemiol 2016; 8:37-47. [PMID: 27051316 PMCID: PMC4807894 DOI: 10.2147/clep.s93014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Despite the widely documented success of antiretroviral therapy (ART), stakeholders continue to face the challenges of poor HIV treatment outcomes. While many studies have investigated patient-level causes of poor treatment outcomes, data on the effect of health systems on ART outcomes are scarce. OBJECTIVE We compare treatment outcomes among patients receiving HIV care and treatment at a public and private HIV clinic in Johannesburg, South Africa. PATIENTS AND METHODS This was a retrospective cohort analysis of ART naïve adults (≥18.0 years), initiating ART at a public or private clinic in Johannesburg between July 01, 2007 and December 31, 2012. Cox proportional-hazards regression was used to identify baseline predictors of mortality and loss to follow-up (>3 months late for the last scheduled visit). Generalized estimating equations were used to determine predictors of failure to suppress viral load (≥400 copies/mL) while the Wilcoxon rank-sum test was used to compare the median absolute change in CD4 count from baseline to 12 months post-ART initiation. RESULTS 12,865 patients initiated ART at the public clinic compared to 610 at the private clinic. The patients were similar in terms of sex and age at initiation. Compared to public clinic patients, private clinic patients initiated ART at higher median CD4 counts (159 vs 113 cells/mm(3)) and World Health Organization stage I/II (76.1% vs 58.5%). Adjusted hazard models showed that compared to public clinic patients, private clinic patients were less likely to die (adjusted hazard ratio [aHR] 0.50; 95% confidence interval [CI] 0.35-0.70) but were at increased risk of loss to follow-up (aHR 1.80; 95% CI 1.59-2.03). By 12 months post-ART initiation, private clinic patients were less likely to have a detectable viral load (adjusted relative risk 0.65; 95% CI 0.49-0.88) and recorded higher median CD4 change from baseline (184 cells/mm(3) interquartile range 101-300 vs 158 cells/mm(3) interquartile range 91-244), when compared to public clinic patients. CONCLUSION We identified differences in treatment outcomes between the two HIV clinics. Findings suggest that the type of clinic at which ART patients initiate and receive treatment can have an impact on treatment outcomes. Further research is necessary to provide more conclusive results.
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Affiliation(s)
- Faith Moyo
- 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
| | - Charles Chasela
- Epidemiology and Biostatistics Department, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Epidemiology and Strategic Information (ESI), HIV/AIDS/STIs and TB, Human Sciences Research Council, Pretoria, South Africa
| | - Alana T Brennan
- 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; Center for Global Health and Development, Boston University, Boston, MA, USA
| | | | - Ian M Sanne
- 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; Right to Care, Helen Joseph Hospital, Westdene, Johannesburg, South Africa
| | - Lawrence Long
- 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
| | - Denise Evans
- 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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Naanyu V, Vedanthan R, Kamano JH, Rotich JK, Lagat KK, Kiptoo P, Kofler C, Mutai KK, Bloomfield GS, Menya D, Kimaiyo S, Fuster V, Horowitz CR, Inui TS. Barriers Influencing Linkage to Hypertension Care in Kenya: Qualitative Analysis from the LARK Hypertension Study. J Gen Intern Med 2016; 31:304-14. [PMID: 26728782 PMCID: PMC4762819 DOI: 10.1007/s11606-015-3566-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 07/24/2015] [Accepted: 12/04/2015] [Indexed: 01/22/2023]
Abstract
BACKGROUND Hypertension, the leading global risk factor for mortality, is characterized by low treatment and control rates in low- and middle-income countries. Poor linkage to hypertension care contributes to poor outcomes for patients. However, specific factors influencing linkage to hypertension care are not well known. OBJECTIVE To evaluate factors influencing linkage to hypertension care in rural western Kenya. DESIGN Qualitative research study using a modified Health Belief Model that incorporates the impact of emotional and environmental factors on behavior. PARTICIPANTS Mabaraza (traditional community assembly) participants (n = 242) responded to an open invitation to residents in their respective communities. Focus groups, formed by purposive sampling, consisted of hypertensive individuals, at-large community members, and community health workers (n = 169). APPROACH We performed content analysis of the transcripts with NVivo 10 software, using both deductive and inductive codes. We used a two-round Delphi method to rank the barriers identified in the content analysis. We selected factors using triangulation of frequency of codes and themes from the transcripts, in addition to the results of the Delphi exercise. Sociodemographic characteristics of participants were summarized using descriptive statistics. KEY RESULTS We identified 27 barriers to linkage to hypertension care, grouped into individual (cognitive and emotional) and environmental factors. Cognitive factors included the asymptomatic nature of hypertension and limited information. Emotional factors included fear of being a burden to the family and fear of being screened for stigmatized diseases such as HIV. Environmental factors were divided into physical (e.g. distance), socioeconomic (e.g. poverty), and health system factors (e.g. popularity of alternative therapies). The Delphi results were generally consistent with the findings from the content analysis. CONCLUSIONS Individual and environmental factors are barriers to linkage to hypertension care in rural western Kenya. Our analysis provides new insights and methodological approaches that may be relevant to other low-resource settings worldwide.
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Affiliation(s)
- Violet Naanyu
- Moi University College of Health Sciences, Eldoret, Kenya.,Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,Kenya Medical Research Institute/Centers for Disease Control Research and Public Health Collaboration, Center for Global Health Research, Kisumu, Kenya
| | - Rajesh Vedanthan
- Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY, USA. .,Kenya Medical Research Institute/Centers for Disease Control Research and Public Health Collaboration, Center for Global Health Research, Kisumu, Kenya.
| | - Jemima H Kamano
- Moi University College of Health Sciences, Eldoret, Kenya.,Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,Kenya Medical Research Institute/Centers for Disease Control Research and Public Health Collaboration, Center for Global Health Research, Kisumu, Kenya
| | - Jackson K Rotich
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,Kenya Medical Research Institute/Centers for Disease Control Research and Public Health Collaboration, Center for Global Health Research, Kisumu, Kenya
| | - Kennedy K Lagat
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,Kenya Medical Research Institute/Centers for Disease Control Research and Public Health Collaboration, Center for Global Health Research, Kisumu, Kenya
| | - Peninah Kiptoo
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,Kenya Medical Research Institute/Centers for Disease Control Research and Public Health Collaboration, Center for Global Health Research, Kisumu, Kenya
| | - Claire Kofler
- Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY, USA.,Kenya Medical Research Institute/Centers for Disease Control Research and Public Health Collaboration, Center for Global Health Research, Kisumu, Kenya
| | - Kennedy K Mutai
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,Kenya Medical Research Institute/Centers for Disease Control Research and Public Health Collaboration, Center for Global Health Research, Kisumu, Kenya
| | - Gerald S Bloomfield
- Kenya Medical Research Institute/Centers for Disease Control Research and Public Health Collaboration, Center for Global Health Research, Kisumu, Kenya.,Duke University Medical Center, Durham, NC, USA
| | - Diana Menya
- Moi University College of Health Sciences, Eldoret, Kenya.,Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,Kenya Medical Research Institute/Centers for Disease Control Research and Public Health Collaboration, Center for Global Health Research, Kisumu, Kenya
| | - Sylvester Kimaiyo
- Moi University College of Health Sciences, Eldoret, Kenya.,Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,Kenya Medical Research Institute/Centers for Disease Control Research and Public Health Collaboration, Center for Global Health Research, Kisumu, Kenya
| | - Valentin Fuster
- Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY, USA.,Kenya Medical Research Institute/Centers for Disease Control Research and Public Health Collaboration, Center for Global Health Research, Kisumu, Kenya.,Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain
| | - Carol R Horowitz
- Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY, USA.,Kenya Medical Research Institute/Centers for Disease Control Research and Public Health Collaboration, Center for Global Health Research, Kisumu, Kenya
| | - Thomas S Inui
- Moi University College of Health Sciences, Eldoret, Kenya.,Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,Kenya Medical Research Institute/Centers for Disease Control Research and Public Health Collaboration, Center for Global Health Research, Kisumu, Kenya.,Indiana University School of Medicine, Indianapolis, IN, USA.,Regenstrief Institute, Inc., Indianapolis, IN, USA
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281
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Enrollment in HIV Care Two Years after HIV Diagnosis in the Kingdom of Swaziland: An Evaluation of a National Program of New Linkage Procedures. PLoS One 2016; 11:e0150086. [PMID: 26910847 PMCID: PMC4766101 DOI: 10.1371/journal.pone.0150086] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 02/09/2016] [Indexed: 01/31/2023] Open
Abstract
To improve early enrollment in HIV care, the Swaziland Ministry of Health implemented new linkage procedures for persons HIV diagnosed during the Soka Uncobe male circumcision campaign (SOKA, 2011–2012) and the Swaziland HIV Incidence Measurement Survey (SHIMS, 2011). Abstraction of clinical records and telephone interviews of a retrospective cohort of HIV-diagnosed SOKA and SHIMS clients were conducted in 2013–2014 to evaluate compliance with new linkage procedures and enrollment in HIV care at 92 facilities throughout Swaziland. Of 1,105 clients evaluated, within 3, 12, and 24 months of diagnosis, an estimated 14.0%, 24.3%, and 37.0% enrolled in HIV care, respectively, after adjusting for lost to follow-up and non-response. Kaplan-Meier functions indicated lower enrollment probability among clients 14–24 (P = 0.0001) and 25–29 (P = 0.001) years of age compared with clients >35 years of age. At 69 facilities to which clients were referred for HIV care, compliance with new linkage procedures was low: referral forms were located for less than half (46.8%) of the clients, and few (9.6%) were recorded in the appointment register or called either before (0.3%) or after (4.9%) their appointment. Of over one thousand clients newly HIV diagnosed in Swaziland in 2011 and 2012, few received linkage services in accordance with national procedures and most had not enrolled in HIV care two years after their diagnosis. Our findings are a call to action to improve linkage services and early enrollment in HIV care in Swaziland.
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282
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Koenig SP, Bernard D, Dévieux JG, Atwood S, McNairy ML, Severe P, Marcelin A, Julma P, Apollon A, Pape JW. Trends in CD4 Count Testing, Retention in Pre-ART Care, and ART Initiation Rates over the First Decade of Expansion of HIV Services in Haiti. PLoS One 2016; 11:e0146903. [PMID: 26901795 PMCID: PMC4763018 DOI: 10.1371/journal.pone.0146903] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 12/23/2015] [Indexed: 12/26/2022] Open
Abstract
Background High attrition during the period from HIV testing to antiretroviral therapy (ART) initiation is widely reported. Though treatment guidelines have changed to broaden ART eligibility and services have been widely expanded over the past decade, data on the temporal trends in pre-ART outcomes are limited; such data would be useful to guide future policy decisions. Methods We evaluated temporal trends and predictors of retention for each step from HIV testing to ART initiation over the past decade at the GHESKIO clinic in Port-au-Prince Haiti. The 24,925 patients >17 years of age who received a positive HIV test at GHESKIO from March 1, 2003 to February 28, 2013 were included. Patients were followed until they remained in pre-ART care for one year or initiated ART. Results 24,925 patients (61% female, median age 35 years) were included, and 15,008 (60%) had blood drawn for CD4 count within 12 months of HIV testing; the trend increased over time from 36% in Year 1 to 78% in Year 10 (p<0.0001). Excluding transfers, the proportion of patients who were retained in pre-ART care or initiated ART within the first year after HIV testing was 84%, 82%, 64%, and 64%, for CD4 count strata ≤200, 201 to 350, 351 to 500, and >500 cells/mm3, respectively. The trend increased over time for each CD4 strata, and in Year 10, 94%, 95%, 79%, and 74% were retained in pre-ART care or initiated ART for each CD4 strata. Predictors of pre-ART attrition included male gender, low income, and low educational status. Older age and tuberculosis (TB) at HIV testing were associated with retention in care. Conclusions The proportion of patients completing assessments for ART eligibility, remaining in pre-ART care, and initiating ART have increased over the last decade across all CD4 count strata, particularly among patients with CD4 count ≤350 cells/mm3. However, additional retention efforts are needed for patients with higher CD4 counts.
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Affiliation(s)
- Serena P. Koenig
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
- Division of Global Health Equity, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States of America
- * E-mail:
| | - Daphne Bernard
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Jessy G. Dévieux
- AIDS Prevention Program, Florida International University, Miami, FL, United States of America
| | - Sidney Atwood
- Division of Global Health Equity, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Margaret L. McNairy
- Center for Global Health, Weill Cornell Medical College, New York, NY, United States of America
| | - Patrice Severe
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Adias Marcelin
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Pierrot Julma
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Alexandra Apollon
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Jean W. Pape
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
- Center for Global Health, Weill Cornell Medical College, New York, NY, United States of America
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283
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People living with HIV travel farther to access healthcare: a population-based geographic analysis from rural Uganda. J Int AIDS Soc 2016; 19:20171. [PMID: 26869359 PMCID: PMC4751409 DOI: 10.7448/ias.19.1.20171] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 12/09/2015] [Accepted: 01/07/2016] [Indexed: 11/21/2022] Open
Abstract
Introduction The availability of specialized HIV services is limited in rural areas of sub-Saharan Africa where the need is the greatest. Where HIV services are available, people living with HIV (PLHIV) must overcome large geographic, economic and social barriers to access healthcare. The objective of this study was to understand the unique barriers PLHIV face when accessing healthcare compared with those not living with HIV in a rural area of sub-Saharan Africa with limited availability of healthcare infrastructure. Methods We conducted a population-based cross-sectional study of 447 heads of household on Bugala Island, Uganda. Multiple linear regression models were used to compare travel time, cost and distance to access healthcare, and log binomial models were used to test for associations between HIV status and access to nearby health services. Results PLHIV travelled an additional 1.9 km (95% CI (0.6, 3.2 km), p=0.004) to access healthcare compared with those not living with HIV, and they were 56% less likely to access healthcare at the nearest health facility to their residence, so long as that facility lacked antiretroviral therapy (ART) services (aRR=0.44, 95% CI (0.24 to 0.83), p=0.011). We found no evidence that PLHIV travelled further for care if the nearest facility supplies ART services (aRR=0.95, 95% CI (0.86 to 1.05), p=0.328). Among those who reported uptake of care at one of two facilities on the island that provides ART (81% of PLHIV and 68% of HIV-negative individuals), PLHIV tended to seek care at a higher tiered facility that provides ART, even when this facility was not their closest facility (30% of PLHIV travelled further than the closest ART facility compared with 16% of HIV-negative individuals), and travelled an additional 2.2 km (p=0.001) to access that facility, relative to HIV-negative individuals (aRR=1.91, 95% CI (1.00 to 3.65), p=0.05). Among PLHIV, residential distance was associated with access to facilities providing ART (RR=0.78, 95% CI (0.61 to 0.99), p=0.044, comparing residential distances of 3–5 km to 0–2 km; RR=0.71, 95% CI (0.58 to 0.87), p=0.001, comparing residential distances of 6–10 km to 0–2 km). Conclusions PLHIV travel longer distances for care, a phenomenon that may be driven by both the limited availability of specialized HIV services and preference for higher tiered facilities.
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284
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Implementation and Operational Research: Distance From Household to Clinic and Its Association With the Uptake of Prevention of Mother-to-Child HIV Transmission Regimens in Rural Zambia. J Acquir Immune Defic Syndr 2016; 70:e94-e101. [PMID: 26470035 DOI: 10.1097/qai.0000000000000739] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In rural settings, HIV-infected pregnant women often live significant distances from facilities that provide prevention of mother-to-child transmission (PMTCT) services. METHODS We offered universal maternal combination antiretroviral regimens in 4 pilot sites in rural Zambia. To evaluate the impact of services, we conducted a household survey in communities surrounding each facility. We collected information about HIV status and antenatal service utilization from women who delivered in the past 2 years. Using household Global Positioning System coordinates collected in the survey, we measured Euclidean (i.e., straight line) distance between individual households and clinics. Multivariable logistic regression and predicted probabilities were used to determine associations between distance and uptake of PMTCT regimens. RESULTS From March to December 2011, 390 HIV-infected mothers were surveyed across four communities. Of these, 254 (65%) had household geographical coordinates documented. One hundred sixty-eight women reported use of a PMTCT regimen during pregnancy including 102 who initiated a combination antiretroviral regimen. The probability of PMTCT regimen initiation was the highest within 1.9 km of the facility and gradually declined. Overall, 103 of 145 (71%) who lived within 1.9 km of the facility initiated PMTCT versus 65 of 109 (60%) who lived farther away. For every kilometer increase, the association with PMTCT regimen uptake (adjusted odds ratio: 0.90, 95% confidence interval: 0.82 to 0.99) and combination antiretroviral regimen uptake (adjusted odds ratio: 0.88, 95% confidence interval: 0.80 to 0.97) decreased. CONCLUSIONS In this rural African setting, uptake of PMTCT regimens was influenced by distance to health facility. Program models that further decentralize care into remote communities are urgently needed.
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285
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Chamie G, Clark TD, Kabami J, Kadede K, Ssemmondo E, Steinfeld R, Lavoy G, Kwarisiima D, Sang N, Jain V, Thirumurthy H, Liegler T, Balzer LB, Petersen ML, Cohen CR, Bukusi EA, Kamya MR, Havlir DV, Charlebois ED. A hybrid mobile approach for population-wide HIV testing in rural east Africa: an observational study. Lancet HIV 2016; 3:e111-9. [PMID: 26939734 PMCID: PMC4780220 DOI: 10.1016/s2352-3018(15)00251-9] [Citation(s) in RCA: 123] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 12/10/2015] [Accepted: 12/11/2015] [Indexed: 11/17/2022]
Abstract
Background Despite large investments in HIV testing, only 45% of HIV-infected persons in sub-Saharan Africa are estimated to know their status. Optimal methods for maximizing population-level testing remain unknown. We sought to demonstrate the effectiveness at achieving population-wide testing coverage of a hybrid mobile HIV testing approach. Methods From 2013–2014, we enumerated 168,772 adult (≥15 years) residents of 32 communities in Uganda (N=20), and Kenya (N=12) using a door-to-door census. “Stable” residence was defined as living in community for ≥6 months over the past year. In each community we performed 2-week multi-disease community health campaigns (CHC) that included HIV testing, counseling, and referral to care if HIV-infected; CHC non-participants were approached for home-based testing (HBT) over 1–2 months. We determined population HIV testing coverage, and predictors of testing via HBT (vs. CHC) and non-testing. Findings HIV testing was achieved in 89% of stable adult residents (131,307/146,906). HIV prevalence was 9.6% (13,043/136,033 stable and non-stable adults); median CD4+ T-cell count was 514 cells/μL (IQR: 355–703). Among stable adults tested, 43% (56,106/131,307) reported no prior testing. Among HIV-infected adults, 38% (4,932/13,043) were unaware of their status. Among stable CHC attendees, 99.5% (104,635/105,170) accepted HIV testing. Of stable adults tested, 80% (104,635/131,307, range: 60–93%) tested via CHCs. In multivariable analyses of stable adults, predictors of non-testing included male gender (risk ratio [RR]: 1.52, 95% CI: 1.48–1.56), single marital status (RR: 1.70, 95% CI: 1.66–1.75), Kenyan residence (RR: 1.46, 95% CI: 1.41–1.50, vs. Ugandan), and out-of-community migration for ≥1 month in past year (RR: 1.60, 95% CI: 1.53–1.68). Testing was more common among farmers (RR: 0.73, 95% CI: 0.67–0.79) and adults with primary education (RR: 0.84, 95% CI: 0.80–0.89). Interpretation High HIV testing coverage was achieved in rural Ugandan and Kenyan communities using a hybrid, mobile approach of multi-disease CHCs followed by HBT. This approach allowed for flexibility at the community and individual level in reaching testing coverage goals. Men and mobile populations remain challenges for universal testing.
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Affiliation(s)
- Gabriel Chamie
- Division of HIV, Infectious Diseases and Global Medicine, San Francisco, CA, USA.
| | - Tamara D Clark
- Division of HIV, Infectious Diseases and Global Medicine, San Francisco, CA, USA
| | - Jane Kabami
- Makerere University-University of California Research Collaboration, Kampala, Uganda
| | - Kevin Kadede
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Emmanuel Ssemmondo
- Makerere University-University of California Research Collaboration, Kampala, Uganda
| | - Rachel Steinfeld
- Division of HIV, Infectious Diseases and Global Medicine, San Francisco, CA, USA
| | - Geoff Lavoy
- Makerere University-University of California Research Collaboration, Kampala, Uganda
| | - Dalsone Kwarisiima
- Makerere University-University of California Research Collaboration, Kampala, Uganda
| | - Norton Sang
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Vivek Jain
- Division of HIV, Infectious Diseases and Global Medicine, San Francisco, CA, USA
| | - Harsha Thirumurthy
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, NC, USA
| | - Teri Liegler
- Division of HIV, Infectious Diseases and Global Medicine, San Francisco, CA, USA
| | - Laura B Balzer
- Department of Biostatistics, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Maya L Petersen
- University of California Berkeley School of Public Health, Berkeley, CA, USA
| | - Craig R Cohen
- Department of Obstetrics, Gynecology and Reproductive Sciences, San Francisco, CA, USA
| | - Elizabeth A Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Moses R Kamya
- Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Diane V Havlir
- Division of HIV, Infectious Diseases and Global Medicine, San Francisco, CA, USA
| | - Edwin D Charlebois
- Department of Medicine, Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, CA, USA
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286
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The neurobiology of HIV and its impact on cognitive reserve: A review of cognitive interventions for an aging population. Neurobiol Dis 2016; 92:144-56. [PMID: 26776767 DOI: 10.1016/j.nbd.2016.01.011] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 12/17/2015] [Accepted: 01/13/2016] [Indexed: 12/21/2022] Open
Abstract
The medications used to treat HIV have reduced the severity of cognitive deficits; yet, nearly half of adults with HIV still exhibit some degree of cognitive deficits, referred to as HIV-associated neurocognitive disorder or HAND. These cognitive deficits interfere with everyday functioning such as emotional regulation, medication adherence, instrumental activities of daily living, and even driving a vehicle. As adults are expected to live a normal lifespan, the process of aging in this clinical population may exacerbate such cognitive deficits. Therefore, it is important to understand the neurobiological mechanisms of HIV on cognitive reserve and develop interventions that are either neuroprotective or compensate for such cognitive deficits. Within the context of cognitive reserve, this article delivers a state of the science perspective on the causes of HAND and provides possible interventions for addressing such cognitive deficits. Suggestions for future research are also provided.
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287
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Tsai AC, Tomlinson M, Comulada WS, Rotheram-Borus MJ. Intimate Partner Violence and Depression Symptom Severity among South African Women during Pregnancy and Postpartum: Population-Based Prospective Cohort Study. PLoS Med 2016; 13:e1001943. [PMID: 26784110 PMCID: PMC4718639 DOI: 10.1371/journal.pmed.1001943] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Accepted: 12/10/2015] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Violence against women by intimate partners remains unacceptably common worldwide. The evidence base for the assumed psychological impacts of intimate partner violence (IPV) is derived primarily from studies conducted in high-income countries. A recently published systematic review identified 13 studies linking IPV to incident depression, none of which were conducted in sub-Saharan Africa. To address this gap in the literature, we analyzed longitudinal data collected during the course of a 3-y cluster-randomized trial with the aim of estimating the association between IPV and depression symptom severity. METHODS AND FINDINGS We conducted a secondary analysis of population-based, longitudinal data collected from 1,238 pregnant women during a 3-y cluster-randomized trial of a home visiting intervention in Cape Town, South Africa. Surveys were conducted at baseline, 6 mo, 18 mo, and 36 mo (85% retention). The primary explanatory variable of interest was exposure to four types of physical IPV in the past year. Depression symptom severity was measured using the Xhosa version of the ten-item Edinburgh Postnatal Depression Scale. In a pooled cross-sectional multivariable regression model adjusting for potentially confounding time-fixed and time-varying covariates, lagged IPV intensity had a statistically significant association with depression symptom severity (regression coefficient b = 1.04; 95% CI, 0.61-1.47), with estimates from a quantile regression model showing greater adverse impacts at the upper end of the conditional depression distribution. Fitting a fixed effects regression model accounting for all time-invariant confounding (e.g., history of childhood sexual abuse) yielded similar findings (b = 1.54; 95% CI, 1.13-1.96). The magnitudes of the coefficients indicated that a one-standard-deviation increase in IPV intensity was associated with a 12.3% relative increase in depression symptom severity over the same time period. The most important limitations of our study include exposure assessment that lacked measurement of sexual violence, which could have caused us to underestimate the severity of exposure; the extended latency period in the lagged analysis, which could have caused us to underestimate the strength of the association; and outcome assessment that was limited to the use of a screening instrument for depression symptom severity. CONCLUSIONS In this secondary analysis of data from a population-based, 3-y cluster-randomized controlled trial, IPV had a statistically significant association with depression symptom severity. The estimated associations were relatively large in magnitude, consistent with findings from high-income countries, and robust to potential confounding by time-invariant factors. Intensive health sector responses to reduce IPV and improve women's mental health should be explored.
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Affiliation(s)
- Alexander C. Tsai
- Massachusetts General Hospital, MGH Global Health, Boston, Massachusetts, United States of America
- Harvard Center for Population and Development Studies, Cambridge, Massachusetts, United States of America
- Mbarara University of Science and Technology, Mbarara, Uganda
- * E-mail:
| | | | - W. Scott Comulada
- Center for HIV Identification, Prevention and Treatment Services, University of California at Los Angeles, Los Angeles, California, United States of America
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California at Los Angeles, Los Angeles, California, United States of America
| | - Mary Jane Rotheram-Borus
- Center for HIV Identification, Prevention and Treatment Services, University of California at Los Angeles, Los Angeles, California, United States of America
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California at Los Angeles, Los Angeles, California, United States of America
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288
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Saleem HT, Mushi D, Hassan S, Bruce RD, Cooke A, Mbwambo J, Lambdin BH. "Can't you initiate me here?": Challenges to timely initiation on antiretroviral therapy among methadone clients in Dar es Salaam, Tanzania. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2015; 30:59-65. [PMID: 26831364 DOI: 10.1016/j.drugpo.2015.12.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 11/11/2015] [Accepted: 12/10/2015] [Indexed: 01/10/2023]
Abstract
BACKGROUND Despite dramatic improvement in antiretroviral therapy (ART) access globally, people living with HIV who inject drugs continue to face barriers that limit their access to treatment. This paper explores barriers and facilitators to ART initiation among clients attending a methadone clinic in Dar es Salaam, Tanzania. METHODS We interviewed 12 providers and 20 clients living with HIV at the Muhimbili National Hospital methadone clinic between January and February 2015. We purposively sampled clients based on sex and ART status and providers based on job function. To analyze interview transcripts, we adopted a content analysis approach. RESULTS Participants identified several factors that hindered timely ART initiation for clients at the methadone clinic. These included delays in CD4 testing and receiving CD4 test results; off-site HIV clinics; stigma operating at the individual, social and institutional levels; insufficient knowledge of the benefits of early ART initiation among clients; treatment breakdown at the clinic level possibly due to limited staff; and initiating ART only once one feels physically ill. Participants perceived social support as a buffer against stigma and facilitator of HIV treatment. Some clients also reported that persistent monitoring and follow-up on their HIV care and treatment by methadone clinic providers led them to initiate ART. CONCLUSION Health system factors, stigma and limited social support pose challenges for methadone clients living with HIV to initiate ART. Our findings suggest that on-site point-of-care CD4 testing, a peer support system, and trained HIV treatment specialists who are able to counsel HIV-positive clients and initiate them on ART at the methadone clinic could help reduce barriers to timely ART initiation for methadone clients.
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Affiliation(s)
- Haneefa T Saleem
- Pangaea Global AIDS, 436, 14th Street, Suite 920, Oakland, CA 94612, United States.
| | - Dorothy Mushi
- Muhimbili University of Health and Allied Sciences, Department of Psychiatry, P.O. Box 65293, Dar es Salaam, Tanzania
| | - Saria Hassan
- Pangaea Global AIDS, 436, 14th Street, Suite 920, Oakland, CA 94612, United States
| | - R Douglas Bruce
- Pangaea Global AIDS, 436, 14th Street, Suite 920, Oakland, CA 94612, United States; Cornell Scott-Hill Health Center, 428 Columbus Avenue, New Haven, CT 06519, United States; Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, United States
| | - Alexis Cooke
- University of California, Los Angeles, Fielding School of Public Health, Department of Community Health Sciences, United States
| | - Jessie Mbwambo
- Muhimbili University of Health and Allied Sciences, Department of Psychiatry, P.O. Box 65293, Dar es Salaam, Tanzania
| | - Barrot H Lambdin
- RTI International, 351 California Street, Suite 500, San Francisco, CA 94104, United States; University of California San Francisco, San Francisco, CA, United States; University of Washington, Seattle, WA, United States
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289
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Gelaw YA, Senbete GH, Adane AA, Alene KA. Determinants of late presentation to HIV/AIDS care in Southern Tigray Zone, Northern Ethiopia: an institution based case-control study. AIDS Res Ther 2015; 12:40. [PMID: 26633988 PMCID: PMC4667535 DOI: 10.1186/s12981-015-0079-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 11/09/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Late diagnosis and presentation to human immune deficiency virus (HIV)/acquired immune deficiency syndrome care reduce the benefits of antiretroviral therapy and increase the risk of HIV transmission. OBJECTIVES This study was conducted to identify determinants of late presentation to HIV care among people living with HIV in Southern Tigray, Northern Ethiopia. METHODS An institution based un-matched case-control (1:2 ratios) supported with qualitative data was conducted in Southern Tigray Zone from March 1 to April 30, 2014. Individuals with HIV enrolled from six randomly selected health facilities were included in the study. Cases were people living with HIV who had cluster of differentiation four count <350 cells/μl or World Health Organization stages 3 or 4. A total of 442 study participants were included by systematic sampling techniques. Bivariable and multivariable binary logistic regression model was used to identify associated factors. Odds ratio with 95 % CI was computed to assess the strength of the associations. RESULT Age categories, 25-29 years [AOR 3, 95 % CI (1.2-8.1)] and 35-39 years [AOR 4.1, 95 % CI (1.4-12.5)], having two [AOR 6, 95 % CI (1.3-28)] and more [AOR 5.2, 95 % CI (1.1-24.8)] lifetime sexual partners, poor social support [AOR 2.3, 95 % CI (1.26-4.30)], second (next to lowest) wealth quintile [AOR 3.3, 95 % CI 91.3-8.5)], fear of stigma [AOR 4.4, 95 % CI (2.2-8.3)], fear of losing job [AOR 6.8, 95 % CI (1.8-24.5)], and reported severe illness [AOR 4.3, 95 % CI (2.26-8)] were identified to be the risk factors for late presentation. CONCLUSION Low socio-economic status and social support, fear of stigma were potential risk factors for late presentation. Efforts towards promoting early care seeking should target on these factors in the study area and other similar settings.
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Affiliation(s)
- Yalemzewod Assefa Gelaw
- />Department of Epidemiology and Biostatistics, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | | | - Akelew Awoke Adane
- />Department of Epidemiology and Biostatistics, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Kefyalew Addis Alene
- />Department of Epidemiology and Biostatistics, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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290
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Elopre L, Hook EW, Westfall AO, Zinski A, Mugavero MJ, Turan J, Van Wagoner N. The Role of Early HIV Status Disclosure in Retention in HIV Care. AIDS Patient Care STDS 2015; 29:646-50. [PMID: 26588053 DOI: 10.1089/apc.2015.0205] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
The objective of this study was to evaluate whether nondisclosure or selective disclosure of HIV status to others is associated with retention in HIV care. This retrospective analysis evaluated the relationship of self-reported disclosure of HIV status as an indicator for poor retention in care (a gap in care >180 days) during the 12 months following initial entry into HIV care. Nondisclosure (disclosure to no one) and selective disclosure were compared to broad disclosure (referent). Univariate and multivariable (MV) logistic regression models were fit, including factors known to be associated with disclosure and retention in care. From 2007 to 2013, 508 HIV-infected patients presented to initiate care, of whom 63% were black, 54% had a CD4 + T lymphocyte count <350, and 82% were men (60% of whom were men who have sex with other men). Of these, 65 (13%) reported nondisclosure, 258 (49%) reported selective disclosure, and 185 (38%) reported broad disclosure. In MV analyses, nondisclosure was associated with poor retention in care (AOR 2.2; 95% CI 1.2, 4.2). Evaluating disclosure patterns among patients establishing HIV care may help predict and prevent inconsistent care. Further work is needed to understand the relationship between disclosure and retention in care in order to guide future interventions to improve HIV-outcomes.
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Affiliation(s)
- Latesha Elopre
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Edward W. Hook
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Andrew O. Westfall
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Anne Zinski
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Michael J. Mugavero
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Janet Turan
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - Nicholas Van Wagoner
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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291
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Iwuji CC, McGrath N, de Oliveira T, Porter K, Pillay D, Fisher M, Newport M, Newell ML. The Art of HIV Elimination: Past and Present Science. JOURNAL OF AIDS & CLINICAL RESEARCH 2015; 6:525. [PMID: 27774350 PMCID: PMC5072486 DOI: 10.4172/2155-6113.1000525] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Remarkable strides have been made in controlling the HIV epidemic, although not enough to achieve epidemic control. More recently, interest in biomedical HIV control approaches has increased, but substantial challenges with the HIV cascade of care hinder successful implementation. We summarise all available HIV prevention methods and make recommendations on how to address current challenges. DISCUSSION In the early days of the epidemic, behavioural approaches to control the HIV dominated, and the few available evidence-based interventions demonstrated to reduce HIV transmission were applied independently from one another. More recently, it has become clear that combination prevention strategies targeted to high transmission geographies and people at most risk of infections are required to achieve epidemic control. Biomedical strategies such as male medical circumcision and antiretroviral therapy for treatment in HIV-positive individuals and as pre-exposure prophylaxis in HIV-negative individuals provide immense promise for the future of HIV control. In resource-rich settings, the threat of HIV treatment optimism resulting in increased sexual risk taking has been observed and there are concerns that as ART roll-out matures in resource-poor settings and the benefits of ART become clearly visible, behavioural disinhibition may also become a challenge in those settings. Unfortunately, an efficacious vaccine, a strategy which could potentially halt the HIV epidemic, remains elusive. CONCLUSION Combination HIV prevention offers a logical approach to HIV control, although what and how the available options should be combined is contextual. Therefore, knowledge of the local or national drivers of HIV infection is paramount. Problems with the HIV care continuum remain of concern, hindering progress towards the UNAIDS target of 90-90-90 by 2020. Research is needed on combination interventions that address all the steps of the cascade as the steps are not independent of each other. Until these issues are addressed, HIV elimination may remain an unattainable goal.
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Affiliation(s)
- Collins C. Iwuji
- Africa Centre for Health and Population Studies, University of KwaZulu Natal, South Africa
- Research Department of Infection and Population Health, University College London, UK
| | - Nuala McGrath
- Africa Centre for Health and Population Studies, University of KwaZulu Natal, South Africa
- Academic Unit of Primary Care and Population Sciences, and Department of Social statistics and Demography, University of Southampton, UK
| | - Tulio de Oliveira
- Africa Centre for Health and Population Studies, University of KwaZulu Natal, South Africa
| | | | - Deenan Pillay
- Africa Centre for Health and Population Studies, University of KwaZulu Natal, South Africa
- Research Department of Infection and Immunity, University College London, UK
| | - Martin Fisher
- Division of Medicine, Brighton and Sussex Medical School, UK
| | - Melanie Newport
- Department of Infectious Diseases and Global Health, Brighton and Sussex Medical School, UK
| | - Marie-Louise Newell
- Faculty of Medicine and Faculty of Social and Human Sciences, University of Southampton, UK
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292
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Sullivan KA, Berger MB, Quinlivan EB, Parnell HE, Sampson LA, Clymore JM, Wilkin AM. Perspectives from the Field: HIV Testing and Linkage to Care in North Carolina. J Int Assoc Provid AIDS Care 2015; 15:477-485. [PMID: 26586789 DOI: 10.1177/2325957415617830] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND HIV testing and linkage to care are critical first steps along the care continuum. Targeted efforts are needed in the South to achieve the goals of the National HIV/AIDS Strategy, and qualitative examination of testing and linkage to care from the perspective of professionals in the field can provide nuanced insight into the strengths and limitations of a care system to inform improvement efforts. These issues are explored in North Carolina (NC), with potential applicability to other Southern states. METHODS Twenty-one interviews were conducted with professionals in the HIV prevention and care systems in NC. Interviews were analyzed for emergent themes. RESULTS Individuals' access barriers, aspects of clinics and clinical care, challenges for community-based organizations, stigma, and the role of the NC Department of Health and Human Services were identified as themes affecting testing and linkage. DISCUSSION These findings can inform efforts to address HIV testing and linkage to care in NC. This approach may provide beneficial insight for other systems of care.
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Affiliation(s)
- Kristen A Sullivan
- Center for Health Policy and Inequalities Research, Duke University, Duke Global Health Institute, Durham, NC, USA
| | - Miriam B Berger
- Center for Health Policy and Inequalities Research, Duke University, Duke Global Health Institute, Durham, NC, USA
| | - Evelyn Byrd Quinlivan
- Center for AIDS Research, University of North Carolina at Chapel Hill, NC, USA.,Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, NC, USA
| | - Heather E Parnell
- Center for Health Policy and Inequalities Research, Duke University, Duke Global Health Institute, Durham, NC, USA
| | - Lynne A Sampson
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, NC, USA.,North Carolina Department of Health and Human Services, HIV/STD Prevention Unit, Communicable Disease Branch, Raleigh, NC, USA
| | - Jacquelyn M Clymore
- North Carolina Department of Health and Human Services, Communicable Disease Branch, Raleigh, NC, USA
| | - Aimee M Wilkin
- Section on Infectious Diseases, Wake Forest University School of Medicine, Winston-Salem, NC, USA
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293
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Meier BM, Gelpi A, Kavanagh MM, Forman L, Amon JJ. Employing human rights frameworks to realize access to an HIV cure. J Int AIDS Soc 2015; 18:20305. [PMID: 26568056 PMCID: PMC4644771 DOI: 10.7448/ias.18.1.20305] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 09/21/2015] [Accepted: 10/08/2015] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION The scale of the HIV pandemic - and the stigma, discrimination and violence that surrounded its sudden emergence - catalyzed a public health response that expanded human rights in principle and practice. In the absence of effective treatment, human rights activists initially sought to protect individuals at high risk of HIV infection. With advances in antiretroviral therapy, activists expanded their efforts under international law, advocating under the human right to health for individual access to treatment. DISCUSSION As a clinical cure comes within reach, human rights obligations will continue to play a key role in political and programmatic decision-making. Building upon the evolving development and implementation of the human right to health in the global response to HIV, we outline a human rights research agenda to prepare for HIV cure access, investigating the role of human rights law in framing 1) resource allocation, 2) international obligations, 3) intellectual property and 4) freedom from coercion. CONCLUSIONS The right to health is widely recognized as central to governmental, intergovernmental and non-governmental responses to the pandemic and critical both to addressing vulnerability to infection and to ensuring universal access to HIV prevention, treatment, care and support. While the advent of an HIV cure will raise new obligations for policymakers in implementing the right to health, the resolution of past debates surrounding HIV prevention and treatment may inform claims for universal access.
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Affiliation(s)
- Benjamin Mason Meier
- Department of Public Policy, University of North Carolina, Chapel Hill, NC, USA;
| | - Adriane Gelpi
- Edmond J. Safra Center for Ethics, Harvard University, Cambridge, MA, USA
| | - Matthew M Kavanagh
- Department of Political Science, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Lisa Forman
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Joseph J Amon
- Health and Human Rights Division, Human Rights Watch, New York, NY, USA
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294
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IAPAC Guidelines for Optimizing the HIV Care Continuum for Adults and Adolescents. J Int Assoc Provid AIDS Care 2015; 14 Suppl 1:S3-S34. [PMID: 26527218 DOI: 10.1177/2325957415613442] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND An estimated 50% of people living with HIV (PLHIV) globally are unaware of their status. Among those who know their HIV status, many do not receive antiretroviral therapy (ART) in a timely manner, fail to remain engaged in care, or do not achieve sustained viral suppression. Barriers across the HIV care continuum prevent PLHIV from achieving the therapeutic and preventive effects of ART. METHODS A systematic literature search was conducted, and 6132 articles, including randomized controlled trials, observational studies with or without comparators, cross-sectional studies, and descriptive documents, met the inclusion criteria. Of these, 1047 articles were used to generate 36 recommendations to optimize the HIV care continuum for adults and adolescents. RECOMMENDATIONS Recommendations are provided for interventions to optimize the HIV care environment; increase HIV testing and linkage to care, treatment coverage, retention in care, and viral suppression; and monitor the HIV care continuum.
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295
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Gwadz M, Cleland CM, Applegate E, Belkin M, Gandhi M, Salomon N, Banfield A, Leonard N, Riedel M, Wolfe H, Pickens I, Bolger K, Bowens D, Perlman D, Mildvan D. Behavioral intervention improves treatment outcomes among HIV-infected individuals who have delayed, declined, or discontinued antiretroviral therapy: a randomized controlled trial of a novel intervention. AIDS Behav 2015; 19:1801-17. [PMID: 25835462 PMCID: PMC4567451 DOI: 10.1007/s10461-015-1054-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Nationally up to 60 % of persons living with HIV are neither taking antiretroviral therapy (ART) nor well engaged in HIV care, mainly racial/ethnic minorities. This study examined a new culturally targeted multi-component intervention to address emotional, attitudinal, and social/structural barriers to ART initiation and HIV care. Participants (N = 95) were African American/Black and Latino adults with CD4 < 500 cells/mm(3) not taking ART, randomized 1:1 to intervention or control arms, the latter receiving treatment as usual. Primary endpoints were adherence, evaluated via ART concentrations in hair samples, and HIV viral load suppression. The intervention was feasible and acceptable. Eight months post-baseline, intervention participants tended to be more likely to evidence "good" (that is, 7 days/week) adherence (60 vs. 26.7 %; p = 0.087; OR = 3.95), and had lower viral load levels than controls (t(22) = 2.29, p = 0.032; OR = 5.20), both large effect sizes. This highly promising intervention merits further study.
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Affiliation(s)
- Marya Gwadz
- Center for Drug Use and HIV Research (CDUHR), New York University College of Nursing, 433 First Avenue, 7th Floor, New York, NY, 10010, USA.
| | - Charles M Cleland
- Center for Drug Use and HIV Research (CDUHR), New York University College of Nursing, 433 First Avenue, 7th Floor, New York, NY, 10010, USA.
| | - Elizabeth Applegate
- Center for Drug Use and HIV Research (CDUHR), New York University College of Nursing, 433 First Avenue, 7th Floor, New York, NY, 10010, USA.
| | - Mindy Belkin
- Center for Drug Use and HIV Research (CDUHR), New York University College of Nursing, 433 First Avenue, 7th Floor, New York, NY, 10010, USA.
| | - Monica Gandhi
- Division of HIV/AIDS, Department of Medicine, University of California San Francisco (UCSF), San Francisco, CA, USA.
| | - Nadim Salomon
- Department of Infectious Diseases, Peter Krueger Center for Immunological Disorders, Mount Sinai Beth Israel, New York, NY, USA.
| | - Angela Banfield
- Center for Drug Use and HIV Research (CDUHR), New York University College of Nursing, 433 First Avenue, 7th Floor, New York, NY, 10010, USA.
| | - Noelle Leonard
- Center for Drug Use and HIV Research (CDUHR), New York University College of Nursing, 433 First Avenue, 7th Floor, New York, NY, 10010, USA.
| | - Marion Riedel
- School of Social Work, Columbia University, New York, NY, USA.
| | - Hannah Wolfe
- Mount Sinai St. Luke's-Roosevelt Hospital Center, Spencer Cox Center for Health, New York, NY, USA.
| | - Isaiah Pickens
- Center for Drug Use and HIV Research (CDUHR), New York University College of Nursing, 433 First Avenue, 7th Floor, New York, NY, 10010, USA.
| | - Kelly Bolger
- Center for Drug Use and HIV Research (CDUHR), New York University College of Nursing, 433 First Avenue, 7th Floor, New York, NY, 10010, USA.
| | - DeShannon Bowens
- Center for Drug Use and HIV Research (CDUHR), New York University College of Nursing, 433 First Avenue, 7th Floor, New York, NY, 10010, USA.
| | - David Perlman
- Department of Infectious Diseases, Mount Sinai Beth Israel, New York, NY, USA.
| | - Donna Mildvan
- Department of Infectious Diseases, Mount Sinai Beth Israel, New York, NY, USA.
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296
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Tran BX, Nguyen LH, Phan HTT, Nguyen LK, Latkin CA. Preference of methadone maintenance patients for the integrative and decentralized service delivery models in Vietnam. Harm Reduct J 2015; 12:29. [PMID: 26377824 PMCID: PMC4574353 DOI: 10.1186/s12954-015-0063-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2015] [Accepted: 08/23/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Integrating and decentralizing services are essential to increase the accessibility and provide comprehensive care for methadone patients. Moreover, they assure the sustainability of a HIV/AIDS prevention program by reducing the implementation cost. This study aimed to measure the preference of patients enrolling in a MMT program for integrated and decentralized MMT clinics and then further examine related factors. METHODS A cross-sectional study was conducted among 510 patients receiving methadone at 3 clinics in Hanoi. Structured questionnaires were used to collect data about the preference for integrated and decentralized MMT services. Covariates including socio-economic status; health-related quality of life (using EQ-5D-5 L instrument) and HIV status; history of drug use along with MMT treatment; and exposure to the discrimination within family and community were also investigated. Multivariate logistic regression with polynomial fractions was used to identify the determinants of preference for integrative and decentralized models. RESULTS Of 510 patients enrolled, 66.7 and 60.8 % preferred integrated and decentralized models, respectively. The main reason for preferring the integrative model was the convenience of use of various services (53.2 %), while more privacy (43.5 %) was the primary reason to select stand-alone model. People preferred the decentralized model primarily because of travel cost reduction (95.0 %), while the main reason for not selecting the model was increased privacy (7.7 %). After adjusting for covariates, factors influencing the preference for integrative model were poor socioeconomic status, anxiety/depression, history of drug rehabilitation, and ever disclosed health status; while exposure to community discrimination inversely associated with this preference. In addition, people who were self-employed, had a longer duration of MMT, and use current MMT with comprehensive HIV services were less likely to select decentralized model. CONCLUSION In conclusion, the study confirmed the high preference of MMT patients for the integrative and decentralized MMT service delivery models. The convenience of healthcare services utilization and reduction of geographical barriers were the main reasons to use those models within drug use populations in Vietnam. Countering community stigma and encouraging communication between patients and their societies needed to be considered when implementing those models.
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Affiliation(s)
- Bach Xuan Tran
- Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam. .,Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Long Hoang Nguyen
- Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam.,School of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
| | | | | | - Carl A Latkin
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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297
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Lima VD, Goldberg N, Lourenço L, Chau W, Hogg RS, Guillemi S, Barrios R, Montaner JSG. Virologic suppression and mortality of patients who migrate for HIV care in the province of British Columbia, Canada, from 2003 to 2012: a retrospective cohort study. BMC Health Serv Res 2015; 15:376. [PMID: 26369664 PMCID: PMC4570764 DOI: 10.1186/s12913-015-1042-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 09/04/2015] [Indexed: 01/27/2023] Open
Abstract
Background Migration among persons living with HIV (PLWH) seeking HIV care is common; however its effect on health outcomes in resource-rich settings is not well understood. We conducted a retrospective cohort study to quantify the extent to which PLWH are migrating for care within British Columbia (BC) and its association with virologic suppression and mortality. Methods Eligible PLWH first initiated treatment in BC between 2003 and 2012 (N = 3653). Analyses were performed at the regional Health Authority (HA) level (N = 5). For privacy reasons, we kept the name of these HAs anonymous and we re-named these five regions as 1 to 5. PLWH were classified according to the HA where they resided and received HIV care. We calculated all-cause mortality rates, life expectancies (at age of 20 years), and in, out and net migration rates across HAs using different demographic methods. Virologic suppression (<50 copies/mL) was based on the last viral load available for each PLWH. We also calculated per-capita rates (per 100 PLWH ever on cART) for each HA by dividing the number of PLWH by the number of physicians attending this population. Results There is considerable heterogeneity in physician availability across all HAs, with per-capita rates (per 100 PLWH ever on cART) ranging from 2.2 (HA 1) to 12.7 (HA 3) based on the HA PLWH received care. We observed that in HAs 1, 4, and 5, between 4 and 10 % of PLWH migrated to HA 3 (i.e. the largest urban center) to receive care, and for HA 2 this proportion increased to 21 %. In HA 3, 77 % of its PLWH residents remained in the same HA for their care. Migrating to a larger center for HIV care was not associated with higher rates of viral load suppression; it was significantly associated with lower mortality rates and higher life expectancies. Conclusions A thorough understanding of the reason(s) for these significant migration rates across BC will be critical to inform resource allocation and optimize the impact of HIV treatment.
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Affiliation(s)
- Viviane Dias Lima
- British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6. .,Division of AIDS, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada, V6Z 1Y6.
| | - Nicola Goldberg
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada, M5S 1A8.
| | - Lillian Lourenço
- British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6.
| | - William Chau
- British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6.
| | - Robert S Hogg
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada, V5A 1S6.
| | - Silvia Guillemi
- British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6.
| | - Rolando Barrios
- British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6.
| | - Julio S G Montaner
- British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6. .,Division of AIDS, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada, V6Z 1Y6.
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298
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Feucht UD, Meyer A, Thomas WN, Forsyth BWC, Kruger M. Early diagnosis is critical to ensure good outcomes in HIV-infected children: outlining barriers to care. AIDS Care 2015; 28:32-42. [PMID: 26273853 DOI: 10.1080/09540121.2015.1066748] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
HIV-infected children require early initiation of antiretroviral therapy (ART) to ensure good outcomes. The aim was to investigate missed opportunities in childhood HIV diagnosis leading to delayed ART initiation. Baseline data were reviewed of all children aged <15 years referred over a 1-year period for ART initiation to the Kalafong Hospital HIV services in Gauteng, South Africa. Of the 250 children, one-quarter (24.5%) was of school-going age, 34.5% in the preschool group, 18% between 6 and 12 months old and 23% below 6 months of age (median age = 1.5 years [interquartile range 0.5-4.8]). Most children (82%) presented with advanced/severe HIV disease, particularly those aged 6-12 months (95%). Malnutrition was prominent and referrals were mostly from hospital inpatient services (61%). A structured caregiver interview was conducted in a subgroup, with detailed review of medical records and HIV results. The majority (≥89%) of the 65 interviewed caregivers reported good access to routine healthcare, except for postnatal care (26%). Maternal HIV-testing was mostly done during the second and third pregnancy trimesters (69%). Maternal non-disclosure of HIV status was common (63%) and 83% of mothers reported a lack of psychosocial support. Routine infant HIV-testing was not done in 66%, and inadequate reporting on patient-held records (Road-to-Health Cards/Booklets) occurred frequently (74%). Children with symptomatic HIV disease were not investigated at primary healthcare in 53%, and in 68% of families the siblings were not tested. One-third of children (35%) had a previous HIV diagnosis, with 77% of caregivers aware of these prior results, while 50% acknowledged failing to attend ART services despite referral. In conclusion, a clear strategy on paediatric HIV case finding, especially at primary healthcare, is vital. Multiple barriers need to be overcome in the HIV care pathway to reach high uptake of services, of which especially maternal reasons for not attending paediatric ART services need further exploration.
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Affiliation(s)
- Ute D Feucht
- a Department of Paediatrics , Kalafong Hospital, University of Pretoria , Pretoria , South Africa
| | - Anell Meyer
- a Department of Paediatrics , Kalafong Hospital, University of Pretoria , Pretoria , South Africa
| | - Winifred N Thomas
- a Department of Paediatrics , Kalafong Hospital, University of Pretoria , Pretoria , South Africa
| | - Brian W C Forsyth
- a Department of Paediatrics , Kalafong Hospital, University of Pretoria , Pretoria , South Africa.,b Department of Pediatrics , Yale University , New Haven , CT , USA
| | - Mariana Kruger
- c Department of Paediatrics and Child Health , University of Stellenbosch , Tygerberg , South Africa
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299
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Tsai AC, Venkataramani AS. The causal effect of education on HIV stigma in Uganda: Evidence from a natural experiment. Soc Sci Med 2015; 142:37-46. [PMID: 26282707 DOI: 10.1016/j.socscimed.2015.08.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Revised: 08/01/2015] [Accepted: 08/06/2015] [Indexed: 12/22/2022]
Abstract
RATIONALE HIV is highly stigmatized in sub-Saharan Africa. This is an important public health problem because HIV stigma has many adverse effects that threaten to undermine efforts to control the HIV epidemic. OBJECTIVE The implementation of a universal primary education policy in Uganda in 1997 provided us with a natural experiment to test the hypothesis that education is causally related to HIV stigma. METHODS For this analysis, we pooled publicly available, population-based data from the 2011 Uganda Demographic and Health Survey and the 2011 Uganda AIDS Indicator Survey. The primary outcomes of interest were negative attitudes toward persons with HIV, elicited using four questions about anticipated stigma and social distance. RESULTS Standard least squares estimates suggested a statistically significant, negative association between years of schooling and HIV stigma (each P < 0.001, with t-statistics ranging from 4.9 to 14.7). We then used a natural experiment design, exploiting differences in birth cohort exposure to universal primary education as an instrumental variable. Participants who were <13 years old at the time of the policy change had 1.36 additional years of schooling compared to those who were ≥13 years old. Adjusting for linear age trends before and after the discontinuity, two-stage least squares estimates suggested no statistically significant causal effect of education on HIV stigma (P-values ranged from 0.21 to 0.69). Three of the four estimated regression coefficients were positive, and in all cases the lower confidence limits convincingly excluded the possibility of large negative effect sizes. These instrumental variables estimates have a causal interpretation and were not overturned by several robustness checks. CONCLUSION We conclude that, for young adults in Uganda, additional years of education in the formal schooling system driven by a universal primary school intervention have not had a causal effect on reducing negative attitudes toward persons with HIV.
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Affiliation(s)
- Alexander C Tsai
- Massachusetts General Hospital, MGH Global Health, Boston, MA, USA; Harvard Center for Population and Development Studies, Cambridge, MA, USA; Mbarara University of Science and Technology, Mbarara, Uganda.
| | - Atheendar S Venkataramani
- Massachusetts General Hospital, MGH Global Health, Boston, MA, USA; Harvard Center for Population and Development Studies, Cambridge, MA, USA; Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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Karageorgopoulos DE, Allen J, Bhagani S. Hepatitis C in human immunodeficiency virus co-infected individuals: Is this still a "special population"? World J Hepatol 2015; 7:1936-52. [PMID: 26244068 PMCID: PMC4517153 DOI: 10.4254/wjh.v7.i15.1936] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 06/24/2015] [Accepted: 07/21/2015] [Indexed: 02/06/2023] Open
Abstract
A substantial proportion of individuals with chronic hepatitis C virus (HCV) are co-infected with human immunodeficiency virus (HIV). Co-infected individuals are traditionally considered as one of the "special populations" amongst those with chronic HCV, mainly because of faster progression to end-stage liver disease and suboptimal responses to treatment with pegylated interferon alpha and ribavirin, the benefits of which are often outweighed by toxicity. The advent of the newer direct acting antivirals (DAAs) has given hope that the majority of co-infected individuals can clear HCV. However the "special population" designation may prove an obstacle for those with co-infection to gain access to the new agents, in terms of requirement for separate pre-licensing clinical trials and extensive drug-drug interaction studies. We review the global epidemiology, natural history and pathogenesis of chronic hepatitis C in HIV co-infection. The accelerated course of chronic hepatitis C in HIV co-infection is not adequately offset by successful combination antiretroviral therapy. We also review the treatment trials of chronic hepatitis C in HIV co-infected individuals with DAAs and compare them to trials in the HCV mono-infected. There is convincing evidence that HIV co-infection no longer diminishes the response to treatment against HCV in the new era of DAA-based therapy. The management of HCV co-infection should therefore become a priority in the care of HIV infected individuals, along with public health efforts to prevent new HCV infections, focusing particularly on specific patient groups at risk, such as men who have sex with men and injecting drug users.
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Affiliation(s)
- Drosos E Karageorgopoulos
- Drosos E Karageorgopoulos, Joanna Allen, Sanjay Bhagani, Department of Infectious Diseases/HIV Medicine, Royal Free London NHS Foundation Trust, London NW3 2QG, United Kingdom
| | - Joanna Allen
- Drosos E Karageorgopoulos, Joanna Allen, Sanjay Bhagani, Department of Infectious Diseases/HIV Medicine, Royal Free London NHS Foundation Trust, London NW3 2QG, United Kingdom
| | - Sanjay Bhagani
- Drosos E Karageorgopoulos, Joanna Allen, Sanjay Bhagani, Department of Infectious Diseases/HIV Medicine, Royal Free London NHS Foundation Trust, London NW3 2QG, United Kingdom
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