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Euvrard J, Timmerman V, Keene CM, Phelanyane F, Heekes A, Rice BD, Grimsrud A, Ehrenkranz P, Boulle A. The cyclical cascade of HIV care: Temporal care engagement trends within a population-wide cohort. PLoS Med 2024; 21:e1004407. [PMID: 38728361 PMCID: PMC11125544 DOI: 10.1371/journal.pmed.1004407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 05/24/2024] [Accepted: 04/22/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND The traditional HIV treatment cascade aims to visualise the journey of each person living with HIV from diagnosis, through initiation on antiretroviral therapy (ART) to treatment success, represented by virological suppression. This representation has been a pivotal tool in highlighting and quantifying sequential gaps along the care continuum. There is longstanding recognition, however, that this may oversimplify the complexity of real-world engagement with HIV services in settings with mature high-burden HIV epidemics. A complementary "cyclical" cascade has been proposed to represent the processes of disengagement at different points on the care continuum, with multiple pathways to re-engagement, although the feasibility of implementing this at scale has been uncertain. This study aimed to populate, refine, and explore the utility of a cyclical representation of the HIV cascade, using routine data from a high-burden HIV setting. METHODS AND FINDINGS This observational cohort study leveraged person-level data on all people living with HIV in the Western Cape (WC), South Africa, who accessed public health services in the 2 years prior to 31 December 2023. Programme data from disease registers were complemented by data from pharmacy and laboratory systems. At study closure, 494 370 people were included, constituting 93% of those of those estimated to be living with HIV in the province, of whom 355 104 were on ART. Substantial disengagement from HIV care was evident at every point on the cascade. Early treatment emerged as a period of higher risk of disengagement, but it did not account for the majority of disengagement. Almost all those currently disengaged had prior experience of treatment. While re-engagement was also common, overall treatment coverage had increased slowly over 5 years. The transition to dolutegravir-based regimens was dramatic with good virological outcomes for those in care, notwithstanding a clearly discernible impact of the Coronavirus Disease 2019 (COVID-19) pandemic on viral load (VL) testing. People currently engaged and disengaged in care are similar with respect to age and gender. Those who died or disengaged recently were previously distributed across a range of cascade statuses, and a substantial proportion of those newly initiating and re-initiating treatment were no longer on treatment 6 months later. The main limitation of this study was incomplete evidence of HIV testing, linkage to HIV-specific services, and out-of-facility mortality. CONCLUSIONS Using routine data, it was possible to populate and automate a cyclical cascade of HIV care that continuously captured the nonlinear care journeys of individuals living with HIV. In this generalised mature HIV epidemic, most people are treatment experienced. Disengagement is common and occurs at various points along the cascade, making it challenging to identify high-impact intervention opportunities. While historical HIV cascades remain valuable for target setting and service monitoring, they can be complemented with insights from more detailed cyclical cascades.
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Affiliation(s)
- Jonathan Euvrard
- School of Public Health, University of Cape Town, Cape Town, South Africa
- Department of Health, Provincial Government of the Western Cape, Cape Town, South Africa
| | - Venessa Timmerman
- School of Public Health, University of Cape Town, Cape Town, South Africa
- Department of Health, Provincial Government of the Western Cape, Cape Town, South Africa
| | - Claire Marriott Keene
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Florence Phelanyane
- School of Public Health, University of Cape Town, Cape Town, South Africa
- Department of Health, Provincial Government of the Western Cape, Cape Town, South Africa
| | - Alexa Heekes
- School of Public Health, University of Cape Town, Cape Town, South Africa
- Department of Health, Provincial Government of the Western Cape, Cape Town, South Africa
| | - Brian D. Rice
- School of Medicine and Population Health, University of Sheffield, Sheffield, United Kingdom
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Anna Grimsrud
- HIV Programmes and Advocacy, IAS–the International AIDS Society, Cape Town, South Africa
| | - Peter Ehrenkranz
- Global Health, Bill & Melinda Gates Foundation, Seattle, Washington State, United States of America
| | - Andrew Boulle
- School of Public Health, University of Cape Town, Cape Town, South Africa
- Department of Health, Provincial Government of the Western Cape, Cape Town, South Africa
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Hines AC, Rose AL, Regenauer KS, Brown I, Johnson K, Bonumwezi J, Ndamase S, Ciya N, Magidson JF, Myers B. " Early in the morning, there's tolerance and later in the day it disappears" - The intersection of resource scarcity, stress and stigma in mental health and substance use care in South Africa. Glob Ment Health (Camb) 2024; 11:e45. [PMID: 38690575 PMCID: PMC11058524 DOI: 10.1017/gmh.2024.41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 02/29/2024] [Accepted: 03/21/2024] [Indexed: 05/02/2024] Open
Abstract
Stress is a challenge among non-specialist health workers worldwide, particularly in low-resource settings. Understanding and targeting stress is critical for supporting non-specialists and their patients, as stress negatively affects patient care. Further, stigma toward mental health and substance use conditions also impacts patient care. However, there is little information on the intersection of these factors. This sub-analysis aims to explore how substance use and mental health stigma intersect with provider stress and resource constraints to influence the care of people with HIV/TB. We conducted semi-structured interviews (N=30) with patients (n=15) and providers (n=15, non-specialist health workers) within a low-resource community in Cape Town, South Africa. Data were analyzed using thematic analysis. Three key themes were identified: (1) resource constraints negatively affect patient care and contribute to non-specialist stress; (2) in the context of stress, non-specialists are hesitant to work with patients with mental health or substance use concerns, who they view as more demanding and (3) stress contributes to provider stigma, which negatively impacts patient care. Findings highlight the need for multilevel interventions targeting both provider stress and stigma toward people with mental health and substance use concerns, especially within the context of non-specialist-delivered mental health services in low-resource settings.
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Affiliation(s)
- Abigail C. Hines
- Department of Psychology, University of Maryland, College Park, MD, USA
| | - Alexandra L. Rose
- Department of Psychology, University of Maryland, College Park, MD, USA
| | | | - Imani Brown
- Department of Psychology, University of Maryland, College Park, MD, USA
| | - Kim Johnson
- Mental Health, Alcohol, Substance Use, Tobacco Research Unit, South African Medical Research Council, Parow, South Africa
| | - Jessica Bonumwezi
- Department of Psychology, University of Maryland, College Park, MD, USA
| | - Sibabalwe Ndamase
- Mental Health, Alcohol, Substance Use, Tobacco Research Unit, South African Medical Research Council, Parow, South Africa
| | - Nonceba Ciya
- Mental Health, Alcohol, Substance Use, Tobacco Research Unit, South African Medical Research Council, Parow, South Africa
| | - Jessica F. Magidson
- Department of Psychology, University of Maryland, College Park, MD, USA
- Center for Substance Use, Addiction & Health Research (CESAR), University of Maryland, College Park, MD, USA
| | - Bronwyn Myers
- Mental Health, Alcohol, Substance Use, Tobacco Research Unit, South African Medical Research Council, Parow, South Africa
- Curtin enAble Institute, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
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Rehman N, Garcia MC, Jones A, Ma J, Mertz D, Mbuagbaw L. Measures of retention in HIV care: A protocol for a mixed methods study. PLoS One 2024; 19:e0294824. [PMID: 38394108 PMCID: PMC10889855 DOI: 10.1371/journal.pone.0294824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 01/19/2024] [Indexed: 02/25/2024] Open
Abstract
INTRODUCTION Retention in HIV care is necessary to achieve adherence to antiretroviral therapy, viral load suppression, and optimal health outcomes. There is no standard definition for retention in HIV care, which compromises consistent and reliable reporting and comparison of retention across facilities, jurisdictions, and studies. OBJECTIVE The objective of this study is to explore how stakeholders involved in HIV care define retention in HIV care and their preferences on measuring retention. METHODS We will use an exploratory sequential mixed methods design involving HIV stakeholder groups such as people living with HIV, people involved in providing care for PLHIV, and people involved in decision-making about PLHIV. In the qualitative phase of the study, we will conduct 20-25 in-depth interviews to collect the perspectives of HIV stakeholders on using their preferred retention measures. The findings from the qualitative phase will inform the development of survey items for the quantitative phase. Survey participants (n = 385) will be invited to rate the importance of each approach to measuring retention on a seven-point Likert scale. We will merge the qualitative and quantitative findings phase findings to inform a consensus-building framework for a standard definition of retention in care. ETHICAL ISSUES AND DISSEMINATION This study has received ethics approval from the Hamilton Integrated Research Ethics Board. The findings will be disseminated through peer-reviewed publications, conference presentations, and among stakeholder groups. LIMITATIONS This study has limitations; we won't be able to arrive at a standard definition; a Delphi technique amongst the stakeholders will be utilized using the framework to reach a consensus globally accepted definition.
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Affiliation(s)
- Nadia Rehman
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | | | - Aaron Jones
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Jinhui Ma
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Dominik Mertz
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
- Centre for Development of Best Practices in Health (CDBPH), Yaoundé Central Hospital, Yaoundé, Cameroon
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
- Biostatistics Unit, Father Sean O’Sullivan Research Centre, St Joseph’s Healthcare, Hamilton, Ontario, Canada
- Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, Cape Town, South Africa
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Logie CH, Toccalino D, MacKenzie F, Hasham A, Narasimhan M, Donkers H, Lorimer N, Malama K. Associations between climate change-related factors and sexual health: A scoping review. Glob Public Health 2024; 19:2299718. [PMID: 38190290 DOI: 10.1080/17441692.2023.2299718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 12/21/2023] [Indexed: 01/10/2024]
Abstract
There is growing attention to the ways in which climate change may affect sexual health, yet key knowledge gaps remain across global contexts and climate issues. In response, we conducted a scoping review to examine the literature on associations between climate change and sexual health. We searched five databases (May 2021, September 2022). We reviewed 3,183 non-duplicate records for inclusion; n = 83 articles met inclusion criteria. Of these articles, n = 30 focused on HIV and other STIs, n = 52 focused on sexual and gender-based violence (GBV), and n = 1 focused on comprehensive sexuality education. Thematic analysis revealed that hurricanes, drought, temperature variation, flooding, and storms may influence HIV outcomes among people with HIV by constraining access to antiretroviral treatment and worsening mental health. Climate change was associated with HIV/STI testing barriers and worsened economic conditions that elevated HIV exposure (e.g. transactional sex). Findings varied regarding associations between GBV with storms and drought, yet most studies examining flooding, extreme temperatures, and bushfires reported positive associations with GBV. Future climate change research can examine understudied sexual health domains and a range of climate-related issues (e.g. heat waves, deforestation) for their relevance to sexual health. Climate-resilient sexual health approaches can integrate extreme weather events into programming.
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Affiliation(s)
- Carmen H Logie
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Canada
- Centre for Gender and Sexual Health Equity, Vancouver, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Canada
- United Nations University Institute for Water, Environment, and Health, Hamilton, Canada
| | - Danielle Toccalino
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Frannie MacKenzie
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Canada
| | - Aryssa Hasham
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Canada
| | - Manjulaa Narasimhan
- Department of Sexual and Reproductive Health and Research, World Health Organization, includes the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Geneva, Switzerland
| | - Holly Donkers
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Canada
| | - Nicole Lorimer
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Canada
| | - Kalonde Malama
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Canada
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Kalinjuma AV, Glass TR, Masanja H, Weisser M, Msengwa AS, Vanobberghen F, Otwombe K. Statistical methods applied for the assessment of the HIV cascade and continuum of care: a systematic scoping review. BMJ Open 2023; 13:e071392. [PMID: 37996221 PMCID: PMC10668296 DOI: 10.1136/bmjopen-2022-071392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 09/28/2023] [Indexed: 11/25/2023] Open
Abstract
OBJECTIVES This scoping review aims to identify and synthesise existing statistical methods used to assess the progress of HIV treatment programmes in terms of the HIV cascade and continuum of care among people living with HIV (PLHIV). DESIGN Systematic scoping review. DATA SOURCES Published articles were retrieved from PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Complete and Excerpta Medica dataBASE (EMBASE) databases between April and July 2022. We also strategically search using the Google Scholar search engine and reference lists of published articles. ELIGIBILITY CRITERIA This scoping review included original English articles that estimated and described the HIV cascade and continuum of care progress in PLHIV. The review considered quantitative articles that evaluated either HIV care cascade progress in terms of the Joint United Nations Programme on HIV and AIDS targets or the dynamics of engagement in HIV care. DATA EXTRACTION AND SYNTHESIS The first author and the librarian developed database search queries and screened the retrieved titles and abstracts. Two independent reviewers and the first author extracted data using a standardised data extraction tool. The data analysis was descriptive and the findings are presented in tables and visuals. RESULTS This review included 300 articles. Cross-sectional study design methods were the most commonly used to assess the HIV care cascade (n=279, 93%). In cross-sectional and longitudinal studies, the majority used proportions to describe individuals at each cascade stage (276/279 (99%) and 20/21 (95%), respectively). In longitudinal studies, the time spent in cascade stages, transition probabilities and cumulative incidence functions was estimated. The logistic regression model was common in both cross-sectional (101/279, 36%) and longitudinal studies (7/21, 33%). Of the 21 articles that used a longitudinal design, six articles used multistate models, which included non-parametric, parametric, continuous-time, time-homogeneous and discrete-time multistate Markov models. CONCLUSIONS Most literature on the HIV cascade and continuum of care arises from cross-sectional studies. The use of longitudinal study design methods in the HIV cascade is growing because such methods can provide additional information about transition dynamics along the cascade. Therefore, a methodological guide for applying different types of longitudinal design methods to the HIV continuum of care assessments is warranted.
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Affiliation(s)
- Aneth Vedastus Kalinjuma
- Department of Interventions and Clinical Trials, Ifakara Health Institute, Ifakara, Dar es Salaam, United Republic of Tanzania
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Tracy Renée Glass
- Medicines Department, Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Honorati Masanja
- Department of Interventions and Clinical Trials, Ifakara Health Institute, Ifakara, Dar es Salaam, United Republic of Tanzania
| | - Maja Weisser
- Department of Interventions and Clinical Trials, Ifakara Health Institute, Ifakara, Dar es Salaam, United Republic of Tanzania
- Medicines Department, Swiss Tropical and Public Health Institute, Basel, Switzerland
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Amina Suleiman Msengwa
- Department of Statistics, University of Dar es Salaam, Dar es Salaam, United Republic of Tanzania
| | - Fiona Vanobberghen
- Medicines Department, Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Kennedy Otwombe
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
- Perinatal HIV Research Unit, Chris Hani Baragwanath Academic Hospital, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Beidelman ET, Bärnighausen T, Wing C, Tollman S, Phillips ML, Rosenberg M. Disease awareness and healthcare utilization in rural South Africa: a comparative analysis of HIV and diabetes in the HAALSI cohort. BMC Public Health 2023; 23:2202. [PMID: 37940928 PMCID: PMC10634006 DOI: 10.1186/s12889-023-17043-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 10/21/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Studies from rural South Africa indicate that people living with HIV (PLHIV) may have better health outcomes than those without, potentially due to the frequent healthcare visits necessitated by infection. Here, we examined the association between HIV status and healthcare utilization, using diabetes as an illustrative comparator of another high-burden, healthcare-intensive disease. METHODS Our exposure of interest was awareness of positive disease status for both HIV and diabetes. We identified 742 individuals who were HIV-positive and aware of their status and 305 who had diabetes and were aware of their status. HIV-positive status was further grouped by viral suppression. For each disease, we estimated the association with (1) other comorbid, chronic conditions, (2) health facility visits, (3) household-level healthcare expenditure, and (4) per-visit healthcare expenditure. We used log-binomial regression models to estimate prevalence ratios for co-morbid chronic conditions. Linear regression models were used for all other outcomes. RESULTS Virally suppressed PLHIV had decreased prevalence of chronic conditions, increased public clinic visits [β = 0.59, 95% CI: 0.5, 0.7], and reduced per-visit private clinic spending [β = -60, 95% CI: -83, -6] compared to those without HIV. No differences were observed in hospitalizations and per-visit spending at hospitals and public clinics between virally suppressed PLHIV and non-PLHIV. Conversely, diabetic individuals had increased prevalence of chronic conditions, increased visits across facility types, increased household-level expenditures (β = 88 R, 95% CI: 29, 154), per-visit hospital spending (β = 54 R, 95% CI: 7, 155), and per-visit public clinic spending (β = 31 R, 95% CI: 2, 74) compared to those without diabetes. CONCLUSIONS Our results suggest that older adult PLHIV may visit public clinics more often than their HIV-negative counterparts but spend similarly on a per-visit basis. This provides preliminary evidence that the positive health outcomes observed among PLHIV in rural South Africa may be explained by different healthcare engagement patterns. Through our illustrative comparison between PLHIV and diabetics, we show that shifting disease burdens towards chronic and historically underfunded diseases, like diabetes, may be changing the landscape of health expenditure inequities.
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Affiliation(s)
- Erika T Beidelman
- Department of Epidemiology and Biostatistics, Indiana University School of Public Health - Bloomington, 1025 E. 7th St, Bloomington, IN, 47405, USA.
| | - Till Bärnighausen
- Heidelberg Institute of Global Health (HIGH), Heidelberg University, Heidelberg, Germany
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt School of Public Health), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Coady Wing
- O'Neill School of Public and Environmental Affairs, Indiana University-Bloomington, Bloomington, USA
| | - Stephen Tollman
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt School of Public Health), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH Network, Accra, Ghana
| | - Meredith L Phillips
- Department of Epidemiology and Biostatistics, Indiana University School of Public Health - Bloomington, 1025 E. 7th St, Bloomington, IN, 47405, USA
| | - Molly Rosenberg
- Department of Epidemiology and Biostatistics, Indiana University School of Public Health - Bloomington, 1025 E. 7th St, Bloomington, IN, 47405, USA
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt School of Public Health), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Keene CM, Euvrard J, Amico KR, Ragunathan A, English M, McKnight J, Orrell C. Conceptualising engagement with HIV care for people on treatment: the Indicators of HIV Care and AntiRetroviral Engagement (InCARE) Framework. BMC Health Serv Res 2023; 23:435. [PMID: 37143067 PMCID: PMC10161576 DOI: 10.1186/s12913-023-09433-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 04/14/2023] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND As the crisis-based approach to HIV care evolves to chronic disease management, supporting ongoing engagement with HIV care is increasingly important to achieve long-term treatment success. However, 'engagement' is a complex concept and ambiguous definitions limit its evaluation. To guide engagement evaluation and development of interventions to improve HIV outcomes, we sought to identify critical, measurable dimensions of engagement with HIV care for people on treatment from a health service-delivery perspective. METHODS We used a pragmatic, iterative approach to develop a framework, combining insights from researcher experience, a narrative literature review, framework mapping, expert stakeholder input and a formal scoping review of engagement measures. These inputs helped to refine the inclusion and definition of important elements of engagement behaviour that could be evaluated by the health system. RESULTS The final framework presents engagement with HIV care as a dynamic behaviour that people practice rather than an individual characteristic or permanent state, so that people can be variably engaged at different points in their treatment journey. Engagement with HIV care for those on treatment is represented by three measurable dimensions: 'retention' (interaction with health services), 'adherence' (pill-taking behaviour), and 'active self-management' (ownership and self-management of care). Engagement is the product of wider contextual, health system and personal factors, and engagement in all dimensions facilitates successful treatment outcomes, such as virologic suppression and good health. While retention and adherence together may lead to treatment success at a particular point, this framework hypothesises that active self-management sustains treatment success over time. Thus, evaluation of all three core dimensions is crucial to realise the individual, societal and public health benefits of antiretroviral treatment programmes. CONCLUSIONS This framework distils a complex concept into three core, measurable dimensions critical for the maintenance of engagement. It characterises elements that the system might assess to evaluate engagement more comprehensively at individual and programmatic levels, and suggests that active self-management is an important consideration to support lifelong optimal engagement. This framework could be helpful in practice to guide the development of more nuanced interventions that improve long-term treatment success and help maintain momentum in controlling a changing epidemic.
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Affiliation(s)
- Claire M Keene
- Oxford Centre for Global Health Research, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Jonathan Euvrard
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - K Rivet Amico
- Health Behaviour and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Ayesha Ragunathan
- Oxford Centre for Global Health Research, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Mike English
- Oxford Centre for Global Health Research, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Jacob McKnight
- Oxford Centre for Global Health Research, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Catherine Orrell
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Keene CM, Ragunathan A, Euvrard J, English M, McKnight J, Orrell C. Measuring patient engagement with HIV care in sub-Saharan Africa: a scoping study. J Int AIDS Soc 2022; 25:e26025. [PMID: 36285618 PMCID: PMC9597383 DOI: 10.1002/jia2.26025] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 09/27/2022] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Engagement with HIV care is a multi-dimensional, dynamic process, critical to maintaining successful treatment outcomes. However, measures of engagement are not standardized nor comprehensive. This undermines our understanding of the scope of challenges with engagement and whether interventions have an impact, complicating patient and programme-level decision-making. This study identified and characterized measures of engagement to support more consistent and comprehensive evaluation. METHODS We conducted a scoping study to systematically categorize measures the health system could use to evaluate engagement with HIV care for those on antiretroviral treatment. Key terms were used to search literature databases (Embase, PsychINFO, Ovid Global-Health, PubMed, Scopus, CINAHL, Cochrane and the World Health Organization Index Medicus), Google Scholar and stakeholder-identified manuscripts, ultimately including English evidence published from sub-Saharan Africa from 2014 to 2021. Measures were extracted, organized, then reviewed with key stakeholders. RESULTS AND DISCUSSION We screened 14,885 titles/abstracts, included 118 full-texts and identified 110 measures of engagement, categorized into three engagement dimensions ("retention," "adherence" and "active self-management"), a combination category ("multi-dimensional engagement") and "treatment outcomes" category (e.g. viral load as an end-result reflecting that engagement occurred). Retention reflected status in care, continuity of attendance and visit timing. Adherence was assessed by a variety of measures categorized into primary (prescription not filled) and secondary measures (medication not taken as directed). Active self-management reflected involvement in care and self-management. Three overarching use cases were identified: research to make recommendations, routine monitoring for quality improvement and strategic decision-making and assessment of individual patients. CONCLUSIONS Heterogeneity in conceptualizing engagement with HIV care is reflected by the broad range of measures identified and the lack of consensus on "gold-standard" indicators. This review organized metrics into five categories based on the dimensions of engagement; further work could identify a standardized, minimum set of measures useful for comprehensive evaluation of engagement for different use cases. In the interim, measurement of engagement could be advanced through the assessment of multiple categories for a more thorough evaluation, conducting sensitivity analyses with commonly used measures for more comparable outputs and using longitudinal measures to evaluate engagement patterns. This could improve research, programme evaluation and nuanced assessment of individual patient engagement in HIV care.
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Affiliation(s)
- Claire M. Keene
- Health Systems CollaborativeOxford Centre for Global Health ResearchNuffield Department of MedicineUniversity of OxfordOxfordUnited Kingdom
| | - Ayesha Ragunathan
- Health Systems CollaborativeOxford Centre for Global Health ResearchNuffield Department of MedicineUniversity of OxfordOxfordUnited Kingdom
| | - Jonathan Euvrard
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| | - Mike English
- Health Systems CollaborativeOxford Centre for Global Health ResearchNuffield Department of MedicineUniversity of OxfordOxfordUnited Kingdom
| | - Jacob McKnight
- Health Systems CollaborativeOxford Centre for Global Health ResearchNuffield Department of MedicineUniversity of OxfordOxfordUnited Kingdom
| | - Catherine Orrell
- Department of MedicineFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
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Keene CM, Ragunathan A, Euvrard J, English M, McKnight J, Orrell C. Measuring patient engagement with HIV care in sub-Saharan Africa: a scoping study. J Int AIDS Soc 2022; 25:e26025. [PMID: 36285618 PMCID: PMC9597383 DOI: 10.1002/jia2.26025/full|10.1002/jia2.26025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 09/27/2022] [Indexed: 05/22/2023] Open
Abstract
INTRODUCTION Engagement with HIV care is a multi-dimensional, dynamic process, critical to maintaining successful treatment outcomes. However, measures of engagement are not standardized nor comprehensive. This undermines our understanding of the scope of challenges with engagement and whether interventions have an impact, complicating patient and programme-level decision-making. This study identified and characterized measures of engagement to support more consistent and comprehensive evaluation. METHODS We conducted a scoping study to systematically categorize measures the health system could use to evaluate engagement with HIV care for those on antiretroviral treatment. Key terms were used to search literature databases (Embase, PsychINFO, Ovid Global-Health, PubMed, Scopus, CINAHL, Cochrane and the World Health Organization Index Medicus), Google Scholar and stakeholder-identified manuscripts, ultimately including English evidence published from sub-Saharan Africa from 2014 to 2021. Measures were extracted, organized, then reviewed with key stakeholders. RESULTS AND DISCUSSION We screened 14,885 titles/abstracts, included 118 full-texts and identified 110 measures of engagement, categorized into three engagement dimensions ("retention," "adherence" and "active self-management"), a combination category ("multi-dimensional engagement") and "treatment outcomes" category (e.g. viral load as an end-result reflecting that engagement occurred). Retention reflected status in care, continuity of attendance and visit timing. Adherence was assessed by a variety of measures categorized into primary (prescription not filled) and secondary measures (medication not taken as directed). Active self-management reflected involvement in care and self-management. Three overarching use cases were identified: research to make recommendations, routine monitoring for quality improvement and strategic decision-making and assessment of individual patients. CONCLUSIONS Heterogeneity in conceptualizing engagement with HIV care is reflected by the broad range of measures identified and the lack of consensus on "gold-standard" indicators. This review organized metrics into five categories based on the dimensions of engagement; further work could identify a standardized, minimum set of measures useful for comprehensive evaluation of engagement for different use cases. In the interim, measurement of engagement could be advanced through the assessment of multiple categories for a more thorough evaluation, conducting sensitivity analyses with commonly used measures for more comparable outputs and using longitudinal measures to evaluate engagement patterns. This could improve research, programme evaluation and nuanced assessment of individual patient engagement in HIV care.
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Affiliation(s)
- Claire M. Keene
- Health Systems CollaborativeOxford Centre for Global Health ResearchNuffield Department of MedicineUniversity of OxfordOxfordUnited Kingdom
| | - Ayesha Ragunathan
- Health Systems CollaborativeOxford Centre for Global Health ResearchNuffield Department of MedicineUniversity of OxfordOxfordUnited Kingdom
| | - Jonathan Euvrard
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| | - Mike English
- Health Systems CollaborativeOxford Centre for Global Health ResearchNuffield Department of MedicineUniversity of OxfordOxfordUnited Kingdom
| | - Jacob McKnight
- Health Systems CollaborativeOxford Centre for Global Health ResearchNuffield Department of MedicineUniversity of OxfordOxfordUnited Kingdom
| | - Catherine Orrell
- Department of MedicineFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
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Implementation Science for the Prevention and Treatment of HIV among Adolescents and Young Adults in Sub-Saharan Africa: A Scoping Review. AIDS Behav 2022; 27:7-23. [PMID: 35947233 DOI: 10.1007/s10461-022-03770-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2022] [Indexed: 11/01/2022]
Abstract
Despite many evidence-based adolescent and young adult (AYA) HIV interventions, few are implemented at scale in sub-Saharan Africa (SSA). A growing implementation science literature provides important context for scaling up AYA HIV interventions in this high HIV-burden region. This scoping review examined the use of implementation research in AYA HIV studies conducted in SSA. We searched five databases and included articles which focused on AYA (10-24 years old), addressed HIV prevention or treatment, were conducted exclusively in SSA countries, and included an implementation science outcome. We included 44 articles in 13 SSA countries. Most were in East (52.3%) and South Africa (27.3%), and half focused exclusively on HIV prevention components of the care continuum. Acceptability and feasibility were the most cited implementation science outcomes. Only four articles used an established implementation science framework. The findings informed our recommendations to guide the design, implementation, and dissemination of further studies and health policymaking.
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11
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Cardenas BF, Geba M, Williams B, Hoang S, Newberry Y, Quass-Ferdinand L, Woodberry L, Dillingham R, Thomas TA. Evaluating the cascade of care for anal cancer screening within a Ryan White HIV/AIDS Program clinic. Int J STD AIDS 2022; 33:906-913. [PMID: 35833535 DOI: 10.1177/09564624221114192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Care cascades can inform providers about differences in engagement and retention in care between patient populations thereby improving participation by targeting interventions more effectively. The objective of this study was to assess the uptake and retention of participants along the anal cancer screening algorithm within a single HIV clinic. METHODS Retrospective procedural and demographic data were collected within a Ryan White HIV/AIDS Program clinic from 18 December 2017 to 29 May 2021. A care cascade was constructed among eligible participants who engaged and were retained in the anal cancer screening algorithm. Engagement was defined as having at least one anal Pap smear. Retention was defined as having a follow-up anal Pap smear, and/or high resolution anoscopy, as indicated. Risk ratios (RR) were calculated to reveal factors associated with initiation and retention in screening. RESULTS Of 821 eligible participants, 312 (38%) engaged in screening and 205 (66%) were retained in care. Anoreceptive intercourse was positively associated with engagement (RR 2.81, 95% confidence interval [CI] 2.05-3.90, p<0.001), whereas male gender was negatively associated (RR 0.26, 95% CI 0.20-0.33, p<0.001). Abnormal cytology results on Pap smear were associated with retention (RR 1.39, 95% CI 1.03-1.86, p=0.03). CONCLUSIONS Overall engagement in anal cancer screening is low within our clinic, particularly among men, but retention in the screening program is notably better, especially among those with abnormal cytology. Target populations have been identified to increase awareness, and qualitative studies are underway to understand perceptions and barriers to engagement in anal cancer screening.
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Affiliation(s)
| | - Maria Geba
- Division of Infectious Diseases and International Health, 2358University of Virginia, Charlottesville, VA, USA
| | - Brooke Williams
- Ryan White HIV/AIDS Program, 2358University of Virginia12350Health System, Charlottesville, VA, USA
| | - Sook Hoang
- Department of Surgery, 2358University of Virginia, Charlottesville, VA, USA
| | - Yvonne Newberry
- Division of Infectious Diseases and International Health, 2358University of Virginia, Charlottesville, VA, USA
| | - Laura Quass-Ferdinand
- Ryan White HIV/AIDS Program, 2358University of Virginia12350Health System, Charlottesville, VA, USA
| | - Lauren Woodberry
- Ryan White HIV/AIDS Program, 2358University of Virginia12350Health System, Charlottesville, VA, USA
| | - Rebecca Dillingham
- Division of Infectious Diseases and International Health, 2358University of Virginia, Charlottesville, VA, USA
| | - Tania A Thomas
- Division of Infectious Diseases and International Health, 2358University of Virginia, Charlottesville, VA, USA
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Taghavi K, Mandiriri A, Shamu T, Rohner E, Bütikofer L, Asangbeh S, Magure T, Chimbetete C, Egger M, Pascoe M, Bohlius J. Cervical Cancer Screening Cascade for women living with HIV: a cohort study from Zimbabwe. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000156. [PMID: 36860760 PMCID: PMC9974171 DOI: 10.1371/journal.pgph.0000156] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Countries with high HIV prevalence, predominantly in sub-Sahahran Africa, have the highest cervical cancer rates globally. HIV care cascades successfully facilitated the scale-up of antiretroviral therapy. A cascade approach could similarly succeed to scale-up cervical cancer screening, supporting WHO's goal to eliminate cervical cancer. We defined a Cervical Cancer Screening Cascade for women living with HIV (WLHIV), evaluating the continuum of cervical cancer screening integrated into an HIV clinic in Zimbabwe. We included WLHIV aged ≥18 years enrolled at Newlands Clinic in Harare from June 2012-2017 and followed them until June 2018. We used a cascade approach to evaluate the full continuum of secondary prevention from screening to treatment of pre-cancer and follow-up. We report percentages, median time to reach cascade stages, and cumulative incidence at two years with 95% confidence intervals (CI). We used univariable Cox proportional hazard regressions to calculate cause-specific hazard ratios with 95% CIs for factors associated with completing the cascade stages. We included 1624 WLHIV in the study. The cumulative incidence of cervical screening was 85.4% (95% CI 83.5-87.1) at two years. Among the 396 WLHIV who received screen-positive tests in the study, the cumulative incidence of treatment after a positive screening test was 79.5% (95% CI 75.1-83.2) at two years. The cumulative incidence of testing negative at re-screening after treatment was 36.1% (95% CI 31.2-40.7) at two years. Using a cascade approach to evaluate the full continuum of cervical cancer screening, we found less-than 80% of WLHIV received treatment after screen-positive tests and less-than 40% were screen-negative at follow-up. Interventions to improve linkage to treatment for screen-positive WLHIV and studies to understand the clinical significance of screen-positive tests at follow-up among WLHIV are needed. These gaps in the continuum of care must be addressed in order to prevent cervical cancer.
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Affiliation(s)
- Katayoun Taghavi
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- The Graduate School for Cellular and Biomedical Sciences of the University of Bern, Bern, Switzerland
- * E-mail:
| | | | - Tinei Shamu
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Newlands Clinic, Harare, Zimbabwe
- The Graduate School for Health Sciences of the University of Bern, Bern, Switzerland
| | - Eliane Rohner
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | | | - Serra Asangbeh
- The Graduate School for Cellular and Biomedical Sciences of the University of Bern, Bern, Switzerland
- Swiss Tropical and Public Health Institute, Basel, Switzerland
| | | | | | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Centre for Infectious Disease Epidemiology and Research, School of Public Health, University of Cape Town, Cape Town, South Africa
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | | | - Julia Bohlius
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
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Ford N, Eshun-Wilson I, Ameyan W, Newman M, Vojnov L, Doherty M, Geng E. Future directions for HIV service delivery research: Research gaps identified through WHO guideline development. PLoS Med 2021; 18:e1003812. [PMID: 34555010 PMCID: PMC8496797 DOI: 10.1371/journal.pmed.1003812] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Revised: 10/07/2021] [Indexed: 11/19/2022] Open
Abstract
Nathan Ford and co-authors discuss the systematic identification of research gaps in improving HIV service delivery.
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Affiliation(s)
- Nathan Ford
- Department of HIV, Viral Hepatitis and STIs, World Health Organization, Geneva, Switzerland
| | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Wole Ameyan
- Department of HIV, Viral Hepatitis and STIs, World Health Organization, Geneva, Switzerland
| | - Morkor Newman
- Department of HIV, Viral Hepatitis and STIs, World Health Organization, Geneva, Switzerland
| | - Lara Vojnov
- Department of HIV, Viral Hepatitis and STIs, World Health Organization, Geneva, Switzerland
| | - Meg Doherty
- Department of HIV, Viral Hepatitis and STIs, World Health Organization, Geneva, Switzerland
| | - Elvin Geng
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, United States of America
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