Person-centred, integrated non-communicable disease and HIV decentralized drug distribution in Eswatini and South Africa: outcomes and challenges

Cost-Effectiveness of Universal Screen-and-Treat Strategies for Reducing Morbidity and Mortality of Chronic Hepatitis B in a High-Endemicity City

In the setting of high hepatitis B virus (HBV) endemicity, we studied the cost-effectiveness of universal HBV screen-and-treat strategies for averting HBV-related morbidity and mortality in Hong Kong, where diagnosis and treatment coverages are low. An age-sex-specific compartmental model for 2000-2040 was developed, with the incorporation of population-based screening strategies targeting different age groups. With a one-time HBV screening programme in 2025-2029, 3.6%-8.9% of HBV-related deaths could be averted. We evaluated the cost-effectiveness of the screening strategies with primary-care-based management in different scenarios with components of annual drug cost levels, screening programme duration, starting year and targeted age groups. Incremental cost-effectiveness ratio (ICER) was calculated, with the willingness-to-pay (WTP) threshold set at USD100,000/quality-adjusted life years (QALY). At the standard drug cost level, only the screening strategy targeting the 40-49 years old is cost-saving. When drug cost decreases to a low level, the strategy targeting the 35-49 years old (ICER USD97,042/QALY gained) is likely to be cost-effective and screening 35-59 years old is marginally cost-effective. In probabilistic sensitivity analysis, screening 40-49 years old (50%) and 35-59 years old (42%) have a half-half probability of being the most cost-effective at USD100,000/QALY WTP threshold, but increased to 93% for screening 35-59 years old at USD150,000/QALY threshold. From scenario analysis, deferred initiation of screening and unlimited programme duration would increase the ICER. Universal HBV screening targeting individuals aged 35-59 years or 40-49 years in the general population, with an earlier start and limited duration of the programme, is likely to be cost-effective.

Early initiation of fast-track care for persons living with HIV initiating dolutegravir-based regimens during a period of severe civil unrest in Port-au-Prince, Haiti: a pilot randomized trial

INTRODUCTION

Differentiated service delivery (DSD) models have been widely implemented for patients in stable HIV care. However, DSD has rarely been offered to newly diagnosed patients. We assessed the effectiveness of early fast-track care during a period of severe civil unrest in Port-au-Prince, Haiti.

METHODS

We conducted a pilot randomized trial among adults presenting with early HIV disease to determine whether early fast-track care (8-12 weeks after same-day HIV testing and antiretroviral therapy [ART] initiation) was associated with superior outcomes compared with standard (deferred eligibility for fast-track care). All participants received tenofovir/lamivudine/dolutegravir (TLD), and HIV-1 RNA <200 copies/ml was required prior to initiating fast-track care. The primary outcome was 48-week HIV-1 RNA <200 copies/ml, with intention-to-treat analysis.

RESULTS

From December 2020 to August 2022, 245 participants were randomized to standard (n = 116) and early fast-track (n = 129) groups. All initiated TLD on the day of HIV diagnosis. In the early fast-track group, one (0.8%) died, 12 (9.3%) were internally displaced/emigrated, five (3.9%) were lost-to-follow-up (LTFU), two (1.6%) had a gap in care/later return, one (0.8%) was transferred and 108 (83.7%) were retained; 88 (68.2%) received 48-week viral load testing and 80 (90.9% of tested; 62.0% of randomized) had HIV-1 RNA <200 copies/ml. In the standard group, two (1.7%) died, six (5.2%) were internally displaced/emigrated, three (2.6%) were LTFU, one (0.9%) had a gap in care/later return, one (0.9%) was transferred and 103 (88.8%) were retained; 78 (67.2%) received 48-week viral load testing and 66 (84.6% of tested; 56.9% of randomized) had HIV-1 RNA <200 copies/ml. By design, the sample size of this pilot study was too small to provide definitive evidence of treatment effect, but the primary outcome was numerically higher in the early fast-track group (62.0% vs. 56.9%; RD: 0.051: 95% CI: -0.072, 0.174).

CONCLUSIONS

Early fast-track care was associated with high levels of viral suppression among adults initiating same-day TLD, despite severe civil unrest in Haiti. Completion of 48-week viral load testing was suboptimal, due to the need for participants to leave Port-au-Prince during peak periods of gang-related violence, and the lack of availability of viral load testing for those receiving non-facility-based ART.

Differentiated HIV Service Delivery vs Conventional Care: Tuberculosis Preventive Therapy Outcomes for People Living with HIV in Sub-Saharan Africa

Introduction

Differentiated service delivery (DSD) models, which are mechanisms of HIV care that reduce provider visits and offer varied ART delivery methods, are scaling up across sub-Saharan Africa. It is unknown how the movement of patients to DSD models impacts services beyond ART, including the uptake and completion of tuberculosis preventive therapy (TPT).

Methods

Using the RE-AIM framework, we analyzed data from Opt4TPT, a longitudinal cohort study examining TPT delivery in South Africa and Zimbabwe. We constructed multivariate logistic regression models to evaluate the association of receiving ART from a DSD model with the proportion of participants who initiated and completed TPT, as measured by electronic medication boxes. We constructed a Cox proportional hazards model to assess the association between DSD models and time to TPT initiation.

Results

Among 1193 participants, 276 received ART through a DSD model, while 917 used the conventional model. Overall, 1035 (87%) initiated TPT, including 242 (88%) in DSD models and 793 (86%) in conventional models. Receiving ART from a DSD model was not significantly associated (OR 1.11, 95% CI 0.74-1.67, p = 0.61) with TPT initiation. DSD models had a significantly longer mean time to initiation (6.5 vs. 2.7 days, p = 0.01). Of the 731 (71%) participants with MERM box data, 356 (49%) completed TPT. Bivariate analysis showed significantly higher odds of completing TPT among those in DSD models (OR 1.53, 95% CI 1.06-2.21, p=0.024). This association was not significant in multivariate analysis after adjusting for demographic and clinical factors (OR 0.89, 95% CI 0.58-1.36, p=0.58).

Conclusions

We found high TPT uptake in DSD and conventional models of care, indicating that TPT delivery in DSD models is feasible. We found low TPT completion in both models of care, showing a need to focus on improving TPT completion overall.

Preferences for Delivery of HIV Prevention Services Among Healthcare Users in South Africa: A Discrete Choice Experiment

Progress has been made to scale oral pre-exposure prophylaxis (PrEP) as part of combination HIV prevention, with the WHO recommending differentiated, simplified and demedicalized approaches. This study explored user preferences for components of a PrEP service delivery package, through a discrete choice experiment (DCE) among 307 people accessing primary healthcare services in South Africa between November 2022 and February 2023. Attributes included were: Source of information about HIV prevention and PrEP; Site for PrEP initiation and follow-up; Frequency of follow-up; PrEP pick-up point; HIV testing whilst using PrEP; Contact between appointments. A D-efficient DCE design was created with 16 choice sets in 2 blocks. DCE data were analysed using generalised multinomial logistic models. Compared to printed materials, participants preferred getting information about PrEP online (aOR = 7.73, 95% CI = 5.13-11.66) and through WhatsApp (aOR = 2.23, 95% CI = 0.98-5.55). PrEP initiation at a pharmacy or mobile clinic was valued equally to initiating PrEP at a clinic, but a community pop-up site was less preferred (aOR = 0.46, 95% CI = 0.33-0.64). There was a preference for 6-monthly over 3-monthly follow-up (aOR = 11.88, 95% CI = 5.44-25.94). Participants preferred collecting PrEP from a pharmacy (aOR = 5.02, 95% CI = 3.45-7.31), through home delivery (aOR = 2.18, 95% CI = 1.26-3.78) and from a vending machine (aOR = 1.43, 95% CI = 1.02-1.99) relative to where they initiated PrEP. Participants also preferred HIV self-testing over a healthcare provider test (aOR = 5.57, 95% CI = 3.72, 8.36). WhatsApp or Facebook groups (aOR = 4.12, 95% CI = 3.00-5.67), monthly phone calls (aOR = 2.84, 95% CI = 1.73-4.67) and weekly messages (aOR = 1.47, 95% CI = 1.10-1.97) were preferred contact between appointments, relative to no contact. To meet users' preferences, there is a need to expand decentralised and self-led HIV prevention services.

Does type of antiretroviral therapy pick-up point influence 12-month virologic suppression in South Africa?

We assessed the impact of community- versus clinic-based medication pick-up on rates of virologic suppression in an observational cohort of adults on ART enrolled in a decentralized antiretroviral therapy program (CCMDD) in South Africa. Participants either attended clinics where they were given the choice to pick up ART in community venues or traditional clinics, or clinics where this pathway was assigned. Among 1856 participants, 977 (53%) opted for community ART pick-up at enrollment, and 1201 (86%) were virologically suppressed at one year. Because of missing data on virologic suppression, primary results are based on a model incorporating multiple imputation. In addition to age and gender, distance from clinic and year of HIV diagnosis were included in the multivariable model. There was no difference in opting for clinic- vs. community-based pick-up with regard to achieving 12-month virologic suppression (aRR 1.02, 95% CI 0.98-1.05) in clinics offering choice. There was no impact of assigning all participants to an external pick-up point (aRR 1.00, 95% CI 0.95-1.06), but virologic suppression was reduced in the clinic that assigned participants to clinic pick-up (aRR 0.87, 95% CI 0.81-0.92). These results suggest that provision of community-based ART has not reduced continued virologic suppression in the population enrolled in the CCMDD program.

'Not taking medications and taking medication, it was the same thing:' perspectives of antiretroviral therapy among people hospitalised with advanced HIV disease

BACKGROUND

Despite HIV's evolution to a chronic disease, the burden of advanced HIV disease (AHD, defined as a CD4 count of < 200 cells/uL or WHO clinical Stage 3 or 4 disease), remains high among People Living with HIV (PLHIV) who have previously been prescribed antiretroviral therapy (ART). As little is known about the experiences of patients hospitalised with AHD, this study sought to discern social forces driving hospitalisation with AHD. Understanding such forces could inform strategies to reduce HIV-related morbidity and mortality.

METHODS

We conducted a qualitative study with patients hospitalised with AHD who had a history of poor adherence. Semi-structured interviews were conducted between October 1 and November 30, 2023. The Patient Health Engagement and socio-ecological theoretical models were used to guide a thematic analysis of interview transcripts.

RESULTS

Twenty individuals participated in the research. Most reported repeated periods of disengagement with HIV services. The major themes identified as driving disengagement included: 1) feeling physically well; 2) life circumstances and relationships; and 3) health system factors, such as clinic staff attitudes and a perceived lack of flexible care. Re-engagement with care was often driven by new physical symptoms but was mediated through life circumstances/relationships and aspects of the health care system.

CONCLUSIONS

Current practices fail to address the challenges to lifelong engagement in HIV care. A bold strategy for holistic care which involves people living with advanced HIV as active members of the health care team (i.e. 'PLHIV as Partners'), could contribute to ensuring health care services are compatible with their lives, reducing periods of disengagement from care.

Mapping evidence on barriers to and facilitators of diagnosing noncommunicable diseases among people living with human immunodeficiency virus in low- and middle-income countries in Africa: A scoping review

Objectives

To map the evidence on the barriers to and facilitators of diagnosing noncommunicable diseases among people living with HIV in low- and middle-income countries in Africa.

Introduction

Noncommunicable diseases are increasing among people living with HIV. Thus, strengthened and sustained diagnosis of noncommunicable diseases through integrated noncommunicable diseases and HIV care is needed to improve patient outcomes. However, there is paucity of evidence on the barriers and facilitators diagnosing noncommunicable diseases among people living with HIV in low- and middle-income countries.

Methods

The Arksey and O'Malley methodological framework was used. A comprehensive systematic search of academic databases (MEDLINE, Academic Search Complete, APA PsycInfo, CAB, and Health Source/Nursing) was performed via EBSCO search and PubMed. The articles were reviewed independently by three reviewers. The results were structured using Capability-Opportunity-Motivation-Behavior model and Theoretical Domains Framework.

Results

A total of 152 articles were retrieved for full-text review. Forty-one articles met the inclusion criteria. The identified barriers were relevant to all the Capability-Opportunity-Motivation-Behavior constructs and 14 Theoretical Domains Framework domains. A lack of knowledge and awareness of noncommunicable diseases, fear of stigma, financial problems and out-of-pocket payments were the most cited patient-level barriers. Healthcare providers (knowledge and awareness gaps, skill and competence deficiencies, unwillingness, burnout, low motivation, and apathy) were frequently cited. Lack of equipment, noncommunicable disease medications and supply chain challenges, lack of integrated noncommunicable disease and HIV care, and shortage of trained healthcare providers were identified as health-system-level barriers.

Conclusion

This scoping review is the first to identify barriers and facilitators using a theoretical framework. The most cited barriers include a lack of integrated HIV and noncommunicable disease care, equipment and logistics chain challenges for noncommunicable diseases, patients' and healthcare providers' lack of knowledge and awareness of noncommunicable diseases, and healthcare provider's skill and competency deficiencies. Addressing these issues is crucial for improving patient outcomes and reducing the burden on healthcare providers and health systems.

Reasons for disengagement from antiretroviral care in the era of "Treat All" in low- or middle-income countries: a systematic review

INTRODUCTION

Disengagement from antiretroviral therapy (ART) care is an important reason why people living with HIV do not achieve viral load suppression become unwell.

METHODS

We searched two databases and conference abstracts from January 2015 to December 2022 for studies which reported reasons for disengagement from ART care. We included quantitative (mainly surveys) and qualitative (in-depth interviews or focus groups) studies conducted after "treat all" or "Option B+" policy adoption. We used an inductive approach to categorize reasons: we report how often reasons were reported in studies and developed a conceptual framework for reasons.

RESULTS

We identified 21 studies which reported reasons for disengaging from ART care in the "Treat All" era, mostly in African countries: six studies in the general population of persons living with HIV, nine in pregnant or postpartum women and six in selected populations (one each in people who use drugs, isolated indigenous communities, men, women, adolescents and men who have sex with men). Reasons reported were: side effects or other antiretroviral tablet issues (15 studies); lack of perceived benefit of ART (13 studies); psychological, mental health or drug use (13 studies); concerns about stigma or confidentiality (14 studies); lack of social or family support (12 studies); socio-economic reasons (16 studies); health facility-related reasons (11 studies); and acute proximal events such as unexpected mobility (12 studies). The most common reasons for disengagement were unexpected events, socio-economic reasons, ART side effects or lack of perceived benefit of ART. Conceptually, studies described underlying vulnerability factors (individual, interpersonal, structural and healthcare) but that often unexpected proximal events (e.g. unanticipated mobility) acted as the trigger for disengagement to occur.

DISCUSSION

People disengage from ART care for individual, interpersonal, structural and healthcare reasons, and these reasons overlap and interact with each other. While HIV programmes cannot predict and address all events that may lead to disengagement, an approach that recognizes that such shocks will happen could help.

CONCLUSIONS

Health services should focus on ways to encourage clients to engage with care by making ART services welcoming, person-centred and more flexible alongside offering adherence interventions, such as counselling and peer support.