How treatment partners help: social analysis of an African adherence support intervention

Pilot Test of Mopati, a Multi-Level Adherence Intervention for People Living with HIV and Their Treatment Partners in Botswana

BACKGROUND

Low-cost, scalable strategies are necessary to reach the UNAIDS 2030 target of ending HIV as a public health threat. Use of treatment partners, informal caregivers selected by people living with HIV to support antiretroviral therapy adherence, is one such strategy that is included in many countries' HIV guidelines, including Botswana, a country with high HIV prevalence.

METHOD

From June 2021 to June 2022, we pilot tested a clinic-based treatment partner intervention ("Mopati"), including standardized language for providers to guide patients on treatment partner selection and workshops to train treatment partners on providing non-directive support to patients using a non-confrontational, non-judgmental approach. Sixty unsuppressed patients (30 per clinic) and 45 treatment partners (17 intervention, 28 control) were recruited from an intervention-control clinic matched-pair in Gaborone, Botswana.

RESULTS

Mopati had medium-to-large effects on increasing patients' adherence, adherence self-efficacy, intrinsic adherence motivation, and perceived non-directive support from treatment partners, and decreasing treatment partner caregiver burden. Aggregate viral suppression rates significantly increased in the intervention (vs. control) clinic. Qualitative data from 14 clinic staff, 21 patients, and 16 treatment partners indicated that Mopati was viewed as effective. Providers said the guidance empowered them to be proactive in communicating about adherence; most reported using the guidance.

CONCLUSION

This study shows preliminary support for the use of treatment partners in HIV care, and further evidence for interventions that leverage patients' existing support. This research can inform ways to improve adherence to HIV treatment as well as the treatment of HIV-related comorbid conditions in lower-resource settings.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04796610.

Enhanced Oral Pre-exposure Prophylaxis (PrEP) Implementation for Ugandan Fisherfolk: Pilot Intervention Outcomes

Mobile populations such as fisherfolk show high HIV incidence and prevalence. We pilot-tested implementation strategies to enhance pre-exposure prophylaxis (PrEP) uptake and adherence in the context of healthcare outreach events in two mainland fisherfolk communities on Lake Victoria, Uganda from September 2021 to February 2022. The implementation strategies included PrEP adherence supporters (selected from PrEP users' social networks), community workshops (to address misconceptions and stigma, and empower PrEP advocacy), and check-in calls (including refill reminders). PrEP medical records data were collected from 6-months pre-intervention to 6-months post-intervention. Qualitative interviews with 20 PrEP users (10 who continued, 10 who discontinued), 9 adherence supporters, and 7 key partners (providers, community leaders) explored acceptability. Percentages of PrEP initiators (of those eligible) were significantly higher during the intervention (96.5%) than 6-months before the intervention (84.5%), p < 0.0001; percentages of PrEP users who persisted (i.e., possessed a refill) 6-months post-initiation (47.9% vs. 6.7%) and had at least 80% PrEP coverage (based on their medication possession ratio) from the initiation date to 6-months later (35.9% vs. 0%) were higher during versus pre-intervention, p < 0.0001. A comparison fisherfolk community with better healthcare access had lower uptake (78.3%; p < 0.0001) and persistence at 6-months (34.0%; p < 0.001), but higher coverage during the intervention period (70.4%; p < 0.0001). Qualitative data suggested the strategies promoted PrEP use through reduced stigma and misconceptions. The intervention bundle cost was $223.95, $172.98, and $94.66 for each additional person for PrEP initiation, persistence, and coverage, respectively. Enhanced community-based PrEP implementation that fosters a supportive community environment can improve PrEP use in mobile populations without easy access to healthcare. (NCT05084716).

Evaluation of an HIV homecare program for lost-to-follow-up populations: a mixed methods study in Detroit, Michigan

BACKGROUND

Maintaining people living with HIV (PLWHIV) in clinical care is a global priority. In the Metro Detroit area of Michigan, approximately 30% of PLWHIV are out of care. To re-engage lost-to-follow-up patients, Wayne Health Infectious Disease clinic launched an innovative Homecare program in 2017. In addition to home healthcare delivery, the program included links to community resources and quarterly community meetings. We aimed to evaluate Homecare's impact on participants' ability to stay engaged in HIV care and reach viral suppression. We included data from PLWHIV and their healthcare workers.

METHODS

We used a convergent mixed-methods design, including first year program record review, semi-structured interviews, and a validated Likert scale questionnaire rating illness perception before and after Homecare. Interview data were collected from 15 PLWHIV in Metro Detroit and two healthcare workers responsible for program delivery. Semi-structured interviews focused on obstacles to clinic-based care, support networks, and illness perceptions. Interview data were transcribed and analyzed using a thematic approach. A fully coded analysis was used to create a conceptual framework of factors contributing to Homecare's success. Means in eight categories of the Brief Illness Perception (IPQ) were compared using paired T-tests.

RESULTS

In the first year of Homecare, 28 of 34 participants (82%) became virally suppressed at least once. The program offered (1) social support and stigma reduction through strong relationships with healthcare workers, (2) removal of physical and resource barriers such as transportation, and (3) positive changes in illness perceptions. PLWHIV worked towards functional coping strategies, including improvements in emotional regulation, acceptance of their diagnosis, and more positive perspectives of control. Brief-IPQ showed significant changes in six domains before and after Homecare.

CONCLUSION

Homecare offers an innovative system for successfully re-engaging and maintaining lost-to-follow-up PLWHIV in care. These findings have implications for HIV control efforts and could inform the development of future programs for difficult to reach populations.

Experiences of people living with HIV in low- and middle-income countries and their perspectives in self-management: a meta-synthesis

INTRODUCTION

Availability of anti-retroviral treatment has changed HIV in to a manageable chronic disease, making effective self-management essential. However, only a few studies in low- and middle-income countries (LMICs) reported experiences of people living with HIV (PLWH) on self-management.

METHODS

This meta-synthesis of qualitative studies investigated perspectives of PLWH in LMICs on self-management. Various databases, including PubMed, EMBASE, EBSCO, and CINHAL, were searched through June 2022. Relevant additional articles were also included using cross-referencing of the identified papers. We used a thematic synthesis guided by the "Model of the Individual and Family Self-Management Theory" (IFSMT).

RESULT

PLWH in LIMICs experience a variety of challenges that restrict their options for effective self-management and compromises their quality of life. The main ones include: misconceptions about the disease, poor self-efficacy and self-management skills, negative social perceptions, and a non-patient-centered model of care that reduces the role of patients. The experiences that influenced the ability to practice self-management are summarized in context (the condition itself, physical and environmental factors, individual and family factors) and process factors (knowledge and beliefs, relationship with the health care worker, self-regulation skills and abilities, and social facilitation). Context and process greatly impacted quality of life through the self-management practices of the patients.

CONCLUSION AND RECOMMENDATION

PLWH encounter multiple challenges, are not empowered enough to manage their own chronic condition, and their needs beyond medical care are not addressed by service providers. Self-management practice of these patients is poor, and service providers do not follow service delivery approaches that empower patients to be at the center of their own care and to achieve an effective and sustainable outcome from treatment. These findings call for a comprehensive well thought self-management interventions.

Qualitative Evaluation of Treatment Partners for People With HIV in Botswana: Current Healthcare Provider Practices and Recommendations for Improvement

Botswana has an adult HIV prevalence of 20.8% and annual incidence of 0.2%. We aimed to evaluate current practices and advance recommendations for treatment partners (informal adherence supporters) for people with HIV in Botswana. In January-February 2020, we conducted seven focus groups with 36 healthcare providers at seven HIV clinics in Gaborone, Botswana. Providers perceived treatment partners to be critical for quality patient care. They shared that in the new era of universal antiretroviral therapy (ART) initiation immediately after diagnosis ("test-and-treat"), providers no longer require patients to select treatment partners at ART initiation. Providers suggested a renewed emphasis on treatment partners. They believed that standard guidance for providers around treatment partner selection would ensure that providers cover similar topics across patients and endorsed implementation of workshops to educate treatment partners on how to support patients. However, streamlined ART initiation policies require innovative strategies, including eHealth interventions, to engage treatment partners.

'You Are Always Worried and Have No Peace, You Cannot Be a Normal Adolescent': A Qualitative Study of the Effects of Mental Health Problems on the Social Functioning of Adolescents Living with HIV in Uganda

Adolescents living with HIV (ALHIV) are at heightened risk of experiencing mental health problems. However, research on the impact of mental health problems on ALHIV's everyday life is scanty. This article explores the effects of anxiety, depression and suicidal behaviour on the social functioning of ALHIV in a low-resource setting. The three mental health conditions were screened using the Patient Health Questionnaire modified for adolescents (PHQ-A) and Screen for Child Anxiety Related Disorder (SCARED), while social functioning was defined by normative role expectations of adolescents in the study setting. We conducted in-depth interviews with 31 ALHIV receiving care at two hospitals in Central Uganda. Data were analysed using thematic analysis techniques. We found that mental health problems impair the social functioning of ALHIV by obstructing them from realising normative expectations of adolescents within their socio-cultural milieu, including academic excellence, maintaining amicable relationships and good physical health. In a context of scarcity, impaired social functioning has grave implications for ALHIV's physical, psychological and social and economic wellbeing and concomitantly HIV treatment outcomes in the immediate and long term. Integration of mental health into HIV care is imperative, if the global goal to end AIDS is to be achieved.

The Effect of the Shikamana Peer-and-Provider Intervention on Depressive Symptoms, Alcohol Use, and Other Drug Use Among Gay, Bisexual, and Other Men Who Have Sex with Men in Kenya

Kenyan gay, bisexual, and other men who have sex with men (GBMSM) face stigma and discrimination, which may adversely impact mental health and limit antiretroviral therapy (ART) adherence among GBMSM living with HIV. We evaluated whether the Shikamana peer-and-provider intervention, which improved ART adherence among participants in a small randomized trial, was associated with changes in mental health or substance use. The intervention was associated with a significant decrease in PHQ-9 score between baseline and month 6 (estimated change - 2.7, 95% CI - 5.2 to - 0.2, p = 0.037) compared to standard care. In an exploratory analysis, each one-point increment in baseline HIV stigma score was associated with a - 0.7 point (95% CI - 1.3 to - 0.04, p = 0.037) greater decrease in PHQ-9 score over the study period in the intervention group. Additional research is required to understand factors that influence this intervention's effects on mental health outcomes.

The '4th 90' target as a strategy to improve health-related quality of life of people living with HIV in sub-Saharan Africa

OBJECTIVES

Next to monitoring the clinical health of people living with HIV through the triple 90 targets, a 4th 90 target was proposed in 2016 to improve HIV health-related quality of life (HrQoL) by addressing comorbidities and other psychosocial challenges. This scoping review aimed at understanding related psychosocial determinants, including strategies to improve HrQoL for people living with HIV in sub-Saharan Africa (SSA), as an initiative to ameliorate the continuum of care.

METHODS

This scoping review followed PRISMA guidelines. We searched PubMed and Wiley databases from 01 January 2011 to 19 April 2021 for articles on HrQoL, including determinants and related interventions in SSA. We also conducted a manual search to retrieve grey literature on the '4th 90' target. The six domains of HrQoL defined in the most widely used instrument (i.e., WHOQOL-HIV-BREF tool) served as a guiding framework.

RESULTS

Thirty-three articles were included for analysis. Seven articles illustrated the ongoing debate on the 4th 90 target, highlighting challenges with measuring indicators. Nine articles discussed HrQoL domains, reporting the highest scores in the spirituality and physical domains and lowest scores in the social and environmental domains. The presence of stigma and depressive symptoms was associated with low HrQoL. Seventeen articles discussed HrQoL interventions, highlighting that improved HrQoL enhanced health-seeking behaviour. Only two interventions addressed the environmental domain highlighting the fact that selection of intervention aims were not evidence led.

CONCLUSION

Introducing the 4th 90 target in SSA as a strategy to enhance HrQoL amongst people living with HIV could improve the HIV continuum of care; however, efforts are required to effectively address environmental and structural determinants.

Understanding how social support influences peer-delivered HIV prevention interventions among Ugandan female sex workers: a case study from HIV self-testing

BACKGROUND

Female sex workers (FSWs) have tightly connected peer networks and remain at high risk of HIV acquisition. Peer delivery of HIV prevention interventions, such as HIV self-testing (HIVST), is a recommended implementation strategy for increasing intervention uptake and continuation among FSWs. We analyzed qualitative data from a peer-delivered HIVST intervention among FSWs in urban Uganda to understand the ways social support within this peer network can motivate or discourage the uptake of peer-delivered HIVST.

METHODS

Between February and April 2017, we conducted in-depth interviews (IDIs) with FSWs (n = 30) and focus group discussions (FGDs) with FSW peer educators (PEs, n = 5) finishing participation in a four-month randomized implementation trial testing models of peer-delivered HIVST in Kampala. FSW participants were ≥ 18 years old, self-reported exchanging sex for money or goods (past month) and had not recently tested for HIV (past 3 months). FSW PEs either directly distributed HIVST kits to participants or provided coupons exchangeable for HIVST kits from specified healthcare facilities. In the IDIs and FGDs, we asked participants to share their experiences receiving or delivering peer-delivered HIVST, respectively. Using a hybrid deductive and inductive coding approach, we arranged findings along the dimensions of an established social support theory: informational, instrumental, and emotional support.

RESULTS

The median age of participants was 30 years (IQR: 27-33) and PEs was 33 years (IQR: 29-37). We found that social support within FSW peer networks both motivated and discouraged uptake of peer-delivered HIVST. For example, sharing positive HIVST experiences (informational support), directly delivering HIVST kits (instrumental support), and encouraging linkage to care (emotional support) motivated HIVST uptake among FSWs. Conversely, the spread of misinformation (informational support), limited HIVST kit availability fostering mistrust of PEs (instrumental support), and fear of social exclusion following HIV status disclosure (emotional support) discouraged HIVST uptake among FSWs.

CONCLUSIONS

In Uganda, social support (e.g., informational, instrumental, and emotional support) among FSW peers can work in ways that both motivate and discourage peer-delivered intervention uptake. Future FSW peer-delivered HIV prevention interventions should be designed around the dimensions of social support within FSW peer networks to maximize initial and repeat intervention delivery and uptake.

Empowerment in pregnancy: ART adherence among women living with HIV in Cape Town, South Africa

RATIONALE

Adherence to antiretroviral therapy (ART) is a global concern among pregnant and postpartum women living with HIV (WLHIV). Research focusing on peripartum WLHIV and how they balance adherence, engaging in HIV care, and other forms of self-care is limited. Women's empowerment theories have been applied to myriad health behaviors to understand patterns, establish mechanisms, and develop interventions; yet empowerment theory as applied to ART is under-researched.

OBJECTIVE

Seeking deeper insight into peripartum health behaviors, we examine these factors using Naila Kabeer's (1999) women's empowerment theory, which denotes resources, agency, and achievements as three primary and interrelated components of empowerment.

METHODS

Data were collected in Gugulethu, South Africa, between March and July 2018. Thirty in-depth interviews were conducted with WLHIV at 32-35 weeks of pregnancy, with topics including experiences related to ART adherence and meanings of empowerment in motherhood. Analyses had two phases: (1) inductive open-coding for emergent themes; and (2) classifying themes into Kabeer's empowerment theory.

RESULTS

Participants expressed that resources play a critical role in adherence, ranging from practical support to motivational support provided by both family and partners. Agency is experienced as a desire to be an independent mother in the often-expected event that partners withdraw support. Participants described achievements as time-oriented goals, ranging from having a baby born without HIV to living a long and productive life.

CONCLUSIONS

These findings suggest that a promising and innovative approach to improving ART adherence across the peripartum transition would focus on understanding resources as an enabling environment, build on existing feelings of agency, and highlight the lifelong goals achievable with high levels of adherence. A better understanding of how women's empowerment evolves over the course of pregnancy and into the postpartum period will support intervention development aimed at improving ART adherence and potentially additional peripartum health behaviors.

Social Networks and Barriers to ART Adherence Among Young Adults (18-24 years) Living with HIV at Selected Primary Health Facilities of South-Western Uganda: A Qualitative Study

Background

Young adults living with HIV (YALWH) struggle to maintain high levels of adherence to antiretroviral therapy (ART) because of numerous barriers. This study describes the social networks of YALWH (18–24 years), their barriers to ART adherence, and the perceived role of social networks in overcoming those barriers.

Methods

This study used a qualitative descriptive research design. Twenty-three (23) YALWH who were on ART for a period of greater than one (1) month and had consented to participate in the study were purposively selected from two primary health care facilities in southwestern Uganda. We held four (4) focus group discussions with the YALWH over 5 weeks between the 24th of July and 7th September 2020. Data were audio recorded, transcribed, and entered in Microsoft word 2010. Using the content analysis techniques, data were inductively coded and categories or themes developed.

Results

Most YALWH belonged to bonding (family, friends, and neighbors), followed by bridging (informal groups), and linking (health professionals) social networks, respectively. Most YALWH, irrespective of gender, had close connections with their mothers or elder sisters. The commonest form of bridging networks was informal community groups that provided financial services, whereas the linking ones comprised health professionals’ directly involved in HIV patient care such as nurses, counselors, and their affiliates (expert clients or clinic based peer supporters), who occasionally acted as bonding networks. Structural barriers to ART adherence (eg, stigma) were the most cited, followed by medication- (eg, pill burden), and patient-related barriers (eg, non-disclosure of HIV status). Bonding networks were perceived to help overcome patient, medication, and structural barriers to ART adherence. Bridging networks overcame structural and medication-related barriers to ART adherence. Linking networks were perceived to help overcome some health systems and medication-related barriers to ART adherence.

Conclusion

Bonding social networks seem to play a prominent role in overcoming numerous barriers to ART adherence compared with bridging and linking social networks.

Health Worker Perspectives on Barriers and Facilitators of Assisted Partner Notification for HIV for Refugees and Ugandan Nationals: A Mixed Methods Study in West Nile Uganda

Assisted partner notification (APN) is recommended by the World Health Organization to notify sexual partners of HIV exposure. Since 2018, APN has been offered in Uganda to Ugandan nationals and refugees. Distinct challenges faced by individuals in refugee settlements may influence APN utilization and effectiveness. To explore APN barriers and facilitators, we extracted index client and sexual partner data from APN registers at 11 health centers providing care to refugees and Ugandan nationals in West Nile Uganda and conducted qualitative interviews with health workers (N = 32). Since APN started, 882 index clients participated in APN identifying 1126 sexual partners. Following notification, 95% (1025/1126) of partners tested for HIV; 22% (230/1025) were diagnosed with HIV with 14% (139/1025) of tested partners newly diagnosed. Fear of stigma and disclosure-related violence limit APN utilization and effectiveness. Prospective research involving index clients and sexual partners is needed to facilitate safe APN optimization in refugee settlements.

Role of Support Reciprocity in HIV Viral Suppression Among People Living with HIV and Their Treatment Partners in Botswana

BACKGROUND

Social support reciprocity (the extent to which people exchange mutual support) is associated with long-term health.

METHOD

We examined whether overall social support and reciprocity of support between people living with HIV and their treatment partners (informal caregivers selected from patients' social networks to support adherence) are associated with HIV viral suppression. A total of 130 patients living with HIV and their treatment partners were recruited from a clinic in Gaborone, Botswana, from May 2016 to April 2017. Participants completed surveys assessing sociodemographic and social network characteristics. Patients and treatment partners rated their emotional closeness to each other (not at all close = 0, somewhat close = 1, very close = 2).

RESULTS

Multivariable logistic regressions indicated a significantly higher likelihood of viral suppression among patients who reported greater average emotional closeness to social network members. The likelihood of viral suppression was lower in asymmetric relationships in which patients felt closer to treatment partners than treatment partners felt to them (compared to when treatment partners felt closer to patients); this negative effect was strongest in dyads with female treatment partners and male patients. Follow-up analyses additionally indicated that asymmetric relationships in which treatment partners felt closer to patients were as protective as symmetric relationships, in which patients and treatment partners felt equally close.

CONCLUSION

Perceptions around reciprocity may matter as much as overall relationship closeness in patients' health outcomes. Interventions to improve the support of informal caregivers could help to improve relationship quality and health outcomes among people with HIV.

Agents of change: Comparing HIV-related risk behavior of people attending ART clinics in Dar es Salaam with members of their social networks

The aim of the study is to compare sociodemographic characteristics, psychosocial factors, HIV knowledge and risk behaviors of people living with HIV (PLH) and their social network members (NMs) to inform HIV prevention programs that engage PLH as prevention educators in their communities. We compared baseline characteristics of PLH enrolled in an intervention to become HIV prevention Change Agents (CAs) (n = 458) and 602 NMs they recruited. CAs and NMs responded to questionnaires through a computer-driven interface with Audio Computer-Assisted Self Interview (ACASI) software. Although NMs scored higher on socio-economic status, self-esteem and general self-efficacy, they had lower HIV knowledge (AOR 1.5; 95% CI: 1.1–2.1), greater inconsistent condom use (AOR 3.2; 95% CI: 2.4–4.9), and recent experience as perpetrators of physical (AOR 2.5; 95% CI: 1.2–5.1) or sexual (AOR 4.1; 95% CI: 1.4–12.7) intimate partner violence; and as victims of physical (AOR 1.5; 95% CI: 1.0–2.3) or sexual (AOR 2.2; 95% CI: 1.3–3.8) forms of violence than CAs. Higher HIV knowledge and lower sexual risk behaviors among CAs suggest PLH’s potential as communicators of HIV prevention information to NMs. CAs’ training should also focus on improving self-esteem, general self-efficacy and social support to increase their potential effectiveness as HIV prevention educators and enhance their own overall health and well-being.

Preferences for Pre-exposure Prophylaxis Service Delivery Among Female Sex Workers in Malawi: A Discrete Choice Experiment

Female sex workers (FSW) in Malawi have among the highest HIV prevalence estimates worldwide. Daily oral pre-exposure prophylaxis (PrEP) is an effective HIV prevention method, yet preferences for PrEP delivery among FSW are lacking. Eight focus group discussions, a literature review, and cognitive interviews were conducted to identify modifiable PrEP delivery attributes and inform discrete-choice experiment (DCE) development for FSW in Lilongwe. Enrolled FSW received an interviewer-assisted DCE. Data were analyzed using mixed logit regression. Dispensing location was most preferred, followed by the provision of additional services. Women preferred receiving PrEP at family planning clinics or non-governmental organization run drop-in centers. Cervical cancer screening was the most preferred additional service, while pregnancy testing and partner risk reduction counseling were less valued. This study was the first study to examine PrEP delivery preferences in Malawi using DCE-a powerful elicitation tool to apply to other key populations at risk for HIV.

Burden of HIV-Related Stigma and Post-Partum Depression: A Cross-Sectional Study of Patients Attending Prevention of Mother-to-Child Transmission Clinic at Kenyatta National Hospital in Nairobi

Background: We look at how various HIV-related stigma subtypes, especially internalizing types, interact with postpartum depression (PPD) among women living with HIV. Additionally, we identify key psychosocial risk factors that influence stigma and PPD among women attending Prevention of Mother-to-Child Transmission (PMTCT) clinics. Methods: In this cross-sectional design, 123 women living with HIV were recruited. Participants ages between 18 and 50, who were at least 8 weeks postpartum seeking PMTCT services at Kenyatta National Hospital (KNH), between June and September 2014 participated in the study. HIV/AIDS Stigma Instrument-PLWHA (HASI-P) was used to assesses stigma and Postpartum depression was assessed by Edinburgh Postnatal Depression Scale (EPDS). Bivariate and multivariate regression models were used to determine the individual characteristics associated with the HIV-related stigma Scale. Post survey a few in-depth-interviews were conducted to explore individuals' stigma and depression experiences. Results: The mean age was 31.2 years (SD = 5.2). Fifty-nine (48%) women screened positive for significant depressive symptoms. Post-partum depression was a significant predictor of internalized stigma, enacted, and total stigma (P < 0.05). Older age was associated with less internalized stigma. Living with a partner was associated with more internalized stigma. Having an income above 100 USD per month was protective against stigma. Having good family social support was protective against internalized stigma. A higher educational level was protective against enacted stigma. Being treated for STIs was a risk factor for both enacted and overall stigma. Conclusions: HIV-related stigma needs to be addressed through integrated mental health care programs in PMTCT. Postpartum depression requires comprehensive management to improve short- and long-term outcomes of women living with HIV.

Using Social Networks to Understand and Overcome Implementation Barriers in the Global HIV Response

BACKGROUND

Despite the development of several efficacious HIV prevention and treatment methods in the past 2 decades, HIV continues to spread globally. Uptake of interventions is nonrandomly distributed across populations. Such inequality is socially patterned and reinforced by homophily arising from both social selection (becoming friends with similar people) and influence (becoming similar to friends).

METHODS

We conducted a narrative review to describe how social network analysis methods-including egocentric, sociocentric, and respondent-driven sampling designs-provide tools to measure key populations, to understand how epidemics spread, and to evaluate intervention take-up.

RESULTS

Social network analysis-informed designs can improve intervention effectiveness by reaching otherwise inaccessible populations. They can also improve intervention efficiency by maximizing spillovers, through social ties, to at-risk but susceptible individuals. Social network analysis-informed designs thus have the potential to be both more effective and less unequal in their effects, compared with social network analysis-naïve approaches. Although social network analysis-informed designs are often resource-intensive, we believe they provide unique insights that can help reach those most in need of HIV prevention and treatment interventions.

CONCLUSION

Increased collection of social network data during both research and implementation work would provide important information to improve the roll-out of existing studies in the present and to inform the design of more data-efficient, social network analysis-informed interventions in the future. Doing so will improve the reach of interventions, especially to key populations, and to maximize intervention impact once delivered.

A Social Network Analysis of HIV Treatment Partners and Patient Viral Suppression in Botswana

OBJECTIVE

Many national HIV guidelines recommend that health care providers encourage patients to identify a treatment partner from their social network to support antiretroviral therapy adherence. This study examined associations of patient and treatment partner characteristics with patient viral suppression in Botswana.

DESIGN

One hundred thirty-one patients [67 (51.1%) virally suppressed and 64 (48.9%) not suppressed] and their treatment partners were recruited for cross-sectional interviews from one HIV clinic.

METHODS

Participants completed surveys assessing social network, sociodemographic, and psychosocial characteristics. Open-ended questions explored treatment partner relationship quality.

RESULTS

Multivariate logistic regressions indicated a higher likelihood of viral suppression among patients who reported greater average emotional closeness to their network members [odds ratio (95% confidence interval) = 3.8 (1.3 to 11.5), P = 0.02] and whose treatment partners were spouses/partners [odds ratio (95% confidence interval) = 2.6 (1.0 to 6.7), P = 0.04]. Qualitative analyses indicated that treatment partners of suppressed patients provided both medical and nonmedical support, whereas treatment partners of unsuppressed patients focused mainly on adherence reminders and appointment accompaniment. Treatment partners, especially of unsuppressed patients, requested ongoing training and counseling skills.

CONCLUSIONS

Additional research is needed to further explore effective characteristics of treatment partners to inform HIV treatment guidelines. Standard training for treatment partners could include medical-related information and counseling education.

Are treatment supporters relevant in long-term Antiretroviral Therapy (ART) adherence? Experiences from a long-term ART cohort in Uganda

BACKGROUND

This study aimed to understand the relevance of treatment supporters in adherence among people living with HIV taking Anti-retroviral therapy (ART) for more than five years in Uganda.

METHODS

In-depth interviews were conducted with 50 participants (28 women and 22 men) of the Complications of Long-Term ART (CoLTART) cohort with experience of at least five years on ART in Uganda. Participants were stratified by line of ART regimen and viral loads of less or above 1000 copies/ml. Data were analyzed thematically.

RESULTS

Many participants felt that a treatment supporter was most useful at the beginning of therapy before individuals get used to the drugs or when they are still weak. However, this did not reflect treatment outcomes, as many individuals without treatment supporters had failed on first line ART regimens and were switched to second line ART. Those who were still on first line had viral loads of ≥1000 copies/ml. There was a preference for female treatment supporters, many of who were persistent in their supportive role.

CONCLUSION

Treatment supporters remain important in adherence to long-term ART. HIV-care providers need to encourage the involvement of a treatment supporter for individuals taking ART long-term.

Multi-level Determinants of Clinic Attendance and Antiretroviral Treatment Adherence Among Fishermen Living with HIV/AIDS in Communities on Lake Victoria, Uganda

This cross-sectional study assessed determinants of HIV clinic appointment attendance and antiretroviral treatment (ART) adherence among 300 male fisherfolk on ART in Wakiso District, Uganda. Multi-level factors associated with missed HIV clinic visits included those at the individual (age, AOR = 0.98, 95% CI 0.97-0.99), interpersonal (being single/separated from partner, AOR: 1.25, 95% CI 1.01-1.54), normative (anticipated HIV stigma, AOR: 1.55, 95% CI 1.05-2.29) and physical/built environment-level (travel time to the HIV clinic, AOR: 1.11, 95% CI 1.02-1.20; structural-barriers to ART adherence, AOR: 1.27, 95% CI 1.04-1.56; accessing care on a landing site vs. an island, AOR: 1.35, 95% CI 1.08-1.67). Factors associated with ART non-adherence included those at the individual (age, β: - 0.01, η2 = 0.03; monthly income, β: - 0.01, η2 = 0.02) and normative levels (anticipated HIV stigma, β: 0.10, η2 = 0.02; enacted HIV stigma, β: 0.11, η2 = 0.02). Differentiated models of HIV care that integrate stigma reduction and social support, and reduce the number of clinic visits needed, should be explored in this setting to reduce multi-level barriers to accessing HIV care and ART adherence.

Dynamics of Treatment Supporters and Patients Starting HIV Therapy in Lima, Peru

As per the National HIV Program in Peru, the designation of a patient-elected treatment supporter is a requisite for starting antiretroviral therapy (ART). These individuals are expected to aid the patient in medical and social support. This qualitative study examines the interaction between treatment supporters and people living with HIV/AIDS (PLWHA) to elucidate key dynamics contributing to care. Twenty individual interviews with treatment supporters were analyzed alongside 5 group interviews: 2 groups of treatment supporters, 2 groups of PLWHA, and 1 group of community health workers. Findings characterized formal means of treatment support and informal emotional and instrumental support. Gradual transfer of treatment responsibilities from supporters to PLWHA was found to foster a sense of self-efficacy among PLWHA, and when paired with open communication and committed emotional support, created an ideal reciprocal relationship. However, lack of HIV-related knowledge among treatment supporters was detrimental. More training and systemic support for treatment supporters may optimize their role as informed participants in the care of PLWHA.

How clinicians experience a simulated antiretroviral therapy adherence exercise: A qualitative study

Background

With the shift of paediatric antiretroviral therapy (ART) from tertiary to primary health care, there has been a need to train clinicians working in primary health care facilities to support adherence to treatment. An adherence simulation exercise was included in a course on paediatric human immunodeficiency virus (HIV) and tuberculosis (TB) to stimulate health care providers’ awareness and generate empathy of complex paediatric adherence practices.

Aim

The aim of this study was to describe the experience of clinicians completing the simulation exercise and to assess whether enhancing their empathy with patients and treatment supporters would improve their perceived clinical and counselling skills.

Setting

The study was conducted at the Faculty of Medicine and Health Sciences, Stellenbosch University, and a guesthouse in Cape Town.

Methods

The adherence module used blended learning methodology consisting of face-to-face contact sessions and distance learning. A qualitative thematic approach was used to understand the participant experiences through focus-group discussions and semi-structured interviews.

Results

Three thematic clusters emerged, namely, experiences of the simulated exercise, patient–provider relationships and adherence strategies. Their experiences were both positive and challenging, especially when a ‘caregiver and/or treatment supporter’ scenario encouraged participants to reflect on their own relationships with their patients. Clinicians had also considered how empathy fits into their scope of responsibilities. Text messaging and adherence counselling strategies were identified.

Conclusion

Simulated learning activities have the potential to create awareness of relationships between clinicians and their patients and generate ideas and discussion that could lead to improvements in clinical practice, and adherence promotion strategies.

Social capital and resilience among people living on antiretroviral therapy in resource-poor Uganda

BACKGROUND

Despite the national roll-out of free HIV medicines in Uganda and other sub-Saharan African countries, many HIV positive patients on antiretroviral therapy (ART) are at risk of non-adherence due to poverty and other structural and health system related constraints. However, several patients exhibit resilience by attaining and sustaining high levels of adherence amid adversity. Social capital, defined as resources embedded within social networks, is key in facilitating resilience but the mechanism through which it operates remains understudied. This article provides insights into mechanisms through which social capital enables patients on ART in a resource-poor setting to overcome risk and sustain adherence to treatment.

METHODOLOGY

The article draws from an ethnographic study of 50 adult male and female HIV patients enrolled at two treatment sites in Uganda, 15 of whom were followed-up for an extended period of six months for narrative interviews and observation. The patients were selected purposively on the basis of socio-demographic and treatment related criteria.

FINDINGS

Social capital protects patients on ART against the risk of non-adherence in three ways. 1) It facilitates access to scarce resources; 2) encourages HIV patients to continue on treatment; and 3) averts risk for non-adherence.

CONCLUSIONS

Social capital is a key resource that can be harnessed to promote resilience among HIV patients in a resource-limited setting amid individual, structural and health system related barriers to ART adherence. Invigoration and maintenance of collectivist norms may however be necessary if its protective benefits are to be fully realized.

Patient-nominated supporters as facilitators for engagement in HIV care in a referral hospital in Peru: A retrospective cohort study

Patient-nominated supporters can potentially improve the continuum of HIV care. We retrospectively determined factors associated with having a patient-nominated supporter among people living with HIV (PLWH), and its association with retention in care and viral suppression. We analysed registries of adults evaluated by social workers (n = 1345) at a referral hospital in Peru between 2011–2014. Nondisclosure of HIV status was associated with lacking supporters (aPR: 5.41, 95% CI: 3.83–7.64). Retention in care was 76.4% and 34.2% after one and two years of enrolment, respectively. PLWH with supporters were more likely to be retained in care after two years (aRR = 1.36, 95% CI: 1.02–1.81), but not after one year (aRR = 1.10, 95% CI: 0.98–1.23) compared to PLWH without supporters. Having supporters who were parents or friends was associated with an increased probability of being retained in care after one and two years of enrolment. Viral suppression after one year of enrolment was 58.7%. Having a supporter was not associated with viral suppression (aRR = 1.18, 95% CI: 0.99–1.41), but PLWH with supporters were more likely to have viral load measurements (p = 0.005). Patient-nominated supporters appear beneficial for engagement in HIV care; these benefits may be related to the nature of their relationship with PLWH.

The effect of community-based support for caregivers on the risk of virological failure in children and adolescents with HIV in Harare, Zimbabwe (ZENITH): an open-label, randomised controlled trial

BACKGROUND

Children and adolescents have poorer HIV treatment outcomes than adults. We aimed to assess the effect of community-based support for caregivers of HIV-infected children and adolescents, who are key mediators to children engaging with care, on treatment outcomes.

METHODS

In this open-label, randomised contolled trial, we recruited children aged 6-15 years with newly-diagnosed HIV attending primary health-care clinics in Harare, Zimbabwe. Children were randomly assigned to receive decentralised primary health-care clinic-based HIV care (control group), according to national guidelines for 18 months, or decentralised care plus structured support visits by trained community health workers (intervention group) according to national guidelines for 18 months. Primary outcomes were the proportion of participants who died or had an HIV viral load of 400 copies per mL or higher at 12 months after antiretroviral therapy (ART) initiation (among those who started ART within 6 months of enrolment); and the proportion who missed two or more scheduled clinic visits by 18 months post-enrolment (among all participants). Analyses were complete-case, modified-intention-to-treat. This trial is registered with the Pan African Clinical Trials Registry, number PACTR201212000442288.

FINDINGS

Between January, 2013, and January, 2015, 470 participants tested HIV-positive at seven study primary health-care clinics and were screened for eligibility. Of the 334 eligible children and adolescents, 166 were randomly assigned to the intervention group and 168 to the control group. The median age of participants was 11 years (IQR 8-13) and 178 (53%) were girls. Among the 238 participants who started ART within 6 months of enrolment, the proportion who died or had a viral load of 400 copies/mL or higher at 12 months post-ART initiation was significantly lower in the intervention group than in the control group (31 [33%] of 94 participants vs 42 [49%] of 86 participants, respectively, adjusted odds ratio [aOR] 0·46, 95% CI 0·23-0·89; p=0·02). The proportion of children missing two or more scheduled visits was similar in the intervention group and control group (27 [17%] of 155 vs 30 [18%] of 165, aOR 0·92, 95% CI 0·49-1·74; p=0·79). One participant withdrew from the trial 240 days after enrolment and 12 died during follow-up (five in the intervention group; seven in the control group).

INTERPRETATION

Community-based support for caregivers has high potential for scalability and could have a substantial effect on HIV virological suppression in children and adolescents, a group with disproportionately poor treatment outcomes.

FUNDING

Wellcome Trust.

Demoralization in medical illness: Feasibility and acceptability of a pilot educational intervention for inpatient oncology nurses

ABSTRACTObjective:Demoralization is a common problem among medical inpatients with such serious health problems as cancer. An awareness of this syndrome, a knowledge of what defines it, and a plan for how to intervene are limited among nursing teams. Nurses are uniquely poised to efficiently provide brief interventions that address demoralization in their patients. To our knowledge, there are no interventions that train nurses to distinguish and treat demoralization in their patients. The objective of the present study was to determine the acceptability, feasibility, and impact of a novel educational intervention for nurses.

METHOD

An educational training video was created and delivered to staff nurses (N = 31) at oncology staff meetings to test the feasibility and acceptability of this intervention. Assessments of nurses' knowledge about demoralization and intervention methods were administered immediately before and after the training intervention and through a web-based survey 6 weeks post-intervention. McNemar's test for dependent categorical data was utilized to evaluate change in survey responses at the three timepoints.

RESULTS

Nurses' understanding of the concept of demoralization and appropriate interventions significantly improved by 30.3% from pre- to posttest (p ≤ 0.0001). These improvements persisted at 6 weeks post-intervention (p ≤ 0.0001). At 6-week follow-up, 74.2% of participants agreed or strongly agreed that the training had positively changed their nursing practice, 96.8% reported that this training benefited their patients, and 100% felt that this training was important for the professional development of nurses.

SIGNIFICANCE OF RESULTS

This pilot intervention appeared feasible and acceptable to nurses and resulted in increased understanding of demoralization, improved confidence to intervene in such cases, and an enhanced sense of professional satisfaction among inpatient oncology floor nurses.

Social Support and the Mediating Roles of Alcohol Use and Adherence Self-Efficacy on Antiretroviral Therapy (ART) Adherence Among ART Recipients in Gauteng, South Africa

We sought to (a) replicate and (b) extend (via the addition of alcohol use) Cha et al.'s cross-sectional multi-component model of ART adherence on the relationship between social support, depression, self-efficacy beliefs, and antiretroviral therapy (ART) adherence, among HIV patients in Tshwane, South Africa. Using purposive sampling, 304 male and female ART recipients were recruited. ART adherence was assessed using three manifest indicators: total adherence ratio, the CASE adherence index and 1-month adherence measure. Data were analysed using structural equation modeling. In our replicated model, social support had both direct and indirect relationships with ART adherence, and inclusion of alcohol use improved prediction of ART adherence. Direct and indirect effects of alcohol use on ART adherence emerged: adherence self-efficacy beliefs partially mediated the latter path. Findings highlight the importance of integrating into ART promotion interventions, the reduction of alcohol use, provision of social support, and enhancement of adherence self-efficacy beliefs.

A Protocol for a Cluster Randomized Trial on the Effect of a "feeding buddy" Program on adherence to the Prevention of Mother-To-Child-Transmission Guidelines in a Rural Area of KwaZulu-Natal, South Africa

Background:

The uptake of prevention of mother-to-child-transmission (PMTCT) services has improved in South Africa but challenges remain, including adherence to the World Health Organization's (WHO) PMTCT recommendations of exclusive breastfeeding (EBF), taking antiretroviral medication (ARV); testing for early infant diagnosis; and reducing stigma. Women who practice EBF for the first 6 months are less likely to transmit HIV to their infants, yet only 7% of women EBF for 6 months in South Africa. Adherence to these recommendations remains challenging because of difficulties relating to disclosure and stigma. To address this challenge, the feeding buddy concept was developed based on studies where ARV buddies have proved effective in providing support for women living with HIV. Buddies have demonstrated a positive effect on providing emotional and social support to adhere to PMTCT guidelines.

Methods:

A cluster randomized controlled trial was conducted in 16 selected randomly assigned clinics in uMhlathuze and uMlalazi districts of KwaZulu Natal, South Africa. HIV-positive pregnant women (n = 625) who intended to breastfeed were enrolled at 8 control clinics and 8 intervention clinics. The clinics were stratified on the basis of urban/rural/periurban locale and then randomly allocated to either intervention or control. In the intervention clinics, the mother chose a feeding buddy to be enrolled alongside her. Quantitative interviews with mothers and their chosen buddies took place at enrollment during pregnancy and at routine postdelivery visits at day 3 and weeks 6, 14 and 22. Women in the control clinics were followed using the same evaluation schedule. The trial evaluated the effect of a voluntary PMTCT feeding buddy program on HIV-infected women's adherence to PMTCT recommendations and stigma reduction. The proportion of women exclusively feeding at 5.5 months postpartum was the primary end-point of the trial. In-depth interviews were conducted among a convenience sample of PMTCT counselors, community caregivers, mothers, and buddies from intervention clinics and control clinics to document their overall experiences.

Discussion:

The information collected in this study could be used to guide recommendations on how to build upon the current South Africa. PMTCT “buddy” strategy and to improve safe infant feeding. The information would be applicable to many other similar resource poor settings with poor social support structures.

Overcoming Health System Challenges for Women and Children Living With HIV Through the Global Plan

To meet the ambitious targets set by the Global Plan Towards the Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive (Global Plan), the initial 22 priority countries quickly developed innovative approaches for overcoming long-standing health systems challenges and providing HIV testing and treatment to pregnant and breastfeeding women and their infants. The Global Plan spurred programs for prevention of mother-to-child HIV transmission to integrate HIV-related care and treatment into broader maternal, newborn, and child health services; expand the effectiveness of the health workforce through task sharing; extend health services into communities; strengthen supply chain and commodity management systems; reduce diagnostic and laboratory hurdles; and strengthen strategic supervision and mentorship. The article reviews the ongoing challenges for prevention of mother-to-child HIV transmission programs as they continue to strive for elimination of vertical transmission of HIV infection in the post-Global Plan era. Although progress has been rapid, health systems still face important challenges, particularly follow-up and diagnosis of HIV-exposed infants, continuity of care, and the promotion of services that are respectful and client centered.

Understanding Patterns of Social Support and Their Relationship to an ART Adherence Intervention Among Adults in Rural Southwestern Uganda

SMS is a widely used technology globally and may also improve ART adherence, yet SMS notifications to social supporters following real-time detection of missed doses showed no clear benefit in a recent pilot trial. We examine the demographic and social-cultural dynamics that may explain this finding. In the trial, 63 HIV-positive individuals initiating ART received a real-time adherence monitor and were randomized to two types of SMS reminder interventions versus a control (no SMS). SMS notifications were also sent to 45 patient-identified social supporters for sustained adherence lapses. Like participants, social supporters were interviewed at enrollment, following their matched participant's adherence lapse and at exit. Social supporters with regular income (RR = 0.27, P = 0.001) were significantly associated with fewer adherence lapses. Instrumental support was associated with fewer adherence lapses only among social supporters who were food secure (RR = 0.58, P = 0.003). Qualitative interview data revealed diverse and complex economic and relationship dynamics, affecting social support. Resource availability in emotionally positive relationships seemingly facilitated helpful support, while limited resources prevented active provision of support for many. Effective social support appeared subject to social supporters' food security, economic stability and a well-functioning social network dependent on trust and supportive disclosure.

Adherence partners are an acceptable behaviour change strategy to support calcium and iron-folic acid supplementation among pregnant women in Ethiopia and Kenya

Antenatal calcium and iron-folic acid (IFA) supplementation can reduce maternal mortality and morbidity. Yet, even when pregnant women have a stable supply of supplements, forgetting is often a barrier to adherence. We assessed the acceptability of adherence partners to support calcium and IFA supplementation among pregnant women in Kenya and Ethiopia. Adherence partners are a behaviour change strategy to improve adherence, where pregnant women are counselled to select a partner (e.g. spouse, relative) to remind them to take their supplements. We conducted trials of improved practices, a formative research method that follows participants over time as they try a new behaviour. We provided pregnant women in Ethiopia (n = 50) and Kenya (n = 35) with calcium and IFA supplements and counselling, and suggested selecting an adherence partner. For each participant, we conducted semi-structured interviews about acceptability and adherence during four interviews over six weeks. We analysed interview transcripts thematically and tallied numerical data. In Kenya, 28 of 35 women agreed to try an adherence partner; almost all selected their husbands. In Ethiopia, 42 of 50 women agreed to try an adherence partner; half asked their husbands, others asked children or relatives. Most women who did not select adherence partners reported not needing help or not having anyone to ask. Participants reported adherence partners reminded and encouraged them, brought supplements, provided food and helped address side-effects. Almost all women with adherence partners would recommend this strategy to others. Adherence partners are an acceptable, low-cost strategy with the potential to support antenatal micronutrient supplementation adherence.

Short message service (SMS) reminders and real-time adherence monitoring improve antiretroviral therapy adherence in rural Uganda

OBJECTIVE

To explore the effects of four types of short message service (SMS) plus real-time adherence monitoring on antiretroviral therapy (ART) adherence: daily reminders, weekly reminders, reminders triggered after a late or missed dose (delivered to patients), and notifications triggered by sustained adherence lapses (delivered to patient-nominated social supporters).

DESIGN

Pilot randomized controlled trial.

METHODS

Sixty-three individuals initiating ART received a real-time adherence monitor and were randomized (1 : 1 : 1): (1) Scheduled SMS reminders (daily for 1 month, weekly for 2 months), then SMS reminders triggered by a late or missed dose (no monitoring signal within 2 h of expected dosing); SMS notifications to social supporters for sustained adherence lapses (no monitoring signal for >48 h) added after 3 months. (2) Triggered SMS reminders starting at enrolment; SMS notifications to social supporters added after 3 months. (3) CONTROL: No SMS. HIV RNA was determined at 9 months. Percentage adherence and adherence lapses were compared by linear generalized estimating equations and Poisson regression, respectively.

RESULTS

Median age was 31 years, 65% were women, and median enrolment CD4 cell count was 322 cells/μl 97% took once daily tenofovir/emtricitabine/efavirenz. Compared to control, adherence was 11.1% higher (P = 0.04) and more than 48-h lapses were less frequent (IRR 0.6, P = 0.02) in the scheduled SMS arm. Adherence and more than 48-h lapses were similar in the triggered SMS arm and control. No differences in HIV RNA were seen.

CONCLUSION

Scheduled SMS reminders improved ART in the context of real-time monitoring. Larger studies are needed to determine the impact of triggered reminders and role of social supporters in improving adherence.

Community-Based Accompaniment Mitigates Predictors of Negative Outcomes for Adults on Antiretroviral Therapy in Rural Rwanda

Clinical, socioeconomic, and access barriers remain a critical problem to antiretroviral (ART) programs in sub-Saharan Africa. Community-based accompaniment (CBA), including daily home visits and psychosocial and socioeconomic support, has been associated with improved patient outcomes at 1 year. We conducted a prospective observational cohort study of 578 HIV-infected adults initiating ART in 2007-2008 with or without CBA in rural Rwanda. Among patients without CBA, those with advanced HIV disease, low CD4 cell counts, lower social support, and transport costs had significantly higher odds of negative outcomes at 1 year; amongst patients who received CBA, only those with low CD4 cell counts had significantly higher odds of negative outcomes at 1 year. CBA also significantly mitigated the effect of transport costs and inaccessibility of services on the likelihood of negative outcome. CBA may be one approach to mitigating known risk factors for negative outcomes for patients on ART in resource-poor settings.

Treatment Buddies Improve Clinic Attendance among Women but Not Men on Antiretroviral Therapy in the Nyanza Region of Kenya

Background. Kenyan antiretroviral (ART) guidelines encourage treatment buddies (TBy) to maximize treatment adherence. This study examined the effect of TBys on clinic attendance in men and women on ART. Methods. This retrospective cohort study included all adult patients initiating ART from August 2007 to December 2011 at four health facilities in Kenya. Data were abstracted from electronic medical records and analyzed using Poisson regression. Results. Of 2,430 patients, 2,199 (91%) had a TBy. Relationship between TBy and clinic attendance differed in females and males (interaction p = 0.09). After demographic and clinic factor adjustment, females with a TBy were 28% more likely to adhere to all appointments than those without (adjusted aRR = 1.28; 95% CI 1.08–1.53), whereas males were no more likely to adhere (aRR = 1.01; 95% CI 0.76–1.32). Males reported partner/spouse (33%) or brother (11%) as the TBy while females reported sister (17%), partner/spouse (14%), or another family member (12%). Multivariable analysis found no association between clinic attendance and TBy relationship in either gender. Conclusion. Clinic attendance was higher among women with TBys but not men. Results support TBys to help women achieve ART success; alternate strategies to bolster TBy benefits are needed for men.

The role of social support on HIV testing and treatment adherence: A qualitative study of HIV-infected refugees in southwestern Uganda

Little is known about the factors that encourage or discourage refugees to test for HIV, or to access and adhere to HIV care. In non-refugee populations, social support has been shown to influence HIV testing and utilisation of services. The present study enrolled HIV-infected refugees on anti-retroviral therapy (ART) in Uganda, who participated in qualitative interviews on HIV testing, treatment, and adherence. Interviews were analysed for themes about four types of social support: emotional, informational, instrumental, and appraisal support. A total of 61 interviews were analysed. Four roles for these types of social support were identified: (1) informational support encouraged refugees to test for HIV; (2) emotional support helped refugees cope with a diagnosis of HIV; (3) instrumental support facilitated adherence to ART and (4) after diagnosis, HIV-infected refugees provided informational and emotional support to encourage other refugees to test for HIV. These results suggest that social support influences HIV testing and treatment among refugees. Future interventions should capitalise on social support within a refugee settlement to facilitate testing and treatment.

A qualitative assessment of barriers and facilitators to antiretroviral adherence in Thai patients

OBJECTIVES

Excellent adherence to combination antiretroviral therapy can suppress HIV replication and produce life expectancies nearing those of individuals without HIV infection. This qualitative study sought to identify the barriers and facilitators to good antiretroviral medication adherence in Thai patients living with HIV.

METHODS

Semi-structured interviews were conducted with a convenience sample (n=21) of patients attending routine clinic visits at Srinagarind Hospital in Khon Kaen, or HIV-NAT, the Thai Red Cross AIDS Research Centre in Bangkok.

RESULTS

Median informant age was 43 years (range 27-60 years) and 43% were female. We identified key facilitators and barriers to adherence among HIV-infected Thai patients along three major themes (patient-related, health system-related and medication-related). Stigma was a primary concern for most informants, operating throughout Thai society to induce feelings of shame for Thai people living with HIV. Determination to stay healthy and incorporate taking cART into their daily routine were key components of good adherence. Supportive and trusting relationships, particularly with the clinic team, empowered patients to maintain good medication adherence.

CONCLUSIONS

Changing public perceptions about HIV, and training of HIV clinic staff on the importance of trusting and supportive provider-patient relationships in promoting good health outcomes, will help Thailand achieve its aim of having zero new HIV infections, zero discrimination and zero AIDS-related deaths by 2030.

Religious Beliefs and Depression: Psychosocial Factors Affecting HIV Treatment Outcomes in South Africa

Analyzing factors associated with virological failure (VF) may improve antiretroviral therapy (ART) outcomes for individuals living with HIV. The Risk Factors for Virological Failure (RFVF) study compared 158 cases with VF (viral load, VL, >1,000 copies/mL) and 300 controls with virological suppression (VL ≤1,000 copies/mL) after ≥5 months on their first ART regimen at McCord Hospital in Durban, South Africa between October 2010 and June 2012. RFVF participants completed a battery of various psychosocial measures. Using multivariate logistic regression stratified for gender, the association of various psychosocial factors with VF was assessed. It was found that not all factors were equally significant for both genders. The factors that were significantly associated with VF for both genders were younger age, shorter treatment duration and reporting depressive symptoms. The factors associated with VF that differed by gender were religious inactivity, having HIV+ family members, and status disclosure to friends.

"Wan Kanyakla" (We are together): Community transformations in Kenya following a social network intervention for HIV care

BACKGROUND

In sub-Saharan Africa, failure to initiate and sustain HIV treatment contributes to significant health, psychosocial, and economic impacts that burden not only infected individuals but diverse members of their social networks. Yet, due to intense stigma, the responsibility for managing lifelong HIV treatment rests solely, and often secretly, with infected individuals. We introduce the concept of "HIV risk induction" to suggest that social networks of infected individuals share a vested interest in improving long-term engagement with HIV care, and may represent an underutilized resource for improving HIV/AIDS outcomes within high prevalence populations.

METHODS

In 2012, we implemented a 'microclinic' intervention to promote social network engagement in HIV/AIDS care and treatment. A microclinic is a therapy management collective comprised of a small group of neighbors, relatives, and friends who are trained as a team to provide psychosocial and adherence support for HIV-infected members. Our study population included 369 patients on ART and members of their social networks on Mfangano Island, Kenya, where HIV prevalence approaches 30%. Here we report qualitative data from 18 focus group discussions conducted with microclinic participants (n = 82), community health workers (n = 40), and local program staff (n = 39).

RESULTS

Participants reported widespread acceptability and enthusiasm for the microclinic intervention. Responses highlight four overlapping community transformations regarding HIV care and treatment, namely (1) enhanced HIV treatment literacy (2) reduction in HIV stigma, (3) improved atmosphere for HIV status disclosure and (4) improved material and psychosocial support for HIV-infected patients. Despite challenges, participants describe an emerging sense of "collective responsibility" for treatment among HIV-infected and HIV-uninfected members of social networks.

DISCUSSION

The lived experiences and community transformations highlighted by participants enrolled in this social network intervention in Western Kenya suggest opportunities to reframe the continuum of HIV care from a secretive individual journey into a network-oriented cycle of engagement.

High rates of unplanned interruptions from HIV care early after antiretroviral therapy initiation in Nigeria

BACKGROUND

Unplanned care interruption (UCI) challenges effective HIV treatment. We determined the frequency and risk factors for UCI in Nigeria.

METHODS

We conducted a retrospective-cohort study of adults initiating antiretroviral therapy (ART) between January 2009 and December 2011. At censor, patients were defined as in care, UCI, or inactive. Associations between baseline factors and UCI rates were quantified using Poisson regression.

RESULTS

Among 2,496 patients, 44 % remained in care, 35 % had ≥1 UCI, and 21 % became inactive. UCI rates were higher in the first year on ART (39/100PY), than the second (19/100PY), third (16/100PY), and fourth (14/100PY) years (p < 0.001). In multivariate analysis, baseline CD4 > 350/uL (IRR 3.21, p < 0.0001), being a student (IRR 1.95, p < 0.0001), and less education (IRR 1.58, p = 0.001) increased risk for UCI. Fifty-five percent of patients with UCI and viral load data had HIV viral load > 1,000 copies/ml upon return to care.

DISCUSSION

UCI were observed in over one-third of patients treated, and were most common in the first year on ART. High baseline CD4 count at ART initiation was the greatest predictor of subsequent UCI.

CONCLUSIONS

Interventions focused on the first year on ART are needed to improve continuity of HIV care.

Implementation and Operational Research: Pulling the Network Together: Quasiexperimental Trial of a Patient-Defined Support Network Intervention for Promoting Engagement in HIV Care and Medication Adherence on Mfangano Island, Kenya

BACKGROUND

Despite progress in the global scale-up of antiretroviral therapy, sustained engagement in HIV care remains challenging. Social capital is an important factor for sustained engagement, but interventions designed to harness this powerful social force are uncommon.

METHODS

We conducted a quasiexperimental study evaluating the impact of the Microclinic Social Network intervention on engagement in HIV care and medication adherence on Mfangano Island, Kenya. The intervention was introduced into 1 of 4 similar communities served by this clinic; comparisons were made between communities using an intention-to-treat analysis. Microclinics, composed of patient-defined support networks, participated in 10 biweekly discussion sessions covering topics ranging from HIV biology to group support and group HIV status disclosure. Nevirapine concentrations in hair were measured before and after study.

RESULTS

One hundred thirteen (74%) intervention community participants joined a microclinic group, 86% of whom participated in group HIV status disclosure. Over 22-month follow-up, intervention community participants experienced one-half the rate of ≥ 90-day clinic absence as those in control communities (adjusted hazard ratio: 0.48; 95% confidence interval: 0.25 to 0.92). Nevirapine hair levels declined in both study arms; in adjusted linear regression analysis, the decline was 6.7 ng/mg less severe in the intervention arm than control arm (95% confidence interval: -2.7 to 16.1).

CONCLUSIONS

The microclinic intervention is a promising and feasible community-based strategy to improve long-term engagement in HIV care and possibly medication adherence. Reducing treatment interruptions using a social network approach has important implications for individual patient virologic suppression, morbidity, and mortality and for broader community empowerment and engagement in healthcare.

Engagement of Traditional Healers and Birth Attendants as a Controversial Proposal to Extend the HIV Health Workforce

"Medical pluralism" is the use of multiple health systems and is common among people living with HIV/AIDS in sub-Saharan Africa. Healers and traditional birth attendants (TBAs) often are a patient's first and/or preferred line of treatment; this often results in delayed, interrupted, or abandoned diagnosis and therapy. Literature from the study of medical pluralism suggests that HIV care and treatment programs are infrequently and inconsistently engaging healers around the world. Mistrust and misunderstanding among patients, clinical providers, and traditional practitioners make the development of effective partnerships difficult, particularly regarding early HIV diagnosis and antiretroviral therapy. We provide recommendations for the development of successful collaboration health workforce efforts based on both published articles and case studies from our work in rural Mozambique.

The role of social relationship in HIV healing and its implications in HIV cure in China

HIV is both a biomedical disease and a social phenomenon that is constructed in particular cultural contexts. A successful and humane HIV cure requires not only the science of eradicating pathogens, but also the art of healing to restore harmony between mind and body. Healing in the context of HIV cure will be both personal and interpersonal, biological and social, and will involve rebuilding connections between HIV patients and their social environment. Social conceptions of healing have been highlighted in many regions with rich non-biomedical healing traditions, including China. Based on an adapted theoretical model on social relationships and health, we address the essential role of social relations for HIV healing in Chinese cultural context, and propose several recommendations for reforming practices and policies regarding HIV healing. In general, family is still a core social unit in HIV patients' medical journey from diagnosis to treatment. A positive patient-physician relationship based on mutual respect and trust also has critical impact on patients' physical and mental health. Physicians may become a key or the main source of social support in circumstances when families are not actively engaged in healing. Reconnecting HIV patients with their communities should be a necessary component of HIV cure, as this will help patients engage more fully in the HIV healing process. We call for a family-centered approach in HIV healing intervention to strengthen patient-family ties; a series of policies to build up and sustain positive patient-physician ties; and multi-level strategies to empower patients and rebuild their bonds to community and larger society. We also call for more empirical research on how non-biomedical healing approaches in various cultural settings could (directly or indirectly) inform HIV cure research.

The impact of community support initiatives on the stigma experienced by people living with HIV/AIDS in South Africa

In the current context of human resource shortages in South Africa, various community support interventions are being implemented to provide long-term psychosocial care to persons living with HIV/AIDS (PLWHA). However, it is important to analyze the unintended social side effects of such interventions in regards to the stigma felt by PLWHA, which might threaten the successful management of life-long treatment. Latent cross-lagged modeling was used to analyze longitudinal data on 294 PLWHA from a randomized controlled trial (1) to determine whether peer adherence support (PAS) and treatment buddying influence the stigma experienced by PLWHA; and (2) to analyze the interrelationships between each support form and stigma. Results indicate that having a treatment buddy decreases felt stigma scores, while receiving PAS increases levels of felt stigma at the second follow up. However, the PAS intervention was also found to have a positive influence on having a treatment buddy at this time. Furthermore, a treatment buddy mitigates the stigmatizing effect of PAS, resulting in a small negative indirect effect on stigma. The study indicates the importance of looking beyond the intended effects of an intervention, with the goal of minimizing any adverse consequences that might threaten the successful long-term management of HIV/AIDS and maximizing the opportunities created by such support.

Incomplete adherence among treatment-experienced adults on antiretroviral therapy in Tanzania, Uganda and Zambia

OBJECTIVES

To characterize antiretroviral therapy (ART) adherence across different programmes and examine the relationship between individual and programme characteristics and incomplete adherence among ART clients in sub-Saharan Africa.

DESIGN

A cross-sectional study.

METHODS

Systematically selected ART clients (≥18 years; on ART ≥6 months) attending 18 facilities in three countries (250 clients/facility) were interviewed. Client self-reports (3-day, 30-day, Case Index ≥48 consecutive hours of missed ART), healthcare provider estimates and the pharmacy medication possession ratio (MPR) were used to estimate ART adherence. Participants from two facilities per country underwent HIV RNA testing. Optimal adherence measures were selected on the basis of degree of association with concurrent HIV RNA dichotomized at less than or greater/equal to 1000 copies/ml. Multivariate regression analysis, adjusted for site-level clustering, assessed associations between incomplete adherence and individual and programme factors.

RESULTS

A total of 4489 participants were included, of whom 1498 underwent HIV RNA testing. Nonadherence ranged from 3.2% missing at least 48 consecutive hours to 40.1% having an MPR of less than 90%. The percentage with HIV RNA at least 1000 copies/ml ranged from 7.2 to 17.2% across study sites (mean = 9.9%). Having at least 48 consecutive hours of missed ART was the adherence measure most strongly related to virologic failure. Factors significantly related to incomplete adherence included visiting a traditional healer, screening positive for alcohol abuse, experiencing more HIV symptoms, having an ART regimen without nevirapine and greater levels of internalized stigma.

CONCLUSION

Results support more in-depth investigations of the role of traditional healers, and the development of interventions to address alcohol abuse and internalized stigma among treatment-experienced adult ART patients.

HIV protective efficacy and correlates of tenofovir blood concentrations in a clinical trial of PrEP for HIV prevention

BACKGROUND

Antiretroviral pre-exposure prophylaxis (PrEP) is a novel HIV prevention strategy for which adherence is a known determinant of efficacy. Blood concentrations of PrEP medications are one objective marker of adherence.

METHODS

In a placebo-controlled PrEP efficacy trial of tenofovir disoproxil fumarate (TDF) and TDF with emtricitabine (FTC/TDF) among 4747 African women and men with an HIV-infected partner, we measured plasma tenofovir concentrations from participants in the active PrEP arms: 29 HIV seroconverters (cases) and 196 randomly selected controls who remained uninfected.

RESULTS

Among controls, 71% of visits had tenofovir concentrations >40 ng/mL, consistent with steady-state daily dosing, compared with 21% of cases at the visit HIV was first detected. Pill count data indicated that 96% of controls and 66% of cases had >80% adherence for these same visits. The estimated protective effect of PrEP against HIV, based on concentrations >40 ng/mL, was 88% (95% confidence interval: 60 to 96, P < 0.001) for individuals receiving TDF and 91% (95% confidence interval: 47 to 98, P = 0.008) for individuals receiving FTC/TDF. Controls had consistent patterns of PrEP concentrations during follow-up; among the 81% with concentrations >40 ng/mL at month 1, 75% maintained this concentration at month 12. Only 5 of 29 seroconverters seemed to be consistently adherent to PrEP. Tenofovir concentrations >40 ng/mL were associated with older age and shorter time on study; concentrations ≤40 ng/mL occurred more commonly when participants reported no sex with their HIV-infected partner.

CONCLUSIONS

Plasma concentrations of tenofovir consistent with daily dosing were highly predictive of protection from HIV acquisition. Most of those who took PrEP seemed to have high and consistent adherence.

Women's experiences with oral and vaginal pre-exposure prophylaxis: the VOICE-C qualitative study in Johannesburg, South Africa

Background

In VOICE, a multisite HIV pre-exposure prophylaxis (PrEP) trial, plasma drug levels pointed to widespread product nonuse, despite high adherence estimated by self-reports and clinic product counts. Using a socio-ecological framework (SEF), we explored socio-cultural and contextual factors that influenced participants’ experience of daily vaginal gel and oral tablet regimens in VOICE.

Methods

In Johannesburg, a qualitative ancillary study was concurrently conducted among randomly selected VOICE participants assigned to in-depth interviews (n = 41), serial ethnographic interviews (n = 21), or focus group discussions (n = 40). Audiotaped interviews were transcribed, translated, and coded thematically for analysis.

Results

Of the 102 participants, the mean age was 27 years, and 96% had a primary sex partner with whom 43% cohabitated. Few women reported lasting nonuse, which they typically attributed to missed visits, lack of product replenishments, and family-related travel or work. Women acknowledged occasionally skipping or mistiming doses because they forgot, were busy, felt lazy or bored, feared or experienced side effects. However, nearly all knew or heard of other study participants who did not use products daily. Three overarching themes emerged from further analyses: ambivalence toward research, preserving a healthy status, and managing social relationships. These themes highlighted the profound and complex meanings associated with participating in a blinded HIV PrEP trial and taking antiretroviral-based products. The unknown efficacy of products, their connection with HIV infection, challenges with daily regimen given social risks, lack of support–from partners and significant others–and the relationship tradeoffs entailed by using the products appear to discourage adequate product use.

Conclusions

Personal acknowledgment of product nonuse was challenging. This qualitative inquiry highlighted key influences at all SEF levels that shaped women’s perceptions of trial participation and experiences with investigational products. Whether these impacted women’s behaviors and may have contributed to ineffective trial results warrants further investigation.

Impact of HIV-related stigma on treatment adherence: systematic review and meta-synthesis

INTRODUCTION

Adherence to HIV antiretroviral therapy (ART) is a critical determinant of HIV-1 RNA viral suppression and health outcomes. It is generally accepted that HIV-related stigma is correlated with factors that may undermine ART adherence, but its relationship with ART adherence itself is not well established. We therefore undertook this review to systematically assess the relationship between HIV-related stigma and ART adherence.

METHODS

We searched nine electronic databases for published and unpublished literature, with no language restrictions. First we screened the titles and abstracts for studies that potentially contained data on ART adherence. Then we reviewed the full text of these studies to identify articles that reported data on the relationship between ART adherence and either HIV-related stigma or serostatus disclosure. We used the method of meta-synthesis to summarize the findings from the qualitative studies.

RESULTS

Our search protocol yielded 14,854 initial records. After eliminating duplicates and screening the titles and abstracts, we retrieved the full text of 960 journal articles, dissertations and unpublished conference abstracts for review. We included 75 studies conducted among 26,715 HIV-positive persons living in 32 countries worldwide, with less representation of work from Eastern Europe and Central Asia. Among the 34 qualitative studies, our meta-synthesis identified five distinct third-order labels through an inductive process that we categorized as themes and organized in a conceptual model spanning intrapersonal, interpersonal and structural levels. HIV-related stigma undermined ART adherence by compromising general psychological processes, such as adaptive coping and social support. We also identified psychological processes specific to HIV-positive persons driven by predominant stigmatizing attitudes and which undermined adherence, such as internalized stigma and concealment. Adaptive coping and social support were critical determinants of participants' ability to overcome the structural and economic barriers associated with poverty in order to successfully adhere to ART. Among the 41 quantitative studies, 24 of 33 cross-sectional studies (71%) reported a positive finding between HIV stigma and ART non-adherence, while 6 of 7 longitudinal studies (86%) reported a null finding (Pearson's χ (2)=7.7; p=0.005).

CONCLUSIONS

We found that HIV-related stigma compromised participants' abilities to successfully adhere to ART. Interventions to reduce stigma should target multiple levels of influence (intrapersonal, interpersonal and structural) in order to have maximum effectiveness on improving ART adherence.

Patient-nominated, community-based HIV treatment supporters: patient perspectives, feasibility, challenges, and factors for success in HIV-infected South African adults

This study aimed to characterize the experience of having a treatment supporter among HIV-infected South African patients enrolled in a randomized controlled trial that compared the efficacy of patient-nominated treatment supporters administering partial directly observed antiretroviral therapy (DOT-ART) versus self-administered ART (Self-ART). Results of the parent study showed no virologic or sustained immunologic differences between groups, but revealed a significant survival benefit among the DOT-ART group. One hypothesis is that this survival benefit may be explained by differences in the training and involvement of the treatment supporters between groups. In the current study, results from a semi-structured exit interview of 172 participants indicate that most participants in both arms maintained a positive, satisfying relationship with a single supporter, typically family member or friend. Most patients (82.6%) perceived supporters as helpful with medication adherence, with no significant difference between groups (p=0.752). Additionally, supporters provided emotional, instrumental, and material support. DOT-ART patients were more likely than Self-ART patients to report that their supporter helped to decrease drug or alcohol use (p=0.03). Patients identified supporter trustworthiness, availability, good communication and reciprocity of support as factors beneficial to a successful relationship. These results suggest: (1) Patient-nominated peers are feasible candidates for ART supporters in this resource-constrained setting; (2) In addition to assistance with medications, treatment supporters have the capacity to promote healthy behaviors and provide other types of support, which may contribute to improved outcomes, particularly with enhanced training; (3) Trustworthiness, availability, good communication, and reciprocity are key factors in a successful patient-supporter relationship.