Long-Distance Travel for HIV-Related Care-Burden or Choice?: A Mixed Methods Study in Tanzania

Hospitalized with HIV in Zambia: individual and system factors driving the high burden of admissions and post-discharge mortality in the era of HIV epidemic control

BACKGROUND

Despite progress towards HIV epidemic control, people living with HIV (PLHIV) in Zambia continue to face high mortality during and especially after hospitalization, with suboptimal post-discharge care leading to poor outcomes. We conducted a qualitative study to better understand factors influencing post-discharge engagement in care for HIV and associated comorbidities.

METHODS

We conducted in-depth interviews with 16 recently discharged PLHIV, seven caregivers, and two doctors; and three focus group discussions with inpatient doctors (n = 8) and lay counsellors (n = 16) at two tertiary hospitals in Lusaka, guided by the social-ecological model. Data were audio-recorded, transcribed verbatim, managed with Atlas.ti 9, and thematically analyzed.

RESULTS

Individual and household-level barriers to post-discharge care for PLHIV included HIV status denial and stigma, limited disclosure, and limited social and emotional support. Health-related barriers included concomitant treatments for TB, HIV comorbidities, and behavioral health issues like depression and alcohol abuse. Health system barriers included limited confidentiality during admission and poor communication between healthcare providers and between facilities aftercare transitions following discharge. Social-economic factors included economic shocks of hospitalization and post-discharge recovery, which compounded pre-existing poverty and high transportation and food costs. Conversely, disclosure of HIV status, better social support, a financially stable household, and hospital follow-up appointment reminders facilitated better post-discharge care.

CONCLUSION

After hospital discharge with HIV, system and individual challenges exacerbate pre-existing interpersonal, health, environmental, and system-related factors to cause poor outcomes. Holistic community-based interventions to facilitate these patients' re-engagement in care after discharge could help HIV programs reach the last mile in epidemic control.

Bypassing primary antiretroviral therapy centres in Sub-Saharan Africa: An integrative review of the theoretical and empirical literature

The uptake of antiretroviral therapy (ART) is critical to meeting the global HIV treatment goal of 95-95-95 by 2025. Although a few Sub-Saharan African countries have already achieved this target, the prevalence of bypassing primary ART centres in many countries in the subregion has negative implications for ART uptake and use. This study used the access to health services framework to analyse the evidence and factors contributing to bypassing primary ART centres by individuals in the sub-region seeking HIV care and support. We found compelling evidence of the prevalence of ART clients bypassing their primary ART centres in search of specialised care in higher-tiered health facilities. Others use bypassing to conceal their HIV-positive status to avoid social stigma. We argue that introducing specialised and differentiated ART at the primary level of care can address this phenomenon. While we anticipate that this measure will satisfy clients' desire for specialised care, we recommend enhancing public awareness about the effectiveness of ART to reduce stigma towards ART clients. Legislation and strict enforcement of anti-HIV stigma laws, which outlaw and criminalise stigmatising people living with HIV (PLHIV), could potentially be an effective stigma-deterring measure. To complement this effort, PLHIV should be empowered to understand legislative instruments and steps to take when confidentiality and discriminatory issues arise. We recommend further research in Sub-Saharan Africa to investigate the relationship between bypassing primary ART centres and client adherence. The findings will help design appropriate strategies to increase ART uptake at primary ART centres.

Travel Burden and Timely Linkage to Care Among People Newly Diagnosed with HIV Infection in South Carolina from 2005 to 2020

This retrospective study explored the association between travel burden and timely linkage to care (LTC) among people with HIV (PWH) in South Carolina. HIV care data were derived from statewide all-payer electronic health records, and timely LTC was defined as having at least one viral load or CD4 count record within 90 days after HIV diagnosis before the year 2015 and 30 days after 2015. Travel burden was measured by average driving time (in minutes) to any healthcare facility visited within six months before and one month after the initial HIV diagnosis. Multivariable logistic regression models with the least absolute shrinkage and selection operator were employed. From 2005 to 2020, 81.2% (3,547 out of 4,366) of PWH had timely LTC. Persons who had longer driving time (adjusted Odds Ratio (aOR): 0.37, 95% CI: 0.14-0.99), were male versus female (aOR: 0.73, 95% CI: 0.58-0.91), had more comorbidities (aOR: 0.73, 95% CI: 0.57-0.94), and lived in counties with a higher percentage of unemployed labor force (aOR: 0.21, 95% CI: 0.06-0.71) were less likely to have timely LTC. However, compared to those aged between 18 and 24 years old, those aged between 45 and 59 (aOR:1.47, 95% CI: 1.14-1.90) or older than 60 (aOR:1.71, 95% CI: 1.14-2.56) were more likely to have timely LTC. Concentrated and sustained interventions targeting underserved communities and the associated travel burden among newly diagnosed PWH who are younger, male, and have more comorbidities are needed to improve LTC and reduce health disparities.

Antiretroviral Therapy Concealment Behaviors and their Association with Antiretroviral Therapy Adherence among People with HIV: Findings from the Florida Cohort Study

Little is known about HIV medication concealment behaviors and the effect of medication concealment on antiretroviral therapy (ART) adherence among people with HIV (PWH). This study aims to (1) to describe medication concealment behaviors and factors associated with these behaviors, and (2) assess the association between medication concealment and suboptimal ART adherence. The Florida Cohort Study enrolled adult PWH from community-based clinics around the state from October 2020 to September 2022 (n = 416, 62% aged 50+, 56% male, 44% non-Hispanic Black, 18% Hispanic). Participants responded to questions about sociodemographics, stigma, ART adherence (≥ 85%), symptoms of depression, social networks and disclosure to their networks, and actions to conceal ART to avoid inadvertent disclosure of their HIV status. Analyses were conducted using multivariable logistic regressions models. The most common concealment behavior was hiding ART while having guests over (32%), followed by removing ART labels (26%), and putting ART into a different bottle (16%). Overall, 43% reported ≥ 1 behavior. In multivariable models, depressive symptoms, incomplete disclosure of HIV to close social networks, and not having a close social network were associated with ART concealment. After adjusting for risk factors for suboptimal ART adherence, endorsing hiding medication while having guests was associated with suboptimal ART adherence (aOR 2.87, 95% CI 1.15-7.55). Taking any action and other individual behaviors were not associated. ART concealment behaviors were common but did not consistently negatively influence adherence when accounting for other factors. PWH may want to receive ART medications in ways that ensure privacy and reduce the risk of inadvertent disclosure.

Urban-rural disparities in geographic accessibility to care for people living with HIV

In the United States, people living with HIV (PLWH) in rural areas fare worse along the HIV care continuum than their urban counterparts; this may be due in part to limited geographic access to care. We estimated drive time to care for PLWH, focusing on urban-rural differences. Adult Medicaid enrollees living with HIV and their usual care clinicians were identified using administrative claims data from 14 states (Medicaid Analytic eXtract, 2009-2012). We used geographic network analysis to calculate one-way drive time from the enrollee's ZIP code tabulation area centroid to their clinician's practice address, then examined urban-rural differences using bivariate statistics. Additional analyses included altering the definition of rurality; examining subsamples based on the state of residence, services received, and clinician specialty; and adjusting for individual and county characteristics. Across n = 49,596 PLWH, median drive time to care was 12.8 min (interquartile range 26.3). Median drive time for rural enrollees (43.6 (82.0)) was nearly four times longer than for urban enrollees (11.9 (20.6) minutes, p < 0.0001), and drive times exceeded one hour for 38% of rural enrollees (versus 12% of urban, p < 0.0001). Urban-rural disparities remained in all additional analyses. Sustained efforts to circumvent limited geographic access to care are critical for rural areas.

Human mobility and the infectious disease transmission: A systematic review

Recent decades have witnessed several infectious disease outbreaks, including the coronavirus disease (COVID-19) pandemic, which had catastrophic impacts on societies around the globe. At the same time, the twenty-first century has experienced an unprecedented era of technological development and demographic changes: exploding population growth, increased airline flights, and increased rural-to-urban migration, with an estimated 281 million international migrants worldwide in 2020, despite COVID-19 movement restrictions. In this review, we synthesized 195 research articles that examined the association between human movement and infectious disease outbreaks to understand the extent to which human mobility has increased the risk of infectious disease outbreaks. This article covers eight infectious diseases, ranging from respiratory illnesses to sexually transmitted and vector-borne diseases. The review revealed a strong association between human mobility and infectious disease spread, particularly strong for respiratory illnesses like COVID-19 and Influenza. Despite significant research into the relationship between infectious diseases and human mobility, four knowledge gaps were identified based on reviewed literature in this study: 1) although some studies have used big data in investigating infectious diseases, the efforts are limited (with the exception of COVID-19 disease), 2) while some research has explored the use of multiple data sources, there has been limited focus on fully integrating these data into comprehensive analyses, 3) limited research on the global impact of mobility on the spread of infectious disease with most studies focusing on local or regional outbreaks, and 4) lack of standardization in the methodology for measuring the impacts of human mobility on infectious disease spread. By tackling the recognized knowledge gaps and adopting holistic, interdisciplinary methods, forthcoming research has the potential to substantially enhance our comprehension of the intricate interplay between human mobility and infectious diseases.

Brief Report: Task-Shifting "Gold Standard" Clinical Assessment and Safety Planning for Suicide Risk Among People Living With HIV: A Feasibility and Fidelity Evaluation in Tanzania

BACKGROUND

Suicide is a leading cause of death among people living with HIV (PLWH) worldwide, with suicide deaths occurring twice as frequently among PLWH than among the general public. In Tanzania, resources for mental health care are sorely lacking, with 55 psychiatrists and psychologists providing treatment for 60 million people. In light of this shortage, nonspecialists play a crucial role. The objective of this study was to assess feasibility of implementing task-shifted screening, assessment, and safety planning for suicide risk among PLWH.

SETTING

Two adult HIV clinics in Kilimanjaro, Tanzania.

METHODS

Registered professional nurses in the HIV clinics were trained to administer brief screening of suicidal ideation in the past month. Patients experiencing suicidal ideation were referred to bachelor's-level counselors for further assessment and safety planning, supervised by specialist providers who reviewed audio recordings for quality assurance.

RESULTS

During 180 days of implementation, nurses screened patients attending 2745 HIV appointments. Sixty-one (2.2%) endorsed suicidal ideation and were linked to further assessment and safety planning. We cross-checked screening with clinic attendance logs on 7 random days and found high fidelity to screening (206 of 228 screened, 90%). Quality assurance ratings demonstrated key assessment pieces were consistently completed (mean = 9.3/10 possible), with "Good" to "Excellent" counseling skills (mean = 23.7/28) and "Good" to "Excellent" quality (mean = 17.1/20), including appropriate referral for higher levels of care.

CONCLUSIONS

Brief screening can be implemented and paired with task-shifted counseling to facilitate high-quality assessment of suicide risk. This model shows excellent potential to extend mental health services for PLWH in low-resource settings.

Implementing Geospatial Science and Technology to Get to Zero New HIV Infections

PURPOSE OF REVIEW

Tremendous advancements have been made in HIV treatment and prevention during the last 40 years that zero new HIV cases has become an attainable goal declared by international agencies. However, new cases of HIV infection persist.

RECENT FINDINGS

The emerging field of geospatial science is positioned to play key role in the reduction of continued HIV incidence through technology-driven interventions and innovative research that gives insights into at-risk populations. As these methods become more utilized, findings consistently show the important role of location and environment plays in HIV incidence and treatment adherence. This includes distance to HIV provider, locations of where HIV transmissions occurs compared to where people with HIV reside, and how geospatial technology has been leveraged to identify unique insights among varying groups of those at increased risk for HIV, among others. Given these insights, leveraging geospatial technology would play a prominent role in achieving zero new cases of HIV infections.

Patient and health worker perspectives on quality of HIV care and treatment services in Haiti

BACKGROUND

Poor quality of care is a barrier to engagement in HIV care and treatment in low- and middle-income country settings. This study involved focus group discussions (FGD) with patients and health workers in two large urban hospitals to describe quality of patient education and psychosocial support services within Haiti's national HIV antiretroviral therapy (ART) program. The purpose of this qualitative study was to illuminate key gaps and salient "ingredients" for improving quality of care.

METHODS

The study included 8 FGDs with a total of 26 male patients and 32 female patients and 15 smaller FGDs with 57 health workers. The analysis used a directed content analysis method, with the goal of extending existing conceptual frameworks on quality of care through rich description.

RESULTS

Dimension of safety, patient-centeredness, accessibility, and equity were most salient. Patients noted risks to privacy with both clinic and community-based services as well as concerns with ART side effects, while health workers described risks to their own safety in providing community-based services. While patients cited examples of positive interactions with health workers that centered their needs and perspectives, they also noted concerns that inhibited trust and satisfaction with services. Health workers described difficult working conditions that challenged their ability to provide patient-centered services. Patients sought favored relationships with health workers to help them navigate the health care system, but this undermined the sense of fairness. Both patients and health workers described frustration with lack of resources to assist patients in dire poverty, and health workers described great pressure to help patients from their "own pockets."

CONCLUSIONS

These concerns reflected the embeddedness of patient - provider interactions within a health system marked by scarcity, power dynamics between patients and health workers, and social stigma related to HIV. Reinforcing a respectful and welcoming atmosphere, timely service, privacy protection, and building patient perception of fairness in access to support could help to build patient satisfaction and care engagement in Haiti. Improving working conditions for health workers is also critical to achieving quality.

Health care seeking in modern urban LMIC settings: evidence from Lusaka, Zambia

Background

In an effort to improve population health, many low- and middle-income countries (LMICs) have expanded access to public primary care facilities and removed user fees for services in these facilities. However, a growing literature suggests that many patients bypass nearby primary care facilities to seek care at more distant or higher-level facilities. Patients in urban areas, a growing segment of the population in LMICs, generally have more options for where to seek care than patients in rural areas. However, evidence on care-seeking trajectories and bypassing patterns in urban areas remains relatively scarce.

Methods

We obtained a complete list of public health facilities and interviewed randomly selected informal sector households across 31 urban areas in Lusaka District, Zambia. All households and facilities listed were geocoded, and care-seeking trajectories mapped across the entire urban area. We analyzed three types of bypassing: i) not using health centers or health posts for primary care; ii) seeking care outside of the residential neighborhood; iii) directly seeking care at teaching hospitals.

Results

A total of 620 households were interviewed, linked to 88 health facilities. Among 571 adults who had recently sought non-emergency care, 65% sought care at a hospital. Among 141 children who recently sought care for diarrhea, cough, fever, or fast breathing, 34% sought care at a hospital. 71% of adults bypassed primary care facilities, 26% bypassed health centers and hospitals close to them for more distant facilities, and 8% directly sought care at a teaching hospital. Bypassing was also observed for 59% of children, who were more likely to seek care outside of the formal care sector, with 21% of children treated at drug shops or pharmacies.

Conclusions

The results presented here strongly highlight the complexity of urban health systems. Most adult patients in Lusaka do not use public primary health facilities for non-emergency care, and heavily rely on pharmacies and drug shops for treatment of children. Major efforts will likely be needed if the government wants to instate health centers as the principal primary care access point in this setting.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13549-3.