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Kebede HK, Gesesew HA, Gebremedhin AT, Ward P. The impact of armed conflicts on HIV treatment outcomes in Sub-Saharan Africa: a systematic review and meta-analysis. Confl Health 2024; 18:40. [PMID: 38760792 PMCID: PMC11100029 DOI: 10.1186/s13031-024-00591-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 03/28/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Despite the fact that Sub-Saharan Africa bears a disproportionate burden of armed conflicts and HIV infection, there has been inadequate synthesis of the impact of armed conflict on HIV treatment outcomes. We summarized the available evidence on the impact of armed conflicts on HIV treatment outcomes in Sub-Saharan Africa from 2002 to 2022. METHODS We searched four databases; MEDLINE, PubMed, CINHAL, and Scopus. We also explored grey literature sources and reviewed the bibliographies of all articles to identify any additional relevant studies. We included quantitative studies published in English from January 1, 2002 to December 30, 2022 that reported on HIV treatment outcomes for patients receiving antiretroviral therapy (ART) in conflict and post-conflict areas, IDP centers, or refugee camps, and reported on their treatment outcomes from sub-Saharan Africa. Studies published in languages other than English, reporting on non-ART patients and reporting on current or former military populations were excluded. We used EndNote X9 and Covidence to remove duplicates, extracted data using JBI-MAStARI, assessed risk of bias using AHRQ criteria, reported results using PRISMA checklist, and determined Statistical heterogeneity using Cochran Q test and Higgins I2, R- and RevMan-5 software were used for meta-analysis. RESULTS The review included 16 studies with participant numbers ranging from 102 to 2572. Lost To Follow-Up (LTFU) percentages varied between 5.4% and 43.5%, virologic non-suppression rates ranged from 25 to 33%, adherence rates were over 88%, and mortality rates were between 4.2% and 13%. A pooled meta-analysis of virologic non-suppression rates from active conflict settings revealed a non-suppression rate of 30% (0.30 (0.26-0.33), I2 = 0.00%, p = 0.000). In contrast, a pooled meta-analysis of predictors of loss to follow-up (LTFU) from post-conflict settings identified a higher odds ratio for females compared to males (1.51 (1.05, 2.17), I2 = 0%, p = 0.03). CONCLUSION The review highlights a lack of research on the relationship between armed conflicts and HIV care outcomes in SSA. The available documents lack quality of designs and data sources, and the depth and diversity of subjects covered.
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Affiliation(s)
- Hafte Kahsay Kebede
- Tigray Health Research Institute, Mekelle, Tigray, Ethiopia.
- College of Health Sciences, Mekelle University, Mekelle, 231, Ethiopia.
- Research Centre for Public Health, Equity, and Human Flourishing, Torrens University Australia, Adelaide, 5000, Australia.
| | - Hailay Abrha Gesesew
- College of Health Sciences, Mekelle University, Mekelle, 231, Ethiopia
- Research Centre for Public Health, Equity, and Human Flourishing, Torrens University Australia, Adelaide, 5000, Australia
| | - Amanuel Tesfay Gebremedhin
- Curtin School of Population Health, Curtin University, Bentley, WA, Australia
- School of Nursing and Midwifery, Edith Cowan University, Perth, Australia
| | - Paul Ward
- Research Centre for Public Health, Equity, and Human Flourishing, Torrens University Australia, Adelaide, 5000, Australia
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Utheim MN, Isaakidis P, Van den Bergh R, Géraud BBG, Mabvouna RB, Omsland TK, Heen E, Dahl C. Provider-initiated HIV testing uptake and socio-economic status among women in a conflict zone in the Central African Republic: a mixed-methods cross-sectional study. Confl Health 2023; 17:14. [PMID: 36973827 PMCID: PMC10041765 DOI: 10.1186/s13031-023-00505-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 02/09/2023] [Indexed: 03/29/2023] Open
Abstract
INTRODUCTION In the Central African Republic (CAR), HIV/AIDS is the main cause of death in women aged 15-49 years. Increased testing coverage is essential in prevention of HIV/AIDS, especially in areas where conflict hinders access to health care. Socio-economic status (SES) has been shown to be associated with HIV testing uptake. We investigated whether "Provider-initiated HIV testing and counselling" (PITC) could be implemented in a family planning clinic in an active conflict zone in the Central African Republic to reach women of reproductive age and assessed whether socioeconomic status was associated with testing uptake. METHODS Women aged 15-49 years were recruited from a free family planning clinic run by Médecins Sans Frontières in the capital Bangui. An asset-based measurement tool was created based on analysis of qualitative in-depth interviews. Measures of socioeconomic status were constructed from the tool, also by using factor analysis. Logistic regression was used to quantify the association between SES and HIV testing uptake (yes/no), while controlling for potential confounders: age, marital status, number of children, education level and head of household. RESULTS A total of 1419 women were recruited during the study period, where 87.7% consented to HIV testing, and 95.5% consented to contraception use. A total of 11.9% had never been tested for HIV previously. Factors negatively associated with HIV testing uptake were: being married (OR = 0.4, 95% CI 0.3-0.5); living in a household headed by the husband as opposed to by another person (OR = 0.4, 95% CI 0.3-0.6), and lower age (OR = 0.96, 95% CI 0.93-0.99). Higher level of education (OR = 1.0, 95% CI 0.97-1.1) and having more children aged under 15 (OR = 0.92, 95% CI 0.81-1.1) was not associated with testing uptake. In multivariable regression, testing uptake was lower in the higher SES groups, but the differences were not significant (OR = 0.80, 95% CI 0.55-1.18). CONCLUSIONS The findings show that PITC can be successfully implemented in the patient flow in a family planning clinic, without compromising contraception uptake. Within the PITC framework in a conflict setting, socioeconomic status was not found to be associated with testing uptake in women of reproductive age.
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Affiliation(s)
- Mari Nythun Utheim
- Institute of Health and Society, University of Oslo, Postboks 1130 Blindern, 0318, Oslo, Norway.
| | - Petros Isaakidis
- Médecins Sans Frontières - Southern African Medical Unit, Marshalltown, South Africa
- Clinical and Molecular Epidemiology Unit, Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece
| | - Rafael Van den Bergh
- Médecins Sans Frontières - Operational Centre Brussels, Operational Research Unit (LuxOR), Brussels, Belgium
| | | | | | - Tone Kristin Omsland
- Institute of Health and Society, University of Oslo, Postboks 1130 Blindern, 0318, Oslo, Norway
| | - Espen Heen
- Institute of Health and Society, University of Oslo, Postboks 1130 Blindern, 0318, Oslo, Norway
| | - Cecilie Dahl
- Institute of Health and Society, University of Oslo, Postboks 1130 Blindern, 0318, Oslo, Norway
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The Relationship Between Intersectional Drug Use and HIV Stigma and HIV Care Engagement Among Women Living with HIV in Ukraine. AIDS Behav 2022; 27:1914-1925. [PMID: 36441406 PMCID: PMC9703403 DOI: 10.1007/s10461-022-03925-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2022] [Indexed: 11/29/2022]
Abstract
This study used an intersectional approach to explore the association between enacted and internalized drug use and HIV stigma on HIV care outcomes among HIV-positive women who inject drugs in Ukraine. Surveys were conducted in Kyiv in 2019-2020. Among the 306 respondents, 55% were engaged in HIV care. More than half (52%) of participants not engaged in care reported internalized stigma related to both drug use and HIV status (i.e., intersectional stigma), compared to only 35% of those who were engaged in HIV care. Among those engaged in care, 36% reported intersectional enacted stigma compared to 44% of those not engaged in care; however, this difference was not statistically significant in the univariable analysis (p = 0.06). In the univariable analysis, participants who reported intersectional internalized stigma had 62% lower odds of being engaged in HIV care (OR 0.38, 95% CI 0.22, 0.65, p < 0.001). In the adjusted model, reported intersectional internalized stigma (aOR 0.52, 95% CI 0.30, 0.92, p = 0.026), reported intersectional enacted stigma (aOR 0.47, 95% CI 0.23, 0.95, p = 0.036), and knowing their HIV status for more than 5-years (aOR 2.29, 95% CI 1.35, 3.87, p = 0.002) were significant predictors of HIV care engagement. These findings indicate that interventions to improve HIV care engagement must address women's experiences of both HIV and drug use stigma and the different mechanisms through which stigma operates.
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Meteke S, Stefopulos M, Als D, Gaffey M, Kamali M, Siddiqui FJ, Munyuzangabo M, Jain RP, Shah S, Radhakrishnan A, Ataullahjan A, Bhutta ZA. Delivering infectious disease interventions to women and children in conflict settings: a systematic reviefw. BMJ Glob Health 2020; 5:e001967. [PMID: 32341087 PMCID: PMC7213813 DOI: 10.1136/bmjgh-2019-001967] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 02/19/2020] [Accepted: 03/07/2020] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Conflict has played a role in the large-scale deterioration of health systems in low-income and middle-income countries (LMICs) and increased risk of infections and outbreaks. This systematic review aimed to synthesise the literature on mechanisms of delivery for a range of infectious disease-related interventions provided to conflict-affected women, children and adolescents. METHODS We searched Medline, Embase, CINAHL and PsychINFO databases for literature published in English from January 1990 to March 2018. Eligible publications reported on conflict-affected neonates, children, adolescents or women in LMICs who received an infectious disease intervention. We extracted and synthesised information on delivery characteristics, including delivery site and personnel involved, as well as barriers and facilitators, and we tabulated reported intervention coverage and effectiveness data. RESULTS A majority of the 194 eligible publications reported on intervention delivery in sub-Saharan Africa. Vaccines for measles and polio were the most commonly reported interventions, followed by malaria treatment. Over two-thirds of reported interventions were delivered in camp settings for displaced families. The use of clinics as a delivery site was reported across all intervention types, but outreach and community-based delivery were also reported for many interventions. Key barriers to service delivery included restricted access to target populations; conversely, adopting social mobilisation strategies and collaborating with community figures were reported as facilitating intervention delivery. Few publications reported on intervention coverage, mostly reporting variable coverage for vaccines, and fewer reported on intervention effectiveness, mostly for malaria treatment regimens. CONCLUSIONS Despite an increased focus on health outcomes in humanitarian crises, our review highlights important gaps in the literature on intervention delivery among specific subpopulations and geographies. This indicates a need for more rigorous research and reporting on effective strategies for delivering infectious disease interventions in different conflict contexts. PROSPERO REGISTRATION NUMBER CRD42019125221.
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Affiliation(s)
- Sarah Meteke
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Marianne Stefopulos
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Daina Als
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Michelle Gaffey
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mahdis Kamali
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Fahad J Siddiqui
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
- Health System and Services Research, Duke-NUS Medical School, Singapore
| | - Mariella Munyuzangabo
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Reena P Jain
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Shailja Shah
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Amruta Radhakrishnan
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Anushka Ataullahjan
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
- Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
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Crellen T, Ssonko C, Piening T, Simaleko MM, Geiger K, Siddiqui MR. What drives mortality among HIV patients in a conflict setting? A prospective cohort study in the Central African Republic. Confl Health 2019; 13:52. [PMID: 31754370 PMCID: PMC6854658 DOI: 10.1186/s13031-019-0236-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 10/18/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Provision of antiretroviral therapy (ART) during conflict settings is rarely attempted and little is known about the expected patterns of mortality. The Central African Republic (CAR) continues to have a low coverage of ART despite an estimated 110,000 people living with HIV and 5000 AIDS-related deaths in 2018. We present results from a cohort in Zemio, Haut-Mboumou prefecture. This region had the highest prevalence of HIV nationally (14.8% in a 2010 survey), and was subject to repeated attacks by armed groups on civilians during the observed period. METHODS Conflict from armed groups can impact cohort mortality rates i) directly if HIV patients are victims of armed conflict, or ii) indirectly if population displacement or fear of movement reduces access to ART. Using monthly counts of civilian deaths, injuries and abductions, we estimated the impact of the conflict on patient mortality. We also determined patient-level risk factors for mortality and how the risk of mortality varies with time spent in the cohort. Model-fitting was performed in a Bayesian framework, using logistic regression with terms accounting for temporal autocorrelation. RESULTS Patients were recruited and observed in the HIV treatment program from October 2011 to May 2017. Overall 1631 patients were enrolled and 1628 were included in the analysis giving 48,430 person-months at risk and 145 deaths. The crude mortality rate after 12 months was 0.92 (95% CI 0.90, 0.93). Our model showed that patient mortality did not increase during periods of heightened conflict; the odds ratios (OR) 95% credible interval (CrI) for i) civilian fatalities and injuries, and ii) civilian abductions on patient mortality both spanned unity. The risk of mortality for individual patients was highest in the second month after entering the cohort, and declined seven-fold over the first 12 months. Male sex was associated with a higher mortality (odds ratio 1.70 [95% CrI 1.20, 2.33]) along with the severity of opportunistic infections (OIs) at baseline (OR 2.52; 95% CrI 2.01, 3.23 for stage 2 OIs compared with stage 1). CONCLUSIONS Our results show that chronic conflict did not appear to adversely affect rates of mortality in this cohort, and that mortality was driven predominantly by patient-specific risk factors. The risk of mortality and recovery of CD4 T-cell counts observed in this conflict setting are comparable to those in stable resource poor settings, suggesting that conflict should not be a barrier in access to ART.
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Affiliation(s)
- Thomas Crellen
- Médecins Sans Frontières Hollande, Avenue Barthelemy Boganda, PK4, Bangui, BP 1793 Central African Republic
- Mahidol-Oxford Tropical Medicine Research Unit, 420/6 Rajvithi Road, Tungphyathai, Bangkok, 10400 Thailand
| | - Charles Ssonko
- Médecins Sans Frontières, The Manson Unit, Chancery Exchange, 10 Furnival Street, London, EC4A 1AB UK
| | - Turid Piening
- Médecins Sans Frontières, Am Köllnischen Park 1, 10179 Berlin, Germany
| | - Marcel Mbeko Simaleko
- Ministre de la Santé Publique et de la Population, Bangui, BP 883 Central African Republic
| | - Karen Geiger
- Médecins Sans Frontières Hollande, Avenue Barthelemy Boganda, PK4, Bangui, BP 1793 Central African Republic
| | - M. Ruby Siddiqui
- Médecins Sans Frontières, The Manson Unit, Chancery Exchange, 10 Furnival Street, London, EC4A 1AB UK
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Ferreyra C, O’Brien D, Alonso B, Al-Zomour A, Ford N. Provision and continuation of antiretroviral therapy during acute conflict: the experience of MSF in Central African Republic and Yemen. Confl Health 2018; 12:30. [PMID: 29988565 PMCID: PMC6027556 DOI: 10.1186/s13031-018-0161-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 04/02/2018] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND Unstable settings present challenges for the effective provision of antiretroviral treatment (ART). In this paper, we summarize the experience and results of providing ART and implementing contingency plans during acute instability in the Central African Republic (CAR) and Yemen. CASE PRESENTATION In CAR, MSF has provided HIV care in three conflict-affected rural regions; these were put on hold throughout the acute phase of violence. "Run-away bags" containing 3 or 4 months of ART were distributed to patients at MSF facilities. Among 1820 HIV patients enrolled into care, 1440 (79%) initiated ART. By December 2016, 782 (54%) patients were still under ART, 354 (25%) have been lost to follow up and 182 (13%) had died. In 2013, when violence disrupted services, 683 patients were receiving ART. Between September-December 2013, 594 (87%) patients received runaway bags and by February 2014, 313 (53%) of these patients returned to the clinic.In Yemen, when violence erupted, patients received a health card that included a helpline to call in case of drug shortages in admission to emergency stocks; this was not possible in CAR due to lack of a functioning telephone network. One thousand six hundred fifty-five PLWHA have been enrolled in care and 1470 (89%) initiated ART; 1056 (72%) are still followed on ART, 126 (9%) were lost to follow up, and 288 (20%) died. In January 2011 clashes began and by April 2011 MSF medical activities were interrupted. Of the 363 patients receiving ART, 363 (100%) received emergency bags to cover 9 months and by February 2012, 354 (98%) patients returned to care. In March 2015 a new wave of conflict affected Yemen, forcing HIV activities to revert to contingency planning. CONCLUSIONS This experience provides further evidence that provision of HIV treatment and emergency drug stocks can be successfully provided to most patients in both conflict-affected settings.
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Affiliation(s)
| | | | | | | | - Nathan Ford
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape town, South Africa
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Ratnayake R, Degomme O, Roberts B, Spiegel P. Conflict and Health: seven years of advancing science in humanitarian crises. Confl Health 2014; 8:7. [PMID: 24843382 PMCID: PMC4024652 DOI: 10.1186/1752-1505-8-7] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 04/29/2014] [Indexed: 11/10/2022] Open
Affiliation(s)
- Ruwan Ratnayake
- International Rescue Committee, 122 E 42nd Street, New York 10168, USA
| | - Olivier Degomme
- International Centre for Reproductive Health, Ghent University, De Pintelaan 185 UZP114, Ghent 9000, Belgium
| | - Bayard Roberts
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Paul Spiegel
- Division of Programme Support and Management, United Nations High Commissioner for Refugees, Geneva, Switzerland
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Goodrich S, Ndege S, Kimaiyo S, Some H, Wachira J, Braitstein P, Sidle JE, Sitienei J, Owino R, Chesoli C, Gichunge C, Komen F, Ojwang C, Sang E, Siika A, Wools-Kaloustian K. Delivery of HIV care during the 2007 post-election crisis in Kenya: a case study analyzing the response of the Academic Model Providing Access to Healthcare (AMPATH) program. Confl Health 2013; 7:25. [PMID: 24289095 PMCID: PMC4176498 DOI: 10.1186/1752-1505-7-25] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 11/20/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Widespread violence followed the 2007 presidential elections in Kenya resulting in the deaths of a reported 1,133 people and the displacement of approximately 660,000 others. At the time of the crisis the United States Agency for International Development-Academic Model Providing Access to Healthcare (USAID-AMPATH) Partnership was operating 17 primary HIV clinics in western Kenya and treating 59,437 HIV positive patients (23,437 on antiretroviral therapy (ART)). METHODS This case study examines AMPATH's provision of care and maintenance of patients on ART throughout the period of disruption. This was accomplished by implementing immediate interventions including rapid information dissemination through the media, emergency hotlines and community liaisons; organization of a Crisis Response leadership team; the prompt assembly of multidisciplinary teams to address patient care, including psychological support staff (in clinics and in camps for internally displaced persons (IDP)); and the use of the AMPATH Medical Records System to identify patients on ART who had missed clinic appointments. RESULTS These interventions resulted in the opening of all AMPATH clinics within five days of their scheduled post-holiday opening dates, 23,949 patient visits in January 2008 (23,259 previously scheduled), uninterrupted availability of antiretrovirals at all clinics, treatment of 1,420 HIV patients in IDP camps, distribution of basic provisions, mobilization of outreach services to locate missing AMPATH patients and delivery of psychosocial support to 300 staff members and 632 patients in IDP camps. CONCLUSION Key lessons learned in maintaining the delivery of HIV care in a crisis situation include the importance of advance planning to develop programs that can function during a crisis, an emphasis on a rapid programmatic response, the ability of clinics to function autonomously, patient knowledge of their disease, the use of community and patient networks, addressing staff needs and developing effective patient tracking systems.
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Affiliation(s)
- Suzanne Goodrich
- Department of Medicine, Indiana University School of Medicine, Indianapolis, USA
| | - Samson Ndege
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Department of Epidemiology, School of Public Health, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Sylvester Kimaiyo
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Department of Medicine, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Hosea Some
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Juddy Wachira
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Paula Braitstein
- Department of Medicine, Indiana University School of Medicine, Indianapolis, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Department of Medicine, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
- Divison of Global Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - John E Sidle
- Department of Medicine, Indiana University School of Medicine, Indianapolis, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Regenstrief Institute, Indianapolis, USA
| | - Jackline Sitienei
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Department of Health Policy and Management, School of Public Health, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Regina Owino
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Cleophas Chesoli
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Catherine Gichunge
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- School of Public Health, Griffith Health Institute, Griffith University, Southport, Queensland, Australia
| | - Fanice Komen
- Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Claris Ojwang
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Edwin Sang
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Abraham Siika
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Department of Medicine, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Kara Wools-Kaloustian
- Department of Medicine, Indiana University School of Medicine, Indianapolis, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
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Omare D, Kanekar A. Determinants of HIV/AIDS in armed conflict populations. J Public Health Afr 2011; 2:e9. [PMID: 28299050 PMCID: PMC5345483 DOI: 10.4081/jphia.2011.e9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2010] [Accepted: 12/22/2010] [Indexed: 11/24/2022] Open
Abstract
More than 40 million people worldwide have been infected with human immunodeficiency virus (HIV) since it was first reported in 1981. Over 25 million of these have lost their lives to the disease. Most of the studies related to HIV/AIDS have been conducted in stable populations across the globe. Few of these studies have been devoted to displaced populations, particularly those in areas of conflict. Displaced populations that are forced to leave their homes in most cases find themselves in unfamiliar territories, often poor and hungry. Many of them become refugees and internally displaced people (IDPs). The objective of this review was to address a number of different social determinants of HIV/AIDS in displaced populations in areas of conflict. A comprehensive review of peer reviewed literature published in English between 1990 and 2010 obtained through an open search of PUBMED database using key words such as HIV and war, HIV/AIDS and conflict, AIDS and security was conducted. Twelve different studies that looked at the implications of HIV/AIDS in conflict or displaced populations were retrieved. The review revealed that there were various factors influencing conflict and HIV/AIDS such as forced population displacement, breakdown of traditional sexual norms, lack of health infrastructure, and poverty and powerlessness of women and children. Social determinants of increased HIV/AIDS prevalence in displaced populations are scarcity of food, poverty, insecurity of displaced populations and gender power differentials.
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Affiliation(s)
- Danvas Omare
- Department of Health Studies, East Stroudsburg University of Pennsylvania, USA
| | - Amar Kanekar
- Department of Health Studies, East Stroudsburg University of Pennsylvania, USA
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Virginie S, Yasmin H, Sally B. Assessing the impact of mass rape on the incidence of HIV in conflict-affected countries. AIDS 2010; 24:2841-7. [PMID: 20859191 PMCID: PMC2978669 DOI: 10.1097/qad.0b013e32833fed78] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To quantify the potential impact of mass rape on HIV incidence in seven conflict-afflicted countries (CACs), with severe HIV epidemics, in sub-Saharan Africa. DESIGN Uncertainty analysis of a risk equation model. METHODS A mathematical model was used to evaluate the potential impact of mass rape on increasing HIV incidence in women and girls in Burundi, Democratic Republic of Congo (DRC), Rwanda, Sierra Leone, Somalia, southern Sudan and Uganda. The model was parameterized with data from UNAIDS/WHO and the US Census Bureau's International Database. Incidence data from UNAIDS/WHO were used for calibration. RESULTS Mass rape could cause approximately five HIV infections per 100,000 females per year in the DRC, Sudan, Somalia and Sierra Leone, double the number in Burundi and Rwanda, and quadruple the number in Uganda. The number of females infected per year due to mass rape is likely to be relatively low in Somalia and Sierra Leone at 127 [median (interquartile range [IQR] 55-254)] and 156 [median (IQR 69-305)], respectively. Numbers could be high in the DRC and Uganda: 1120 [median (IQR 527-2360)] and 2172 [median (IQR 1031-4668)], respectively. In Burundi, Rwanda and Sudan, the numbers are likely to be intermediate. Under extreme conditions, 10,000 women and girls could be infected per year in the DRC and 20 000 women and girls could be infected per year in Uganda. Mass rape could increase annual incidence by approximately 7% [median (IQR 3-15)]. CONCLUSION Interventions and treatment targeted to rape survivors during armed conflicts could reduce HIV incidence. Support should be provided both on the basis of human rights and public health.
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Affiliation(s)
- Supervie Virginie
- Semel Institute of Neuroscience & Human Behavior, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Halima Yasmin
- Global Campaign for Microbicides, Washington DC and School of International Studies, American University, Washington DC
| | - Blower Sally
- Semel Institute of Neuroscience & Human Behavior, David Geffen School of Medicine, University of California, Los Angeles, California
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O'Brien DP, Venis S, Greig J, Shanks L, Ellman T, Sabapathy K, Frigati L, Mills C. Provision of antiretroviral treatment in conflict settings: the experience of Médecins Sans Frontières. Confl Health 2010; 4:12. [PMID: 20553624 PMCID: PMC2911421 DOI: 10.1186/1752-1505-4-12] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Accepted: 06/17/2010] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Many countries ravaged by conflict have substantial morbidity and mortality attributed to HIV/AIDS yet HIV treatment is uncommonly available. Universal access to HIV care cannot be achieved unless the needs of populations in conflict-affected areas are addressed. METHODS From 2003 Médecins Sans Frontières introduced HIV care, including antiretroviral therapy, into 24 programmes in conflict or post-conflict settings, mainly in sub-Saharan Africa. HIV care and treatment activities were usually integrated within other medical activities. Project data collected in the Fuchia software system were analysed and outcomes compared with ART-LINC data. Programme reports and other relevant documents and interviews with local and headquarters staff were used to develop lessons learned. RESULTS In the 22 programmes where ART was initiated, more than 10,500 people were diagnosed with HIV and received medical care, and 4555 commenced antiretroviral therapy, including 348 children. Complete data were available for adults in 20 programmes (n = 4145). At analysis, 2645 (64%) remained on ART, 422 (10%) had died, 466 (11%) lost to follow-up, 417 (10%) transferred to another programme, and 195 (5%) had an unclear outcome. Median 12-month mortality and loss to follow-up were 9% and 11% respectively, and median 6-month CD4 gain was 129 cells/mm 3.Patient outcomes on treatment were comparable to those in stable resource-limited settings, and individuals and communities obtained significant benefits from access to HIV treatment. Programme disruption through instability was uncommon with only one program experiencing interruption to services, and programs were adapted to allow for disruption and population movements. Integration of HIV activities strengthened other health activities contributing to health benefits for all victims of conflict and increasing the potential sustainability for implemented activities. CONCLUSIONS With commitment, simplified treatment and monitoring, and adaptations for potential instability, HIV treatment can be feasibly and effectively provided in conflict or post-conflict settings.
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Affiliation(s)
- Daniel P O'Brien
- Public Health Department, Médecins Sans Frontières, Amsterdam, Netherlands
- Department of Infectious Diseases, Geelong Hospital, Geelong, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, Australia
| | - Sarah Venis
- Manson Unit, Médecins Sans Frontières, London, UK
| | - Jane Greig
- Manson Unit, Médecins Sans Frontières, London, UK
| | - Leslie Shanks
- Public Health Department, Médecins Sans Frontières, Amsterdam, Netherlands
| | - Tom Ellman
- Manson Unit, Médecins Sans Frontières, London, UK
| | - Kalpana Sabapathy
- Public Health Department, Médecins Sans Frontières, Amsterdam, Netherlands
| | - Lisa Frigati
- Public Health Department, Médecins Sans Frontières, Amsterdam, Netherlands
- School of Child and Adolescent Health, Red Cross Childrens' Hospital, Capetown, South Africa
| | - Clair Mills
- Public Health Department, Médecins Sans Frontières, Amsterdam, Netherlands
- Te Kupenga Hauora Maori, Faculty of Medical and Health Sciences,University of Auckland, Auckland, New Zealand
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Monjok E, Smesny A, Okokon IB, Mgbere O, Essien EJ. Adherence to antiretroviral therapy in Nigeria: an overview of research studies and implications for policy and practice. HIV AIDS-RESEARCH AND PALLIATIVE CARE 2010; 2:69-76. [PMID: 22096386 PMCID: PMC3218702 DOI: 10.2147/hiv.s9280] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Both Human Immunodeficiency Virus (HIV) infection and AIDS remain major public health crises in Nigeria, a country which harbors more people living with HIV/AIDS than any country in the world, with the exception of South Africa and India. In response to the HIV pandemic, global and international health initiatives have targeted several countries, including Nigeria, for the expansion of antiretroviral therapy (ART) programs for the increasing number of affected patients. The success of these expanded ART initiatives depends on the treated individual's continual adherence to antiretroviral (ARV) drugs. Thirteen peer-reviewed studies concerning adherence to ART in Nigeria were reviewed with very few pediatric and adolescent studies being found. Methodologies of adherence measurement were analyzed and reasons for nonadherence were identified in the geopolitical zones in the federal republic of Nigeria. The results of the literature review indicate that adherence to ART is mixed (both high and low adherence) with patient self-recall identified as the common method of assessment. The most common reasons identified for patient nonadherence include the cost of therapy (even when the drugs are heavily subsidized), medication side effects, nonavailability of ARV drugs, and the stigma of taking the drugs. This manuscript highlights the policy and practice implications from these studies and provides recommendations for future ART program management.
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Affiliation(s)
- Emmanuel Monjok
- Institute of Community Health, University of Houston, Texas Medical Center, Houston Texas 77030, USA
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13
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Antiretroviral therapy adherence and retention in care in middle-income and low-income countries: current status of knowledge and research priorities. Curr Opin HIV AIDS 2010; 5:70-7. [PMID: 20046150 DOI: 10.1097/coh.0b013e328333ad61] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Adherence to combination antiretroviral therapy (cART) is one of the most important contributing factors to positive clinical outcomes in patients with HIV, and long-term retention of patients in low-income and middle-income countries is emerging as an important issue in rapidly expanding cART programs. This review presents recent developments in both treatment adherence and retention of patients in low-income and middle-income countries. RECENT FINDINGS Adherence is among the most modifiable variables in treatment, but there still is no 'gold standard' measurement. Best estimates demonstrate that adherence in resource-limited settings is equal or superior to that in resource-rich settings, possibly due to focused efforts on support groups and community acceptance of adherence behaviors. However, long-term data show that sustained efforts to ensure high cART adherence and evidence of intervention effects are critical, but that resource-intensive interventions are not warranted in settings where cART adherence is high. Furthermore, well conducted evaluation of culturally sensitive interventions to maximize pre-cART and post-cART initiation retention is badly needed in low-income and middle-income settings. SUMMARY Further research is needed to identify risk factors and to improve adherence and retention among children, adolescents, and adults through use of social networks or emerging technologies for patients at risk for poor adherence.
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Abstract
There has been an historic expectation that delivering combination antiretroviral therapy (cART) to populations affected by violent conflict is untenable due to population movement and separation of drug supplies. There is now emerging evidence that cART provision can be successful in these populations. Using examples from Médecins Sans Frontières experience in a variety of African settings and also local nongovernmental organizations' experiences in northern Uganda, we examine novel approaches that have ensured retention in programs and adequate adherence. Emerging guidelines from United Nations bodies now support the expansion of cART in settings of conflict.
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Affiliation(s)
- Edward J Mills
- BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada.
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15
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Reconsidering the impact of conflict on HIV infection among women in the era of antiretroviral treatment scale-up in sub-Saharan Africa: a gender lens. AIDS 2008; 22:1705-7. [PMID: 18753938 DOI: 10.1097/qad.0b013e328308de0e] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Chamla DD, Olu O, Wanyana J, Natseri N, Mukooyo E, Okware S, Alisalad A, George M. Geographical information system and access to HIV testing, treatment and prevention of mother-to-child transmission in conflict affected Northern Uganda. Confl Health 2007; 1:12. [PMID: 18053189 PMCID: PMC2228274 DOI: 10.1186/1752-1505-1-12] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2007] [Accepted: 12/03/2007] [Indexed: 11/25/2022] Open
Abstract
Objectives Using Geographical Information System (GIS) as a tool to determine access to and gaps in providing HIV counselling and testing (VCT), treatment (ART) and mother-to-child transmission (PMTCT) services in conflict affected northern Uganda. Methods Cross-sectional data on availability and utilization, and geo-coordinates of health facilities providing VCT, PMTCT, and ART were collected in order to determine access. ArcView software produced maps showing locations of facilities and Internally Displaced Population(IDP) camps. Findings There were 167 health facilities located inside and outside 132 IDP camps with VCT, PMTCT and ART services provided in 32 (19.2%), 15 (9%) and 10 (6%) facilities respectively. There was uneven availability and utilization of services and resources among districts, camps and health facilities. Inadequate staff and stock-out of essential commodities were found in lower health facility levels. Provision of VCT was 100% of the HSSP II target at health centres IV and hospitals but 28% at HC III. For PMTCT and ART, only 42.9% and 20% of the respective targets were reached at the health centres IV. Conclusion Access to VCT, PMTCT and ART services was geographically limited due to inadequacy and heterogeneous dispersion of these services among districts and camps. GIS mapping can be effective in identifying service delivery gaps and presenting complex data into simplistic results hence can be recommended in need assessments in conflict settings.
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Affiliation(s)
- Dick D Chamla
- World Health Organization, formerly with Health Leadership services (HLS), 20 avenue appia, Geneva 1211, Switzerland.
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Culbert H, Tu D, O'Brien DP, Ellman T, Mills C, Ford N, Amisi T, Chan K, Venis S. HIV treatment in a conflict setting: outcomes and experiences from Bukavu, Democratic Republic of the Congo. PLoS Med 2007; 4:e129. [PMID: 17535100 PMCID: PMC1880839 DOI: 10.1371/journal.pmed.0040129] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Providing HIV care in conflict settings involves additional obstacles to those generally encountered in other resource-limited settings, say Heather Culbert and colleagues.
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Singh S, Orbinski JJ, Mills EJ. Conflict and health: a paradigm shift in global health and human rights. Confl Health 2007; 1:1. [PMID: 17411453 PMCID: PMC1839764 DOI: 10.1186/1752-1505-1-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2007] [Accepted: 03/01/2007] [Indexed: 11/17/2022] Open
Affiliation(s)
- Sonal Singh
- Wake-Forest University Health Sciences, Winston-Salem, North Carolina, USA
| | | | - Edward J Mills
- Centre for International Health and Human Rights Studies, North York, Ontario, Canada
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