Improvements in physical wellbeing over the first two years on antiretroviral therapy in western Kenya

What constitutes a palliative care need in people with serious illnesses across Africa? A mixed-methods systematic review of the concept and evidence

BACKGROUND

Clarity on what constitutes a palliative care need is essential to ensure that health systems and clinical services deliver an appropriate response within Universal Health Coverage.

AIM

To synthesise primary evidence from Africa for palliative care needs among patients and families with serious illness.

DESIGN

We conducted a mixed methods systematic review with sequential synthesis design. The protocol was registered with PROSPERO (CRD42019136606) and included studies were quality assessed using Mixed Method Appraisal Tool.

DATA SOURCES

Six global literature databases and Three Africa-specific databases were searched up to October 2020 for terms related to palliative care, serious illnesses and Africa. Palliative care need was defined as multidimensional problems, symptoms, distress and concerns which can benefit from palliative care.

RESULTS

Of 7810 papers screened, 159 papers met eligibility criteria. Palliative care needs were mostly described amongst patients with HIV/AIDS (n = 99 studies) or cancer (n = 59), from East (n = 72) and Southern (n = 89) Africa. Context-specific palliative care needs included managing pregnancy and breastfeeding, preventing infection transmission (physical); health literacy needs, worry about medical bills (psychological); isolation and stigma, overwhelmed families needing a break, struggling to pay children's school fees and selling assets (social and practical needs); and rites associated with cultural and religious beliefs (spiritual).

CONCLUSIONS

Palliative care assessment and care must reflect the context-driven specific needs of patients and families in Africa, in line with the novel framework. Health literacy is a crucial need in this context that must be met to ensure that the benefits of palliative care can be achieved at the patient-level.

Work and home productivity of people living with HIV in Zambia and South Africa

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Objective:

To compare number of days lost to illness or accessing healthcare for HIV-positive and HIV-negative individuals working in the informal and formal sectors in South Africa and Zambia.

Design:

As part of the HPTN 071 (PopART) study, data on adults aged 18–44 years were gathered from cross-sectional surveys of random general population samples in 21 communities in Zambia and South Africa. Data on the number of productive days lost in the last 3 months, laboratory-confirmed HIV status, labour force status, age, ethnicity, education, and recreational drug use was collected.

Methods:

Differences in productive days lost between HIV-negative and HIV-positive individuals (’excess productive days lost’) were estimated with negative binomial models, and results disaggregated for HIV-positive individuals after various durations on antiretroviral treatment (ART).

Results:

From samples of 19 330 respondents in Zambia and 18 004 respondents in South Africa, HIV-positive individuals lost more productive days to illness than HIV-negative individuals in both countries. HIV-positive individuals in Zambia lost 0.74 excess productive days [95% confidence interval (CI) 0.48–1.01; P < 0.001] to illness over a 3-month period. HIV-positive in South Africa lost 0.13 excess days (95% CI 0.04–0.23; P = 0.007). In Zambia, those on ART for less than 1 year lost most days, and those not on ART lost fewest days. In South Africa, results disaggregated by treatment duration were not statistically significant.

Conclusion:

There is a loss of work and home productivity associated with HIV, but it is lower than existing estimates for HIV-positive formal sector workers. The findings support policy makers in building an accurate investment case for HIV interventions.

The Impact of Company-Level ART Provision to a Mining Workforce in South Africa: A Cost-Benefit Analysis

BACKGROUND

HIV impacts heavily on the operating costs of companies in sub-Saharan Africa, with many companies now providing antiretroviral therapy (ART) programmes in the workplace. A full cost-benefit analysis of workplace ART provision has not been conducted using primary data. We developed a dynamic health-state transition model to estimate the economic impact of HIV and the cost-benefit of ART provision in a mining company in South Africa between 2003 and 2022.

METHODS AND FINDINGS

A dynamic health-state transition model, called the Workplace Impact Model (WIM), was parameterised with workplace data on workforce size, composition, turnover, HIV incidence, and CD4 cell count development. Bottom-up cost analyses from the employer perspective supplied data on inpatient and outpatient resource utilisation and the costs of absenteeism and replacement of sick workers. The model was fitted to workforce HIV prevalence and separation data while incorporating parameter uncertainty; univariate sensitivity analyses were used to assess the robustness of the model findings. As ART coverage increases from 10% to 97% of eligible employees, increases in survival and retention of HIV-positive employees and associated reductions in absenteeism and benefit payments lead to cost savings compared to a scenario of no treatment provision, with the annual cost of HIV to the company decreasing by 5% (90% credibility interval [CrI] 2%-8%) and the mean cost per HIV-positive employee decreasing by 14% (90% CrI 7%-19%) by 2022. This translates into an average saving of US$950,215 (90% CrI US$220,879-US$1.6 million) per year; 80% of these cost savings are due to reductions in benefit payments and inpatient care costs. Although findings are sensitive to assumptions regarding incidence and absenteeism, ART is cost-saving under considerable parameter uncertainty and in all tested scenarios, including when prevalence is reduced to 1%-except when no benefits were paid out to employees leaving the workforce and when absenteeism rates were half of what data suggested. Scaling up ART further through a universal test and treat strategy doubles savings; incorporating ART for family members reduces savings but is still marginally cost-saving compared to no treatment. Our analysis was limited to the direct cost of HIV to companies and did not examine the impact of HIV prevention policies on the miners or their families, and a few model inputs were based on limited data, though in sensitivity analysis our results were found to be robust to changes to these inputs along plausible ranges.

CONCLUSIONS

Workplace ART provision can be cost-saving for companies in high HIV prevalence settings due to reductions in healthcare costs, absenteeism, and staff turnover. Company-sponsored HIV counselling and voluntary testing with ensuing treatment of all HIV-positive employees and family members should be implemented universally at workplaces in countries with high HIV prevalence.

Antiretroviral therapy adherence in a sample of men with low socioeconomic status: The role of task-specific treatment self-efficacy

Disparities continue to persist in HIV care and treatment outcomes among racial/ethnic minorities, men who have sex with men (MSM), and individuals with low socioeconomic status. Much research has identified treatment self-efficacy as a key factor in antiretroviral therapy adherence and subsequent treatment outcomes. Few studies, however, have elaborated on these links and their potential in reducing HIV treatment disparities by examining the role of task-specific types of treatment self-efficacy. In this study, we examined the effect of four types of task-specific treatment self-efficacy on antiretroviral adherence among patients in a predominantly racial/ethnic minority sample of HIV-seropositive MSM with low socioeconomic status. We grouped participants by duration of treatment to determine whether certain types of self-efficacy were more salient based on treatment experience. We found that participants with optimal adherence tended to have higher levels of task-specific self-efficacy related to medication management and mood management than participants with suboptimal adherence. After a Bonferroni correction for multiple comparisons, only task-specific self-efficacy for medication management showed significant effects on adherence. Findings suggest that using focused, task-specific measures of treatment self-efficacy could strengthen our ability to aid patients at risk for adherence difficulties and tailor interventions to more effectively meet their needs.

Progression of pain in ambulatory HIV-positive South Africans

Cross-sectional studies report that pain in ambulatory HIV-infected individuals is frequent and often undermanaged. Expanding access to HIV treatment in developing countries means that infected individuals are living longer, but there is a dearth of pain-directed studies from developing countries that describe the progression of pain and its treatment over any period of time. The aim of this study was to characterize the progression of pain and its treatment over a 6-month period in 92 ambulatory HIV-positive patients attending an outpatient clinic in Johannesburg, South Africa. We used the Wisconsin Brief Pain Questionnaire to assess changes in pain intensity, pain sites, pain interference, and pain treatment. At visit 1, pain was present in 78 of 92 patients (85%). Of the 78 patients with pain, 67 had moderate or severe pain (86%) and pain affected two or more body sites simultaneously in 57 of these patients (73%). After 6 months, pain prevalence still was high, but had fallen to 50 patients (54%). Of the patients with pain at visit 2, the proportion with moderate or severe pain (82%), or two or more pain sites (62%) had decreased. Analgesic use was low at both time points (5% and 25% analgesic use at visit 1 and 2, respectively). Despite the high pain burden, pain interference in daily activities was very low across the period assessed. The burden of pain in this cohort of ambulatory HIV-positive patients was high, but there were significant reductions in pain burden over time.

A systematic review of treatment fatigue among HIV-infected patients prescribed antiretroviral therapy

HIV treatment requires lifelong adherence to medication regimens that comprise inconvenient scheduling, adverse side effects, and lifestyle changes. Antiretroviral adherence and treatment fatigue have been inextricably linked. Adherence in HIV-infected populations has been well investigated; however, little is known about treatment fatigue. This review examines the current state of the literature on treatment fatigue among HIV populations and provides an overview of its etiology and potential consequences. Standard systematic research methods were used to gather published papers on treatment fatigue and HIV. Five databases were searched using PRISMA criteria. Of 1557 studies identified, 21 met the following inclusion criteria: (a) study participants were HIV-infected; (b) participants were prescribed antiretroviral medication; (c) the article referenced treatment fatigue; (d) the article was published in a peer-reviewed journal; and (e) text was available in English. Only seven articles operationally defined treatment fatigue, with three themes emerging throughout the definitions: (1) pill burden; (2) loss of desire to adhere to the regimen; and (3) nonadherence to regimens as a consequence of treatment fatigue. Based on these studies, treatment fatigue may be defined as "decreased desire and motivation to maintain vigilance in adhering to a treatment regimen among patients prescribed long-term protocols." The cause and course of treatment fatigue appear to vary by developmental stage. To date, only structured treatment interruptions have been examined as an intervention to reduce treatment fatigue in children and adults. No behavioral interventions have been developed to reduce treatment fatigue. Further, only qualitative studies have examined treatment fatigue conceptually. Studies designed to systematically assess treatment fatigue are needed. Increased understanding of the course and duration of treatment fatigue is expected to improve adherence interventions, thereby improving clinical outcomes for individuals living with HIV.

Prevalence and correlates of pain and pain treatment in a western Kenya referral hospital

BACKGROUND

Pain is often inadequately evaluated and treated in sub-Saharan Africa (SSA).

OBJECTIVE

We sought to assess pain levels and pain treatment in 400 hospitalized patients at a national referral hospital in western Kenya, and to identify factors associated with pain and pain treatment.

DESIGN

Using face-validated Kiswahili versions of two single-item pain assessment tools, the Numerical Rating Scale (NRS) and the Faces Pain Scale-Revised (FPS-R), we determined patients' pain levels. Additional data collected included patient demographics, prescribed analgesics, and administered analgesics. We calculated mean pain ratings and pain management index (PMI) scores.

RESULTS

Averaged between the NRS and FPS-R, 80.5% of patients endorsed a nonzero level of pain and 30% of patients reported moderate to severe pain. Older patients, patients with HIV, and cancer patients had higher pain ratings. Sixty-six percent of patients had been prescribed analgesics at some point during their hospitalization, the majority of which were nonopioids. A majority of patients (66%) had undertreated pain (negative scores on the PMI).

CONCLUSION

This study shows that hospitalized patients in Kenya are experiencing pain and that this pain is often undertreated.

Assessment of the face validity of two pain scales in Kenya: a validation study using cognitive interviewing

BACKGROUND

Patients in sub-Saharan Africa commonly experience pain, which often is un-assessed and undertreated. One hindrance to routine pain assessment in these settings is the lack of a single-item pain rating scale validated for the particular context. The goal of this study was to examine the face validity and cultural acceptability of two single-item pain scales, the Numerical Rating Scale (NRS) and the Faces Pain Scale-Revised (FPS-R), in a population of patients on the medical, surgical, and pediatric wards of Moi Teaching and Referral Hospital in Kenya.

METHODS

Swahili versions of the NRS and FPS-R were developed by standard translation and back-translation. Cognitive interviews were performed with 15 patients at Moi Teaching and Referral Hospital in Eldoret, Kenya. Interview transcripts were analyzed on a question-by-question basis to identify major themes revealed through the cognitive interviewing process and to uncover any significant problems participants encountered with understanding and using the pain scales.

RESULTS

Cognitive interview analysis demonstrated that participants had good comprehension of both the NRS and the FPS-R and showed rational decision-making processes in choosing their responses. Participants felt that both scales were easy to use. The FPS-R was preferred almost unanimously to the NRS.

CONCLUSIONS

The face validity and acceptability of the Swahili versions of the NRS and FPS-R has been demonstrated for use in Kenyan patients. The broader application of these scales should be evaluated and may benefit patients who currently suffer from pain.

Health and functional status among older people with HIV/AIDS in Uganda

BACKGROUND

In sub-Saharan Africa, little is known about the health and functional status of older people who either themselves are HIV infected or are affected by HIV and AIDS in the family. This aim of this study was to describe health among older people in association with the HIV epidemic.

METHODS

The cross-sectional survey consisted of 510 participants aged 50 years and older, equally divided into five study groups including; 1) HIV infected and on antiretroviral therapy (ART) for at least 1 year; 2) HIV infected and not yet eligible for ART; 3) older people who had lost a child due to HIV/AIDS; 4) older people who have an adult child with HIV/AIDS; 5) older people not known to be infected or affected by HIV in the family. The participants were randomly selected from ongoing studies in a rural and peri-urban area in Uganda. Data were collected using a WHO standard questionnaire and performance tests. Eight indicators of health and functioning were examined in an age-adjusted bivariate and multivariate analyses.

RESULTS

In total, 198 men and 312 women participated. The overall mean age was 65.8 and 64.5 years for men and women respectively. Men had better self-reported health and functional status than women, as well as lower self-reported prevalence of chronic diseases. In general, health problems were common: 35% of respondents were diagnosed with at least one of the five chronic conditions, including 15% with depression, based on algorithms; 31% of men and 35% of women had measured hypertension; 25% of men and 21% of women had poor vision test results. HIV-positive older people, irrespective of being on ART, and HIV-negative older people in the other study groups had very similar results for most health status and functioning indicators. The main difference was a significantly lower BMI among HIV-infected older people.

CONCLUSION

The systematic exploration of health and well being among older people, using eight self-reported and objective health indicators, showed that basic health problems are very common at older ages and poorly addressed by existing health services. HIV-infected older people, however, whether on ART or not yet on ART, had a similar health and functional status as other older people.

Palliative care and support for persons with HIV/AIDS in 7 African countries: implementation experience and future priorities

To combat morbidity and mortality from the worldwide epidemic of the human immunodeficiency virus (HIV), the United States Congress implemented a President's Emergency Plan for AIDS Relief (PEPFAR) in 30 resource-limited countries to integrate combination antiretroviral therapy (ART) for both prevention and cure. Over 35% of eligible persons have been successfully treated. Initial legislation cited palliative care as an essential aspect of this plan but overall health strengthening became critical to sustainability of programming and funding priorities shifted to assure staffing for care delivery sites; laboratory and pharmaceutical infrastructure; data collection and reporting; and financial management as individual countries are being encouraged to assume control of in-country funding. Given infrastructure requisites, individual care delivery beyond ART management alone has received minimal funding yet care remains necessary for durable viral suppression and overall quality of life for individuals. Technical assistance staff of one implementing partner representing seven African countries met to clarify domains of palliative care compared with the substituted term "care and support" to understand potential gaps in on-going HIV care. They prioritized care needs as: 1) mental health (depression and other mood disorders); 2) communication skills (age-appropriate disclosure of HIV status); 3) support of care-providers (stress management for sustainability of a skilled HIV workforce); 4) Tied Priorities: symptom management in opportunistic infections; end-of-life care; spiritual history-taking; and 5) Tied Priorities: attention to grief-related needs of patients, their families and staff; and management of HIV co-morbidities. This process can inform health policy as funding transitions to new priorities.

Economic returns to investment in AIDS treatment in low and middle income countries

Since the early 2000s, aid organizations and developing country governments have invested heavily in AIDS treatment. By 2010, more than five million people began receiving antiretroviral therapy (ART)--yet each year, 2.7 million people are becoming newly infected and another two million are dying without ever having received treatment. As the need for treatment grows without commensurate increase in the amount of available resources, it is critical to assess the health and economic gains being realized from increasingly large investments in ART. This study estimates total program costs and compares them with selected economic benefits of ART, for the current cohort of patients whose treatment is cofinanced by the Global Fund to Fight AIDS, Tuberculosis and Malaria. At end 2011, 3.5 million patients in low and middle income countries will be receiving ART through treatment programs cofinanced by the Global Fund. Using 2009 ART prices and program costs, we estimate that the discounted resource needs required for maintaining this cohort are $14.2 billion for the period 2011-2020. This investment is expected to save 18.5 million life-years and return $12 to $34 billion through increased labor productivity, averted orphan care, and deferred medical treatment for opportunistic infections and end-of-life care. Under alternative assumptions regarding the labor productivity effects of HIV infection, AIDS disease, and ART, the monetary benefits range from 81 percent to 287 percent of program costs over the same period. These results suggest that, in addition to the large health gains generated, the economic benefits of treatment will substantially offset, and likely exceed, program costs within 10 years of investment.

An obese body mass increases the adverse effects of HIV/AIDS on balance and gait

BACKGROUND

Balance and gait problems have been detected among patients with HIV/AIDS. The extent to which these problems are exacerbated by either frailty or obesity has not been examined. Objective The purpose of this study was to compare participants who differed in body mass and the presence or absence of HIV/AIDS.

DESIGN

This was a cross-sectional study.

METHODS

Quantitative measurements were obtained from 86 participants who were HIV-type 1 (HIV-1) seronegative and 121 participants who were seropositive divided into subgroups based on their body mass index (BMI <21, 21-29, or >29 kg/m(2)).

RESULTS

Participants who were seropositive were impaired relative to seronegative controls on several indices, including the limit of stability, sway amplitude and sway strategy, gait initiation time, and gait speed during a fast pace condition. Participants who were obese also exhibited impairments, which were evident during assessments of the limit of stability, nonpreferred leg stance time, sway strategy, normal and fast gait speed, fast gait initiation time, and 360-degree turn time. Importantly, the analysis revealed that participants with both attributes were more impaired than those with either or neither attribute: patients who were obese and seropositive were more impaired in fast gait initiation time and cadence, nonpreferred leg stance time, 360-degree turn time, and sway strategy scores. Limitations The validity of BMI as a measure of body mass can be challenged. In addition, the validity of chair rise time and 360-degree turn time as estimates of lower-extremity strength (force-generating capacity) can be argued.

CONCLUSIONS

The present findings have an obvious and unfortunate implication: as more patients who are HIV-1 seropositive join the seronegative community in becoming obese, the effects of obesity and their disease may summate and their risk for balance and gait problems may increase.

Economic outcomes of patients receiving antiretroviral therapy for HIV/AIDS in South Africa are sustained through three years on treatment

Background

Although the medical outcomes of antiretroviral therapy (ART) for HIV/AIDS are well described, less is known about how ART affects patients' economic activities and quality of life, especially after the first year on ART. We assessed symptom prevalence, general health, ability to perform normal activities, and employment status among adult antiretroviral therapy patients in South Africa over three full years following ART initiation.

Methodology/Principal Findings

A cohort of 855 adult pre-ART patients and patients on ART for <6 months was enrolled and interviewed an average of 4.4 times each during routine clinic visits for up to three years after treatment initiation using an instrument designed for the study. The probability of pain in the previous week fell from 74% before ART initiation to 32% after three years on ART, fatigue from 66% to 12%, nausea from 28% to 4%, and skin problems from 55% to 10%. The probability of not feeling well physically yesterday fell from 46% to 23%. Before starting ART, 39% of subjects reported not being able to perform their normal activities sometime during the previous week; after three years, this proportion fell to 10%. Employment rose from 27% to 42% of the cohort. Improvement in all outcomes was sustained over 3 years and for some outcomes increased in the second and third year.

Conclusions/Significance

Improvements in adult ART patients' symptom prevalence, general health, ability to perform normal activities, and employment status were large and were sustained through the first three years on treatment. These results suggest that some of the positive economic and social externalities anticipated as a result of large-scale treatment provision, such as increases in workforce participation and productivity and the ability of patients to carry on normal lives, may indeed be accruing.