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Srinivasan K, Heylen E, Raj T, Nyblade L, Devadass D, Pereira M, Ekstrand ML. Reduction in Stigma Drivers Partially Mediates the Effect of a Stigma Reduction Intervention Among Nursing Students in India: The DriSti Cluster Randomized Controlled Trial. J Acquir Immune Defic Syndr 2021; 86:182-190. [PMID: 33105394 PMCID: PMC7884286 DOI: 10.1097/qai.0000000000002543] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 10/09/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND HIV stigma in health care settings acts as a significant barrier to health care. Stigma drivers among health professionals include transmission fears and misconceptions and pre-existing negative attitudes toward marginalized groups vulnerable to HIV. The DriSti intervention, consisted of 2 sessions with videos and interactive exercises on a computer tablet and one interactive face-to-face group session, mostly tablet administered, was designed to target key stigma drivers that included instrumental stigma, symbolic stigma, transmission misconceptions and blame to reduce HIV stigma, and discrimination among nursing students (NS) and ward staff and tested in a cluster randomized trial. SETTING This report focuses on second and third year NS recruited from a range of nursing schools that included private, nonprofit, and government-run nursing schools in south India. RESULTS Six hundred seventy-nine NS received intervention and 813 NS were in the wait-list control group. Twelve months outcome analyses showed significant reduction among intervention participants in endorsement of coercive policies (P < 0.001) and in the number of situations in which NS intended to discriminate against PLWH (P < 0.001). Mediation analysis revealed that the effects of intervention on endorsement of coercive policies and intent to discriminate against PLWH were partially mediated by reductions in key stigma drivers. CONCLUSIONS This brief scalable stigma reduction intervention targeting key stigma drivers fills a critical gap in identifying the mechanistic pathways that aid in stigma reduction among health professionals.
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Affiliation(s)
- Krishnamachari Srinivasan
- Division of Mental Health and Neurosciences, St John's Research Institute and St. John's Medical College, Bangalore, India
| | - Elsa Heylen
- Division of Prevention Sciences, Department of Medicine, University of California, San Francisco, CA
| | - Tony Raj
- Division of Medical Informatics, St John's Research Institute, and St. John's Medical College, Bangalore, India; and
| | - Laura Nyblade
- Global Health Division, International Development Group, RTI International, Washington, DC
| | - Dhinagaran Devadass
- Division of Medical Informatics, St John's Research Institute, and St. John's Medical College, Bangalore, India; and
| | - Matilda Pereira
- Division of Prevention Sciences, Department of Medicine, University of California, San Francisco, CA
| | - Maria L Ekstrand
- Division of Prevention Sciences, Department of Medicine, University of California, San Francisco, CA
- Division of Medical Informatics, St John's Research Institute, and St. John's Medical College, Bangalore, India; and
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A Behavioral Adherence Intervention Improves Rates of Viral Suppression Among Adherence-Challenged People Living with HIV in South India. AIDS Behav 2020; 24:2195-2205. [PMID: 31933020 DOI: 10.1007/s10461-020-02785-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The success of antiretroviral therapy (ART) has led to both extended life expectancy and improved quality of life among people living with HIV (PLWH). To maximize the efficacy of first line ART regimens in low- and middle-income countries (LMIC), we need culturally-relevant interventions that empower participants to reduce barriers to long-term uninterrupted adherence. The Chetana adherence intervention trial was designed in collaboration with local community groups as a comprehensive wellness program for adherence-challenged PLWH and included peer-led adherence support, yoga, nutrition, information about local resources, and individual counseling using motivational interviewing techniques. Intervention arm participants were almost twice as likely to be virally suppressed at their 12-month follow-up visit (AOR = 1.98; 95% CI [1.2, 3.23]) as were participants in the active control arm. They were also about twice as likely as control arm participants to self-report ≥ 95% adherence (AOR = 1.86, 95% CI [1.09, 3.15]), and as having eliminated individual adherence barriers (AOR = 2.33, 95% CI [1.51, 3.62]) and clinic attendance barriers (AOR = 2.01, 95% CI [1.20, 3.38]) These low-cost strategies can be implemented by local NGOs, making it both scalable and sustainable in this and similar settings.
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Heylen E, Chandy S, Shamsundar R, Nair S, Ravi Kumar BN, Ekstrand ML. Correlates of and barriers to ART adherence among adherence-challenged people living with HIV in southern India. AIDS Care 2020; 33:486-493. [PMID: 32172599 DOI: 10.1080/09540121.2020.1742862] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Suboptimal adherence to Antiretroviral Therapy (ART) regimens can lead to the development of drug resistance, virologic and clinical failure, and, on the community level, the spread of drug-resistant HIV. To design effective interventions, it is crucial to understand locally specific barriers to optimal adherence. Self-report data from a cross-sectional sample of 527 adherence-challenged people living with HIV (PLWH) in the South-Indian state of Karnataka showed that they took on average 68% of prescribed doses in the past month. Large majorities of participants encountered individual (95%), social/structural (88%), and clinic/regimen (80%) adherence barriers. Multivariate linear regression analyses of past month adherence showed that disclosure to all adults in the household was positively related to adherence, as was employing a larger number of adherence strategies, perceiving more benefits of ART, and having been on ART for longer. Fears of stigmatization upon disclosure of HIV-status to friends and people at work were negatively related to adherence. These results suggest that some barriers, especially individual-level barriers like forgetfulness are very common and can be targeted with relatively simple individual-level strategies. Other barriers, related to fear of stigma and lack of disclosure may require family- or community-level interventions.
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Affiliation(s)
- Elsa Heylen
- Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Sara Chandy
- Department of Medicine, St. John's Medical College, St John's National Academy of Health Sciences, Bangalore, India
| | - Ranjani Shamsundar
- Department of Microbiology, St. John's Medical College, St John's National Academy of Health Sciences, Bangalore, India
| | - Shoba Nair
- Department of Pain and Palliative Medicine, St John's Medical College, St John's National Academy of Health Sciences, Bangalore, India
| | - B N Ravi Kumar
- Karnataka State AIDS Prevention Society, Bangalore, India
| | - Maria L Ekstrand
- Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco, San Francisco, CA, USA.,St. John's Research Institute, St John's National Academy of Health Sciences, Bangalore, India
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Ekstrand ML, Raj T, Heylen E, Nyblade L, Devdass D, Pereira M, Mazur A, Srinivasan K. Reducing HIV stigma among healthcare providers in India using a partly tablet-administered intervention: the DriSti trial. AIDS Care 2020; 32:14-22. [PMID: 32151146 DOI: 10.1080/09540121.2020.1739221] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
HIV stigma has long been recognized as a significant barrier in the worldwide fight against HIV. Across cultures, stigma has been shown to cause psychological distress and act as a barrier to engagement in care. Health professionals can serve as a crucial source of HIV stigma, with drivers that include fears and transmission misconceptions and pre-existing negative attitudes towards marginalized groups. To increase their impact, stigma reduction interventions need to be scalable and sustainable as well as adaptable to different cultural contexts. The DriSti intervention was designed to meet these needs through an easily adaptable, mostly tablet-administered, interactive intervention delivered to ward staff (n = 1,557) and nursing students (n = 1,625) in 62 Indian institutions, using a cRCT design, with wait-list controls. Six-month outcome analyses, showed significant reductions in misconceptions (p < .001) and worry about acquiring HIV at work (p < .001). Intervention participants also reported significantly greater reductions in endorsement of coercive policies (p < .001) and in the number of situations in which they intended to discriminate against PLWH (p < .001) than control participants. This brief, scaleable intervention could be adapted for similar populations in the region, using different mHealth platforms and thus has important implications for current global stigma reduction initiatives and training curricula.
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Affiliation(s)
- Maria L Ekstrand
- Division of Prevention Sciences, Department of Medicine, University of California, San Francisco, CA, USA.,Division of Medical Informatics, St. John's Research Institute, Bangalore, India
| | - Tony Raj
- Division of Medical Informatics, St. John's Research Institute, Bangalore, India
| | - Elsa Heylen
- Division of Prevention Sciences, Department of Medicine, University of California, San Francisco, CA, USA
| | - Laura Nyblade
- Global Health Division, International Development Group, RTI International, USA
| | - Dhinagaran Devdass
- Division of Medical Informatics, St. John's Research Institute, Bangalore, India
| | - Matilda Pereira
- Division of Medical Informatics, St. John's Research Institute, Bangalore, India
| | - Amanda Mazur
- Division of Prevention Sciences, Department of Medicine, University of California, San Francisco, CA, USA
| | - Krishnamachari Srinivasan
- Division of Mental Health and Neurosciences, Department of Psychiatry, St. John's Research Institute, Bangalore, India
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Ekstrand ML, Bharat S, Srinivasan K. HIV stigma is a barrier to achieving 90-90-90 in India. Lancet HIV 2018; 5:e543-e545. [PMID: 30319116 DOI: 10.1016/s2352-3018(18)30246-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 08/29/2018] [Accepted: 08/31/2018] [Indexed: 11/16/2022]
Affiliation(s)
- Maria L Ekstrand
- University of California San Francisco, San Francisco, CA 94158, USA; St. John's Research Institute, Bangalore, India.
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Nyamathi A, Ekstrand M, Heylen E, Ramakrishna P, Yadav K, Sinha S, Hudson A, Carpenter CL, Arab L. Relationships Among Adherence and Physical and Mental Health Among Women Living with HIV in Rural India. AIDS Behav 2018; 22:867-876. [PMID: 27990577 PMCID: PMC5476510 DOI: 10.1007/s10461-016-1631-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
We conducted a cross-sectional examination of the physical and psychological factors related to ART adherence among a sample of 400 women living with HIV/AIDS in rural India. Interviewer-administered measures assessed adherence, internalized stigma, depressive symptoms, quality of life, food insecurity, health history and sociodemographic information. CD4 counts were measured using blood collected at screening. Findings revealed that adherence to ART was generally low, with 94% of women taking 50% or less of prescribed medication in past month. Multivariate analyses showed a non-linear association between numbers of self-reported opportunistic infections (OIs) in past 6 months (p = 0.016) and adherence, with adherence decreasing with each additional OI for 0-5 OIs. For those reporting more than 5 OIs, the association reversed direction, with increasing OIs beyond 5 associated with greater adherence.
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Affiliation(s)
- Adeline Nyamathi
- School of Nursing, University of California, Room 2-250, Factor Building, Los Angeles, CA, 90095-1702, USA.
| | - Maria Ekstrand
- Center for AIDS Prevention Studies, University of California, San Francisco, USA
| | - Elsa Heylen
- Center for AIDS Prevention Studies, University of California, San Francisco, USA
| | | | - Kartik Yadav
- School of Nursing, University of California, Room 2-250, Factor Building, Los Angeles, CA, 90095-1702, USA
| | - Sanjeev Sinha
- Department of Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Angela Hudson
- School of Medicine, Cal State University, Los Angeles, USA
| | - Catherine L Carpenter
- School of Nursing, University of California, Room 2-250, Factor Building, Los Angeles, CA, 90095-1702, USA
| | - Lenore Arab
- School of Medicine, University of California, Los Angeles, USA
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Mobile phones to support adherence to antiretroviral therapy: what would it cost the Indian National AIDS Control Programme? J Int AIDS Soc 2014; 17:19036. [PMID: 25186918 PMCID: PMC4154142 DOI: 10.7448/ias.17.1.19036] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Revised: 05/26/2014] [Accepted: 06/11/2014] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Adherence to antiretroviral treatment (ART) is critical to maintaining health and good clinical outcomes in people living with HIV/AIDS. To address poor treatment adherence, low-cost interventions using mobile communication technology are being studied. While there are some studies that show an effect of mobile phone reminders on adherence to ART, none has reported on the costs of such reminders for national AIDS programmes. This paper aims to study the costs of mobile phone reminder strategies (mHealth interventions) to support adherence in the context of India's National AIDS Control Program (NACP). METHODS The study was undertaken at two tertiary level teaching hospitals that implement the NACP in Karnataka state, South India. Costs for a mobile phone reminder application to support adherence, implemented at these sites (i.e. weekly calls, messages or both) were studied. Costs were collected based on the concept of avoidable costs specific to the application. The costs that were assessed were one-time costs and recurrent costs that included fixed and variable costs. A sequential procedure for costing was used. Costs were calculated at national-programme level, individual ART-centre level and individual patient level from the NACP's perspective. The assessed costs were pooled to obtain an annual cost per patient. The type of application, number of ART centres and number of patients on ART were varied in a sensitivity analysis of costs. RESULTS The Indian NACP would incur a cost of between 79 and 110 INR (USD 1.27-1.77) per patient per year, based on the type of reminder, the number of patients on ART and the number of functioning ART centres. The total programme costs for a scale-up of the mHealth intervention to reach the one million patients expected to be on treatment by 2017 is estimated to be 0.36% of the total five-year national-programme budget. CONCLUSIONS The cost of the mHealth intervention for ART-adherence support in the context of the Indian NACP is low and is facilitated by the low cost of mobile communication in the country. Extending the use of mobile communication applications beyond adherence support under the national programme could be done relatively inexpensively.
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McMahon JH, Manoharan A, Wanke C, Mammen S, Jose H, Malini T, Kadavanu T, Jordan MR, Elliott JH, Lewin SR, Mathai D. Targets for intervention to improve virological outcomes for patients receiving free antiretroviral therapy in Tamil Nadu, India. AIDS Care 2013; 26:559-66. [PMID: 24125035 DOI: 10.1080/09540121.2013.845282] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Operational research to identify factors predicting poor clinical outcomes is critical to maximize patient care and prolong first-line regimens for those receiving free antiretroviral therapy (ART) in India. We sought to identify social or clinical factors amenable to intervention that predict virological outcomes after 12 months of ART. We examined a retrospective cohort of consecutive adults initiating free nonnucleoside reverse transcriptase inhibitor-based regimens. Individuals remaining in care 12 months post-ART initiation were tested for HIV viral load and surveyed to identify barriers and facilitators to adherence, and to determine clinic travel times and associated costs. Uni- and multivariate logistic regression identified factors predicting HIV viral load >200 copies/mL after 12 months of ART. Of 230 adults initiating ART, 10% of patients died, 8% transferred out, 5% were lost to follow-up, and 174/230 (76%) completed 12 months of ART, the questionnaire, and viral load testing. HIV viral load was <200 copies/mL in 140/174 (80%) patients. In multivariate models, being busy with work or caring for others (OR 2.9, p < 0.01), having clinic transport times ≥ 3 hours (OR 3.0, p = 0.02), and alcohol use (OR 4.8, p = 0.03) predicted viral load >200 copies/mL after 12 months of ART. Clinical outcomes following ART are related to programmatic factors such as prolonged travel time and individual factors such as being busy with family or using alcohol. Simple interventions that alter these factors should be evaluated to improve clinical outcomes for populations receiving free ART in similar settings.
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Affiliation(s)
- James H McMahon
- a Infectious Diseases Unit , Alfred Hospital , Melbourne , VIC , Australia
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McMahon JH, Manoharan A, Wanke CA, Mammen S, Jose H, Malini T, Kadavanu T, Jordan MR, Elliott JH, Lewin SR, Mathai D. Pharmacy and self-report adherence measures to predict virological outcomes for patients on free antiretroviral therapy in Tamil Nadu, India. AIDS Behav 2013; 17:2253-9. [PMID: 23435750 DOI: 10.1007/s10461-013-0436-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Over 480,000 individuals receive free antiretroviral therapy (ART) in India yet data associating ART adherence with HIV viral load for populations exclusively receiving free ART are not available. Additionally estimates of adherence using pharmacy data on ART pick-up are not available for any population in India. After 12-months ART we found self-reported estimates of adherence were not associated with HIV viral load. Individuals with <100% adherence using pharmacy data predicted HIV viral load, and estimates combining pharmacy data and self-report were also predictive. Pharmacy adherence measures proved a feasible method to estimate adherence in India and appear more predictive of virological outcomes than self-report. Predictive adherence measures identified in this study warrant further investigation in populations receiving free ART in India to allow for identification of individuals at risk of virological failure and in need of adherence support.
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Trotter AB, Hong SY, Srikantiah P, Abeyewickreme I, Bertagnolio S, Jordan MR. Systematic review of HIV drug resistance in Southeast Asia. AIDS Rev 2013; 15:162-170. [PMID: 24002200 PMCID: PMC3955359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
In 2010, 3.5 million people were living with HIV in the World Health Organization Southeast Asia Region (SEAR), giving this region the greatest burden of HIV after Africa. Scale-up of antiretroviral therapy has resulted in over 717,000 benefitting from it by the end of 2010. A systematic review of studies of HIV drug resistance in the SEAR published between 2000 and 2011 was performed. Of 10 studies of transmitted HIV drug resistance in recently infected patients, all but two reported low levels (< 5%) of transmitted resistance. Of 23 studies of HIV drug resistance in pretreatment populations initiating antiretroviral therapy, three reported moderate levels (5-15%) of HIV drug resistance and 20 reported low levels. Amongst 17 studies of acquired HIV drug resistance, levels of nucleoside reverse transcriptase inhibitor and nonnucleoside reverse transcriptase inhibitor resistance ranged from 52 to 92% and 43 to 100%, respectively, amongst those with virological failure. Overall, data included in this review suggest that currently recommended first- and second-line regimens are appropriate for the cohorts studied. However, data were only available from two of 11 Southeast Asia Region countries and studies largely examined urban populations. Results are unlikely to be representative of the region. Studies lacked standardized methods, which greatly limits comparability of data and their use for public health and antiretroviral therapy program planning. Routine, standardized, and nationally representative HIV drug resistance surveillance should be strongly encouraged in the Southeast Asia Region countries to best characterize population-level HIV drug resistance. National-level HIV drug resistance surveillance data may be used to optimize delivery of HIV care and treatment and minimize emergence of population-level HIV drug resistance, thus promoting the long-term efficacy and durability of available first- and second-line antiretroviral therapy regimens.
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Affiliation(s)
- Andrew B Trotter
- Division of Geographic Medicine and Infectious Disease, Tufts Medical Center, Boston, USA.
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Management of Chronic Diseases in Sub-Saharan Africa: Cross-Fertilisation between HIV/AIDS and Diabetes Care. J Trop Med 2012; 2012:349312. [PMID: 23209477 PMCID: PMC3508584 DOI: 10.1155/2012/349312] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2012] [Accepted: 10/16/2012] [Indexed: 12/19/2022] Open
Abstract
There is growing attention for chronic diseases in sub-Saharan Africa (SSA) and for bridges between the management of HIV/AIDS and other (noncommunicable) chronic diseases. This becomes more urgent with increasing numbers of people living with both HIV/AIDS and other chronic conditions. This paper discusses
the commonalities between chronic diseases by reviewing models of care, focusing on the two most dominant ones, diabetes mellitus type 2 (DM2) and HIV/AIDS. We argue that in order to cope with care for HIV patients and diabetes patients, health systems in SSA need to adopt new strategies taking into account essential elements of chronic disease care. We developed a “chronic dimension
framework,” which analyses the “disease dimension,” the “health provider dimension,” the patient or “person dimension,” and the “environment dimension” of chronic diseases. Applying this framework to HIV/AIDS and DM2 shows that it
is useful to think about management of both in tandem, comparing care delivery platforms and self-management strategies. A literature review on care delivery models for diabetes and HIV/AIDS in SSA revealed potential elements for cross-fertilisation: rapid scale-up approaches through the public health approach by simplification and decentralisation; community involvement, peer support, and self-management strategies; and strengthening health services.
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