The heterogeneous effect of short-term transfers for improving ART adherence among HIV-infected Tanzanian adults

The effects of cash transfer programmes on HIV/AIDS prevention and care outcomes: a systematic review and meta-analysis of intervention studies

BACKGROUND

Poverty and social inequality are risk factors for poor health outcomes in patients with HIV/AIDS. In addition to eligibility, cash transfer programmes can be divided into two categories: those with specific requirements (conditional cash transfers [CCTs]) and those without specific requirements (unconditional cash transfers). Common CCT requirements include health care (eg, undergoing an HIV test) and education (eg, children attending school). Trials assessing the effect of cash transfer programmes on HIV/AIDS outcomes have yielded divergent findings. This review aimed to summarise evidence to evaluate the effects of cash transfer programmes on HIV/AIDS prevention and care outcomes.

METHODS

For this systematic review and meta-analysis, we searched PubMed, EMBASE, Cochrane Library, LILACS, WHO IRIS, PAHO-IRIS, BDENF, Secretaria Estadual de Saúde SP, Localizador de Informação em Saúde, Coleciona SUS, BINACIS, IBECS, CUMED, SciELO, and Web of Science up to Nov 28, 2022. We included randomised controlled trials (RCTs) that evaluated the effects of cash transfer programmes on HIV incidence, HIV testing, retention in HIV care, and antiretroviral therapy adherence, and conducted risk of bias and quality of evidence assessments using the Cochrane Risk of Bias tool and the Grading of Recommendations, Assessment, Development, and Evaluations approach. A random-effects meta-analysis model was used to combine studies and calculate risk ratios (RRs). Subgroup analyses were performed using conditionality types (ie, school attendance or health care). The protocol was registered with PROSPERO, CRD42021274452.

FINDINGS

16 RCTs, which included 5241 individuals, fulfilled the inclusion criteria. Of these, 13 studies included conditionalities for receiving cash transfer programmes. The results showed that receiving a cash transfer was associated with lowered HIV incidence among individuals who had to meet health-care conditionalities (RR 0·74, 95% CI 0·56-0·98) and with increased retention in HIV care for pregnant women (1·14, 95% CI 1·03-1·27). No significant effect was observed for HIV testing (RR 0·45, 95% CI 0·18-1·12) or antiretroviral therapy adherence (1·13, 0·73-1·75). Lower risk of bias was observed for HIV incidence and having an HIV test. The strength of available evidence can be classified as moderate.

INTERPRETATION

Cash transfer programmes have a positive effect on mitigating HIV incidence for individuals who have to meet health-care conditionalities and on increasing retention in HIV care for pregnant women. These results show the potential of cash transfer programmes for HIV prevention and care, especially among people in extreme poverty, and highlight that cash transfer programmes must be considered when developing policies for HIV/AIDS control, as indicated by the UNAIDS 95-95-95 target of the HIV care continuum.

FUNDING

National Institute of Allergy and Infectious Diseases, National Institutes of Health, USA.

Review of antiretroviral therapy coverage in 10 highest burden HIV countries in Africa: 2015-2020

Africa is responsible for two-thirds of the global total of new HIV infections. South Africa, Nigeria, Mozambique, Uganda, Tanzania, Zambia, Zimbabwe, Kenya, Malawi, and Ethiopia were responsible for 80% of HIV cases in Africa in 2014 according to the Joint United Nations Programme on HIV/AIDS (UNAIDS). This study assesses antiretroviral coverage strategies implemented by these countries after the initiation of the "Fast-Track strategy to end the AIDS epidemic by 2030." Data reported in this review were obtained from different e-bibliographic including PubMed, Google Scholar, and Research Gate. Key terms were "Antiretroviral therapy," "Antiretroviral treatment," "HIV treatment," "HIV medication," "HIV/AIDS therapy," "HIV/AIDS treatment" + each of the countries listed earlier. We also extracted data on antiretroviral therapy (ART) coverage from the UNAIDS database. About 50 papers published from 2015 to 2021 met the inclusion criteria. All 10 countries have experienced an increase in ART coverage from 2015 to 2020 with an average of 47.6% increment. Nigeria recorded the highest increase in the rate of ART coverage (72% increase) while Ethiopia had the least (30%). New strategies adopted to increase ART coverage and retention in most countries were community-based models and the use of mobile health technology rather than clinic-based. These strategies focus on promoting task shifting, door-to-door access to HIV services, and a long-term supply of antiretroviral medications. Most of these strategies are still in the piloting stage. However, some new strategies and frameworks have been adopted nationwide in countries like Mozambique, Tanzania, Zambia, Zimbabwe, Kenya, and Malawi. Identified challenges include lack of funding, inadequate testing and surveillance services, poor digital penetration, and cultural/religious beliefs. The adoption of community-based and digital health strategies could have contributed to increased ART coverage and retention. African countries should facilitate nationwide scaling of ART coverage strategies to attain the 95-95-95 goal by 2030.

Systematic review of interventions aimed at improving HIV adherence to care in low- and middle-income countries in Sub-Saharan Africa

Long-term adherence to antiretroviral medication continues to present as a challenge along the continuum of the HIV care cascade. HIV interventions and support programs are significantly threatened in resource-limited settings by challenges in maintaining long-term follow-up for ART adherence. We sought to complete a systematic review to comprehensively examine ART adherence and retention in care interventions in Sub-Saharan Africa and to report on the implementation of interventions in real-world settings to inform future health investments in HIV care. Interventions were grouped according to their impact on individual, community, and health-systems levels. While a vast majority of studies evaluated a combination of interventions, those studies that incorporated the community as a resource were most successful. In addition, providing education and behavior reminders proved effective and should be accompanied by community and peer efforts for best results. Multi-level interventions, such as combining individual and community-level interventions showed promising results for long term ART adherence.

Factors Associated with Retention of HIV Patients on Antiretroviral Therapy in Care: Evidence from Outpatient Clinics in Two Provinces of the Democratic Republic of the Congo (DRC)

Interruptions in the continuum of care for HIV can inadvertently increase a patient’s risk of poor health outcomes such as uncontrolled viral load and a greater likelihood of developing drug resistance. Retention of people living with HIV (PLHIV) in care and determinants of attrition, such as adherence to treatment, are among the most critical links strengthening the continuum of care, reducing the risk of treatment failure, and assuring viral load suppression. Objective: To analyze the variation in, and factors associated with, retention of patients enrolled in HIV services at outpatient clinics in the provinces of Kinshasa and Haut-Katanga, Democratic Republic of the Congo (DRC). Methods: Data for the last visit of 51,286 patients enrolled in Centers for Disease Control (CDC)-supported outpatient HIV clinics in 18 health zones in Haut-Katanga and Kinshasa, DRC were extracted in June 2020. Chi-square tests and multivariable logistic regressions were performed. Results: The results showed a retention rate of 78.2%. Most patients were classified to be at WHO clinical stage 1 (42.1%), the asymptomatic stage, and only 3.2% were at stage 4, the severest stage of AIDS. Odds of retention were significantly higher for patients at WHO clinical stage 1 compared to stage 4 (adjusted odds ratio (AOR), 1.325; confidence interval (CI), 1.13−1.55), women as opposed to men (AOR, 2.00; CI, 1.63−2.44), and women who were not pregnant (vs. pregnant women) at the start of antiretroviral therapy (ART) (AOR, 2.80; CI, 2.04−3.85). Odds of retention were significantly lower for patients who received a one-month supply rather than multiple months (AOR, 0.22; CI, 0.20−0.23), and for patients in urban health zones (AOR, 0.75; CI, 0.59−0.94) rather than rural. Compared to patients 55 years of age or older, the odds of retention were significantly lower for patients younger than 15 (AOR, 0.35; CI, 0.30−0.42), and those aged 15 and <55 (AOR, 0.75; CI, 0.68−0.82). Conclusions: Significant variations exist in the retention of patients in HIV care by patient characteristics. There is evidence of strong associations of many patient characteristics with retention in care, including clinical, demographic, and other contextual variables that may be beneficial for improvements in HIV services in DRC.

Durability of effects from short-term economic incentives for clinic attendance among HIV positive adults in Tanzania: long-term follow-up of a randomised controlled trial

Introduction

Conditional economic incentives are shown to promote medication adherence across a range of health conditions and settings; however, any long-term harms or benefits from these time-limited interventions remain largely unevaluated. We assessed 2–3 years outcomes from a 6-month incentive programme in Tanzania that originally improved short-term retention in HIV care and medication possession.

Methods

We traced former participants in a 2013–2016 trial, which randomised 800 food-insecure adults starting HIV treatment at three clinics to receive either usual care (control) or up to 6 months of cash or food transfers (~US$11/month) contingent on timely attendance at monthly clinic appointments. The primary intention-to-treat analysis estimated 24-month and 36-month marginal risk differences (RD) between incentive and control groups for retention in care and all-cause mortality, using multiple imputation for a minority of missing outcomes. We also estimated mortality HRs from time-stratified Cox regression.

Results

From 3 March 2018 to 19 September 2019, we determined 36-month retention and mortality statuses for 737 (92%) and 700 (88%) participants, respectively. Overall, approximately 660 (83%) participants were in care at 36 months while 43 (5%) had died. There were no differences between groups in retention at 24 months (86.5% intervention vs 84.4% control, RD 2.1, 95% CI −5.2 to 9.3) or 36 months (83.3% vs 77.8%, RD 5.6, –2.7 to 13.8), nor in mortality at either time point. The intervention group had a lower rate of death during the first 18 months (HR 0.27, 95% CI 0.10 to 0.74); mortality was similar thereafter (HR 1.13, 95% CI 0.33 to 3.79).

Conclusion

These findings confirm that incentives are a safe and effective tool to promote short-term adherence and potentially avert early deaths at the critical time of HIV treatment initiation. Complementary strategies are recommended to sustain lifelong retention in HIV care.

Trial registration number

NCT01957917

The Utilisation of Payment Models Across the HIV Continuum of Care: Systematic Review of Evidence

The increasing chronicity and multimorbidities associated with people living with HIV have posed important challenges to health systems across the world. In this context, payment models hold the potential to improve care across a spectrum of clinical conditions. This study aims to systematically review the evidence of HIV performance-based payments models. Literature searches were conducted in March 2020 using multiple databases and manual searches of relevant papers. Papers were limited to any study design that considers the real-world utilisation of performance-based payment models applied to the HIV domain. A total of 23 full-text papers were included. Due to the heterogeneity of study designs, the multiple types of interventions and its implementation across distinct areas of HIV care, direct comparisons between studies were deemed unsuitable. Most evidence focused on healthcare users (83%), seeking to directly affect patients' behaviour based on principles of behavioural economics. Despite the variability between interventions, the implementation of performance-based payment models led to either a neutral or positive impact throughout the HIV care continuum. Moreover, this improvement was likely to be cost-effective or, at least, did not compromise the healthcare system's financial sustainability. However, more research is needed to assess the durability of incentives and its appropriate relative magnitude.

A Cascade of Interventions to Promote Adherence to Antiretroviral Therapy in African Countries

Purpose of Review

We reviewed interventions to improve uptake and adherence to antiretroviral therapy (ART) in African countries in the Treat All era.

Recent Findings

ART initiation can be improved by facilitated rapid receipt of first prescription, including community-based linkage and point-of-care strategies, integration of HIV care into antenatal care and peer support for adolescents. For people living with HIV (PLHIV) on ART, scheduled SMS reminders, ongoing intensive counselling for those with viral non-suppression and economic incentives for the most deprived show promise. Adherence clubs should be promoted, being no less effective than facility-based care for stable patients. Tracing those lost to follow-up should be targeted to those who can be seen face-to-face by a peer worker.

Summary

Investment is needed to promote linkage to initiating ART and for differentiated approaches to counselling for youth and for those with identified suboptimal adherence. More evidence from within Africa is needed on cost-effective strategies to identify and support PLHIV at an increased risk of non-adherence across the treatment cascade.

Electronic supplementary material

The online version of this article (10.1007/s11904-020-00511-4) contains supplementary material, which is available to authorized users.