Linkage to intensive adherence counselling among HIV-positive persons on ART with detectable viral load in Gomba district, rural Uganda

Adherence of healthcare providers to Enhanced Adherence Counseling (EAC) intervention protocol in West Amhara Public Health Facilities, Northwest Ethiopia, 2023: mixed method evaluation

BACKGROUND

In Ethiopia, there were an estimated 670,906 people living with the Human Immune Virus (HIV). Implementing an HIV test and treat strategy and rapid scale-up of anti-retroviral treatment (ART) provided health facilities increased the number of the number of people living with HIV/AIDS. In the same way, the expansion of viral load monitoring in these health facilities and poor adherence to ART increase the number of high-viral load (HVL) patients. To alleviate this problem, the World Health Organization (WHO) recommended EAC intervention for HVL patients. Therefore, the aim of this research was to determine the level of healthcare providers' adherence to the EAC intervention protocol and explore barriers and facilitators of the intervention in West Amhara, Northwest Ethiopia.

METHOD

Descriptive cross-sectional study design with concurrent mixed-method evaluation was employed. The adherence dimension, with its sub-dimensions of content, coverage, frequency, and duration of the EAC intervention, was used with sixteen indicators. A total of 20 high-case-load public health facilities and 173 HVL patients were included in our study. Quantitative data was entered into Epi Info and exported to SPSS version 25 for analysis. Descriptive statistics are analyzed in terms of frequencies, percentages, variances, and means and presented as narrations, frequency tables, graphs, and charts. Qualitative data were transcribed, translated, coded, and analyzed thematically using Open Code version 4.0 software. The qualitative findings were used to triangulate the quantitative findings.

RESULT

The average adherence level of health care providers (HCPs) to the EAC intervention protocol was 55.3%, from which content, coverage, frequency, and duration of the intervention contributed 70.3%, 86.3%, 36.9%, and 27.7%, respectively. Most of the intervention contents were delivered during the session, but none of the providers developed a patient adherence plan at the end of the session. All HVL patients were linked and enrolled in the EAC intervention. But only 6% of them were tested for repeat VL.

CONCLUSION

The average adherence level of HCPs to the EAC intervention protocol was very inadequate. The main gap identified was difficulties in completing the EAC intervention sessions based on schedules. Implementing adherence improvement strategies, assigning an adequate number of EAC providers in ART and Prevention of Mother-to-Child Transmission (PMTCT) clinics, and allowing sufficient time during EAC sessions are important.

High viral suppression rates among PLHIV on dolutegravir who had an initial episode of viral non-suppression in Uganda September 2020-July 2021

BACKGROUND

In 2019, WHO recommended dolutegravir (DTG) as a backbone for first- and second-line antiretroviral therapy (ART) regimens for people living with HIV (PLHIV). According to the 2018 Uganda's HIV treatment guidelines, patients with viral non-suppression (≥1,000 copies/mL) should receive intensive adherence counseling (IAC) with repeat viral load (VL) within 6 months. This analysis focused on the prevalence and factors associated with viral suppression following IAC among PLHIV on DTG-based regimens (DBRs) with an initial episode of viral non-suppression (VNS) in Uganda.

METHODS

We conducted a retrospective analysis for PLHIV on DBRs with an initial episode of VNS (≥1,000 copies/mL) in Uganda during October 2019-September 2020 who had a follow up VL test result during September 2020-July 2021. Data were abstracted from the Central Public Health Laboratory (CPHL) database, including patient demographics and VL results. Viral non-suppression (VNS) was defined as a VL test result of ≥1,000 copies/mL. We characterized PLHIV on DBRs and used logistic regression models to determine factors associated with VL suppression after an initial episode of VNS.

RESULTS

A total of 564 PLHIV on DBRs with an initial episode of VNS were followed up and 43 were excluded due to missing data. Of the 521, 220 (42.2%) were children (<15 years) and 231 (44.3%) were female. Median age was 28 years (interquartile range [IQR]: 12-43 years), and median duration on DBRs was 12 months (IQR: 6-15 months). Overall, 80.8% (421/521) PLHIV had a suppressed viral load at first follow up testing (children = 74.5% [164/220]; adults = 85.4% [257/301]). Children with initial VL results ≥5,000 copies/mL were less likely to achieve viral suppression at follow up testing compared to those with <5,000 copies/mL (AOR: 0.38; 95% CI: 0.20-0.71; p = 0.002).

CONCLUSIONS

In a programmatic setting, most adults and children suppressed following an initial episode of VNS on DBRs. High rates of suppression after VNS suggest adherence challenges, rather than drug resistance. Continuation of DBRs should be considered before regimen switch.

Viral load suppression and its predictor among HIV seropositive people who receive enhanced adherence counseling at public health institutions in Bahir Dar, Northwest Ethiopia. Retrospective follow-up study

BACKGROUND

For those HIV seropositive people with high viral loads, the World Health Organization recommends more counseling before changing ART regimens. A high viral load can lead to increased HIV transmission and lower survival rates. Clients with viral loads above 1000 copies/mL should receive enhanced adherence counseling for 3-6 months before switching. Despite enhanced adherence counseling programs, most countries struggle with viral load suppression. Little is known about viral load suppression in Ethiopia and the research area after counseling.

OBJECTIVE

This study aims to assess viral load suppression and its predictors among HIV-positive individuals receiving enhanced adherence counseling in Bahir Dar, Northwest Ethiopia, in 2022.

METHODS

An institution-based retrospective follow-up study was conducted among randomly selected 546 clients on Enhanced Adherence Counseling at public health facilities in Bahir Dar city. The Epicollect5 mobile application was used to collect the data, which was then exported to Stata version 14 for analysis. A Log-Binomial regression model was fitted for each explanatory variable. Variables having a p-value <0.25 in bivariate analysis were entered into a multivariable Log-Binomial regression model. Finally, an adjusted risk ratio with a 95% confidence interval and a p-value <0.05 was used to measure the strength of the prediction.

RESULTS

Following enhanced adherence counseling, 312 (57.1%) people had their viral load suppressed. Absence of recurrent OI (ARR 1.40; CI 1.03-1.91), EAC stay less than 3 months (ARR 1.54; CI 1.19-1.99), EAC stay 3-6 months (ARR 1.38; CI 1.12-1.69), once-daily ARV dose regimen (ARR 1.28; CI 1.03-1.58), baseline viral load of 2879.00 copies/ml (ARR 1.30, CI 1.06-1.60), being orthodox Tewahido Christian (ARR 0.37; CI 0.18-0.75) were significant predictors of viral load suppression after Enhanced Adherence Counseling.

CONCLUSION AND RECOMMENDATION

Most importantly, this study found that most people had suppressed viral loads after receiving enhanced adherence counseling. Significant predictors of viral load suppression included recurrent OI, length of stay on EAC, daily ARV dosing regimen, baseline viral load, and religion. Clients with a high baseline viral load and those who experience recurring opportunistic infections should get extra care during EAC sessions.

Culturally adapting a mindfulness and acceptance-based intervention to support the mental health of adolescents on antiretroviral therapy in Uganda

The dual burden of living with HIV and negotiating life stage changes has been identified as a contributing factor to lapsed adherence among adolescents with HIV in sub-Saharan Africa. While psychosocial support can promote medication adherence, most interventions in use with adolescents were originally developed for the general population creating a gap in appropriate support. Life-stage-appropriate, evidence-based psychosocial support interventions have been used with young people in high-income contexts, prompting interest in their use in low-income contexts. However, many interventions are less effective when implemented outside of their original settings, hence the need for modifications before implementation. We aimed to culturally adapt an evidence-based psychosocial support intervention designed to improve the mental health of young people for use among adolescents with HIV in a sub-Saharan African context and to explore the acceptability of the adapted intervention among adolescents. We engaged thirty stakeholders (n = 30) in Kampala, Uganda including psychologists, psychiatrists, social workers, HIV counselors, religious leaders and adolescent peers from December 2021 to April 2022 to modify an evidence-based intervention for adolescents. Key adaptations included simplifying the language, adding local practices, integrating locally relevant slang and stories into therapy, introducing racially-congruent visuals and cards representing emotions, and adjusting therapy materials for use in resource-constrained settings. We then tested the acceptability of the intervention in a small sample of service users using a qualitative approach. We recruited nine adolescents with HIV from a participating clinic in Kampala, delivered six 90-minute sessions of the adapted intervention across three weeks and conducted in-depth interviews to assess the acceptability of the intervention. We used thematic analysis to analyze the qualitative data. The adapted intervention was perceived as acceptable among adolescents with HIV, with many stating that it helped them overcome fears, increased their self-acceptance, and gave them the confidence to make careful health-enhancing decisions.

Barriers and facilitators to the utilization of the intensive adherence counselling framework by healthcare providers in Uganda: a qualitative study

Background

Uganda Ministry of Health (UMOH) embraced the World Health Organization recommendation for people living with human immunodeficiency virus with a detectable viral load (VL) exceeding 1000 copies/mL to receive intensive adherence counselling (IAC). The IAC framework was developed as a step-by-step guide for healthcare providers to systematically support persons with non-suppressed VL to develop a comprehensive plan for adhering to treatment. The objective of this study was to explore the current practice of the healthcare providers when providing IAC, and identify the barriers and facilitators to the utilization of the UMOH IAC framework at two health centers IV level in rural Uganda.

Methods

This was a descriptive cross-sectional qualitative study that explored the current practices of the healthcare providers when providing IAC, and identified the barriers and facilitators to the utilization of the UMOH IAC framework. We used an interview guide with unstructured questions about what the participants did to support the clients with non-suppressed VL, and semi-structured questions following a checklist of categories of barriers and facilitators that affect ‘providers of care’ as provided by the Supporting the Use of Research Evidence for policy in African health systems (SURE) framework. Current practice as well as the categories of barriers and facilitators formed the a priori themes which guided data collection and analysis. In this study we only included healthcare providers (i.e., medical doctors, clinical officer, nurses, and counsellors) as ‘providers of care’ excluding family members because we were interested in the health system.

Results

A total of 19 healthcare providers took part in the interviews. The healthcare providers reported lack of sufficient knowledge on the UMOH IAC framework; most of them did not receive prior training or sensitization when it was first introduced. They indicated that they lacked counselling and communication skills to effectively utilize the IAC framework, and they were not motivated to utilize it because of the high workload at the clinics compounded by the limited workforce.

Conclusions

Although the UMOH IAC framework is a good step-by-step guide for the healthcare providers, there is need to understand their context and assess readiness to embrace the new behavior before expecting spontaneous uptake and utilization.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08495-0.

Unsuppressed viral load after intensive adherence counselling in rural eastern Uganda; a case of Kamuli district, Uganda

BACKGROUND

The East Central (EC) region of Uganda has the least viral suppression rate despite having a relatively low prevalence of human immunodeficiency virus (HIV). Although the viral suppression rate in Kamuli district is higher than that observed in some of the districts in the region, the district has one of the largest populations of people living with HIV (PLHIV). We sought to examine the factors associated with viral suppression after the provision of intensive adherence counselling (IAC) among PLHIV in the district.

METHODS

We reviewed records of PLHIV and used them to construct a retrospective cohort of patients that started and completed IAC during January - December 2019 at three high volume HIV treatment facilities in Kamuli district. We also conducted key informant interviews of focal persons at the study sites. We summarized the data descriptively, tested differences in the outcome (viral suppression after IAC) using chi-square and t-tests, and established independently associated factors using log-binomial regression analysis with robust standard errors at 5% statistical significance level using STATA version 15.

RESULTS

We reviewed 283 records of PLHIV. The mean age of the participants was 35.06 (SD 18.36) years. The majority of the participants were female (56.89%, 161/283). The viral suppression rate after IAC was 74.20% (210/283). The most frequent barriers to ART adherence reported were forgetfulness 166 (58.66%) and changes in the daily routine 130 (45.94). At multivariable analysis, participants that had a pre-IAC viral load that was greater than 2000 copies/ml [adjusted Prevalence Risk Ratio (aPRR)= 0.81 (0.70 - 0.93), p=0.002] and those that had a previous history of viral load un-suppression [aPRR= 0.79 (0.66 - 0.94), p=0.007] were less likely to achieve a suppressed viral load after IAC. ART drug shortages were rare, ART clinic working hours were convenient for clients and ART clinic staff received training in IAC.

CONCLUSION

Despite the consistency in drug availability, counselling training, flexible and frequent ART clinic days, the viral suppression rate after IAC did not meet recommended targets. A high viral load before IAC and a viral rebound were independently associated with having an unsuppressed viral load after IAC. IAC alone may not be enough to achieve viral suppression among PLHIV. To improve viral suppression rates after IAC, other complementary services should be paired with IAC.

Improving viral load suppression among men and children active in care through community-designed and led solutions: Protocol for retrospective closed cohort study in Eastern Uganda (Preprint)

Background

In collaboration with facilities, communities, district local government, and the United States Agency for International Development (USAID) implementing partners, the iDARE methodology was implemented at the community level to address root causes of low HIV antiretroviral therapy adherence among men and children actively enrolled in care, resulting in low viral load suppression (VLS) in two districts in the eastern region of Uganda. The methodology encourages the use of cocreated sustainable solutions addressing gender, youth, and social inclusion issues to reduce barriers to care and reach the 95-95-95 Joint United Nations Programme on HIV/AIDS target for HIV epidemic control. We aim to measure the impact of iDARE on VLS for men and children active in care and investigate the practical scale up of the solutions designed using the iDARE methodology.

Objective

The primary objective of this study will be to measure the implementation impact of the iDARE methodology at the facility and community levels on VLS for people living with HIV. The secondary objective is to investigate the practical scale up of the iDARE methodology using evidence-based gender, youth, and social inclusion social behavior change packages to rapidly meet the Ugandan Ministry of Health targets for VLS.

Methods

A retrospective cohort study design will be used to analyze program data that aims to increase the rates of VLS in men and children who are classified as active in care using community engagement and quality improvement techniques. We will examine 3 pilot health centers’ data from a USAID-funded program aimed at social behavior change to increase health-seeking behavior in Uganda. Based on the iDARE process and results, change packages were developed to highlight lessons learned and best practices in order to share with subsequent implementation sites.

Results

The USAID-funded Social and Behavior Change Activity began implementation of iDARE in September 2020, with baseline data collected in August 2020.

Conclusions

Data on viral load suppression was collected from facilities on a monthly basis to record progress toward the 95-95-95 goal. The expected primary outcome is an increase in actively enrolled men and children reaching VLS in order to meet the Ugandan Ministry of Health target of 95% VLS among those active in care.

International Registered Report Identifier (IRRID)

DERR1-10.2196/32784