Provision and continuation of antiretroviral therapy during acute conflict: the experience of MSF in Central African Republic and Yemen

Early initiation of fast-track care for persons living with HIV initiating dolutegravir-based regimens during a period of severe civil unrest in Port-au-Prince, Haiti: a pilot randomized trial

INTRODUCTION

Differentiated service delivery (DSD) models have been widely implemented for patients in stable HIV care. However, DSD has rarely been offered to newly diagnosed patients. We assessed the effectiveness of early fast-track care during a period of severe civil unrest in Port-au-Prince, Haiti.

METHODS

We conducted a pilot randomized trial among adults presenting with early HIV disease to determine whether early fast-track care (8-12 weeks after same-day HIV testing and antiretroviral therapy [ART] initiation) was associated with superior outcomes compared with standard (deferred eligibility for fast-track care). All participants received tenofovir/lamivudine/dolutegravir (TLD), and HIV-1 RNA <200 copies/ml was required prior to initiating fast-track care. The primary outcome was 48-week HIV-1 RNA <200 copies/ml, with intention-to-treat analysis.

RESULTS

From December 2020 to August 2022, 245 participants were randomized to standard (n = 116) and early fast-track (n = 129) groups. All initiated TLD on the day of HIV diagnosis. In the early fast-track group, one (0.8%) died, 12 (9.3%) were internally displaced/emigrated, five (3.9%) were lost-to-follow-up (LTFU), two (1.6%) had a gap in care/later return, one (0.8%) was transferred and 108 (83.7%) were retained; 88 (68.2%) received 48-week viral load testing and 80 (90.9% of tested; 62.0% of randomized) had HIV-1 RNA <200 copies/ml. In the standard group, two (1.7%) died, six (5.2%) were internally displaced/emigrated, three (2.6%) were LTFU, one (0.9%) had a gap in care/later return, one (0.9%) was transferred and 103 (88.8%) were retained; 78 (67.2%) received 48-week viral load testing and 66 (84.6% of tested; 56.9% of randomized) had HIV-1 RNA <200 copies/ml. By design, the sample size of this pilot study was too small to provide definitive evidence of treatment effect, but the primary outcome was numerically higher in the early fast-track group (62.0% vs. 56.9%; RD: 0.051: 95% CI: -0.072, 0.174).

CONCLUSIONS

Early fast-track care was associated with high levels of viral suppression among adults initiating same-day TLD, despite severe civil unrest in Haiti. Completion of 48-week viral load testing was suboptimal, due to the need for participants to leave Port-au-Prince during peak periods of gang-related violence, and the lack of availability of viral load testing for those receiving non-facility-based ART.

Continuity of care during severe civil unrest with a model of community-based HIV care: a retrospective cohort study from Haiti

Background

There are limited data on the effectiveness of differentiated service delivery (DSD) for HIV care during sociopolitical turmoil. We assessed outcomes with a DSD model of care that includes patient choice between community-based antiretroviral therapy (ART) centres, home-based ART dispensing, or facility-based care at GHESKIO clinic during a period of severe civil unrest in Port-au-Prince, Haiti.

Methods

This retrospective analysis included data on patients with at least one HIV visit at GHESKIO between May 1, 2019, and December 31, 2021. Multivariable logistic regression models were used to assess predictors of attending ≥1 community visit during the study period, and failure to attend timely visits. HIV-1 RNA test results were reported among patients who had been ART for ≥3 months at last visit.

Findings

Of the 18,625 patients included in the analysis, 9659 (51.9%) attended at least one community visit. The proportion of community visits ranged from 0.3% (2019) to 44.1% (2021). Predictors of ≥1 community visit included male sex (aOR: 1.13; 95% CI: 1.06, 1.20), secondary education (aOR: 1.07; 95% CI: 1.01, 1.14), income > $USD 1.00/day (aOR: 1.24; 95% CI: 1.14, 1.35), longer duration on ART (aOR: 1.08 per additional year; 95% CI: 1.07, 1.09), and residence in Carrefour/Gressier (p < 0.0001 in comparisons with all other zones). Younger age and shorter time on ART were associated with late visits and loss to follow-up. Among 12,586 patients with an on-time final visit who had been on ART for ≥3 months, 11,131 (88.4%) received a viral load test and 9639 (86.6%) had HIV-1 RNA < 1000 copies/mL.

Interpretation

The socio-political situation in Haiti has presented extraordinary challenges to the health care system, but retention and viral suppression rates remain high with a model of community-based HIV care. Additional interventions are needed to improve outcomes for younger patients, and those with shorter time on ART.

Funding

No funding.

Factors associated with ART interruption during the COVID-19 crisis in Burundi (the EPIC community-based research program)

With a national prevalence of 0.9%, Burundi is close to achieving UNAIDS' 2025 targets. Despite this, different types of crises periodically disrupt its HIV health services. The community-based program EPIC measured the impact of the COVID-19 health crisis on people living with HIV (PLHIV) in Burundi in 2021. Specifically, it assessed ART interruption and associated factors since the beginning of the pandemic. The study questionnaire was administered to PLHIV in three cities between October and November 2021. Participants were recruited using convenience sampling. Logistic regression models helped identify factors associated with ART interruption. Of the 317 respondents, 37 (11.7%) reported interruption. The majority (79.2%) self-identified as belonging to key populations. Interruption was significantly associated with: fewer HIV medical follow-up visits (adjusted Odds Ratio, aOR = 7.80, p = 0.001) and forced HIV status disclosure (aOR = 4.10, p = 0.004). It was inversely associated with multi-month ART dispensing (aOR = 0.36, p = 0.017) since the beginning of the pandemic and the perception of not having been sufficiently informed by the HIV medical team about the risk of COVID-19 infection (aOR = 0.11, p < 0.001). Our results highlight the importance of multi-month ART dispensing, enhanced communication, and voluntary disclosure of one's HIV status in preventing ART interruption in times of crises in Burundi.

Equity in HIV/AIDS services requires optimization of mainstreaming sectors in Ethiopia

BACKGROUND

Mainstreaming HIV and AIDS across sectors is crucial to close the disparities in service provision and coverage. However, evidence has shown that certain social groups are left behind in receiving HIV/AIDS services. The objective of this study was twofold: to understand the reasons behind the existing inequities and to explore challenges of equity in HIV/AIDS services in the Amhara region of Ethiopia.

METHODS

Twenty-two adults (aged 26-57 years) from eighteen sectors that are mainstreaming HIV and AIDS were purposefully selected until the point of saturation and participated in a semi-structured in-depth interview conducted between January 20 and February 17, 2023. Interviewees were asked to describe their mainstreaming experiences in equitable HIV/AIDS services, reflect on the challenges and barriers that impede equitable service provision, or explain the reasons behind the existence of inequity in HIV/AIDS services. The interviews were audio recorded, transcribed, translated, and iteratively analysed, with early analysis informing subsequent interviews. An inductive-reflexive thematic analysis was conducted, whereby themes and subthemes were identified, and the relationships between subthemes and patterns were critically reviewed.

RESULTS

The challenges to equitable HIV/AIDS service provision were grouped into eight thematic areas: (1) changing contexts that shifts public and government attention to emerging diseases, war and political instability, and poverty; (2) leadership-related, such as the lack of supervision and monitoring, not politicising HIV/AIDS (not providing political attention to HIV/AIDS) and weak intersectoral collaboration; (3) financial constraints due to a random budgeting and contract interruption with non-governmental organisations (NGOs); (4) lack of resources due to scarcity and unfair distribution; (5) inadequate skilled personnel due to inadequate numbers and lack of continuous professional and career development; (6) lack of equity-related evidence-based tools and guidelines; (7) inadequate understanding of equity due to lack of training and misunderstanding, and lack of access to equity-oriented tools and guidelines; and (8) cultural norms, values, and perceptions.

CONCLUSIONS

This study identified critical challenges faced in the equitable HIV/AIDS services provision. To achieve equity in HIV/AIDS services, mainstreaming sectors need to invest in mechanisms to sustain services in emergency situations; identify effective leaders to maintain collaboration, monitoring, and evaluation; institutionalise responsive budgeting and establish alternative funds to maintain non-governmental organisations initiatives; provide continuous up-to-date training and create a common evidence-sharing platform; implement proper recruitment, education, and professional development of HIV/AIDS focal persons; and promote and practice culturally safe care. It is, therefore, essential to optimise sectors that are mainstreaming HIV/AIDS and incorporate equity considerations in their strategic plans and working guidelines.

The impact of armed conflicts on HIV treatment outcomes in Sub-Saharan Africa: a systematic review and meta-analysis

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.

Rapidly adapted community health strategies to prevent treatment interruption and improve COVID-19 detection for Syrian refugees and the host population with hypertension and diabetes in Jordan

BACKGROUND

We evaluated community health volunteer (CHV) strategies to prevent non-communicable disease (NCD) care disruption and promote coronavirus disease 2019 (COVID-19) detection among Syrian refugees and vulnerable Jordanians, as the pandemic started.

METHODS

Alongside medication delivery, CHVs called patients monthly to assess stockouts and adherence, provide self-management and psychosocial support, and screen and refer for complications and COVID-19 testing. Cohort analysis was undertaken of stockouts, adherence, complications and suspected COVID-19. Multivariable models of disease control assessed predictors and non-inferiority of the strategy pre-/post-initiation. Cost-efficiency and patient/staff interviews assessed implementation.

RESULTS

Overall, 1119 patients were monitored over 8 mo. The mean monthly proportion of stockouts was 4.9%. The monthly proportion non-adherent (past 5/30 d) remained below 5%; 204 (18.1%) patients had complications, with 63 requiring secondary care. Mean systolic blood pressure and random blood glucose remained stable. For hypertensive disease control, age 41-65 y (OR 0.46, 95% CI 0.2 to 0.78) and with diabetes (OR 0.73, 95% CI 0.54 to 0.98) had decreased odds, and with baseline control had increased odds (OR 3.08, 95% CI 2.31 to 4.13). Cumulative suspected COVID-19 incidence (2.3/1000 population) was suggestive of ongoing transmission. While cost-efficient (108 US${\$}$/patient/year), funding secondary care was challenging.

CONCLUSIONS

During multiple crises, CHVs prevented care disruption and reinforced COVID-19 detection.

The impact of war on HIV/AIDS service provision: In rural health facilities of Tigray, northern Ethiopia, a cross-sectional study

BACK GROUND

HIV/AIDS remained among the common public health problems in developing country. Despite the extensive delivery of ART and improved coverage of the service access, still, man-made problems like war have negatively influenced the utilization of antiretroviral treatment services. The war in Tigray Region in the northern Ethiopia broke out in November 2020 and thereby has brought about an extreme damage on most of the infrastructure in Tigray, including the health institutions. The purpose of this study is, therefore, to assess and report the trend of HIV service provision across the war affected rural health facilities in Tigray.

METHODS

The study was conducted in 33 rural health facilities during the active war in Tigray. A facility based retrospective cross-sectional study design was conducted among health facilities from July 03 to August 05, 2021.

RESULT

A total of 33 health facilities from 25 rural districts were included in the HIV service delivery assessment. A total of 3274 and 3298 HIV patients were seen during pre-war period in September and October 2020, respectively. The number of follow-up patients during the war period in January remained to be only 847(25%) which is significantly reduced with a P value<0.001. A similar trend was observed during the subsequent months until May. The trend of follow-up patients on ART significantly declined from 1940 in September (pre-war) to 331(16.6%) in May (during the war). This study also revealed a 95.5% reduction of laboratory service provision to HIV/AIDS patients during the war in January and with similar trends thereafter (P<0.001).

CONCLUSION

The war has led to a significant decline of HIV service provision in the rural health facilities and most part of the region during the first eight months of active war in Tigray.

Determinants of Survival of HIV Patients Receiving Dolutegravir: A Prospective Cohort Study in Conflict-Affected Bunia, Democratic Republic of Congo

This study aims to determine the factors influencing HIV-related mortality in settings experiencing continuous armed conflict atrocities. In such settings, people living with HIV (PLHIV), and the partners of those affected may encounter specific difficulties regarding adherence to antiretroviral therapy (ART), and retention in HIV prevention, treatment, and care programs. Between July 2019 and July 2021, we conducted an observational prospective cohort study of 468 PLHIV patients treated with Dolutegravir at all the ART facilities in Bunia. The probability of death being the primary outcome, as a function of time of inclusion in the cohort, was determined using Kaplan-Meier plots. We used the log-rank test to compare survival curves and Cox proportional hazard modeling to determine mortality predictors from the baseline to 31 July 2021 (endpoint). The total number of person-months (p-m) was 3435, with a death rate of 6.70 per 1000 p-m. Compared with the 35-year-old reference group, older patients had a higher mortality risk. ART-naïve participants at the time of enrollment had a higher mortality risk than those already using ART. Patients with a high baseline viral load (≥1000 copies/mL) had a higher mortality risk compared with the reference group (adjusted hazard ratio = 6.04; 95% CI: 1.78-20.43). One-fourth of deaths in the cohort were direct victims of armed conflict, with an estimated excess death of 35.6%. Improving baseline viral load monitoring, starting ART early in individuals with high baseline viral loads, the proper tailoring of ART regimens and optimizing long-term ART, and care to manage non-AIDS-related chronic complications are recommended actions to reduce mortality. Not least, fostering women's inclusion, justice, peace, and security in conflict zones is critical in preventing premature deaths in the general population as well as among PLHIV.

HIV outcomes within the context of orphans and vulnerable children programing: the 4Children project in South Sudan

Background

Poor antiretroviral therapy (ART) adherence is a challenge to containing the spread of HIV. This is an especially difficult challenge in conflict and post-conflict settings. This study investigates the relationship between attendance in an Orphan and Vulnerable Children program in South Sudan and HIV-related outcomes, including clinic appointment attendance, frequency of viral load testing and viral load suppression rates.

Methods

Patient records (n = 295) were selected from project-supported clinics in Juba, South Sudan, and analyzed to measure the association between enrollment status and select health outcomes. Data were collected at multiple time points between 2018 and 2019, to measure the strength of relationship between select treatment variables (e.g., viral load, retention in care, etc.). Given the structure of the data, non-parametric tests were applied to answer the research questions.

Results

Analysis revealed three important trends: (1) enrollment in the 4Children project was associated with a statistically significant increase in the frequency of viral load testing; (2) there was an increase in median appointment attendance after program enrollment; and (3) there was improved management of viral load and CD4 count, albeit small, during the time period before and after enrollment.

Conclusions

Data from South Sudan suggests that caregivers and children receiving project services saw improvement in treatment-related indicators. After enrolling in the project, overall amount of viral load testing increased from previous counts before enrollment. This suggests that after providing additional services with psychosocial and financial support to patients at the two hospitals in Juba, there was potential that similar interventions can support improved HIV outcomes.

Evaluation of a community-based HIV test and start program in a conflict affected rural area of Yambio County, South Sudan

BACKGROUND

Antiretroviral therapy (ART) coverage in South Sudan is around 10%. Access to HIV care in settings with low ART coverage or conflict affected is still low; innovative strategies are needed to increase access and ensure continuation of ART during instability. A pilot HIV test and start project was implemented in a conflict-affected area of South Sudan. In a retrospective analysis, we determined the feasibility and outcomes of this intervention.

METHODS

Programme data from July 2015 to June 2018 was analysed. The project involved five mobile teams offering HIV counselling and testing (HCT) and same day ART initiation at community level. Baseline and follow-up information on clinical, immunological and viral load (VL) was routinely recorded, as well as treatment outcomes. A semi-qualitative study was conducted to assess acceptability of the program among beneficiaries and community members.

RESULTS

By June 2018, 14824 people received counselling and testing for HIV and 498 (3.4%) tested positive. Out of those 395 (79.3%) started ART. A total of 72 ART patients were organized in 26 Community ART Groups (CAGs) and contingency plan was activated 9 times for 101 patients. Kaplan-Meier estimated retention in care (RIC) at 12 and 18 months was 80.6% [95% CI: 75.9-84.5%] and 69.9% [95% CI: 64.4-74.8%] respectively. RIC was significantly higher at 18 months in patients under community ART groups (CAGs) (90.9% versus 63.4% p<0.001) when compared to patients on regular follow up. VL suppression at 12 months was 90.3% and overall virological suppression reached 91.2%. A total of 279 persons were interviewed about the MSF program perception and acceptance: 98% had heard about the programme and 84% found it beneficial for the community, 98% accepted to be tested and only 4% found disadvantages to the programme.

CONCLUSIONS

Our study shows that HCT and early ART initiation in conflict affected populations can be provided with good program outcomes. RIC and virological suppression are comparable with facility-based HIV programs and to those in stable contexts. This model could be extrapolated to other similar contexts with low access to ART and where security situation is a concern.

Early Experiences in the Integration of Non-communicable Diseases into Emergency Primary Health Care, Beni Region, Democratic Republic of the Congo

Background

Health services in humanitarian crises increasingly integrate the management of non-communicable diseases into primary care. As there is little description of such programs, this case study aims to describe the initial implementation of non-communicable disease management within emergency primary care in the conflict-affected Beni Region of Democratic Republic of the Congo (DRC).

Objectives

We implemented and evaluated a primary care approach to hypertension and diabetes management to assess the feasibility of patient monitoring, early clinical and programmatic outcomes, and costs, after seven months of care.

Methods

We designed clinical and programmatic modules for diabetes and hypertension management for clinical officers and the use of patient cards and community health workers to improve adherence. We used cohort analysis (April to October 2018), time-trend analysis, semi-structured interviews, and costing to evaluate the program.

Findings

Increases in consultations for hypertension (incidence rate ratio [IRR] 13.5, 95% CI 5.8-31.5, p < 0.00) and diabetes (IRR 3.6, 95% CI 1-12.9, p < 0.05) were demonstrated up to the onset of violence and an Ebola epidemic in August 2018. Of 833 patients, 67% were women of median age 56. Nearly all were hypertensives (88.7%) and newly diagnosed (95.9%). Treatment adherence, defined as attending ≥2 visits in the seven month period, was demonstrated by 45.4% of hypertension patients. Community health workers had contact with 3.2-3.8 patients per month. Respondents stated that diabetes care remained fragmented with insulin and laboratory testing located outside of primary care. Program and management costs were 115 USD per person per treatment course.

Conclusions

In an active conflict setting, we demonstrated that non-communicable disease care can be well-organized through clinical training and cohort analysis, and adherence can be addressed using patient-held cards and monitoring by community health workers. Nearly all diagnoses were new, emphasizing the need to establish self-management. Insecurity reduced access for patients but care continued for a subset of patients during the Ebola epidemic.

Potential effects of disruption to HIV programmes in sub-Saharan Africa caused by COVID-19: results from multiple mathematical models

Background

The COVID-19 pandemic could lead to disruptions to provision of HIV services for people living with HIV and those at risk of acquiring HIV in sub-Saharan Africa, where UNAIDS estimated that more than two-thirds of the approximately 38 million people living with HIV resided in 2018. We aimed to predict the potential effects of such disruptions on HIV-related deaths and new infections in sub-Saharan Africa.

Methods

In this modelling study, we used five well described models of HIV epidemics (Goals, Optima HIV, HIV Synthesis, an Imperial College London model, and Epidemiological MODeling software [EMOD]) to estimate the effect of various potential disruptions to HIV prevention, testing, and treatment services on HIV-related deaths and new infections in sub-Saharan Africa lasting 6 months over 1 year from April 1, 2020. We considered scenarios in which disruptions affected 20%, 50%, and 100% of the population.

Findings

A 6-month interruption of supply of antiretroviral therapy (ART) drugs across 50% of the population of people living with HIV who are on treatment would be expected to lead to a 1·63 times (median across models; range 1·39–1·87) increase in HIV-related deaths over a 1-year period compared with no disruption. In sub-Saharan Africa, this increase amounts to a median excess of HIV deaths, across all model estimates, of 296 000 (range 229 023–420 000) if such a high level of disruption occurred. Interruption of ART would increase mother-to-child transmission of HIV by approximately 1·6 times. Although an interruption in the supply of ART drugs would have the largest impact of any potential disruptions, effects of poorer clinical care due to overstretched health facilities, interruptions of supply of other drugs such as co-trimoxazole, and suspension of HIV testing would all have a substantial effect on population-level mortality (up to a 1·06 times increase in HIV-related deaths over a 1-year period due to disruptions affecting 50% of the population compared with no disruption). Interruption to condom supplies and peer education would make populations more susceptible to increases in HIV incidence, although physical distancing measures could lead to reductions in risky sexual behaviour (up to 1·19 times increase in new HIV infections over a 1-year period if 50% of people are affected).

Interpretation

During the COVID-19 pandemic, the primary priority for governments, donors, suppliers, and communities should focus on maintaining uninterrupted supply of ART drugs for people with HIV to avoid additional HIV-related deaths. The provision of other HIV prevention measures is also important to prevent any increase in HIV incidence.

Funding

Bill & Melinda Gates Foundation.