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Milewska-Buzun M, Cybulski M, Baranowska A, Kózka M, Paradowska-Stankiewicz I. Quality of Life in HIV-Positive People in Poland Treated in the City of Bialystok: A Cross-Sectional Study. J Clin Med 2023; 12:5593. [PMID: 37685659 PMCID: PMC10488938 DOI: 10.3390/jcm12175593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 08/23/2023] [Accepted: 08/25/2023] [Indexed: 09/10/2023] Open
Abstract
The quality of life is one of the key factors in assessing the health status of HIV-positive individuals, with its improvement considered an important goal of treatment. Assessment of the quality of life helps accurately evaluate the impact of diseases and treatment on the patient's life. The aim of this study was to assess the quality of life of HIV-positive people in Poland using the example of patients treated in the Observation and Infection Clinic with the Subunit for HIV/AIDS Patients of the University Clinical Hospital in Bialystok, based on the evaluation of HIV-positive status acceptance in HIV patients as well as sociometric variables such as age, gender and marital status. A total of 147 patients participated in this study, including 104 men (70.7%) and 43 women (29.3%). This study was conducted between May 2019 and January 2020 in the Observation and Infection Clinic with the Subunit for HIV/AIDS Patients with the Consultation and Diagnostic Centre at the Teaching Hospital of the Medical University of Bialystok. This study used a diagnostic survey method with a modified questionnaire "Psychosocial Situation of People Living with HIV/AIDS in Poland" by Dr. Magdalena Ankiersztejn-Bartczak and the following standardised psychometric tools: the World Health Organization Quality of Life (WHOQOL-BREF), Short-Form Health Survey (SF-36), Acceptance of Illness Scale (AIS) and Satisfaction with Life Scale (SWLS). The majority of respondents (60%) reported no significant changes in their lives as a result of HIV infection. Gender was not a differentiating factor in the quality of life of people living with HIV. The variation in psychometric measures within the female and male groups was far greater than the difference between them. Marital status clearly differentiated the quality of life. The following conclusions were drawn from this study: The surveyed HIV patients presented a moderate level of quality of life, which was mainly determined by marital status. Higher quality of life was presented by married persons. Duration of infection was not correlated with quality of life. The level of acceptance of HIV infection was relatively high among respondents. A higher level of HIV acceptance was associated with a higher quality of life. The respondents presented a relatively poor level of satisfaction with life. Changing jobs, going on disability, relationship breakdown, not having a family of their own and losing friends were the key HIV-related changes in the lives of the respondents.
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Affiliation(s)
- Marta Milewska-Buzun
- Department of Integrated Medical Care, Faculty of Health Sciences, Medical University of Bialystok, 15-096 Bialystok, Poland; (M.C.); (A.B.)
| | - Mateusz Cybulski
- Department of Integrated Medical Care, Faculty of Health Sciences, Medical University of Bialystok, 15-096 Bialystok, Poland; (M.C.); (A.B.)
| | - Anna Baranowska
- Department of Integrated Medical Care, Faculty of Health Sciences, Medical University of Bialystok, 15-096 Bialystok, Poland; (M.C.); (A.B.)
| | - Maria Kózka
- Department of Clinical Nursing, Institute of Nursing and Midwifery, Faculty of Health Sciences, Jagiellonian University Medical College, 31-501 Krakow, Poland;
| | - Iwona Paradowska-Stankiewicz
- Department of Epidemiology and Surveillance of Infectious Diseases, National Institute of Public Health NIH—National Research Institute, 00-791 Warsaw, Poland;
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Owan VJ, Akah LU, Ekpo AJ, Ubi IO, Abeng FA, Akah GT. Socioeconomic factors and the evaluation of HIV/AIDS prevention programs: A psychometric analysis of an instrument. ELECTRONIC JOURNAL OF GENERAL MEDICINE 2022. [DOI: 10.29333/ejgm/12320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Khademi N, Zanganeh A, Saeidi S, Teimouri R, Khezeli M, Jamshidi B, Yigitcanlar T, Salimi Y, Almasi A, Gholami Kiaee K. Quality of life of HIV-infected individuals: insights from a study of patients in Kermanshah, Iran. BMC Infect Dis 2021; 21:203. [PMID: 33622262 PMCID: PMC7903600 DOI: 10.1186/s12879-021-05908-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 02/16/2021] [Indexed: 11/10/2022] Open
Abstract
Background Quality of life (QOL) is one of the major factors to assessing the health and wellbeing of People living with HIV (PLWH). Likewise, improved QOL is among the prominent goals of patient treatment. This study was conducted to investigate the QOL of PLWH in Kermanshah, Iran. Methods This cross-sectional study was conducted on 364 PLWH of Kermanshah between 2016 and 2017. Outpatients were selected as the sample through the convenience sampling method from HIV Positive Clients of Kermanshah Behavioral Diseases Counseling Center. The reasons for the selection of outpatients include: (a) some patients were substance users, homeless or did not have a fixed address to follow-up; (b) addresses and personal details that were registered on the first admission were incorrect or incomplete; (c) due to financial issues, some were forced to relocate frequently and were difficult to track; (d) some patients were convicts or prisoners, making it hard to find them after their release; (e) some of them were from other provinces, where managing access was not easy/possible. Data was collected using WHOQOL-HIV BREF questionnaire (Persian Version). Data also analyzed with STATA 14, and SPSS 23 using T-test and multiple regression. Results This study showed that mean (SD) age of PLWH was 40.21 (10.45) years. Females had better QOL than males except for spirituality, religion and personal beliefs. The gender differences disappeared in multivariate results. A significant association was observed between education and the independence, environment, and spirituality domains of QOL. In addition, being married was correlated with overall QOL, psychological and social relationships domains of QOL of PLWH. Drug use was a behavioral factor with negative influence on the QOL. Conclusion This study found that marital status and drug use were the main predictors of various domains of QOL. Drug use was a behavioral factor with a negative influence on the QOL. Hence, it is recommended that health professionals, planners, and policymakers take effective measures to improve the status quo.
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Affiliation(s)
- Nahid Khademi
- Vice Chancellery for Disease Prevention and Control, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Alireza Zanganeh
- Social Development and Health Promotion Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran.
| | - Shahram Saeidi
- Social Development and Health Promotion Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Raziyeh Teimouri
- UniSA Creative, University of South Australia, Adelaide, Australia
| | - Mehdi Khezeli
- Social Development and Health Promotion Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Babak Jamshidi
- Social Development and Health Promotion Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Tan Yigitcanlar
- School of Built Environment, Queensland University of Technology, Brisbane, Australia
| | - Yahya Salimi
- Social Development and Health Promotion Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Ali Almasi
- Social Development and Health Promotion Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Kobra Gholami Kiaee
- Social Development and Health Promotion Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
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Mayanja Y, Abaasa A, Namale G, Asiki G, Price MA, Kamali A. Factors associated with vaccination completion and retention among HIV negative female sex workers enrolled in a simulated vaccine efficacy trial in Kampala, Uganda. BMC Infect Dis 2019; 19:725. [PMID: 31420019 PMCID: PMC6698002 DOI: 10.1186/s12879-019-4328-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 07/29/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Female sex workers (FSWs) at substantial risk of HIV are potentially a suitable group for HIV prevention trials including vaccine trials. Few HIV vaccine preparatory studies have been conducted among FSWs in Sub-Saharan Africa (SSA); data are therefore limited on acceptability of vaccine trial procedures. We determined vaccination completion and one-year retention among FSWs in Kampala, Uganda. METHODS We conducted a prospective study that simulated a vaccine efficacy trial among HIV negative FSWs (18-49 years). Hepatitis B vaccine (Engerix B) was used to mimic an HIV vaccine product. Volunteers received 1 ml intramuscular injection at 0, 1 and 6 months, and made additional visits (3 days post-vaccination and months 3, 9 and 12). They were censored at that visit if diagnosed as HIV positive or pregnant. We collected socio-demographic, behavioral and clinical data at baseline, 6 and 12 months and fitted Poisson regression models with robust standard error to find factors associated with vaccination completion and retention. RESULTS We enrolled 290 volunteers (median age 27 years) of whom 230 reached a study end-point as follows: 7 became HIV infected, 11 became pregnant and 212 completed both the vaccination schedule and 12-month visit giving a retention of 77.9% (212/272). Vaccination completion was 82.4%. Non-retention at 1 year was more likely among those reporting symptoms of genital ulcer disease (GUD) in the past 3 months (IRR 1.90; 95% CI 1.09-3.32) and those < 35 years; (IRR 6.59; 95% CI 2.11-20.57). Non-completion of the vaccination schedule was associated with being < 35 years (IRR 13.10; 95% CI 1.89-90.92, reporting GUD symptoms (IRR 3.02; 95% CI 1.71-5.33) and reporting consistent condom use with new sexual partners (IRR 2.57; 95% CI 1.10-6.07). CONCLUSIONS FSWs are at substantial risk of HIV infection and yet willing to participate in HIV vaccine and prevention research; young FSWs should be empowered, and those reporting GUD symptoms need close follow up to improve participation in future HIV vaccine trials.
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Affiliation(s)
- Yunia Mayanja
- MRC/UVRI & LSHTM Uganda Research Unit, Plot 51-59 Nakiwogo Road, P. O Box 49, Entebbe, Uganda
| | - Andrew Abaasa
- MRC/UVRI & LSHTM Uganda Research Unit, Plot 51-59 Nakiwogo Road, P. O Box 49, Entebbe, Uganda
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Gertrude Namale
- MRC/UVRI & LSHTM Uganda Research Unit, Plot 51-59 Nakiwogo Road, P. O Box 49, Entebbe, Uganda
| | - Gershim Asiki
- African Population and Health Research Center, P.O. Box 10787-00100, Nairobi, Kenya
- Department of Women’s and Children’s Health, Karolinska Institutet, Tomtebodavägen 18a, 171 77 Stockholm, Sweden
| | - Matthew A. Price
- International AIDS Vaccine Initiative, 125 Broad St, New York, NY 10004 USA
- Department of Epidemiology and Biostatistics, University of California San Francisco, 550 16th Street, San Francisco, CA 94143 USA
| | - Anatoli Kamali
- International AIDS Vaccine Initiative, 125 Broad St, New York, NY 10004 USA
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Filimão DBC, Moon TD, Senise JF, Diaz RS, Sidat M, Castelo A. Individual factors associated with time to non-adherence to ART pick-up within HIV care and treatment services in three health facilities of Zambézia Province, Mozambique. PLoS One 2019; 14:e0213804. [PMID: 30908522 PMCID: PMC6433271 DOI: 10.1371/journal.pone.0213804] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 02/28/2019] [Indexed: 02/04/2023] Open
Abstract
Introduction Mozambique has made significant gains in addressing its HIV epidemic, yet adherence to visit schedules remains a challenge. HIV programmatic gains to date could be impaired if adherence and retention to ART remains low. We investigate individual factors associated with non-adherence to ART pick-up in Mozambique. Methods This was a retrospective cohort of patients initiating ART between January 2013 and June 2014. Non-adherence to ART pick-up was defined as a delay in pick-up ≥ 15 days. Descriptive statistics were used to calculate socio-demographic and clinical characteristics. Adherence to ART pick-up was assessed using Kaplan Meier estimates. Cox proportional hazards model was used to determine factors associated with non-adherence. Results 1,413 participants were included (77% female). Median age was 30.4 years. 19% of patients remained adherent to ART pick-up during the evaluation period, while 81% of patients were non-adherent to ART pick-up. Probability of being non-adherent to ART pick-up by 166 days following initiation was 50%. In univariate analysis, being widowed was associated with higher adherence to ART pick-up than other marital status groups (p = 0.01). After adjusting, being ≥35 years (aHR: 0.843, 95% CI: 0.738–0.964, p = 0.012); receiving efavirenz (aHR: 0.932, 95% CI: 0.875–0.992, p = 0.026); and being urban (aHR: 0.754, 95% CI: 0.661–0.861, p<0.0001) were associated with improved adherence. Non-participation in a Community ART Support Group (CASG) was associated with a 43% increased hazard of non-adherence to ART pick-up (aHR 1.431, 1.192–1.717, p<0.0001) Conclusions Interventions should focus on the first 6 months following ARV initiation for improvements. Younger persons and widows are two target groups for better understanding facilitators and barriers to visit schedule adherence. Future strategies should explore the benefits of joining CASGs earlier in one´s treatment course. Finally, greater efforts should be made to accelerate the scale-up of viral load capacity and HIV resistance monitoring.
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Affiliation(s)
- Dércio B. C. Filimão
- Provincial Directorate of Health, Zambézia Province, Quelimane, Mozambique
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Department of Medicine, Federal University of São Paulo, São Paulo, Brazil
- Retrovirology Laboratory, Federal University of São Paulo, São Paulo, Brazil
- * E-mail:
| | - Troy D. Moon
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Jorge F. Senise
- Department of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - Ricardo S. Diaz
- Retrovirology Laboratory, Federal University of São Paulo, São Paulo, Brazil
| | - Mohsin Sidat
- Faculty of Medicine, University Eduardo Mondlane, Maputo, Mozambique
| | - Adauto Castelo
- Department of Medicine, Federal University of São Paulo, São Paulo, Brazil
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Mayanja Y, Kamacooko O, Bagiire D, Namale G, Kaleebu P, Seeley J. 'Test and Treat' Among Women at High Risk for HIV-infection in Kampala, Uganda: Antiretroviral Therapy Initiation and Associated Factors. AIDS Behav 2018; 22:1053-1061. [PMID: 29127534 PMCID: PMC5847220 DOI: 10.1007/s10461-017-1973-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Data on implementation of 'Test and Treat' among key populations in sub-Saharan Africa are still limited. We examined factors associated with prompt antiretroviral therapy/ART (within 1 month of HIV-positive diagnosis or 1 week if pregnant) among 343 women at high risk for HIV infection in Kampala-Uganda, of whom 28% initiated prompt ART. Most (95%) reported paid sex within 3 months prior to enrolment. Multivariable logistic regression was used to determine baseline characteristics associated with prompt ART. Sex work as main job, younger age and being widowed/separated were associated with lower odds of prompt ART; being enrolled after 12 months of implementing the intervention was associated with higher odds of prompt ART. Younger women, widowed/separated and those reporting sex work as their main job need targeted interventions to start ART promptly after testing. Staff supervision and mentoring may need strengthening during the first year of implementing 'test and treat' interventions.
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Affiliation(s)
- Yunia Mayanja
- MRC/UVRI Uganda Research Unit on AIDS, Plot 51-59 Nakiwogo Road, Entebbe, Uganda.
| | - Onesmus Kamacooko
- MRC/UVRI Uganda Research Unit on AIDS, Plot 51-59 Nakiwogo Road, Entebbe, Uganda
| | - Daniel Bagiire
- MRC/UVRI Uganda Research Unit on AIDS, Plot 51-59 Nakiwogo Road, Entebbe, Uganda
| | - Gertrude Namale
- MRC/UVRI Uganda Research Unit on AIDS, Plot 51-59 Nakiwogo Road, Entebbe, Uganda
| | - Pontiano Kaleebu
- MRC/UVRI Uganda Research Unit on AIDS, Plot 51-59 Nakiwogo Road, Entebbe, Uganda
| | - Janet Seeley
- MRC/UVRI Uganda Research Unit on AIDS, Plot 51-59 Nakiwogo Road, Entebbe, Uganda
- London School of Hygiene and Tropical Medicine, London, UK
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Galárraga O, Wamai RG, Sosa-Rubí SG, Mugo MG, Contreras-Loya D, Bautista-Arredondo S, Nyakundi H, Wang’ombe JK. HIV prevention costs and their predictors: evidence from the ORPHEA Project in Kenya. Health Policy Plan 2017; 32:1407-1416. [PMID: 29029086 PMCID: PMC5886164 DOI: 10.1093/heapol/czx121] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2017] [Indexed: 01/14/2023] Open
Abstract
We estimate costs and their predictors for three HIV prevention interventions in Kenya: HIV testing and counselling (HTC), prevention of mother-to-child transmission (PMTCT) and voluntary medical male circumcision (VMMC). As part of the 'Optimizing the Response of Prevention: HIV Efficiency in Africa' (ORPHEA) project, we collected retrospective data from government and non-governmental health facilities for 2011-12. We used multi-stage sampling to determine a sample of health facilities by type, ownership, size and interventions offered totalling 144 sites in 78 health facilities in 33 districts across Kenya. Data sources included key informants, registers and time-motion observation methods. Total costs of production were computed using both quantity and unit price of each input. Average cost was estimated by dividing total cost per intervention by number of clients accessing the intervention. Multivariate regression methods were used to analyse predictors of log-transformed average costs. Average costs were $7 and $79 per HTC and PMTCT client tested, respectively; and $66 per VMMC procedure. Results show evidence of economies of scale for PMTCT and VMMC: increasing the number of clients per year by 100% was associated with cost reductions of 50% for PMTCT, and 45% for VMMC. Task shifting was associated with reduced costs for both PMTCT (59%) and VMMC (54%). Costs in hospitals were higher for PMTCT (56%) in comparison to non-hospitals. Facilities that performed testing based on risk factors as opposed to universal screening had higher HTC average costs (79%). Lower VMMC costs were associated with availability of male reproductive health services (59%) and presence of community advisory board (52%). Aside from increasing production scale, HIV prevention costs may be contained by using task shifting, non-hospital sites, service integration and community supervision.
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Affiliation(s)
- Omar Galárraga
- School of Public Health, Brown University, Providence, RI, USA
| | - Richard G Wamai
- Global Health Initiative, Northeastern University, Boston, MA, USA
| | - Sandra G Sosa-Rubí
- Health Economics Unit, Mexican Institute of Public Health, Cuernavaca, Mexico
| | - Mercy G Mugo
- Department of Economics, University of Nairobi, Nairobi, Kenya
| | - David Contreras-Loya
- School of Public Health, University of California at Berkeley, Berkeley, CA, USA and
| | | | - Helen Nyakundi
- School of Public Health, University of Nairobi, Nairobi, Kenya
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Luboga SA, Stover B, Lim TW, Makumbi F, Kiwanuka N, Lubega F, Ndizihiwe A, Mukooyo E, Hurley EK, Borse N, Wood A, Bernhardt J, Lohman N, Sheppard L, Barnhart S, Hagopian A. Did PEPFAR investments result in health system strengthening? A retrospective longitudinal study measuring non-HIV health service utilization at the district level. Health Policy Plan 2016; 31:897-909. [PMID: 27017824 PMCID: PMC4977428 DOI: 10.1093/heapol/czw009] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2016] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVES : PEPFAR's initial rapid scale-up approach was largely a vertical effort focused fairly exclusively on AIDS. The purpose of our research was to identify spill-over health system effects, if any, of investments intended to stem the HIV epidemic over a 6-year period with evidence from Uganda. The test of whether there were health system expansions (aside from direct HIV programming) was evidence of increases in utilization of non-HIV services-such as outpatient visits, in-facility births or immunizations-that could be associated with varying levels of PEPFAR investments at the district level. METHODS : Uganda's Health Management Information System article-based records were available from mid-2005 onwards. We visited all 112 District Health offices to collect routine monthly reports (which contain data aggregated from monthly facility reports) and annual reports (which contain data aggregated from annual facility reports). Counts of individuals on anti-retroviral therapy (ART) at year-end served as our primary predictor variable. We grouped district-months into tertiles of high, medium or low PEPFAR investment based on their total reported number of patients on ART at the end of the year. We generated incidence-rate ratios, interpreted as the relative rate of the outcome measure in relation to the lowest investment PEPFAR tertile, holding constant control variables in the model. RESULTS : We found PEPFAR investment overall was associated with small declines in service volumes in several key areas of non-HIV care (outpatient care for young children, TB tests and in-facility deliveries), after adjusting for sanitation, elementary education and HIV prevalence. For example, districts with medium and high ART investment had 11% fewer outpatient visits for children aged 4 and younger compared with low investment districts, incidence rate ratio (IRR) of 0.89 for high investment compared with low (95% CI, 0.85-0.94) and IRR of 0.93 for medium compared with low (0.90-0.96). Similarly, 22% fewer TB sputum tests were performed in high investment districts compared with low investment, [IRR 0.78 (0.72-0.85)] and 13% fewer in medium compared with low, [IRR 0.88 (0.83-0.94)]. Districts with medium and high ART investment had 5% fewer in-facility deliveries compared with low investment districts [IRR 0.95 for high compared with low, (91-1.00) and 0.96 for medium compared with low (0.93-0.99)]. Although not statistically significant, the rate of maternal deaths in high investment district-months was 13% lower than observed in low investment districts. CONCLUSIONS : This study sought to understand whether PEPFAR, as a vertical programme, may have had a spill-over effect on the health system generally, as measured by utilization. Our conclusion is that it did not, at least not in Uganda.
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Affiliation(s)
- Samuel Abimerech Luboga
- Faculty of Health Sciences, Makerere University, PO Box 7062, Kampala University Road, Kampala, Uganda
| | - Bert Stover
- Department of Health Services, University of Washington, PO Box 357660, Seattle, WA 98195, USA
| | - Travis W Lim
- Division of Global HIV and Tuberculosis, 1600 Clifton Road, Atlanta, GA 30333, USA
| | - Frederick Makumbi
- Faculty of Health Sciences, Makerere University, PO Box 7062, Kampala University Road, Kampala, Uganda
| | - Noah Kiwanuka
- Faculty of Health Sciences, Makerere University, PO Box 7062, Kampala University Road, Kampala, Uganda
| | - Flavia Lubega
- Faculty of Health Sciences, Makerere University, PO Box 7062, Kampala University Road, Kampala, Uganda
| | - Assay Ndizihiwe
- Division of Global HIV and Tuberculosis, 1600 Clifton Road, Atlanta, GA 30333, USA
| | - Eddie Mukooyo
- Resource Center for the Uganda Ministry of Health, Uganda Ministry of Health, PO Box 7272 Kampala Uganda Plot 6 Lourdel Road, Nakasero
| | - Erin K Hurley
- Division of Global HIV and Tuberculosis, 1600 Clifton Road, Atlanta, GA 30333, USA
| | - Nagesh Borse
- Division of Global HIV and Tuberculosis, 1600 Clifton Road, Atlanta, GA 30333, USA
| | - Angela Wood
- Department of Global Health, University of Washington, PO Box 357965, Seattle, WA 98195, USA and
| | - James Bernhardt
- Department of Global Health, University of Washington, PO Box 357965, Seattle, WA 98195, USA and
| | - Nathaniel Lohman
- Department of Global Health, University of Washington, PO Box 357965, Seattle, WA 98195, USA and
| | - Lianne Sheppard
- Department of Biostatistics, University of Washington, PO Box 357232, Seattle, WA 98195, USA
| | - Scott Barnhart
- Department of Global Health, University of Washington, PO Box 357965, Seattle, WA 98195, USA and
| | - Amy Hagopian
- Department of Health Services, University of Washington, PO Box 357660, Seattle, WA 98195, USA Department of Global Health, University of Washington, PO Box 357965, Seattle, WA 98195, USA and
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Khademi N, Reshadat S, Zangeneh A, Saeidi S, Ghasemi SR, Rajabi-Gilan N, Zakiei A. A comparative study of the spatial distribution of HIV prevalence in the metropolis of Kermanshah, Iran, in 1996-2014 using geographical information systems. HIV Med 2016; 18:220-224. [PMID: 27535117 DOI: 10.1111/hiv.12416] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Geographical information systems (GISs) have made spatiotemporal understanding of geographical patterns possible and have contributed to the identification and analysis of factors relating to health care behaviours and outcomes. The present study is the first to examine the spatial distribution of HIV prevalence in the metropolis of Kermanshah, Iran, using GISs. METHODS The research methods were descriptive, analytical and comparative. Additionally, data recorded for HIV-infected patients in 1996-2014 were used and then the loci of HIV infection in the metropolis of Kermanshah were identified and analysed spatially using ArcGIS (Esri, New York, NY, USA). RESULTS HIV prevalence in the metropolis of Kermanshah increased from 1996 to 2014. Analysis of the spatial distribution of the prevalence of HIV using ArcGIS indicated the presence of clusters of HIV infection. The findings demonstrate that there were many clusters of high HIV prevalence throughout the city of Kermanshah and that these clusters increased in size during the study period. Furthermore, the statistics are indicative of a growing number of HIV-infected women as well as a significant reduction in the mean age of the HIV-infected female population. CONCLUSIONS The spatial differences in HIV prevalence across the city of Kermanshah, as well as the identification of the resulting spatial clusters in different parts of the city, suggest that measures should be put in place to prevent the growth of these clusters and to reduce the number of women being infected with HIV.
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Affiliation(s)
- N Khademi
- CDC Department, Kermanshah Health Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - S Reshadat
- Center of Excellence for Community Oriented Medicine Education, Social Development and Health Promotion Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - A Zangeneh
- Social Development and Health Promotion Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - S Saeidi
- Social Development and Health Promotion Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - S R Ghasemi
- Social Development and Health Promotion Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - N Rajabi-Gilan
- Social Development and Health Promotion Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - A Zakiei
- Social Development and Health Promotion Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
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Structural Barriers to Antiretroviral Therapy Among Sex Workers Living with HIV: Findings of a Longitudinal Study in Vancouver, Canada. AIDS Behav 2016; 20:977-86. [PMID: 26148850 DOI: 10.1007/s10461-015-1102-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
In light of limited data on structural determinants of access and retention in antiretroviral therapy (ART) among sex workers, we examined structural correlates of ART use among sex workers living with HIV over time. Longitudinal data were drawn from a cohort of 646 female sex workers in Vancouver, Canada (2010-2012) and linked pharmacy records on ART dispensation. We used logistic regression with generalized estimating equations (GEE) to examine correlates of gaps in ART use (i.e., treatment interruptions or delayed ART initiation), among HIV seropositive participants (n = 74). Over a 2.5-year period, 37.8 % of participants experienced gaps in ART use (i.e., no ART dispensed in a 6-month period). In a multivariable GEE model, younger age, migration/mobility, incarceration, and non-injection drug use independently correlated with gaps in ART use. In spite of successes scaling-up ART in British Columbia, younger, mobile, or incarcerated sex workers face persistent gaps in access and retention irrespective of drug use. Community-based, tailored interventions to scale-up entry and retention in ART for sex workers should be further explored in this setting.
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Koenig SP, Bernard D, Dévieux JG, Atwood S, McNairy ML, Severe P, Marcelin A, Julma P, Apollon A, Pape JW. Trends in CD4 Count Testing, Retention in Pre-ART Care, and ART Initiation Rates over the First Decade of Expansion of HIV Services in Haiti. PLoS One 2016; 11:e0146903. [PMID: 26901795 PMCID: PMC4763018 DOI: 10.1371/journal.pone.0146903] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 12/23/2015] [Indexed: 12/26/2022] Open
Abstract
Background High attrition during the period from HIV testing to antiretroviral therapy (ART) initiation is widely reported. Though treatment guidelines have changed to broaden ART eligibility and services have been widely expanded over the past decade, data on the temporal trends in pre-ART outcomes are limited; such data would be useful to guide future policy decisions. Methods We evaluated temporal trends and predictors of retention for each step from HIV testing to ART initiation over the past decade at the GHESKIO clinic in Port-au-Prince Haiti. The 24,925 patients >17 years of age who received a positive HIV test at GHESKIO from March 1, 2003 to February 28, 2013 were included. Patients were followed until they remained in pre-ART care for one year or initiated ART. Results 24,925 patients (61% female, median age 35 years) were included, and 15,008 (60%) had blood drawn for CD4 count within 12 months of HIV testing; the trend increased over time from 36% in Year 1 to 78% in Year 10 (p<0.0001). Excluding transfers, the proportion of patients who were retained in pre-ART care or initiated ART within the first year after HIV testing was 84%, 82%, 64%, and 64%, for CD4 count strata ≤200, 201 to 350, 351 to 500, and >500 cells/mm3, respectively. The trend increased over time for each CD4 strata, and in Year 10, 94%, 95%, 79%, and 74% were retained in pre-ART care or initiated ART for each CD4 strata. Predictors of pre-ART attrition included male gender, low income, and low educational status. Older age and tuberculosis (TB) at HIV testing were associated with retention in care. Conclusions The proportion of patients completing assessments for ART eligibility, remaining in pre-ART care, and initiating ART have increased over the last decade across all CD4 count strata, particularly among patients with CD4 count ≤350 cells/mm3. However, additional retention efforts are needed for patients with higher CD4 counts.
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Affiliation(s)
- Serena P. Koenig
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
- Division of Global Health Equity, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States of America
- * E-mail:
| | - Daphne Bernard
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Jessy G. Dévieux
- AIDS Prevention Program, Florida International University, Miami, FL, United States of America
| | - Sidney Atwood
- Division of Global Health Equity, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Margaret L. McNairy
- Center for Global Health, Weill Cornell Medical College, New York, NY, United States of America
| | - Patrice Severe
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Adias Marcelin
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Pierrot Julma
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Alexandra Apollon
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Jean W. Pape
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
- Center for Global Health, Weill Cornell Medical College, New York, NY, United States of America
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Aliyu MH, Blevins M, Arinze F, Megazzini KM, Bussell S, Dunlap J, Odoh C, Gebi UI, Muhammad MY, Shepherd BE, Audet CM, Vermund SH, Wester CW. Enrolment trends in a comprehensive HIV programme in rural north-central Nigeria: improved care indices, but declining quality of clinical data over time. Pathog Glob Health 2016; 109:75-83. [PMID: 25822098 DOI: 10.1179/2047773215y.0000000007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Vanderbilt University affiliate Friends in Global Health was funded in 2008 to support comprehensive HIV/AIDS services in north-central Nigeria. We summarise programme characteristics and trends in enrolment and quality of data collection in this rural, resource-limited environment. METHODS We used routinely collected programme data in supported sites from June 1 2009 to September 30, 2013.Baseline characteristics were defined as those collected closest to a 90-day window period before and after enrolment. Summary characteristics were compared by site and enrolment year. RESULTS We enrolled 3,960 HIV-infected patients into care (68% women), median age of 32 years [interquartile range (IQR): 27-40]. Most clients were married (79%) and unemployed (60%). At enrolment, median CD4+ cell count was 230 cells/μL (IQR: 114-390) and haemoglobin was 10.7 g/dL (IQR: 9.3-11.9). Advanced clinical disease [World Health Organization (WHO) clinical stage III/IV] at enrolment was documented in 29% of clients. Cumulative enrolment increased from 377 patients in 2009 to 3,960 patients by 2013.With each successive year, more clients were enrolled at earlier stages of disease; in 2009, 37% of patients were identified as WHO clinical stage I, while in 2013, 55% of patients were so classified. While documentation of clinical staging remained stable, the completeness of CD4+ cell count and haemoglobin data declined with time. CONCLUSION Expanded testing in a comprehensive HIV programme in rural Nigeria brought persons to care at earlier stages of illness. Yet, as clinical services expanded, data collection quality declined. The paradox of successful scaling up HIV services but deteriorating quality of data underscores the importance of data management training and quality improvement efforts.
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Brentlinger PE, Silva WP, Vermund SH, Valverde E, Buene M, Moon TD. Practical Management of HIV-Associated Anemia in Resource-Limited Settings: Prospective Observational Evaluation of a New Mozambican Guideline. AIDS Res Hum Retroviruses 2016; 32:12-25. [PMID: 26178574 DOI: 10.1089/aid.2015.0030] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Mozambique's updated guideline for management of HIV-associated anemia prompts clinicians to consider opportunistic conditions, adverse drug reactions, and untreated immunosuppression in addition to iron deficiency, intestinal helminthes, and malaria. We prospectively evaluated this guideline in rural Zambézia Province. Likely cause(s) of anemia were determined through prespecified history, physical examination, and laboratory testing. Diagnoses were "etiologic" if laboratory confirmed (sputum microscopy, blood culture, Plasmodium falciparum malaria rapid test) or "syndromic" if not. To assess hemoglobin response, we used serial point-of-care measurements. We studied 324 ambulatory, anemic (hemoglobin <10 g/dl) HIV-infected adults. Study clinicians treated nearly all [315 (97.2%)] for suspected iron deficiency and/or helminthes; 56 (17.3%) had laboratory-confirmed malaria. Other assigned diagnoses included tuberculosis [30 (9.3%)], adverse drug reactions [26 (8.0%)], and bacteremia [13 (4.1%)]. Etiologic diagnosis was achieved in 79 (24.4%). Of 169 (52.2%) subjects who improved (hemoglobin increase of ≥1 g/dl without indications for hospitalization), only 65 (38.5%) received conventional management (iron supplementation, deworming, and/or antimalarials) alone. Thirty (9.3%) died and/or were hospitalized, and 125 (38.6%) were lost to follow-up. Multivariable linear and logistic regression models described better hemoglobin responses and/or outcomes in subjects with higher CD4(+) T-lymphocyte counts, pre-enrollment antiretroviral therapy and/or co-trimoxazole prophylaxis, discontinuation of zidovudine for suspected adverse reaction, and smear-positive tuberculosis. Adverse outcomes were associated with fever, low body mass index, bacteremia, esophageal candidiasis, and low or missing CD4(+) T cell counts. In this severely resource-limited setting, successful anemia management often required interventions other than conventional presumptive treatment, thus supporting Mozambique's guideline revision.
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Affiliation(s)
| | - Wilson P. Silva
- Friends in Global Health, LLC, Maputo, Mozambique, and Quelimane, Mozambique
- Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, Tennessee
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University, Nashville, Tennessee
| | - Sten H. Vermund
- Friends in Global Health, LLC, Maputo, Mozambique, and Quelimane, Mozambique
- Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, Tennessee
- Department of Pediatrics, Vanderbilt University, Nashville, Tennessee
| | - Emilio Valverde
- Friends in Global Health, LLC, Maputo, Mozambique, and Quelimane, Mozambique
- Department of Health Policy, Vanderbilt University, Nashville, Tennessee
| | - Manuel Buene
- Friends in Global Health, LLC, Maputo, Mozambique, and Quelimane, Mozambique
| | - Troy D. Moon
- Friends in Global Health, LLC, Maputo, Mozambique, and Quelimane, Mozambique
- Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, Tennessee
- Department of Pediatrics, Vanderbilt University, Nashville, Tennessee
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Medley A, Bachanas P, Grillo M, Hasen N, Amanyeiwe U. Integrating prevention interventions for people living with HIV into care and treatment programs: a systematic review of the evidence. J Acquir Immune Defic Syndr 2015; 68 Suppl 3:S286-96. [PMID: 25768868 PMCID: PMC4666299 DOI: 10.1097/qai.0000000000000520] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION This review assesses the impact of prevention interventions for people living with HIV on HIV-related mortality, morbidity, retention in care, quality of life, and prevention of ongoing HIV transmission in resource-limited settings (RLSs). METHODS We conducted a systematic review of studies reporting the results of prevention interventions for people living with HIV in RLS published between January 2000 and August 2014. Standardized methods of searching and data abstraction were used. RESULTS Ninety-two studies met the eligibility criteria: 24 articles related to adherence counseling and support, 13 on risk reduction education and condom provision, 19 on partner HIV testing and counseling, 14 on provision of family planning services, and 22 on assessment and treatment of other sexually transmitted infections. Findings indicate good evidence that adherence counseling and sexually transmitted infection treatment can have a high impact on morbidity, whereas risk reduction education, partner HIV testing and counseling, and family planning counseling can prevent transmission of HIV. More limited evidence was found to support the impact of these interventions on retention in care and quality of life. Most studies did not report cost information, making it difficult to draw conclusions about the cost-effectiveness of these interventions. CONCLUSIONS This evidence suggests that these prevention interventions, if brought to sufficient scale and coverage, can help support and optimize the impact of core treatment and prevention interventions in RLS. Further operational research with more rigorous study designs, and ideally with biomarkers and costing information, is needed to determine the best model for providing these interventions in RLS.
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Affiliation(s)
- Amy Medley
- US Centers for Disease Control and Prevention, Division of Global HIV/AIDS, Atlanta, GA
| | - Pamela Bachanas
- US Centers for Disease Control and Prevention, Division of Global HIV/AIDS, Atlanta, GA
| | - Michael Grillo
- Naval Health Research Center, Department of Defense, HIV/AIDS Prevention Program, San Diego, CA
| | - Nina Hasen
- U.S. Department of State, Office of the US Global AIDS Coordinator and Health Diplomacy, Washington, DC
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Edwards LJ, Moisés A, Nzaramba M, Cassimo A, Silva L, Mauricio J, Wester CW, Vermund SH, Moon TD. Implementation of a health management mentoring program: year-1 evaluation of its impact on health system strengthening in Zambézia Province, Mozambique. Int J Health Policy Manag 2015; 4:353-61. [PMID: 26029894 DOI: 10.15171/ijhpm.2015.58] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 03/06/2015] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Avante Zambézia is an initiative of a Non-Governmental Organization (NGO), Friends in Global Health, LLC (FGH) and the Vanderbilt Institute for Global Health (VIGH) to provide technical assistance to the Mozambican Ministry of Health (MoH) in rural Zambézia Province. Avante Zambézia developed a district level Health Management Mentorship (HMM) program to strengthen health systems in ten of Zambézia's 17 districts. Our objective was to preliminarily analyze changes in four domains of health system capacity after the HMM's first year: accounting, Human Resources (HRs), Monitoring and Evaluation (M&E), and transportation management. METHODS Quantitative metrics were developed in each domain. During district visits for weeklong, on-site mentoring, the health management mentoring teams documented each indicator as a success ratio percentage. We analyzed data using linear regressions of each indicator's mean success ratio across all districts submitting a report over time. RESULTS Of the four domains, district performance in the accounting domain was the strongest and most sustained. Linear regressions of mean monthly compliance for HR objectives indicated improvement in three of six mean success ratios. The M&E capacity domain showed the least overall improvement. The one indicator analyzed for transportation management suggested progress. CONCLUSION Our outcome evaluation demonstrates improvement in health system performance during a HMM initiative. Evaluating which elements of our mentoring program are succeeding in strengthening district level health systems is vital in preparing to transition fiscal and managerial responsibility to local authorities.
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Affiliation(s)
- Laura J Edwards
- Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, TN, USA
| | - Abú Moisés
- Friends in Global Health, Maputo, Mozambique
| | | | | | - Laura Silva
- Friends in Global Health, Maputo, Mozambique
| | | | - C William Wester
- Vanderbilt Institute for Global Health, Department of Medicine, Division of Infectious Diseases, Vanderbilt University, Nashville, TN, USA
| | - Sten H Vermund
- Vanderbilt Institute for Global Health, Department of Pediatrics, Division of Infectious Diseases, Vanderbilt University, Nashville, TN, USA
| | - Troy D Moon
- Vanderbilt Institute for Global Health, Department of Pediatrics, Division of Infectious Diseases, Vanderbilt University, Nashville, TN, USA
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Buehler CP, Blevins M, Ossemane EB, González-Calvo L, Ndatimana E, Vermund SH, Sidat M, Olupona O, Moon TD. Assessing spatial patterns of HIV knowledge in rural Mozambique using geographic information systems. Trop Med Int Health 2015; 20:353-364. [PMID: 25430042 DOI: 10.1111/tmi.12437] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To conduct a cross-sectional mapping analysis of HIV knowledge in Zambézia Province, Mozambique, and to examine spatial patterns of HIV knowledge and associated household characteristics. METHODS A population-based cluster survey was administered in 2010; data were analysed from 201 enumeration areas in three geographically diverse districts: Alto Molócuè, Morrumbala and Namacurra. We assessed HIV knowledge scores (0-9 points) using previously validated assessment tools. Using geographic information systems (GIS), we mapped hot spots of high and low HIV knowledge. Our multivariable linear regression model estimated HIV knowledge associations with distance to nearest clinic offering antiretroviral therapy, respondent age, education, household size, number of children under five, numeracy, literacy and district of residence. RESULTS We found little overall HIV knowledge in all three districts. People in Alto Molócuè knew comparatively most about HIV, with a median score of 3 (IQR 2-5) and 22 of 51 (43%) enumeration areas scoring ≥4 of 9 points. Namacurra district, closest to the capital city and expected to have the best HIV knowledge levels, had a median score of 1 (IQR 0-3) and only 3 of 57 (5%) enumeration areas scoring ≥4 points. More HIV knowledge was associated with more education, age, household size, numeracy and proximity to a health facility offering antiretroviral therapy. CONCLUSIONS HIV knowledge is critical for its prevention and treatment. By pinpointing areas of poor HIV knowledge, programme planners can prioritize educational resources and outreach initiatives within the context of antiretroviral therapy expansion.
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Paulin HN, Blevins M, Koethe JR, Hinton N, Vaz LME, Vergara AE, Mukolo A, Ndatimana E, Moon TD, Vermund SH, Wester CW. HIV testing service awareness and service uptake among female heads of household in rural Mozambique: results from a province-wide survey. BMC Public Health 2015; 15:132. [PMID: 25881182 PMCID: PMC4339241 DOI: 10.1186/s12889-015-1388-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 01/09/2015] [Indexed: 01/12/2023] Open
Abstract
Background HIV voluntary counseling and testing (VCT) utilization remains low in many sub-Saharan African countries, particularly in remote rural settings. We sought to identify factors associated with service awareness and service uptake of VCT among female heads of household in rural Zambézia Province of north-central Mozambique which is characterized by high HIV prevalence (12.6%), poverty, and suboptimal health service access and utilization. Methods Our population-based survey of female heads of household was administered to a representative two-stage cluster sample using a sampling frame created for use on all national surveys and based on census results. The data served as a baseline measure for the Ogumaniha project initiated in 2009. Survey domains included poverty, health, education, income, HIV stigma, health service access, and empowerment. Descriptive statistics and logistic regression were used to describe service awareness and service uptake of VCT. Results Of 3708 women surveyed, 2546 (69%) were unaware of available VCT services. Among 1162 women who were aware of VCT, 673 (58%) reported no prior testing. In the VCT aware group, VCT awareness was associated with higher education (aOR = 2.88; 95% CI = 1.61, 5.16), higher income (aOR = 1.41, 95% CI = 1.06, 1.86), higher numeracy (aOR = 1.05, CI 1.03, 1.08), more children < age 5 in the home (aOR = 1.53; 95% CI = 1.07, 2.18), closer proximity to a health facility (aOR = 1.05; 95% CI = 1.03, 1.07), and mobile phone ownership (aOR = 1.37; 95% CI = 1.03, 1.84) (all p-values < 0.04). Having a higher HIV-associated stigma score was the factor most strongly associated with being less likely to test. (aOR = 0.41; 95% CI = 0.23, 0.71; p<0.001). Conclusions Most women were unaware of available VCT services. Even women who were aware of services were unlikely to have been tested. Expanded VCT and social marketing of VCT are needed in rural Mozambique with special attention to issues of community-level stigma reduction.
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Affiliation(s)
- Heather N Paulin
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University School of Medicine, 1611 21st Avenue South, A-2200, Medical Center North, Nashville, TN, USA.
| | - Meridith Blevins
- Department of Biostatistics, Nashville, TN, USA. .,Vanderbilt University, Vanderbilt Institute for Global Health (VIGH), Nashville, TN, USA.
| | - John R Koethe
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University School of Medicine, 1611 21st Avenue South, A-2200, Medical Center North, Nashville, TN, USA.
| | | | - Lara M E Vaz
- Department of Preventive Medicine, Nashville, TN, USA. .,Friends in Global Health (FGH), Maputo, Mozambique. .,Save the Children, Washington, D.C., USA.
| | - Alfredo E Vergara
- Department of Preventive Medicine, Nashville, TN, USA. .,Vanderbilt University, Vanderbilt Institute for Global Health (VIGH), Nashville, TN, USA.
| | - Abraham Mukolo
- Department of Preventive Medicine, Nashville, TN, USA. .,Vanderbilt University, Vanderbilt Institute for Global Health (VIGH), Nashville, TN, USA.
| | | | - Troy D Moon
- Department of Pediatrics, Nashville, TN, USA. .,Vanderbilt University, Vanderbilt Institute for Global Health (VIGH), Nashville, TN, USA. .,Friends in Global Health (FGH), Maputo, Mozambique.
| | - Sten H Vermund
- Department of Pediatrics, Nashville, TN, USA. .,Vanderbilt University, Vanderbilt Institute for Global Health (VIGH), Nashville, TN, USA.
| | - C William Wester
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University School of Medicine, 1611 21st Avenue South, A-2200, Medical Center North, Nashville, TN, USA. .,Vanderbilt University, Vanderbilt Institute for Global Health (VIGH), Nashville, TN, USA.
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Blevins M, José E, Bilhete FR, Vaz LM, Shepherd BE, Audet CM, Vermund SH, Moon TD. Two-year death and loss to follow-up outcomes by source of referral to HIV care for HIV-infected patients initiating antiretroviral therapy in rural Mozambique. AIDS Res Hum Retroviruses 2015; 31:198-207. [PMID: 25381732 DOI: 10.1089/aid.2014.0007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
We studied patient outcomes by type of referral site following 2 years of combination antiretroviral therapy (cART) during scale-up from June 2006 to July 2011 in Mozambique's rural Zambézia Province. Loss to follow-up (LTFU) was defined as no contact within 60 days after scheduled medication pickup. Endpoints included LTFU, mortality, and combined mortality/LTFU; we used Kaplan-Meier and cumulative incidence estimates. The referral site was the source of HIV testing. We modeled 2-year outcomes using Cox regression stratified by district, adjusting for sociodemographics and health status. Of 7,615 HIV-infected patients ≥15 years starting cART, 61% were female and the median age was 30 years. Two-year LTFU was 38.1% (95% CI: 36.9-39.3%) and mortality was 14.2% (95% CI 13.2-15.2%). Patients arrived from voluntary counseling and testing (VCT) sites (51%), general outpatient clinics (21%), antenatal care (8%), inpatient care (3%), HIV/tuberculosis/laboratory facilities (<4%), or other sources of referral (14%). Compared with VCT, patients referred from inpatient, tuberculosis, or antenatal care had higher hazards of LTFU. Adjusted hazard ratios (AHR; 95% CI) for 2-year mortality by referral site (VCT as referent) were inpatient 1.87 (1.36-2.58), outpatient 1.44 (1.11-1.85), and antenatal care 0.69 (0.43-1.11) and for mortality/LTFU were inpatient 1.60 (1.34-1.91), outpatient 1.17 (1.02-1.33), tuberculosis care 1.38 (1.08-1.75), and antenatal care 1.24 (1.06-1.44). That source of referral was associated with mortality/LTFU after adjusting for patient characteristics at cART initiation suggests that (1) additional unmeasured factors are influential, and (2) retention programs may benefit from targeting patient populations based on source of referral with focused counseling and/or social support.
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Affiliation(s)
- Meridith Blevins
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Eurico José
- Friends in Global Health, Quelimane and Maputo, Mozambique
| | | | - Lara M.E. Vaz
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee
- Friends in Global Health, Quelimane and Maputo, Mozambique
- Department of Preventive Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Bryan E. Shepherd
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Carolyn M. Audet
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Preventive Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Sten H. Vermund
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee
- Friends in Global Health, Quelimane and Maputo, Mozambique
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Troy D. Moon
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee
- Friends in Global Health, Quelimane and Maputo, Mozambique
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
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Agrawal A, Bloom SS, Suchindran C, Curtis S, Angeles G. Gender-based power and couples' HIV risk in Uttar Pradesh and Uttarakhand, north India. INTERNATIONAL PERSPECTIVES ON SEXUAL AND REPRODUCTIVE HEALTH 2014; 40:196-205. [PMID: 25565347 PMCID: PMC4399762 DOI: 10.1363/4019614] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
CONTEXT Gender inequality is a long-recognized driver of the HIV epidemic. However, few studies have investigated the association between gender-based power and HIV risk in India, which has the world's third largest HIV epidemic. METHODS Population-based data collected in 2003 from 3,385 couples residing in Uttar Pradesh and Uttarakhand, North India, were used to examine associations between gender-based power (wife's autonomy and husband's inequitable gender attitudes) and indicators of couples' HIV risk (whether the husband had had premarital sex with someone other than his eventual spouse, extramarital sex in the past year or STI symptoms in the past year). Structural equation modeling was used to create composite variables for the gender-based power measures and test their associations with HIV risk measures. RESULTS Twenty-four percent of husbands had had premarital sex, 7% had had extramarital sex in the past year and 6% had had STI symptoms in the past year. Structural equation models indicated that wives who reported higher levels of autonomy were less likely than other wives to have husbands who had had extramarital sex in the past year (direct association) or STI symptoms in the past year (indirect association). Moreover, husbands who endorsed more inequitable gender attitudes were more likely than others to report having had premarital sex with someone other than their spouse, which in turn was associated with having had extramarital sex and STI symptoms in the past year. CONCLUSIONS If the associations identified in this study reflect a causal relationship between gender-based power and HIV risk behavior, then HIV prevention programs that successfully address inequitable gender roles may reduce HIV risks in North India.
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Affiliation(s)
- Alpna Agrawal
- Medical student, School of Medicine, University of Texas Health Science Center at Houston, USA,
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Vermund SH, Blevins M, Moon TD, José E, Moiane L, Tique JA, Sidat M, Ciampa PJ, Shepherd BE, Vaz LME. Poor clinical outcomes for HIV infected children on antiretroviral therapy in rural Mozambique: need for program quality improvement and community engagement. PLoS One 2014; 9:e110116. [PMID: 25330113 PMCID: PMC4203761 DOI: 10.1371/journal.pone.0110116] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Accepted: 09/16/2014] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Residents of Zambézia Province, Mozambique live from rural subsistence farming and fishing. The 2009 provincial HIV prevalence for adults 15-49 years was 12.6%, higher among women (15.3%) than men (8.9%). We reviewed clinical data to assess outcomes for HIV-infected children on combination antiretroviral therapy (cART) in a highly resource-limited setting. METHODS We studied rates of 2-year mortality and loss to follow-up (LTFU) for children <15 years of age initiating cART between June 2006-July 2011 in 10 rural districts. National guidelines define LTFU as >60 days following last-scheduled medication pickup. Kaplan-Meier estimates to compute mortality assumed non-informative censoring. Cumulative LTFU incidence calculations treated death as a competing risk. RESULTS Of 753 children, 29.0% (95% CI: 24.5, 33.2) were confirmed dead by 2 years and 39.0% (95% CI: 34.8, 42.9) were LTFU with unknown clinical outcomes. The cohort mortality rate was 8.4% (95% CI: 6.3, 10.4) after 90 days on cART and 19.2% (95% CI: 16.0, 22.3) after 365 days. Higher hemoglobin at cART initiation was associated with being alive and on cART at 2 years (alive: 9.3 g/dL vs. dead or LTFU: 8.3-8.4 g/dL, p<0.01). Cotrimoxazole use within 90 days of ART initiation was associated with improved 2-year outcomes Treatment was initiated late (WHO stage III/IV) among 48% of the children with WHO stage recorded in their records. Marked heterogeneity in outcomes by district was noted (p<0.001). CONCLUSIONS We found poor clinical and programmatic outcomes among children taking cART in rural Mozambique. Expanded testing, early infant diagnosis, counseling/support services, case finding, and outreach are insufficiently implemented. Our quality improvement efforts seek to better link pregnancy and HIV services, expand coverage and timeliness of infant diagnosis and treatment, and increase follow-up and adherence.
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Affiliation(s)
- Sten H. Vermund
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Friends in Global Health, Quelimane and Maputo, Mozambique
| | - Meridith Blevins
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Troy D. Moon
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Friends in Global Health, Quelimane and Maputo, Mozambique
| | - Eurico José
- Friends in Global Health, Quelimane and Maputo, Mozambique
| | - Linda Moiane
- Friends in Global Health, Quelimane and Maputo, Mozambique
| | - José A. Tique
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Friends in Global Health, Quelimane and Maputo, Mozambique
| | - Mohsin Sidat
- School of Medicine, Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Philip J. Ciampa
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Bryan E. Shepherd
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Lara M. E. Vaz
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Department of Preventive Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Friends in Global Health, Quelimane and Maputo, Mozambique
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Antiretroviral therapy program expansion in Zambézia Province, Mozambique: geospatial mapping of community-based and health facility data for integrated health planning. PLoS One 2014; 9:e109653. [PMID: 25329169 PMCID: PMC4201452 DOI: 10.1371/journal.pone.0109653] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2014] [Accepted: 08/19/2014] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To generate maps reflecting the intersection of community-based Voluntary Counseling and Testing (VCT) delivery points with facility-based HIV program demographic information collected at the district level in three districts (Ile, Maganja da Costa and Chinde) of Zambézia Province, Mozambique; in order to guide planning decisions about antiretroviral therapy (ART) program expansion. METHODS Program information was harvested from two separate open source databases maintained for community-based VCT and facility-based HIV care and treatment monitoring from October 2011 to September 2012. Maps were created using ArcGIS 10.1. Travel distance by foot within a 10 km radius is generally considered a tolerable distance in Mozambique for purposes of adherence and retention planning. RESULTS Community-based VCT activities in each of three districts were clustered within geographic proximity to clinics providing ART, within communities with easier transportation access, and/or near the homes of VCT volunteers. Community HIV testing results yielded HIV seropositivity rates in some regions that were incongruent with the Ministry of Health's estimates for the entire district (2-13% vs. 2% in Ile, 2-54% vs. 11.5% in Maganja da Costa, and 23-43% vs. 14.4% in Chinde). All 3 districts revealed gaps in regional disbursement of community-based VCT activities as well as access to clinics offering ART. CONCLUSIONS Use of geospatial mapping in the context of program planning and monitoring allowed for characterizing the location and size of each district's HIV population. In extremely resource limited and logistically challenging settings, maps are valuable tools for informing evidence-based decisions in planning program expansion, including ART.
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Victor B, Blevins M, Green AF, Ndatimana E, González-Calvo L, Fischer EF, Vergara AE, Vermund SH, Olupona O, Moon TD. Multidimensional poverty in rural Mozambique: a new metric for evaluating public health interventions. PLoS One 2014; 9:e108654. [PMID: 25268951 PMCID: PMC4182519 DOI: 10.1371/journal.pone.0108654] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 08/24/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Poverty is a multidimensional phenomenon and unidimensional measurements have proven inadequate to the challenge of assessing its dynamics. Dynamics between poverty and public health intervention is among the most difficult yet important problems faced in development. We sought to demonstrate how multidimensional poverty measures can be utilized in the evaluation of public health interventions; and to create geospatial maps of poverty deprivation to aid implementers in prioritizing program planning. METHODS Survey teams interviewed a representative sample of 3,749 female heads of household in 259 enumeration areas across Zambézia in August-September 2010. We estimated a multidimensional poverty index, which can be disaggregated into context-specific indicators. We produced an MPI comprised of 3 dimensions and 11 weighted indicators selected from the survey. Households were identified as "poor" if were deprived in >33% of indicators. Our MPI is an adjusted headcount, calculated by multiplying the proportion identified as poor (headcount) and the poverty gap (average deprivation). Geospatial visualizations of poverty deprivation were created as a contextual baseline for future evaluation. RESULTS In our rural (96%) and urban (4%) interviewees, the 33% deprivation cut-off suggested 58.2% of households were poor (29.3% of urban vs. 59.5% of rural). Among the poor, households experienced an average deprivation of 46%; thus the MPI/adjusted headcount is 0.27 ( = 0.58×0.46). Of households where a local language was the primary language, 58.6% were considered poor versus Portuguese-speaking households where 73.5% were considered non-poor. Living standard is the dominant deprivation, followed by health, and then education. CONCLUSIONS Multidimensional poverty measurement can be integrated into program design for public health interventions, and geospatial visualization helps examine the impact of intervention deployment within the context of distinct poverty conditions. Both permit program implementers to focus resources and critically explore linkages between poverty and its social determinants, thus deriving useful findings for evidence-based planning.
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Affiliation(s)
- Bart Victor
- Owen Graduate School of Management, Vanderbilt University, Nashville, Tennessee, United States of America
- Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Meridith Blevins
- Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, Tennessee, United States of America
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Ann F. Green
- Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, Tennessee, United States of America
| | | | | | - Edward F. Fischer
- Vanderbilt Center for Latin American Studies and Department of Anthropology, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Alfredo E. Vergara
- Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, Tennessee, United States of America
- Department of Preventive Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Sten H. Vermund
- Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, Tennessee, United States of America
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Friends in Global Health, Maputo, Mozambique
| | - Omo Olupona
- World Vision International, Maputo, Mozambique
| | - Troy D. Moon
- Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, Tennessee, United States of America
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Friends in Global Health, Maputo, Mozambique
- * E-mail:
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Symptomatic HIV-positive persons in rural Mozambique who first consult a traditional healer have delays in HIV testing: a cross-sectional study. J Acquir Immune Defic Syndr 2014; 66:e80-6. [PMID: 24815853 DOI: 10.1097/qai.0000000000000194] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Delays in HIV diagnosis and initiation of antiretroviral therapy are common even among symptomatic individuals in Africa. We hypothesized that antiretroviral therapy delays might be more common if traditional healers (THs) were the first practitioners consulted. DESIGN Cross-sectional study. METHODS We interviewed 530 newly diagnosed HIV-infected adults (≥18 years of age) who were clinically symptomatic at the time of HIV testing in 2 rural districts in Zambézia Province, Mozambique. We ascertained their previous health care seeking behavior, duration of their symptoms, CD4 cell counts at the time of entry into care, and treatment provided by TH(s). RESULTS Of 517 patients (97.5%) with complete histories, 62% sought care from a healer before presenting to the local health facility. The median time to first health facility visit from first relevant symptom was 2 months [interquartile range (IQR): 1-4.5] for persons who had not visited a healer, 3 months (IQR: 2-6) for persons visiting 1 healer, and 9 months (IQR: 5-12) for persons visiting >1 healer (P < 0.001). Healers diagnosed 56% of patients with a social or ancestral curse and treated 66% with subcutaneous herbal remedies. A nonsignificant trend toward lower CD4 cells for persons who had seen multiple healers was noted. CONCLUSIONS Seeking initial care from healers was associated with delays in HIV testing among symptomatic HIV-seropositive persons. We had no CD4 evidence that sicker patients bypass THs, a potential inferential bias. Engaging THs in a therapeutic alliance may facilitate the earlier diagnosis of HIV/AIDS.
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Ojikutu B, Higgins-Biddle M, Greeson D, Phelps BR, Amzel A, Okechukwu E, Kolapo U, Cabral H, Cooper E, Hirschhorn LR. The association between quality of HIV care, loss to follow-up and mortality in pediatric and adolescent patients receiving antiretroviral therapy in Nigeria. PLoS One 2014; 9:e100039. [PMID: 25075742 PMCID: PMC4116117 DOI: 10.1371/journal.pone.0100039] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 05/22/2014] [Indexed: 11/18/2022] Open
Abstract
Access to pediatric HIV treatment in resource-limited settings has risen significantly. However, little is known about the quality of care that pediatric or adolescent patients receive. The objective of this study is to explore quality of HIV care and treatment in Nigeria and to determine the association between quality of care, loss-to-follow-up and mortality. A retrospective cohort study was conducted including patients ≤18 years of age who initiated ART between November 2002 and December 2011 at 23 sites across 10 states. 1,516 patients were included. A quality score comprised of 6 process indicators was calculated for each patient. More than half of patients (55.5%) were found to have a high quality score, using the median score as the cut-off. Most patients were screened for tuberculosis at entry into care (81.3%), had adherence measurement and counseling at their last visit (88.7% and 89.7% respectively), and were prescribed co-trimoxazole at some point during enrollment in care (98.8%). Thirty-seven percent received a CD4 count in the six months prior to chart review. Mortality within 90 days of ART initiation was 1.9%. A total of 4.2% of patients died during the period of follow-up (mean: 27 months) with 19.0% lost to follow-up. In multivariate regression analyses, weight for age z-score (Adjusted Hazard Ratio (AHR): 0.90; 95% CI: 0.85, 0.95) and high quality indicator score (compared a low score, AHR: 0.43; 95% CI: 0.26, 0.73) had a protective effect on mortality. Patients with a high quality score were less likely to be lost to follow-up (Adjusted Odds Ratio (AOR): 0.42; 95% CI: 0.32, 0.56), compared to those with low score. These findings indicate that providing high quality care to children and adolescents living with HIV is important to improve outcomes, including lowering loss to follow-up and decreasing mortality in this age group.
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Affiliation(s)
- Bisola Ojikutu
- John Snow Inc., Boston, Massachusetts, United States of America
- Massachusetts General Hospital, Infectious Disease Division, Boston, Massachusetts, United States of America
- * E-mail:
| | | | - Dana Greeson
- Columbia University, Department of Epidemiology, New York, New York, United States of America
| | - Benjamin R. Phelps
- United States Agency for International Development (USAID), Washington, D. C., United States of America
| | - Anouk Amzel
- United States Agency for International Development (USAID), Washington, D. C., United States of America
| | - Emeka Okechukwu
- United States Agency for International Development (USAID), Abuja, Nigeria
| | | | - Howard Cabral
- Boston University School of Public Health, Department of Biostatistics, Boston, Massachusetts, United States of America
| | - Ellen Cooper
- Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - Lisa R. Hirschhorn
- Harvard Medical School, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
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Linkage to HIV care and antiretroviral therapy by HIV testing service type in Central Mozambique: a retrospective cohort study. J Acquir Immune Defic Syndr 2014; 66:e37-44. [PMID: 24326605 DOI: 10.1097/qai.0000000000000081] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Access to antiretroviral therapy (ART) has increased dramatically in resource-limited settings since its introduction a decade ago. However, ART coverage remains low in countries with the highest disease burden, which may be partially explained by poor testing to care linkages. HIV testing service may impact early attrition in the HIV treatment cascade. METHODS A retrospective cohort study was conducted in 18 clinics in central Mozambique using routine patient data and monthly reports. Patients referred from voluntary counseling and testing (VCT) were compared with those referred from prevention of mother-to-child transmission (PMTCT) for 3 outcomes: (1) enrollment at an HIV clinic ≤30 days after testing HIV positive, (2) CD4 test ≤30 days after enrollment, and (3) ART initiation ≤90 days after first CD4 test. RESULTS Patient retention in the HIV care system dropped at each step from HIV testing to ART initiation. Enrollment in HIV care was not significantly different between PMTCT and VCT [risk ratio (RR) = 0.84, 0.72 < RR < 1.02]. Women tested in PMTCT were less likely to have a CD4 test ≤30 days after enrollment when adjusting for age, education level, and marital status (adjusted RR = 0.84, 0.70 < RR < 1.00), and were less likely to initiate ART ≤90 days after their first CD4 test when adjusting for age, education, and marital status (adjusted RR = 0.56, 0.44 < RR < 0.71). CONCLUSIONS Poor linkages between HIV testing and care hamper efforts to improve coverage for HIV care and treatment services. Increased loss to follow-up among women diagnosed in PMTCT relative to VCT is worrisome and merits further qualitative research and programmatic attention.
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Moon TD, Jequicene T, Blevins M, José E, Lankford JR, Wester CW, Fuchs MC, Vermund SH. Mobile clinics for antiretroviral therapy in rural Mozambique. Bull World Health Organ 2014; 92:680-4. [PMID: 25378759 PMCID: PMC4208568 DOI: 10.2471/blt.13.129478] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Revised: 03/12/2014] [Accepted: 03/17/2014] [Indexed: 11/27/2022] Open
Abstract
Problem Despite seven years of investment from the President's Emergency Plan For AIDS Relief (PEPFAR), the expansion of human immunodeficiency virus (HIV)-related services continues to challenge Mozambique’s health-care infrastructure, especially in the country’s rural regions. Approach In 2012, as part of a national acceleration plan for HIV care and treatment, Namacurra district employed a mobile clinic strategy to provide temporary manpower and physical space to expand services at four rural peripheral clinics. This paper describes the strategy deployed, the uptake of services and the key lessons learnt in the first 18 months of implementation. Local setting In 2012, Namacurra´s adult population was estimated to be 125 425, and of those 15 803 were estimated to be HIV infected. Although there is consistent government support of antiretroviral therapy (ART) programmes, national coverage remains low, with less than 15% of those eligible having received ART by December 2012. Relevant changes Between April 2012 and September 2013, Namacurra district enrolled 4832 new patients into HIV care and treatment. By using the mobile clinic strategy for ART expansion, the district was able to expand provision of ART from two to six (of a desired seven) clinics by September 2013. Lessons learnt Mobile clinic strategies could rapidly expand HIV care and treatment in under-funded settings in ways that both build local capacity and are sustainable for local health systems. The clinics best serve as a transition to improved capacity at fixed-site services.
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Affiliation(s)
- Troy D Moon
- Vanderbilt Institute for Global Health, 2525 West End Avenue, Suite 750, Nashville, Tennessee 37203, United States of America (USA)
| | - Tito Jequicene
- Friends in Global Health, Limited Liability Corporation, Quelimane, Mozambique
| | - Meridith Blevins
- Vanderbilt Institute for Global Health, 2525 West End Avenue, Suite 750, Nashville, Tennessee 37203, United States of America (USA)
| | - Eurico José
- Friends in Global Health, Limited Liability Corporation, Quelimane, Mozambique
| | - Julie R Lankford
- Friends in Global Health, Limited Liability Corporation, Quelimane, Mozambique
| | - C William Wester
- Vanderbilt Institute for Global Health, 2525 West End Avenue, Suite 750, Nashville, Tennessee 37203, United States of America (USA)
| | | | - Sten H Vermund
- Vanderbilt Institute for Global Health, 2525 West End Avenue, Suite 750, Nashville, Tennessee 37203, United States of America (USA)
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Moon TD, Silva WP, Buene M, Morais L, Valverde E, Vermund SH, Brentlinger PE. Bacteremia as a cause of fever in ambulatory, HIV-infected Mozambican adults: results and policy implications from a prospective observational study. PLoS One 2013; 8:e83591. [PMID: 24386229 PMCID: PMC3875454 DOI: 10.1371/journal.pone.0083591] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Accepted: 11/13/2013] [Indexed: 11/23/2022] Open
Abstract
Fever is typically treated empirically in rural Mozambique. We examined the distribution and antimicrobial susceptibility patterns of bacterial pathogens isolated from blood-culture specimens, and clinical characteristics of ambulatory HIV-infected febrile patients with and without bacteremia. This analysis was nested within a larger prospective observational study to evaluate the performance of new Mozambican guidelines for fever and anemia in HIV-infected adults (clinical trial registration NCT01681914, www.clinicaltrials.gov); the guidelines were designed to be used by non-physician clinicians who attended ambulatory HIV-infected patients in very resource-constrained peripheral health units. In 2012 (April-September), we recruited 258 HIV-infected adults with documented fever or history of recent fever in three sites within Zambézia Province, Mozambique. Although febrile patients were routinely tested for malaria, blood culture capacity was unavailable in Zambézia prior to study initiation. We confirmed bacteremia in 39 (15.1%) of 258 patients. The predominant organisms were non-typhoid Salmonella, nearly all resistant to multiple first-line antibiotics (ampicillin, chloramphenicol, and trimethoprim-sulfamethoxazole). Features most associated with bacteremia included higher temperature, lower CD4+ T-lymphocyte count, lower hemoglobin, and headache. Introduction of blood cultures allowed us to: 1) confirm bacteremia in a substantial proportion of patients; 2) tailor specific antimicrobial therapy for confirmed bacteremia based on known susceptibilities; 3) make informed choices of presumptive antibiotics for patients with suspected bacteremia; and 4) construct a preliminary clinical profile to help clinicians determine who would most likely benefit from presumptive bacteremia treatment. Our findings demonstrate that in resource-limited settings, there is urgent need to expand local microbiologic capacity to better identify and treat cases of bacteremia in HIV-infected and other patients, and to support surveillance. Data on the prevalence and susceptibility patterns of important pathogens can guide national formulary and prescribing practices.
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Affiliation(s)
- Troy D. Moon
- Vanderbilt Institute for Global Health, Nashville, Tennessee, United States of America
- Friends in Global Health, Maputo, Mozambique
- * E-mail:
| | | | | | - Luís Morais
- Friends in Global Health, Maputo, Mozambique
| | | | - Sten H. Vermund
- Vanderbilt Institute for Global Health, Nashville, Tennessee, United States of America
- Friends in Global Health, Maputo, Mozambique
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Nuwagaba-Biribonwoha H, Kilama B, Antelman G, Khatib A, Almeida A, Reidy W, Ramadhani G, Lamb MR, Mbatia R, Abrams EJ. Reviewing progress: 7 year trends in characteristics of adults and children enrolled at HIV care and treatment clinics in the United Republic of Tanzania. BMC Public Health 2013; 13:1016. [PMID: 24160907 PMCID: PMC3937235 DOI: 10.1186/1471-2458-13-1016] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 10/21/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To evaluate the on-going scale-up of HIV programs, we assessed trends in patient characteristics at enrolment and ART initiation over 7 years of implementation. METHODS Data were from Optimal Models, a prospective open cohort study of HIV-infected (HIV+) adults (≥15 years) and children (<15 years) enrolled from January 2005 to December 2011 at 44 HIV clinics in 3 regions of mainland Tanzania (Kagera, Kigoma, Pwani) and Zanzibar. Comparative statistics for trends in characteristics of patients enrolled in 2005-2007, 2008-2009 and 2010-2011 were examined. RESULTS Overall 62,801 HIV + patients were enrolled: 58,102(92.5%) adults, (66.5% female); 4,699(7.5%) children.Among adults, pregnant women enrolment increased: 6.8%, 2005-2007; 12.1%, 2008-2009; 17.2%, 2010-2011; as did entry into care from prevention of mother-to-child HIV transmission (PMTCT) programs: 6.6%, 2005-2007; 9.5%, 2008-2009; 12.6%, 2010-2011. WHO stage IV at enrolment declined: 27.1%, 2005-2007; 20.2%, 2008-2009; 11.1% 2010-2011. Of the 42.5% and 29.5% with CD4+ data at enrolment and ART initiation respectively, median CD4+ count increased: 210 cells/μL, 2005-2007; 262 cells/μL, 2008-2009; 266 cells/μL 2010-2011; but median CD4+ at ART initiation did not change (148 cells/μL overall). Stavudine initiation declined: 84.9%, 2005-2007; 43.1%, 2008-2009; 19.7%, 2010-2011.Among children, median age (years) at enrolment decreased from 6.1(IQR:2.7-10.0) in 2005-2007 to 4.8(IQR:1.9-8.6) in 2008-2009, and 4.1(IQR:1.5-8.1) in 2010-2011 and children <24 months increased from 18.5% to 26.1% and 31.5% respectively. Entry from PMTCT was 7.0%, 2005-2007; 10.7%, 2008-2009; 15.0%, 2010-2011. WHO stage IV at enrolment declined from 22.9%, 2005-2007, to 18.3%, 2008-2009 to 13.9%, 2010-2011. Proportion initiating stavudine was 39.8% 2005-2007; 39.5%, 2008-2009; 26.1%, 2010-2011. Median age at ART initiation also declined significantly. CONCLUSIONS Over time, the proportion of pregnant women and of adults and children enrolled from PMTCT programs increased. There was a decline in adults and children with advanced HIV disease at enrolment and initiation of stavudine. Pediatric age at enrolment and ART initiation declined. Results suggest HIV program maturation from an emergency response.
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Mukolo A, Blevins M, Victor B, Vaz LME, Sidat M, Vergara A. Correlates of social exclusion and negative labeling and devaluation of people living with HIV/AIDS in rural settings: evidence from a General Household Survey in Zambézia Province, Mozambique. PLoS One 2013; 8:e75744. [PMID: 24146771 PMCID: PMC3795715 DOI: 10.1371/journal.pone.0075744] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Accepted: 08/20/2013] [Indexed: 12/19/2022] Open
Abstract
Background Increased HIV/AIDS knowledge and access to antiretroviral treatment (ART) have been hypothesized to decrease HIV stigma. However, stigma persists as a barrier to HIV services uptake. We studied the relationship between stigma, knowledge and attitudes towards HIV and its treatment, and confidence in the legal system (legal rights certitude). Methods We analyzed data from a household survey of 3749 randomly sampled female heads of households in 259 enumeration areas across 14 districts of Zambézia Province, Mozambique. The questionnaire included questions about beliefs, attitudes and behavior towards PLWHA, HIV transmission knowledge, treatment-related beliefs, and legal rights certitude. Factor analysis distinguished two stigma constructs: Negative labeling and devaluation (NLD) and social exclusion (SoE). Multivariable linear regression was used to determine the association between stigma, knowledge of HIV/AIDS, treatment-related beliefs, and legal rights certitude, while controlling for variance in socio-demographics. Results A 4-point increase in knowledge about HIV transmission was associated with more than a 3 unit decrease in NLD and SoE stigma scores (p<0.001). Given HIV transmission knowledge, a 25-point increase in legal rights certitude was associated with a 4.62 unit drop in NLD stigma (p<0.001); we did not detect an association between legal rights certitude and SoE stigma. Knowing at least one HIV positive person was associated with lower SoE (−3.17, 95% CI: −5.78, −0.56); no association with NLD (p = 0.1) was detected. ART efficacy belief was associated with higher NLD and lower SoE (2.90 increase and 6.94 decrease, respectively; p≤0.001). Conclusion Increasing knowledge about HIV transmission and access to ART are likely to reduce stigma, but neither of the two is a panacea. Raising community awareness of the legal rights of PLWHA might improve the efficacy of stigma reduction efforts. Strategies that focus on specific domains of stigma might be more effective than generic stigma reduction strategies.
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Affiliation(s)
- Abraham Mukolo
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Department of Preventive Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- * E-mail:
| | - Meridith Blevins
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Bart Victor
- Owen Graduate School of Management, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Lara M. E. Vaz
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Department of Preventive Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Friends in Global Health, Maputo, Mozambique
| | - Mohsin Sidat
- School of Medicine, Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Alfredo Vergara
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Department of Preventive Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
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Shepherd BE, Blevins M, Vaz LME, Moon TD, Kipp AM, José E, Ferreira FG, Vermund SH. Impact of definitions of loss to follow-up on estimates of retention, disease progression, and mortality: application to an HIV program in Mozambique. Am J Epidemiol 2013; 178:819-28. [PMID: 23785113 PMCID: PMC3755641 DOI: 10.1093/aje/kwt030] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Accepted: 02/07/2013] [Indexed: 11/14/2022] Open
Abstract
Patient retention is critical to the management of chronic diseases such as human immunodeficiency virus (HIV); hence, accurate measures of loss to follow-up (LTF) are important. Many different LTF definitions have been proposed. In a cohort of 9,692 HIV-infected patients initiating antiretroviral therapy in Mozambique from 2006 to 2011, we investigated the impact of the definition of LTF on estimated rates of LTF, acquired immunodeficiency syndrome (AIDS)-defining events, and death by applying 17 different definitions of LTF gleaned from HIV literature. We further investigated the impact of 4 specific components of the LTF definitions. Cumulative incidences of LTF and AIDS-defining events were estimated by treating death as a competing risk; Kaplan-Meier techniques and variations to account for informative censoring were used to estimate rates of mortality. Estimates of LTF 2 years after treatment initiation were high and varied substantially, from 22% to 84% depending on the LTF definition used. Estimates of 2-year mortality varied from 11% to 16%, and estimates of 2-year AIDS-defining events varied from 6% to 8%. As seen here, the choice of LTF definition can greatly affect study conclusions and program evaluations. Selection of LTF definitions should be based on the study outcome, available data on clinical encounters, and the patients' visit schedules; we suggest some general guidelines.
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Affiliation(s)
- Bryan E Shepherd
- Vanderbilt University School of Medicine, 1161 21st Avenue South, Nashville,TN 37232-2158, USA.
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Attrition from HIV testing to antiretroviral therapy initiation among patients newly diagnosed with HIV in Haiti. J Acquir Immune Defic Syndr 2013; 62:e61-9. [PMID: 23254154 DOI: 10.1097/qai.0b013e318281e772] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE We report rates and risk factors for attrition in the first cohort of patients followed through all stages from HIV testing to antiretroviral therapy (ART) initiation. DESIGN Cohort study of all patients diagnosed with HIV between January and June 2009. METHODS We calculated the proportion of patients who completed CD4 cell counts and initiated ART or remained in pre-ART care during 2 years of follow-up and assessed predictors of attrition. RESULTS Of 1427 patients newly diagnosed with HIV, 680 (48%) either initiated ART or were retained in pre-ART care for the subsequent 2 years. One thousand eighty-three patients (76%) received a CD4 cell count, and 973 (90%) returned for result; 297 (31%) had CD4 cell count <200 cells per microliter, and of these, 256 (86%) initiated ART. Among 429 patients with CD4 >350 cells per microliter, 215 (50%) started ART or were retained in pre-ART care. Active tuberculosis was associated with not only lower odds of attrition before CD4 cell count [odds ratio (OR): 0.08; 95% confidence interval (CI): 0.03 to 0.25] but also higher odds of attrition before ART initiation (OR: 2.46; 95% CI: 1.29 to 4.71). Lower annual income (≤US $125) was associated with higher odds of attrition before CD4 cell count (OR: 1.65; 95% CI: 1.25 to 2.19) and before ART initiation among those with CD4 cell count >350 cells per microliter (OR: 1.74; 95% CI: 1.20 to 2.52). After tracking patients through a national database, the retention rate increased to only 57%. CONCLUSIONS Fewer than half of patients newly diagnosed with HIV initiate ART or remain in pre-ART care for 2 years in a clinic providing comprehensive services. Additional efforts to improve retention in pre-ART are critically needed.
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Bachanas P, Medley A, Pals S, Kidder D, Antelman G, Benech I, DeLuca N, Nuwagaba-Biribonwoha H, Muhenje O, Cherutich P, Kariuki P, Katuta F, Bukuku M. Disclosure, knowledge of partner status, and condom use among HIV-positive patients attending clinical care in Tanzania, Kenya, and Namibia. AIDS Patient Care STDS 2013; 27:425-35. [PMID: 23829332 PMCID: PMC3704112 DOI: 10.1089/apc.2012.0388] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
We describe the frequency of and factors associated with disclosure, knowledge of partner's HIV status, and consistent condom use among 3538 HIV-positive patients attending eighteen HIV care and treatment clinics in Kenya, Namibia, and Tanzania. Overall, 42% of patients were male, and 64% were on antiretroviral treatment. The majority (80%) had disclosed their HIV status to their partners, 64% knew their partner's HIV status, and 77% reported consistent condom use. Of those who knew their partner's status, 18% reported their partner was HIV negative. Compared to men, women were significantly less likely to report disclosing their HIV status to their sex partner(s), to knowing their partner's HIV status, and to using condoms consistently with HIV-negative partners. Other factors negatively associated with consistent condom use include nondisclosure, alcohol use, reporting a casual sex partner, and desiring a pregnancy. Health care providers should target additional risk reduction counseling and support services to patients who report these characteristics.
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Affiliation(s)
- Pamela Bachanas
- Division of Global HIV/AIDS, U.S. Centers for Disease Control and Prevention, Atlanta, GA 30329, USA.
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Mortality associated with delays between clinic entry and ART initiation in resource-limited settings: results of a transition-state model. J Acquir Immune Defic Syndr 2013; 63:105-11. [PMID: 23392457 DOI: 10.1097/qai.0b013e3182893fb4] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To estimate the mortality impact of delay in antiretroviral therapy (ART) initiation from the time of entry into care. DESIGN A state-transition Markov process model. This technique allows for assessing mortality before and after ART initiation associated with delays in ART initiation among a general population of ART-eligible patients without conducting a randomized trial. METHODS We used patient-level data from 3 South African cohorts to determine transition probabilities for pre-ART CD4 count changes and pre-ART and on-ART mortality. For each parameter, we generated probabilities and distributions for Monte Carlo simulations with 1-week cycles to estimate mortality 52 weeks from clinic entry. RESULTS We estimated an increase in mortality from 11.0% to 14.7% (relative increase of 34%) with a 10-week delay in ART for patients entering care with our pre-ART cohort CD4 distribution. When we examined low CD4 ranges, the relative increase in mortality delays remained similar; however, the absolute increase in mortality rose. For example, among patients entering with CD4 count 50-99 cells per cubic millimeter, 12-month mortality increased from 13.3% with no delay compared with 17.0% with a 10-week delay and 22.9% with a 6-month delay. CONCLUSIONS Delays in ART initiation, common in routine HIV programs, can lead to important increases in mortality. Prompt ART initiation for patients entering clinical care and eligible for ART, especially those with lower CD4 counts, could be a relatively low-cost approach with a potential marked impact on mortality.
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Abstract
HIV research has identified approaches that can be combined to be more effective in transmission reduction than any 1 modality alone: delayed adolescent sexual debut, mutual monogamy or sexual partner reduction, correct and consistent condom use, pre-exposure prophylaxis with oral antiretroviral drugs or vaginal microbicides, voluntary medical male circumcision, antiretroviral therapy (ART) for prevention (including prevention of mother to child HIV transmission [PMTCT]), treatment of sexually transmitted infections, use of clean needles for all injections, blood screening prior to donation, a future HIV prime/boost vaccine, and the female condom. The extent to which evidence-based modalities can be combined to prevent substantial HIV transmission is largely unknown, but combination approaches that are truly implementable in field conditions are likely to be far more effective than single interventions alone. Analogous to PMTCT, "treatment as prevention" for adult-to-adult transmission reduction includes expanded HIV testing, linkage to care, antiretroviral coverage, retention in care, adherence to therapy, and management of key co-morbidities such as depression and substance use. With successful viral suppression, persons with HIV are far less infectious to others, as we see in the fields of sexually transmitted infection control and mycobacterial disease control (tuberculosis and leprosy). Combination approaches are complex, may involve high program costs, and require substantial global commitments. We present a rationale for such investments and cite an ongoing research agenda that seeks to determine how feasible and cost-effective a combination prevention approach would be in a variety of epidemic contexts, notably that in a sub-Saharan Africa.
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Affiliation(s)
- Sten H Vermund
- Vanderbilt Institute for Global Health and Department of Pediatrics, Vanderbilt School of Medicine, Nashville, TN 37203, USA.
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Santelli JS, Speizer IS, Edelstein ZR. Abstinence promotion under PEPFAR: the shifting focus of HIV prevention for youth. Glob Public Health 2013; 8:1-12. [PMID: 23327516 PMCID: PMC3984004 DOI: 10.1080/17441692.2012.759609] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Abstinence-until-marriage (AUM) - strongly supported by religious conservatives in the USA - became a key element of initial human immunodeficiency virus (HIV) prevention efforts under the President's Emergency Plan for AIDS Relief (PEPFAR). AUM programmes have demonstrated limited efficacy in changing behaviours, promoted medically inaccurate information and withheld life-saving information about risk reduction. A focus on AUM also undermined national efforts in Africa to create integrated youth HIV prevention programmes. PEPFAR prevention efforts after 2008 shifted to science-based programming, however, vestiges of AUM remain. Primary prevention programmes within PEPFAR are essential and nations must be able to design HIV prevention based on local needs and prevention science.
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Affiliation(s)
- John S Santelli
- Mailman School of Public Health, Columbia University, New York, NY, USA.
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Factors associated with late antiretroviral therapy initiation among adults in Mozambique. PLoS One 2012; 7:e37125. [PMID: 22615917 PMCID: PMC3352894 DOI: 10.1371/journal.pone.0037125] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Accepted: 04/17/2012] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Despite recent changes to expand the ART eligibility criteria in sub-Saharan Africa, many patients still initiate ART in the advanced stages of HIV infection, which contributes to increased early mortality rates, poor patient outcomes, and onward transmission. METHODS To evaluate individual and clinic-level factors associated with late ART initiation in Mozambique, we conducted a retrospective sex-specific analysis of data from 36,411 adult patients who started ART between January 2005 and June 2009 at 25 HIV clinics in Mozambique. Late ART initiation was defined as CD4 count<100 cells/µL or WHO stage IV. Mixed effects models were used to identify patient- and clinic-level factors associated with late ART initiation. RESULTS The proportion of patients initiating ART late decreased from 46% to 37% during 2005-2007, but remained constant (between 37-33%) from 2007-2009. Of those who initiated ART late (median CD4 = 57 cells/µL), 5% were known to have died and 54% were lost to clinic within 6 months of ART initiation (compared with 2% and 47% among other patients starting ART [median CD4 = 192 cells/µL]). In multivariate analysis, female sex and pregnancy at ART initiation (AOR(female_not_pregnant_vs._male) = 0.66, 95%CI [0.62-0.69]; AOR(pregnant_vs._non_pregnant) = 0.60, 95%CI [0.49-0.73]), younger and older age (AOR(15-25_vs.26-30) = 0.86, 95%CI [0.79-0.94], AOR(>45_vs.26-30) = 0.72, 95%CI [0.67-0.77]), entry into care via PMTCT (AOR(entry_through_PMTCT_vs.VCT) = 0.42, 95%CI [0.35-0.50]), marital status (AOR(married/in union_vs.single) = 0.87, 95%CI [0.83-0.92]), education (AOR(secondary_or_higher_vs.primary) = 0.87, 95%CI [0.83-0.93]) and year of ART initiation were associated with a lower likelihood of late ART initiation. Clinic-level factors independently associated with a lower likelihood of late ART initiation included CD4 machine on-site (AOR(CD4_machine_onsite_vs.offsite) = 0.83, 95%CI [0.74-0.94]) and presence of PMTCT services onsite (AOR = 0.85, 95%CI [0.77-0.93]). CONCLUSION The risk of starting ART late remained persistently high. Efforts are needed to ensure identification and enrollment of patients at earlier stages of HIV disease. Individual and clinic level factors identified may provide clues for upstream structural interventions.
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