Facilitators and barriers for retention in HIV care between testing and treatment in Asia-A study in Bangladesh, Indonesia, Lao, Nepal, Pakistan, Philippines and Vietnam

Barriers and enablers to people-centred viral hepatitis care in Vietnam and the Philippines: Results of a patient journey mapping study

In Vietnam and the Philippines, viral hepatitis is the leading cause of cirrhosis and liver cancer. This study aims to understand the barriers and enablers of people receiving care for hepatitis B and C to support both countries' efforts to eliminate viral hepatitis as a public health threat by 2030. Retrospective, semi-structured interviews were conducted with a purposive, quota-based sample of 63 people living with hepatitis B or C in one province of Vietnam and one region of the Philippines. A rapid deductive approach to thematic analysis produced key findings among the three phases of care: (1) pre-awareness and testing, (2) linkage and treatment initiation and (3) ongoing treatment and recovery. The research found that participants followed five typical journeys, from a variety of entry points. Barriers during the pre-awareness and testing phase included limited awareness about hepatitis and its management, stigma and psychological impacts. Enablers included being familiar with the health system and/or patients benefiting from social connections within the health systems. During the linkage and treatment initiation phase, barriers included difficult physical access, complex navigation and inadequate counselling. In this phase, family support emerged as a critical enabler. During the ongoing treatment and recovery phase, the cost of care and socially and culturally informed perceptions of the disease and medication use were both barriers and enablers. Exploring peoples' journeys with hepatitis B and C in Vietnam and the Philippines revealed many similarities despite the different cultural and health system contexts. Insights from this study may help generate a contextualized, people-centred evidence base to inform the design and improvement of primary care services for hepatitis in both research sites.

Barriers to longitudinal follow-up for hepatitis B treatment in rural Sierra Leone: A mixed methods study of retention in care

HBV disproportionately affects resource-limited settings, and retaining patients in longitudinal care remains challenging. We conducted a mixed methods investigation to understand the causes of losses to follow-up within an HBV clinic in rural Sierra Leone. We developed a multivariable logistic regression model of baseline clinical and sociodemographic factors predicting losses to follow-up, defined as failing to present for a follow-up visit within 14 months of enrollment. We included patients enrolled between April 30, 2019 and March 1, 2020, permitting 14 months of follow-up by April 30, 2021. We then developed a survey to solicit patient perspectives on the challenges surrounding retention. We interviewed randomly selected patients absent from HBV care for at least 6 months. Among 271 patients enrolled in the Kono HBV clinic, 176 (64.9%) did not have a follow-up visit within 14 months of the study end point. Incomplete baseline workup (aOR 2.9; 95% CI: 1.6-4.8), lack of treatment at baseline (aOR 5.0; 95% CI: 1.7-14.4), and having cirrhosis at baseline (aOR 3.3; 95% CI: 0.99-10.8) were independently associated with being lost to follow-up. For the patient survey, 21 patients completed the interview (median age 34 years [IQR: 25-38]). Travel-related factors were the most frequently reported barrier to retention (57%). Almost 30% suggested improved customer care might support retention in care; 24% requested to be given medication. In our setting, factors that might reduce losses to follow-up included expanded criteria for treatment initiation, overcoming transportation barriers, reducing wait times, ensuring against stockouts, and scaling up point-of-care testing services.

The State of the HIV Epidemic in the Philippines: Progress and Challenges in 2023

In the past decade, the Philippines has gained notoriety as the country with the fastest-growing human immunodeficiency virus (HIV) epidemic in the Western Pacific region. While the overall trends of HIV incidence and acquired immunodeficiency syndrome (AIDS)-related deaths are declining globally, an increase in new cases was reported to the HIV/AIDS and ART Registry of the Philippines. From 2012 to 2023, there was a 411% increase in daily incidence. Late presentation in care remains a concern, with 29% of new confirmed HIV cases in January 2023 having clinical manifestations of advanced HIV disease at the time of diagnosis. Men having sex with men (MSM) are disproportionately affected. Various steps have been taken to address the HIV epidemic in the country. The Philippine HIV and AIDS Policy Act of 2018 (Republic Act 11166) expanded access to HIV testing and treatment. HIV testing now allows for the screening of minors 15-17 years old without parental consent. Community-based organizations have been instrumental in expanding HIV screening to include self-testing and community-based screening. The Philippines moved from centralized HIV diagnosis confirmation by Western blot to a decentralized rapid HIV diagnostic algorithm (rHIVda). Dolutegravir-based antiretroviral therapy is now the first line. Pre-exposure prophylaxis in the form of emtricitabine-tenofovir disoproxil fumarate has been rolled out. The number of treatment hubs and primary HIV care facilities continues to increase. Despite these efforts, barriers to ending the HIV epidemic remain, including continued stigma, limited harm reduction services for people who inject drugs, sociocultural factors, and political deterrents. HIV RNA quantification and drug resistance testing are not routinely performed due to associated costs. The high burden of tuberculosis and hepatitis B virus co-infection complicate HIV management. CRF_01AE is now the predominant subtype, which has been associated with poorer clinical outcomes and faster CD4 T-cell decline. The HIV epidemic in the Philippines requires a multisectoral approach and calls for sustained political commitment, community involvement, and continued collaboration among various stakeholders. In this article, we outline the current progress and challenges in curbing the HIV epidemic in the Philippines.

Place of death and associated factors among reviewed maternal deaths in Ethiopia: a generalised structural equation modelling

OBJECTIVE

The study aims to determine the magnitude and factors that affect maternal death in different settings.

DESIGN, SETTING AND ANALYSIS

A review of national maternal death surveillance data was conducted. The data were obtained through medical record review and verbal autopsies of each death. Generalised structural equation modelling was employed to simultaneously examine the relationships among exogenous, mediating (urban/rural residence) and endogenous variables.

OUTCOME

Magnitude and factors related to the location of maternal death.

PARTICIPANTS

A total of 4316 maternal deaths were reviewed from 2013 to 2020.

RESULTS

Facility death constitutes 69.0% of maternal deaths in the reporting period followed by home death and death while in transit, each contributing to 17.0% and 13.6% of maternal deaths, respectively. Educational status has a positive direct effect on death occurring at home (β=0.42, 95% CI 0.22 to 0.66), obstetric haemorrhage has a direct positive effect on deaths occurring at home (β=0.41, 95% CI 0.04 to 0.80) and death in transit (β=0.68, 95% CI 0.48 to 0.87), while it has a direct negative effect on death occurring at a health facility (β=-0.60, 95% CI -0.77 to -0.44). Moreover, unanticipated management of complication has a positive direct (β=0.99, 95% CI 0.34 to 1.63), indirect (β=0.05, 95% CI 0.04 to 0.07) and total (β=1.04, 95% CI 0.38 to 1.70) effect on facility death. Residence is a mediator variable and is associated with all places of death. It has a connection with facility death (β=-0.70, 95% CI -0.95 to -0.46), death during transit (β=0.51, 95% CI 0.20 to 0.83) and death at home (β=0.85, 95% CI 0.54 to 1.17).

CONCLUSION

Almost 7 in 10 maternal deaths occurred at the health facility. Sociodemographic factors, medical causes of death and non-medical causes of death mediated by residence were factors associated with the place of death. Thus, factors related to the place of death should be considered as an area of intervention to mitigate preventable maternal death that occurred in different settings.

A descriptive retrospective study on HIV care cascade in a tertiary hospital in the Philippines

INTRODUCTION

The HIV care cascade is a model used to examine the engagement of people living with HIV (PLHIV) in medical care from the time of diagnosis to sustained viral suppression. This study describes the stages of the cascade from linkage to care, antiretroviral therapy (ART) initiation, retention in care, and virologic suppression- at the University of the Philippines-Philippine General Hospital (UP-PGH) STD/AIDS Guidance and Intervention Prevention (SAGIP) treatment hub in the context of existing cascades with similar demographics.

METHODS

We retrospectively reviewed the medical records of patients enrolled at the UP-PGH SAGIP treatment hub from June 2015 to December 2017. Baseline demographic and clinical data were collected, relevant to each stage of the cascade. Descriptive statistics using Microsoft Excel version 16.0 was used to characterize data and cumulative and conditional proportions were reported.

RESULTS

Of the 584 patients included in the cohort, majority were male (91.1%), with a median age of 29 years (range, 0.17 to 68 years). Male-to-male sex was the most common mode of transmission (325/584, 55.6%). Among all patients enrolled at the UP PGH SAGIP treatment hub, 99.5% were linked to care, 95.0% initiated ART, 78.8% were retained in care and maintained on ART, 47.9% were tested for HIV viral load, and 45.5% achieved viral suppression.

CONCLUSION

A high proportion of patients enrolled at the UP-PGH SAGIP treatment hub are linked to care and initiate ART, exceeding the set goal of 90%, which is higher than reported nationwide. However, there is a substantial decrease in the number of patients who are subsequently retained in care, tested for HIV viral load, and achieve viral suppression. Gaps in the cascade related to healthcare delivery need to be investigated further and addressed by future studies. We recommend implementation of a community-based, patient-centered approach in order to reach the goals of the HIV cascade, with particular focus on young, MSM-PLHIV.

Association Between Maternal HIV Stigma Among South Indian Mothers Living with HIV and the CD4 Count of Children Living with HIV

HIV stigma takes a multidimensional toll on a mother’s ability to care for herself and subsequently may impact her ability to care for her child, particularly when mother and child are seroconcordant. A cross-sectional analysis was conducted to examine the association between maternal HIV stigma and child CD4 count in rural India. We assessed 108 mother–child dyads and found that a one-unit increase in community stigma fear decreased child CD4 count by 352 cells (95% CI = − 603, − 102), highlighting the need to develop a better understanding of the consequences of HIV-related stigma on the compounded burden of care in households where mother and child both live with HIV.

Global Health Facility-Based Interventions to Achieve UNAIDS 90-90-90: A Systematic Review and Narrative Analysis

To evaluate whether health facility-based HIV interventions align with UNAIDS 90-90-90 targets, we performed a systematic review through the lens of UNAIDS targets. We searched 11 databases, retrieving 5201 citations with 26 eligible studies classified by country income and UNAIDS target. We analyzed whether reporting of study outcome metrics was in line with UNAIDS targets using a standardized extraction form and results were summarized in a narrative synthesis given data heterogeneity. We also assessed the quality of randomized trials with the Cochrane Risk of Bias Tool and observational studies with the Newcastle-Ottawa Scale. Stratification of interventions by country income level revealed themes in successful interventions that provide insight for scale-up in similar resource contexts. Few studies reported outcomes using metrics according to UNAIDS targets. Standardization of reporting according to the UNAIDS framework could facilitate comparability of interventions and inform country-level progress on an international scale.

Determinants of Late HIV Presentation at Ndlavela Health Center in Mozambique

Background: There has been tremendous progress in the fight against HIV worldwide; however, challenges persist in the control of HIV infection. These challenges include the high prevalence of late presenters. There are many disadvantages of late presentation—from reduced survival of the infected person to the risk of transmitting the infection. This research aims to analyze the factors that influence the late presentation in patients attending Ndlavela Health Center in Mozambique. Methodology: A retrospective cross-sectional study was carried out at Ndlavela Health Center including patients diagnosed with HIV between 2015 and 2020. The European Late Presenter Consensus working group definitions were used, and univariate and multivariate logistic regression were used to identify factors associated with late presentation. Results: In total, 519 participants were included in the study, of which nearly 47% were classified as late presenters. The male gender (AOR = 2.41), clinical suspicious test (AOR = 4.03), initiated by the health professional (AOR = 2.1,9), and fear of stigma (AOR = 2.80) were the main risk factors for late HIV presentation. Conclusion: Factors that are potentially determinant for late HIV presentation were identified. Actions are needed to focus on risk factors that are most likely to delay presentation.

The Optimization of HIV Testing in Eastern Indonesia: Findings from the 2017 Indonesian Demographic and Health Survey

There is a concerning increase in human immunodeficiency virus (HIV) incidence in eastern Indonesia. HIV testing rates in this area are the lowest in the country. This study aimed to analyze the determinants of HIV testing in the Public Health Centers (PHCs) in eastern Indonesia. A cross-sectional study design was utilized using secondary data from the 2017 Indonesian Demographic and Health Survey (IDHS). We focused the survey on eastern Indonesia (Sulawesi, Maluku, and Papua) with PHC settings. After we weighted and removed missing data, we obtained 2118 surveys (425 males and 1693 females aged 14−54 years). Chi-square and binary logistic regression were used to analyze the determinants of HIV testing optimization in eastern Indonesia with a significance level of p < 0.05. The HIV testing coverage at the PHCs in eastern Indonesia was found to be 28.28%. From the survey, we found that respondents from the province of Papua (AOR: 1.45; 95% CI: 1.09−1.91), those who were female (AOR: 2.37; 95% CI: 1.75−3.12), and those with more information on HIV (AOR: 1.88; 95% CI: 1.41−2.51) were more likely to undergo HIV testing at the PHCs. Meanwhile, the wealthiest respondents (AOR: 0.61; 95% CI: 0.42−0.89) and the respondents who engaged in the perpetuation of stigmatization (AOR: 0.65; 95% CI: 0.42−1.02) were less likely to undergo HIV testing at the PHCs. The coverage of HIV testing in eastern Indonesia needs special attention from the Indonesian government. Increasing equity, distributing information regarding HIV and acquired immunodeficiency syndrome (AIDS) through social media, and creating accessible HIV testing in rural areas are vital for developing appropriate interventions.

ART uptake and adherence among female sex workers (FSW) globally: A scoping review

We conducted the first scoping literature review on ART uptake and adherence among Female Sex Workers (FSW), following PRISMA-ScR guidelines. Searches were conducted in PubMed, Embase, CINAHL, PsycInfo, and Sociological Abstracts. Eligibility criteria included: reporting an ART uptake or adherence result among FSW aged 18 or older; peer-reviewed; published in English between 1996 and 2018. Our search identified 6,735 studies; 30 met eligibility requirements. ART uptake ranges from 0 to 100% and adherence ranges from 50-90%, depending on measurement methods. Uptake and adherence influencing factors are mapped onto a social ecological model (SEM). Knowledge and beliefs, substance use, food insecurity and sex-work engagement were negatively associated, while older age, relationships and social support were positively associated with ART uptake and adherence. Standardised methods to measure uptake and adherence prevalence must be established for data comparison. Evidence regarding ART uptake and adherence barriers and facilitators span multiple SEM levels, although more research is needed regarding structural and occupational level influencers. Results suggest that the multi-level ART uptake and adherence barriers faced by FSW require complex multi-level evidence-based interventions. Study findings can inform ART interventions, future research, and offer guidance to other support services with FSW, such as PrEP interventions.

Stigma Determines Antiretroviral Adherence in Adults With HIV in Myanmar

INTRODUCTION

Understanding social and structural barriers that determine antiretroviral therapy (ART) adherence can improve care. Assessment of such factors is limited in Myanmar, a country with high HIV prevalence and increasing number of people living with HIV initiating ART.

METHODS

Questionnaires were administered to adults with HIV across 4 Myanmar cities to estimate adherence and its potential determinants, including HIV knowledge, social support, barriers to care, enacted and internalized stigma, and engagement in peer-to-peer HIV counseling (PC). Associations were determined using logistic mixed-effects modeling.

RESULTS

Among 956 participants, the mean age was 39 years, 52% were female, 36% had CD4 <350 cells/mm3, and 50% received pre-ART PC. Good adherence was reported by 74% of participants who had better HIV knowledge than those reporting nonadherence. Among nonadherent, 44% were forgetful and 81% were careless about taking ART. Among all participants, most (53%) were very satisfied with their social support and 79% reported lack of financial resources as barriers to care. Participants most frequently reported being viewed differently by others (30%) and feeling as if they were paying for past karma or sins because of their HIV diagnosis (66%). Enacted stigma (odds ratio 0.86; 95% confidence interval 0.79 to 0.92, P < 0.01) and internalized stigma (odds ratio 0.73; 95% confidence interval: 0.56 to 0.95, P = 0.023) were associated with worse adherence.

CONCLUSIONS

Increased self-reported ART adherence in Myanmar is associated with less enacted and internalized stigma. These findings suggest the benefit of developing and promoting adherence interventions, which are focused on mitigating HIV-related stigma in the county.

What Shapes Late HIV Diagnosis in Vietnam? A Qualitative Investigation of Multilevel Factors

Late HIV treatment remains a global public health issue despite significant efforts. To better understand what shapes this issue, we interviewed 36 Vietnamese ART-naive patients who came to HIV treatment in 2017. Half of them had intake CD4 counts fewer than 100 cells/mm³, the others had intake CD4 counts of 350 cells/mm³ and above. Late diagnosis was the reason of late treatment in our sample. Most late presenters were not members of the key populations at increased risk of HIV (e.g., people who inject drugs, commercial sex workers, and men who have sex with men). Individual-level factors included low risk appraisal, habit of self-medication, and fear of stigma. Network and structural-level factors included challenges to access quality health care, normalization of HIV testing in key populations and inconsistent provider-initiated HIV testing practices. Structural interventions coupled with existing key population-targeted strategies would improve the issue of late HIV diagnosis.

Measuring the uptake of continuous care among people living with HIV receiving antiretroviral therapy and social determinants of the uptake of continuous care in the southwest of China: a cross-sectional study

Background

Continuous care is essential for people living with HIV. This study aimed to measure continuous care uptake and investigate the association between higher uptake of continuous care and behavioral and social factors, including HIV-acquisition risk and socioeconomic characteristics.

Methods

A hospital-based cross-sectional study was conducted from April to November 2019 in an HIV treatment center of a specialized hospital in Kunming city, China. Fourteen service indicators were used to calculate composite care scores, which were classified into three levels (low, middle, and high), using principal component analysis. The Behavioral Model for Vulnerable Populations was employed to examine predisposing, enabling, and need factors associated with composite care scores among people living with HIV.

Results

A total of 702 participants living with HIV aged ≥ 18 years (median age: 41.0 years, 69.4% male) who had been on ART for 1–5 years were recruited. Based on ordinal logistic regression modeling, predisposing factors: being employed (adjusted odds ratio (AOR): 1.54, 95% confidence interval (CI): 1.13–2.11), heterosexuals (AOR: 1.58, 95% CI: 1.11–2.25) and men who have sex with men (AOR: 2.05, 95% CI: 1.39–3.02) and enabling factors: Urban Employee Basic Medical Insurance (AOR: 1.90, 95% CI: 1.03–3.54), middle socioeconomic status (SES) (AOR: 1.42, 95% CI: 1.01–2.01), were positively associated with the higher level of continuous care uptake, compared to the unemployed, people who inject drugs, those with no medical insurance and low SES, respectively.

Conclusion

There were large differences in continuous care uptake among people living with HIV. HIV-acquisition risk categories and socioeconomic factors were significant determinants of uptake of continuous care. Our findings could inform the development of evidence-based strategies that promote equitable healthcare for all people living with HIV.

Determinants of the quality of life amongst HIV clinic attendees in Malang, Indonesia

BACKGROUND

As the number of people living with human immunodeficiency virus (HIV; PLHIV) in Indonesia has increased in recent years, more efforts have been expended to improve their health status. However, in a country where PLHIV are very much stigmatized, there has been little research concerning their quality of life (QoL). Hence, this study aimed to assess the QoL among PLHIV and its associated factors. Findings of this research can contribute to improving the health and wellbeing of PLHIV in Indonesia.

METHODS

A cross-sectional survey with convenience sampling was conducted from June to September 2018, at four healthcare centers in Malang, Indonesia. PLHIV, aged 18 years or over, were asked if they would like to participate in this study when they came to a health center to receive services. To protect confidentiality, the healthcare staff at the clinics assisted with recruitment and face-to-face interviews with structured questionnaires. Measurements included sociodemographic, medication-related, social support, HIV-stigma, and QoL variables.

RESULTS

In total, 634 PLHIV agreed to participate in this study. A multivariate linear regression analysis showed that being older, having a job, living in an urban area, having better access to healthcare services, adhering to medication, being in an antiretroviral therapy (ART) program for more than 1 year, experiencing a lower level of stigma, and receiving more social support were associated with a better QoL. The regression model had an adjusted R2 of 0.21.

CONCLUSIONS

Findings from this research have significant policy implications. Policies focused on reducing social stigma and promoting medication adherence will likely have a positive impact on the QoL of PLHIV. Increasing public awareness and acceptance of PLHIV in Indonesia remains challenging, but would likely have significant impacts. Furthermore, interventions should also focus on reducing disparities in QoL between PLHIV living in rural areas and those in urban areas.

Frequency and reasons for delayed treatment initiation after HIV diagnosis: cross-sectional study in Lahore, Pakistan

Background

Well-timed initiation of HIV therapy enhances life expectancy, decreases mortality and morbidity, and inhibits the transmission of HIV and complications related to it. The purpose of the present survey is to investigate the frequency and reasons for delayed initiation of anti-retroviral therapy (ART) and to determine its relationship with various socio-demographic variables and HIV-related characteristics.

Methods

The analysis is based on a cross-sectional study involving 355 people living with HIV (diagnosed by PCR) who were more than 18 years of age and not receiving HIV therapy before enrolment at the HIV clinics of two selected tertiary-care teaching hospitals in Lahore, Pakistan. In this study, delayed initiation of ART was defined as not attending the HIV management centre or a clinic for ART within 3 months of a confirmed diagnosis. The participants were selected using a systematic probability sampling technique. Bivariate logistic regression was performed using a backward stepwise technique to establish the variables related to delayed onset of HIV therapy. Factors significant at p ≤ 0.20 were considered for multivariate analysis, which was used to describe the association between independent factors and delayed initiation of treatment.

Results

Delayed onset of ART was observed in 28.5% of individuals. Factors such as no schooling (AOR = 5.92; 95% CI: 1.38–25.41; p = 0.017) and occasional household income (AOR = 3.88; 95% CI: 1.01–14.89; p = 0.048) were significantly associated with late onset of ART. Our research findings also indicated that the main reasons for late beginning of HIV therapy were: feeling healthy (45.5%), did not have time to go to the HIV treatment centre (42.6%), did not want to discuss HIV test result (37.6%), and fear of stigma and discrimination within their community (35.6%).

Conclusions

Late commencement of HIV therapy in Pakistan is common, and an improved connection is needed between identification of HIV and beginning of therapy. HIV management centres should counsel and monitor patients from the time of a positive HIV test result until they initiate therapy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11031-0.

Structural barriers for retention of HIV/AIDS patients after initiating antiretroviral therapy in outpatient clinics of Vietnam

Little evidence is available about structural factors associated with the retention in care for people living with HIV/AIDS (PLWH) in Vietnam. This retrospective longitudinal study was conducted among PLWH initiating antiretroviral therapy (ART) in 62 ART clinics from 15 provinces, to estimate retention rates and identify specific related structural factors. Facility-related factors such as location, duration of HIV service implantation, level of healthcare facility, frequency of drugs dispensed, integration of HIV care were examined. Cox proportional hazard model was employed to estimate the retention rate and association between facility-level factors and loss-to-follow up (LTFU). Among 20,119 patients, the retention rates after 6, 12, 24, 36 and 48 months were 96.5% (95% CI = 96.2%-96.7%), 93.6% (95% CI = 93.2%-93.9%), 90.2% (95% CI = 89.8%-90.6%), 87.9% (95% CI = 87.4%-88.4%) and 86.0% (95% CI = 85.4%-86.5%), respectively. Facility-level factors associated with increased risk of LTFU included duration of HIV service implementation, frequency of drug dispensed per month, integration of HIV care and of treatment procedures into general care, clinics at central or provincial level and in the Middle region of Vietnam. Such association should be addressed in future care planning and HIV/AIDS management to ensure greater coverage of therapy in Vietnam.

Measuring and explaining inequality of continuous care for people living with HIV receiving antiretroviral therapy in Kunming, China

Background

In the context of scaling up free antiretroviral therapy (ART), healthcare equality is essential for people living with HIV. We aimed to assess socioeconomic-related inequalities in uptake of continuous care for people living with HIV receiving ART, including retention in care in the last six months, routine toxicity monitoring, adequate immunological and virological monitoring, and uptake of mental health assessment in the last 12 months. We also determined the contributions of socioeconomic factors to the degree of inequalities.

Methods

A hospital-based cross-sectional survey was conducted among consecutive clients visiting an HIV treatment center in Kunming, China in 2019. Participants were 702 people living with HIV aged ≥18 years (median age: 41.0 years, 69.4% male) who had been on ART for 1–5 years. Socioeconomic-related inequality and its contributing factors were assessed by a normalized concentration index (CI_n) with a decomposition approach.

Results

The uptake of mental health assessment was low (15%) but significantly higher among the rich (CI_n 0.1337, 95% CI: 0.0140, 0.2534). Retention in care, toxicity, and immunological monitoring were over 80% but non-significant in favor of the rich (CI_n: 0.0117, 0.0315, 0.0736, respectively). The uptake of adequate virological monitoring was 15% and higher among the poor (CI_n = -0.0308). Socioeconomic status positively contributed to inequalities of all care indicators, with the highest contribution for mental health assessment (124.9%) and lowest for virological monitoring (2.7%).

Conclusions

These findings suggest virological monitoring and mental health assessment be given more attention in long-term HIV care. Policies allocating need-oriented resources geared toward improving equality of continuous care should be developed.

Ethics and the treatment as prevention strategy among transgender women living with HIV in Argentina

While numerous ethical concerns have been voiced regarding HIV service scale-up strategies targeting key populations, few studies have examined these from the perspective of affected groups. This study therefore sought to understand transgender women's experiences and perspectives of targeted HIV services scale-up in the context of Argentina's Treatment as Prevention strategy. In 2016, 25 purposively selected transgender women living with HIV were interviewed by a peer research associate. Interviews were audio recorded, transcribed verbatim and analysed using participatory coding techniques. Findings suggest that procedures around informed consent, including the provision of full information in lay language and voluntariness, were lacking both pre- and post-HIV test. Further, many transgender women felt disrespected and disregarded by healthcare workers. While the majority of participants were unaware of Treatment as Prevention, once explained, most felt the approach was ethical overall, and helped improve equity in HIV service access. Study findings offer several community-driven suggestions to support patient rights and the ethical scale-up of HIV services for transgender women in Buenos Aires, including the need for training in and the provision of non-judgemental, gender-affirmative care and the inclusion of peer-navigators.

Intersecting Stigmas among HIV-Positive People Who Inject Drugs in Vietnam

HIV-related stigma remains a barrier to ART adherence among people living with HIV (PLWH) globally. People who inject drugs (PWID) may face additional stigma related to their behavior or identity; yet, there is little understanding of how these stigmas may co-exist and interact among these key populations. This study aims to explore the existence of multiple dimensions of HIV-related stigma, and how they may intersect with stigma related to drug injection. The study took place in Vietnam, where the HIV epidemic is concentrated among 3 key population groups; of those, PWID account for 41% of PLWH. The vast majority (95%) of PWID in Vietnam are male. Data came from in-depth interviews with 30 male PWID recruited from outpatient clinics, where they had been receiving ART medications. Deductive, thematic analysis was employed to organize stigma around the 3 dimensions: enacted, anticipated, and internalized stigma. Findings showed that HIV- and drug use-related stigma remained high among participants. All 3 stigma dimensions were prevalent and perceived to come from different sources: family, community, and health workers. Stigmas related to HIV and drug injection intersected among these individuals, and such intersection varied widely across types of stigma. The study revealed nuanced perceptions of stigma among this marginalized population. It is important for future studies to further investigate the influence of each dimension of stigma, and their interactive effects on HIV and behavioral outcomes among PWID.

HIV care cascade among cisgender men who have sex with men in a key population-led community center in the Philippines

The HIV epidemic in the Philippines is the fastest growing globally, and disproportionately affects cisgender men who have sex with men (cis-MSM) demanding effective strategies for this key population (KP) group. KP-specific and community-based (CB) interventions have improved the HIV response elsewhere, but these have yet to be evaluated locally. We analyzed the HIV care cascade outcomes in a KP-led, CB HIV test-and-treat center and determined factors that affect these by performing a retrospective study of medical records of 3137 patients diagnosed from January 2016 to March 2019 in LoveYourself in Manila, Philippines. Multivariate logistic regression was performed to determine predictors affecting the likelihood of antiretroviral therapy (ART) initiation and viral load (VL) suppression. As to UNAIDS 90-90-90 targets, LoveYourself had higher rates than national outcomes with 78% initiated ART and 84% achieved VL suppression. Such satisfactory performance is consistent with other studies exploring CB, KP-led approaches among cis-MSM. Patients who presented with WHO Stages 2-4 and those with sexually transmitted infections were less likely to initiate ART. Patients who presented with WHO Stages 2-4 and those whose ART was started late were less likely to be virally suppressed. These findings suggest the need to develop responsive interventions to reach the UNAIDS targets.

Health literacy of people living with HIV in a rural area in Indonesia: A cross-sectional study

Indonesia, the fourth most populated country in the world, has experienced a fivefold increase in Human Immunodeficiency Virus (HIV)-infected individuals since 2001. Little is known about health literacy in people living with HIV (PLHIV) in Indonesia. This study aimed to determine the level of health literacy among PLHIV in Indonesia and assess associations between sociodemographic variables, beliefs about medicines, stigma and health literacy. We conducted a cross-sectional study using questionnaires in PLHIV in Papua, Indonesia. The short version of the Test of Functional Health Literacy in Adults (S-TOFHLA), Beliefs about Medicines Questionnaire (BMQ) and HIV stigma scale as well as questions on demographic information were completed by the participants from two hospitals in Papua, Indonesia. In a multivariate logistic regression analysis, we assessed the association between sociodemographic variables, stigma, beliefs about medicine and low health literacy. Overall, 331 participants were included, 62.0% female, 67.0% Papuans. A total of 38.5% of participants had low health literacy. PLHIV with multi-dose regimen were less likely to have low health literacy than those taking a fixed-dose combination (OR = 0.51; 95%CI = 0.32-0.82). PLHIV who had social support in medicine-taking were more likely to have low health literacy (OR = 1.78; 95%CI = 1.07-2.97). More awareness about medication overuse (OR = 1.17; 95%CI = 1.06-1.29) and medication harm (OR = 1.10; 95%CI = 1.01-1.20) were also associated with having low health literacy. Overall, interventions targeting health literacy may be a promising strategy to improve self-management.

HIV treatment cascade among people who inject drugs in Ukraine

The HIV treatment cascade is an effective tool to track progress and gaps in the HIV response among key populations. People who inject drugs (PWID) remain the most affected key population in Ukraine with HIV prevalence of 22% in 2015. We performed secondary analysis of the 2017 Integrated Bio-Behavioral Surveillance (IBBS) survey data to construct the HIV treatment cascade for PWID and identify correlates of each indicator achievement. The biggest gap in the cascade was found in the first "90", HIV status awareness: only 58% [95% CI: 56%-61%] of HIV-positive PWID reported being aware of their HIV-positive status. Almost 70% [67%-72%] of all HIV-infected PWID who were aware of their status reported that they currently received antiretroviral therapy (ART). Almost three quarters (74% [71%-77%]) of all HIV-infected PWID on ART were virally suppressed. Access to harm reduction services in the past 12 months and lifetime receipt of opioid agonist treatment (OAT) had the strongest association with HIV status awareness. Additionally, OAT patients who were aware of HIV-positive status had 1.7 [1.2-2.3] times the odds of receiving ART. Being on ART for the last 6 months or longer increased odds to be virally suppressed; in contrast, missed recent doses of ART significantly decreased the odds of suppression. The HIV treatment cascade analysis for PWID in Ukraine revealed substantial gaps at each step and identified factors contributing to achievement of the outcomes. More intensive harm reduction outreach along with targeted case finding could help to fill the HIV awareness gap among PWID in Ukraine. Scale up of OAT and community-level linkage to care and ART adherence interventions are viable strategies to improve ART coverage and viral suppression among PWID.

Challenges to Antiretroviral Therapy Adherence and Coping Strategies to Overcome Them: Qualitative Investigations of Adolescents Living with HIV, their Caregivers, and Clinicians in Vietnam

Background:

Adolescents living with HIV (ALHIV) in Vietnam are known to struggle with adherence to Antiretroviral Therapy (ART).

Objective:

To examine treatment challenges and facilitators experienced by ALHIV from the perspective of adolescents, their caregivers, and providers, and to inform an adherence intervention.

Methods:

In-depth Interviews (IDIs) of adolescent/caregiver dyads and Focus Group Discussions (FGDs) with adolescents, caregivers, and clinicians were conducted in Hanoi, Vietnam. We used semi-structured guides to encourage open-ended responses. We queried the challenges adolescents experience taking ART medications and being adherent, their awareness of disease status, and facilitators to support high adherence. Audio-recorded IDIs were translated into English, and coded and analyzed in NVivo using a thematic approach.

Results:

A total of 78 individuals participated in the study. Forty individuals participated in IDIs (20 adolescents and 20 caregivers). All adolescents had acquired HIV perinatally. We conducted six FGDs: four with adolescents, and one each with caregivers and clinicians. We identified major themes regarding awareness of HIV status (most caregivers reported they had disclosed to their child, while few adolescents revealed the knowledge of their status); perceived barriers to adherence (medication-related challenges, stigma, school-associated issues, financial obstacles, system challenges, awareness of HIV status); and adherence facilitators (development of dose-taking habits, reminder systems, social support). Differences between adolescents and caregivers related to key issues were evident.

Conclusion:

Further research is needed to elucidate discrepancies in adolescent-caregiver viewpoints and develop interventions tailored to both ALHIV and their caregivers.

HIV incidence and factors associated with testing positive for HIV among men who have sex with men and transgender women in Myanmar: data from community-based HIV testing services

Introduction

In Myanmar, men who have sex with men (MSM) and transgender women (TW) are disproportionately affected by HIV, despite national HIV program scale‐up. However, limited HIV surveillance capacity prevents monitoring of epidemic trends and program impact. This study aimed to estimate HIV prevalence and incidence and explore associated sexual risk behaviours among MSM and TW clients attending HIV testing clinics in Myanmar.

Methods

An electronic data management system was implemented in two community‐based, MSM and TW ‐tailored HIV testing clinics in Myanmar in August 2016. Unique client identifiers enabled prospective monitoring of service engagement, testing frequency and outcomes. We estimated HIV incidence and rate of HIV diagnosis at baseline testing visit among clients over a 15 month period. Correlates of HIV diagnoses were identified using multivariable logistic regression.

Results

2794 MSM and TW were tested for HIV. At their baseline test, 38% of clients reported any previous testing and 93% reported being sexually active over the previous three months, with 74% reporting sex with casual male partners and 28% reporting consistent condom use with casual partners. 291 clients tested positive for HIV for the first time at baseline (10.4%; 95% CI: 9.3 to 11.6). Twelve incident cases were detected among 279 clients receiving ≥2 tests (incidence = 10.1 per 100 person‐years; 95% CI: 5.73 to 17.8). HIV diagnosis at baseline was significantly associated with being a transgender woman or a non‐openly disclosing man who has sex with men, age 26 to 39 years, and reporting no testing history.

Conclusions

High HIV incidence and new diagnoses being associated with reporting no testing history points to undiagnosed HIV driving transmissions in Myanmar. Repeat testing was uncommon. HIV programs in Myanmar must focus on promoting frequent HIV testing alongside adequate coverage of education and primary prevention interventions among MSM and TW.

Strategies for engaging transgender populations in HIV prevention and care

PURPOSE OF REVIEW

Transgender (trans) populations are heavily impacted by HIV, yet face structural, social, and individual barriers to engagement in HIV prevention and care. In this review, we summarize the data on barriers and facilitators and discuss evidence-informed strategies to facilitate access to and engagement in HIV prevention and care by trans communities.

RECENT FINDINGS

Intersectional stigma and discrimination at structural, community, individual levels present substantial impediments to HIV prevention and optimal care. Access to gender-affirming health care is a priority for trans communities. Where trans communities are highly networked, these networks may provide a strong infrastructure for disseminating HIV innovations and reaching individuals who are not engaged in HIV services. Efforts to engage trans people in HIV prevention and care must address stigma, provide gender-affirming services, and build on community strengths and priorities to ensure trans populations achieve maximum benefit from advances in HIV prevention and care.

SUMMARY

Combination approaches that respond to the complex drivers of HIV in trans communities represent promising strategies for engaging trans people and their partners in HIV prevention and care.

Exploring the acceptability of HIV partner notification in prisons: Findings from a survey of incarcerated people living with HIV in Indonesia

Assisted HIV partner notification services provide a safe and effective way for people living with HIV (PLHIV) to inform their partners about the possibility of exposure and to offer them testing, treatment, and support. This study examined whether or not PLHIV in prison might be willing to participate in assisted HIV partner notification services and their reasons for and against disclosing their HIV-positive status to their partners. PLHIV (n = 150) recruited from Jakarta's two largest all-male prisons completed an interviewer-administered questionnaire collecting demographic and risk behavior data, and attitudes toward HIV disclosure and partner services. Among those who were sexually active and/or injecting drugs before incarceration, two-thirds (66.4%, 91/137) endorsed provider referral as an acceptable way to notify their sex partners, and nearly three quarters (72.4%, 89/123) endorsed provider referral to notify their drug-injecting partners. Only a quarter (25.1%) of participants reported that their main sex partner had ever received an HIV test. Participants with anticipated stigma were less likely to endorse provider referral for sex partners (adjusted odds ratio [aOR] = 0.58, 95% CI: 0.35, 0.96) and drug-injecting partners (aOR = 0.54, 95% CI: 0.29, 1.00). Relationship closeness was associated with higher odds of endorsing provider referral for drug-injecting partners (aOR = 2.08, 95% CI: 1.25, 3.45). Protecting partners from infection and a moral duty to inform were main reasons to disclose, while stigma and privacy concerns were main reasons not to disclose. Most incarcerated PLHIV have at-risk partners in the community who they would be willing to notify if provided with assistance. Assisted partner notification for prison populations offers a promising public health approach to accelerate diagnosis, treatment, and prevention of HIV infection in the community, particularly among women.

A Qualitative Exploration of Family, Work, Community, and Health Service Influences on HIV Treatment Uptake and Adherence Among Female Sex Workers in Three Cities in Indonesia

Qualitative data were collected from 34 Indonesian female sex workers to understand their engagement with HIV treatment. Influences that enhanced treatment initiation and adherence included women's desires to stay healthy to continue working to provide for families; awareness of the biomedical benefits of treatment; support from bosses, outreach workers, and peer support groups; and flexible, nonjudgmental HIV service provision. Influences inhibiting treatment initiation and adherence included concerns about unwanted disclosure in the workplace and side effects of medication on women's capacity to earn money through sex work; geographical location of services; discrimination and confidentiality concerns in HIV care services. To improve HIV treatment initiation and adherence among Indonesian female sex workers, future responses should explore health promotion messages that engage with women's family and livelihood obligations; increased funding for community-based peer outreach workers; community-based treatment initiation and supply; and advocacy in work environments to secure support for treatment initiatives.

Development of a Mobile Game to Influence Behavior Determinants of HIV Service Uptake Among Key Populations in the Philippines: User-Centered Design Process

Background

Opportunities in digital distribution place mobile games as a promising platform for games for health. However, designing a game that can compete in the saturated mobile games market and deliver persuasive health messages can feel like an insurmountable challenge. Although user-centered design is widely advocated, factors such as the user’s subject domain expertise, budget constraints, and poor data collection methods can restrict the benefits of user involvement.

Objective

This study aimed to develop a playable and acceptable game for health, targeted at young key populations in the Philippines.

Methods

Authors identified a range of user-centered design methods to be used in tandem from published literature. The resulting design process involved a phased approach, with 40 primary and secondary users engaged during the initial ideation and prototype testing stages. Selected methods included participatory design workshops, playtests, playability heuristics, and focus group discussions. Subject domain experts were allocated roles in the development team. Data were analyzed using a framework approach. Conceptual frameworks in health intervention acceptability and game design guided the analysis. In-game events were captured through the Unity Analytics service to monitor uptake and game use over a 12-month period.

Results

Early user involvement revealed a strong desire for online multiplayer gameplay, yet most reported that access to this type of game was restricted because of technical and economic constraints. A role-playing game (RPG) with combat elements was identified as a very appealing gameplay style. Findings guided us to a game that could be played offline and that blended RPG elements, such as narrative and turn-based combat, with match-3 puzzles. Although the game received a positive response during playtests, gameplay was at times perceived as repetitive and predicted to only appeal to casual gamers. Knowledge transfer was predominantly achieved through interpretation of the game’s narrative, highlighting this as an important design element. Uptake of the game was positive; between December 1, 2017, and December 1, 2018, 3325 unique device installs were reported globally. Game metrics provided evidence of adoption by young key populations in the Philippines. Game uptake and use were substantially higher in regions where direct engagement with target users took place.

Conclusions

User-centered design activities supported the identification of important contextual requirements. Multiple data collection methods enabled triangulation of findings to mediate the inherent biases of the different techniques. Game acceptance is dependent on the ability of the development team to implement design solutions that address the needs and desires of target users. If target users are expected to develop design solutions, they must have adequate expertise and a significant role within the development team. Facilitating meaningful partnerships between health professionals, the games industry, and end users will support the games for health industry as it matures.

Barriers and Enablers to HIV Care Among Waria (Transgender Women) in Indonesia: A Qualitative Study

Transgender women (waria) in Indonesia have high rates of HIV and experience barriers accessing HIV services. This qualitative research explored barriers and facilitators to HIV care among waria in Indonesia. Between 2015 and 2016, 42 participants were involved in focus group discussions and in-depth interviews across three urban sites in Indonesia to examine participants' experiences and views on HIV prevention, testing, treatment initiation, and treatment adherence. Data were analyzed thematically. Barriers to accessing HIV care services included perceptions of health and HIV treatment, confidentiality and stigma concerns, and poor access to health insurance. Facilitators to HIV care included recognition of health and perceived susceptibility, perceptions of treatment benefits and consequences of non-adherence, access to social support, and patient-friendly services. Research findings highlight the importance of improving HIV treatment literacy, safeguarding community responses to addressing HIV vulnerability, addressing confidentiality and stigma issues, ensuring services are transgender-friendly, and increasing health insurance coverage.

The relationship between alcohol use and anxiety and retrospective attendance of primary care visits among women with human immunodeficiency virus

In this retrospective study, we sought to determine the associations between alcohol use and anxiety and RIC among WHIV. Alcohol use was assessed using the Timeline Follow-back to measure use over the 90 days preceding the interview. Anxiety symptoms scores, assessed with the Hospital Anxiety and Depression Scale- Anxiety Subscale (HADS-A). Primary care visits over twelve months prior to the interview were collected from clinic registration records. We used three logistic mixed models, adjusting for age, race, education, cocaine use, depression, viral load, and antiretroviral therapy (ART) status. Among 364 WHIV, mean attendance of primary care visits was 63.9%. Every one-day increase in drinking days (OR = 0.99, 95% CI 0.99, 1.00) or heavy drinking days (OR = 0.99, 95% CI 0.90, 1.00) was associated with decreased odds of attending primary care visits (P = 0.02). Moderate/severe anxiety scores, compared to minimal anxiety scores, were associated with decreased odds of attending primary care visits (OR = 0.69, 95% CI 0.50, 0.97). Cocaine use was associated with decreased odds of attending primary care visits (OR 0.56, 0.57). Our findings indicate that identifying and treating WHIV with alcohol use (especially heavy drinking), moderate/severe anxiety symptoms and/or cocaine use could potentially improve their RIC.

Increasing retention of HIV positive pregnant and breastfeeding mothers on option-b plus by upgrading and providing full time HIV services at a lower health facility in rural Uganda

Background

Despite advancement in Prevention of Mother to Child Transmission (PMTCT) services, the rate of MTCT of HIV in sub-Saharan Africa is still high. This is partly due to low retention of HIV positive mothers in HIV care. We sought to determine the level of retention and the factors associated with retention among HIV positive pregnant and breastfeeding mothers following accreditation of an antiretroviral therapy (ART) clinic to offer full time ART services in one of the lower health facilities in rural Western Uganda.

Methods

This study was a mixed methods study conducted in 5 health centres in rural Western Uganda from 10th April to 10th May 2017. A total of 132 retained and non-retained HIV positive pregnant and breastfeeding mothers were recruited. A Mother was categorized as retained if she had not missed her ART appointments at antenatal or postnatal clinic for ≥3 consecutive months. Questionnaires were administered and four focus group discussions were held. We used descriptive statistics to understand characteristics of mothers and their levels of retention. Thematic analysis was used to analyze qualitative data.

Results

About a third (35.6%) of the mothers were aged 18–24 with a median age of 26 (IQR 23, minimum age of 16 and maximum age of 39). More than half, 73 (55.3%) of all mothers were in HIV care for 3–24 months and about 116(87.9%) of all mothers were retained in HIV care. This was an improvement from 53% reported in 2015. We found lack of formal education, lack of disclosure of HIV status to the spouse, perceived lack of confidentiality and self stigmatization as factors hindering retention. The desire to have an HIV free baby, fear of death and opportunistic infections, support from significant others and community groups were factors associated with retention.

Conclusions

We observed improved retention in lower health centres and to achieve 100% retention, we recommend interventions such as sensitizing HIV positive mothers on disclosure of HIV status to spouse, maintaining confidentiality of client information at the clinic, support to girl child education and formation of community support groups.

Trial registration

This study was retrospectively registered with the Uganda National Council for Science and Technology (UNCST), registration receipt number 10961 on the 9th March, 2018.

Examining engagement in care of women living with HIV in South India

HIV seropositive adherence-challenged women, who reported being on ART for at least four months were interviewed. Data on healthcare history, anti-retroviral therapy, clinic visits, doctor communication, disclosure and fear of stigma were collected. Better engagement in care was significantly more likely among older women, ≥ 10 years of education, higher income, HIV status disclosure to family, with higher community stigma fears and fewer healthcare access barriers. To promote retention, women may be encouraged to consider disclosing their HIV serostatus to supportive household members. A variety of possible interventions to overcome the prevalent barriers to care are provided.

Understanding the Social Influences on Engaging Key Populations With HIV Prevention: A Qualitative Study With Men Who Have Sex With Men in Three Indonesian Cities

The globally recognized test and treat approach underpins Indonesian national strategies to reduce and prevent HIV among key populations, including men who have sex with men. More comprehensive understanding of how engagement with HIV prevention is shaped by social and community practices will support these efforts. Between 2015 and 2016, focus groups and semi-structured interviews were conducted with 54 men who have sex with men in three urban settings in Indonesia to elicit their views on, and experiences of, HIV prevention and care. Focused on data relating to testing, findings documented the important influence of informal peer networks, community-based organizations and outreach workers. Some social dimensions of service access complicated this, particularly fear of stigma or lack of confidentiality in large service settings. The many differences between men challenges assumptions that a single set of HIV prevention strategies will work to engage all men who have sex with men living in Indonesia.

HIV-related care for transgender people: A systematic review of studies from around the world

RATIONALE

Transgender people face unique challenges, such as structural, interpersonal, and individual vulnerabilities to chronic diseases. Stigma and prejudice may hamper their access to health care and prevent their inclusion in the labor market, as well as cause exposition to violence. Labor market exclusion contributes to engagement in survival sex work, which increases HIV infection vulnerability. HIV continuum of care combines HIV prevention (including antiretroviral pre-exposure prophylaxis (PrEP), antiretroviral post-exposure prophylaxis (PEP) and HIV testing) with linkage to care (that is, initiating, maintaining and monitoring antiretroviral therapy). Currently, many studies evaluate the access barriers and facilitators to HIV care for transgender people.

OBJECTIVE

The present systematic review aimed to provide a clear summary of the current literature on HIV-related care for transgender men, transgender women and gender diverse people.

METHOD

Inclusion criteria were peer-reviewed quantitative studies, published through April 04, 2018, concerning transgender women, transgender men and gender diverse people and HIV-related care, which was any intervention aiming to prevent, treat or alleviate the impact of HIV on these populations.

RESULTS

From 6,585 references, 62 articles were included: Three articles had results on PEP, 18 on PrEP, 29 on HIV-testing, 17 on access to health care, and 13 on adherence to treatment.

CONCLUSIONS

The present study is the first systematic review evaluating HIV-related care for transgender people. Data collection is still scarce regarding transgender men and gender diverse people. Worldwide, testing for HIV infection does not necessarily enable access to the HIV continuum of care for transgender populations or even guarantee awareness of HIV seropositivity.

People who inject drugs remain hard-to-reach population across all HIV continuum stages in Central, Eastern and South Eastern Europe - data from Euro-guidelines in Central and Eastern Europe Network

BACKGROUND/OBJECTIVES

Inadequate HIV care for hard-to-reach populations may result in failing the UNAIDS 90-90-90 goal. Therefore, we aimed to review the HIV continuum of care and hard-to-reach populations for each step of the continuum in Central, Eastern and South Eastern Europe.

METHODS

Euro-guidelines in Central and Eastern Europe (ECEE) Network Group were created in February 2016. The aim of the network was to review the standards of HIV care in the countries of the region. Information about each stage of HIV continuum of care and hard-to-reach populations for each stage was collected through on-line surveys. Respondents were ECEE members chosen based on their expertise and involvement in national HIV care. Data sources (year 2016) used by respondents included HIV Clinics electronic databases, Institutes of Public Health, Centres for AIDS Prevention, and HIV Programme Reviews.

RESULTS

The percentage of people living with HIV (PLHIV) linked to HIV care after HIV diagnosis was ranged between 80% and 96% in Central Europe, 51% and 92% in Eastern Europe and 80% and 100% in South-Eastern Europe. The percentage of PLHIV who are on ART was ranged from 80% to 93% in Central Europe, 18% to 92% in Eastern Europe and 80% to 100% in South-Eastern Europe. The percentage of people virologically suppressed while on ART was reported as 70-95%, 12-95% and 62-97% in Central, Eastern, and South Eastern Europe, respectively. All three regions reported people who inject drugs (PWID) as hard-to-reach population across all HIV continuum stages. Migrants were the second most reported hard-to-reach population. The proportion of late presenters among newly diagnosed ranged between 20% and 55%, 40% and 55% and 48% and 60% in Central, Eastern and South Eastern Europe, respectively. Four countries reported ARVs' delivery delays resulting in treatment interruptions in 2016: two (25%) in South-Eastern, one (20%) in Central and 1 (16.7%) in Eastern Europe.

CONCLUSION

Irrespective of the diversity in national HIV epidemics, countries from all three regions reported PWIDs as hard-to-reach population across all HIV continuum stages. Some countries are close to the UNAIDS 2020 goals, others need to strive for progress. However, differences in data sources and variations in definitions limit the utility of continuum of care as a comparative tool.

HIV testing history and access to treatment among migrants living with HIV in Europe

INTRODUCTION

Migrants are overrepresented in the European HIV epidemic. We aimed to understand the barriers and facilitators to HIV testing and current treatment and healthcare needs of migrants living with HIV in Europe.

METHODS

A cross-sectional study was conducted in 57 HIV clinics in nine countries (Belgium, Germany, Greece, Italy, The Netherlands, Portugal, Spain, Switzerland and United Kingdom), July 2013 to July 2015. HIV-positive patients were eligible for inclusion if they were as follows: 18 years or older; foreign-born residents and diagnosed within five years of recruitment. Questionnaires were completed electronically in one of 15 languages and linked to clinical records. Primary outcomes were access to primary care and previous negative HIV test. Data were analysed using random effects logistic regression. Outcomes of interest are presented for women, heterosexual men and gay/bisexual men.

RESULTS

A total of 2093 respondents (658 women, 446 heterosexual men and 989 gay/bisexual men) were included. The prevalence of a previous negative HIV test was 46.7%, 43.4% and 82.0% for women, heterosexual and gay/bisexual men respectively. In multivariable analysis previous testing was positively associated with: receipt of post-migration antenatal care among women, permanent residency among heterosexual men and identifying as gay rather than bisexual among gay/bisexual men. Access to primary care was found to be high (>83%) in all groups and was strongly associated with country of residence. Late diagnosis was common for women and heterosexual men (60.8% and 67.1%, respectively) despite utilization of health services prior to diagnosis. Across all groups almost three-quarters of people on antiretrovirals had an HIV viral load <50 copies/mL.

CONCLUSIONS

Migrants access healthcare in Europe and while many migrants had previously tested for HIV, that they went on to test positive at a later date suggests that opportunities for HIV prevention are being missed. Expansion of testing beyond sexual health and antenatal settings is still required and testing opportunities should be linked with combination prevention measures such as access to PrEP and treatment as prevention.

Rethinking retention: Mapping interactions between multiple factors that influence long-term engagement in HIV care

BACKGROUND

Failure to keep people living with HIV engaged in life-long care and treatment has serious implications for individual and population-level health. Nested within a four-province study of HIV care and treatment outcomes, we explored the dynamic role of social and service-related factors influencing retention in HIV care in Zambia.

METHODS

From a stratified random sample of 31 facilities, eight clinics were selected, one urban and one rural from each province. Across these sites we conducted a total of 69 in-depth interviews, including with patients (including pregnant women) engaged in-care (n = 28), disengaged from care (n = 15), engaged facility transferee (n = 12), and friends/family of deceased patients (n = 14). At the same sites we conducted 24 focus group discussions with a total of 192 lay and professional healthcare workers (HCWs). Two-day observations in each of the eight facilities helped triangulate data on operational context, provider relations and patient-provider interactions. We ordered and analysed data using an adapted version of Ewart's Social Action Theory.

RESULTS

Three overarching findings emerged. First, the experience of living with HIV and engaging in HIV care in Zambia is a social, not individual experience, influenced by social and gendered norms and life goals including financial stability, raising family and living stigma-free. Second, patients and their networks act collectively to negotiate and navigate HIV care. Anticipated responses from social network influenced patients' willingness to engage in care, while emotional and material support from those networks influenced individuals' capacity to remain in HIV care. Lastly, health system factors were most influential where they facilitated or undermined peoples' collective approach to health service use. Participants living with HIV reported facilitation of both their initial and continued engagement in care where services involved social networks, such as during couples testing and community outreach. Conversely, service features that were poorly aligned with respondents' social reality (e.g. workplace obligations) hindered long-term engagement.

CONCLUSIONS

This study moves beyond listing barriers or socio-ecological groupings, to explain how social and health systems interact to produce HIV care outcomes. Our findings challenge the implicit assumption of individual agency underpinning many retention studies to highlight the social nature of illness and healthcare utilization for HIV in Zambia. This understanding of collective action for accessing and remaining in HIV care should underpin future efforts to revise and reform HIV and potentially other chronic service models and systems.

Rethinking retention: Mapping interactions between multiple factors that influence long-term engagement in HIV care

BACKGROUND

Failure to keep people living with HIV engaged in life-long care and treatment has serious implications for individual and population-level health. Nested within a four-province study of HIV care and treatment outcomes, we explored the dynamic role of social and service-related factors influencing retention in HIV care in Zambia.

METHODS

From a stratified random sample of 31 facilities, eight clinics were selected, one urban and one rural from each province. Across these sites we conducted a total of 69 in-depth interviews, including with patients (including pregnant women) engaged in-care (n = 28), disengaged from care (n = 15), engaged facility transferee (n = 12), and friends/family of deceased patients (n = 14). At the same sites we conducted 24 focus group discussions with a total of 192 lay and professional healthcare workers (HCWs). Two-day observations in each of the eight facilities helped triangulate data on operational context, provider relations and patient-provider interactions. We ordered and analysed data using an adapted version of Ewart's Social Action Theory.

RESULTS

Three overarching findings emerged. First, the experience of living with HIV and engaging in HIV care in Zambia is a social, not individual experience, influenced by social and gendered norms and life goals including financial stability, raising family and living stigma-free. Second, patients and their networks act collectively to negotiate and navigate HIV care. Anticipated responses from social network influenced patients' willingness to engage in care, while emotional and material support from those networks influenced individuals' capacity to remain in HIV care. Lastly, health system factors were most influential where they facilitated or undermined peoples' collective approach to health service use. Participants living with HIV reported facilitation of both their initial and continued engagement in care where services involved social networks, such as during couples testing and community outreach. Conversely, service features that were poorly aligned with respondents' social reality (e.g. workplace obligations) hindered long-term engagement.

CONCLUSIONS

This study moves beyond listing barriers or socio-ecological groupings, to explain how social and health systems interact to produce HIV care outcomes. Our findings challenge the implicit assumption of individual agency underpinning many retention studies to highlight the social nature of illness and healthcare utilization for HIV in Zambia. This understanding of collective action for accessing and remaining in HIV care should underpin future efforts to revise and reform HIV and potentially other chronic service models and systems.

Why don't key populations access HIV testing and counselling centres in Nepal? Findings based on national surveillance survey

OBJECTIVES

To assess the demographic, behavioural, psychosocial and structural factors associated with non-utilisation of HIV testing and counselling (HTC) services by female sex workers (FSWs) and men who have sex with men/transgender (MSM/TG).

METHODS

This study involved a cross-sectional design. We used the national surveillance survey data of 2012, which included 610 FSWs and 400 MSM/TG recruited randomly from 22 and three districts of Nepal, respectively. Adjusted prevalence ratio (aPR) and 95% confidence interval (CI) using modified Poisson regression was used to assess and infer the association between outcome (non-utilisation of HTC in last year) and independent variables.

RESULTS

Non-utilisation of HTC in the last year was 54% for FSWs and 55% for MSM/TG. The significant factors for non-utilisation of HTC among FSWs were depression (aPR=1.4 (95% CI 1.1 to 1.6)), injectable drug abuse (ever) (aPR=1.4 (95% CI 1.1 to 1.8)), participation (ever) in HIV awareness programmes (aPR=1.2 (95% CI 1.0 to 1.4)), experience of forced sex in previous year (aPR=1.1 (95% CI 1.0 to 1.3)) and absence of dependents in the family (aPR=1.1 (95% CI 1.0 to 1.3)). Non-utilisation of HTC among MSM/TG had significant association with age 16-19 years (aPR=1.4 (95% CI 1.1 to 1.7)), non-condom use (aPR=1.2 (95% CI 1.0 to 1.4)), participation (ever) in HIV awareness programmes (aPR=1.6 (95% CI 1.3 to 2.0)), physical assault in previous year (aPR=1.8 (95% CI 1.0 to 3.1)), experience of forced sex in previous year (aPR=0.5 (95% CI 0.3 to 0.9)).

CONCLUSION

Although limited by cross-sectional design, we found many programmatically relevant findings. Creative strategies should be envisaged for effective behavioural change communication to improve access to HIV testing. Psychosocial and structural interventions should be integrated with HIV prevention programmes to support key populations in accessing HIV testing.

Condom use behaviour among people living with HIV: a seven-country community-based participatory research in the Asia-Pacific region

Objectives

We examined the prevalence of inconsistent condom use and its correlates among people living with HIV (PLHIV) in the Asia-Pacific region.

Methods

Between 1 October 2012 and 31 May 2013, a total of 7843 PLHIV aged 18–50 years were recruited using targeted and venue-based sampling in Bangladesh, Indonesia, Lao People’s Democratic Republic (PDR), Nepal, Pakistan, Philippines and Vietnam. Logistic regression was used to explore the association between condom use behaviour and demographics, social support, stigma and discrimination and various health-related variables.

Results

Overall, 43% of 3827 PLHIV practised inconsistent condom use at sexual intercourse with their regular partner. An even higher proportion, 46% of 2044 PLHIV admitted that they practised unprotected sex with a casual partner. Participants from Lao PDR reported the lowest prevalence of inconsistent condom use for both regular and casual partners, while participants from the Philippines had the highest risk behaviour. Inconsistent condom use was significantly associated with belonging to a key population (drug user, sex worker or refugee subpopulation), not knowing that condoms are still needed if both partners are HIV positive, having a regular partner whose HIV status was either positive or unknown, having experienced physical assault and not receiving antiretroviral treatment.

Conclusions

This large seven-country study highlights a high prevalence of inconsistent condom use among PLHIV in the Asia-Pacific region. In addition to knowledge-imparting interventions, the adoption and expansion of the ‘Test and Treat’ strategy could help to maximise the prevention benefits of antiretroviral treatment.