Finding, treating and retaining persons with HIV in a high HIV prevalence and high treatment coverage country: Results from the Botswana Combination Prevention Project

Universal "Test and Treat" for HIV Had Little Effect on Outcomes, but Missed Clinic Visits Threaten Success of Botswana's National Antiretroviral Treatment Program

In 2016, Botswana changed the policy to institute universal "test and treat" (UTT) in people with human immunodeficiency virus or HIV (PWH). It is unclear whether these policy changes have yielded any clinical benefits or harms. We conducted a retrospective cohort analysis of PWH aged ≥18 years to compare patient outcomes in individuals who received antiretroviral treatment (ART) under (1) the introduction of UTT and (2) rapid versus delayed ART start, at two clinics in Gaborone, Botswana, between 2014 and 2020. Multivariate logistic regression and propensity score models were used to control for potential confounding and selection bias. Of the 2008 participants who had a complete plasma HIV RNA at 1 year following ART initiation, 59 (2.9%) experienced virologic failure, and 665 (33.1%) were lost to follow-up (LTFU). Higher LTFU was recorded in UTT than in delayed ART period (43% vs 31%, p < 0.001); the same trend was upheld on further examination treating all LTFU as treatment failure (47% vs 37%, p < 0.001). In adjusted models, neither the UTT policy: odds ratio (OR) 1.91 [95% confidence interval (CI): 0.90, 3.56] nor rapid ART start: OR 1.31 (95% CI: 0.75, 2.34) was associated with viral failure. UTT was not associated with LTFU: OR 1.04, 95% CI (0.75, 1.45). Missed clinic visits were associated with viral failure regardless of policy period: OR 1.17 (95% CI: 1.03, 1.31) or rapid start: OR 1.20 (95% CI: 1.07,1.35). Neither UTT policy nor rapid ART start was associated with any one of the composite unfavorable outcomes. However, missing clinic visits was an independent risk factor for unfavorable outcomes.

Experiences of nurses in patient adherence to antiretoroviral therapy in Mpumalanga, South Africa

BACKGROUND

 Human immunodeficiency virus (HIV) is a global health pandemic. Mpumalanga is a province with a high burden of HIV or acquired immunodeficiency syndrome (AIDS). Antiretroviral (ARV) therapy should be initiated for all HIV-positive patients. Monitoring of patients' adherence to ARV therapy is important to ensure continued viral suppression.

AIM

 The study aimed to report on the experiences of primary health care (PHC) nurses in monitoring patients' adherence to ARV therapy in PHC facilities in Mpumalanga, South Africa.

SETTING

 Six PHC clinics in a district in Mpumalanga were purposively selected.

METHODS

 Employing a qualitative, exploratory, descriptive research design, 12 PHC nurses were interviewed in 2023. The data were coded, categorised and clustered into themes and categories. Ethical considerations and measures to ensure trustworthiness were adhered to.

RESULTS

 The findings revealed four themes: PHC nurses' experience in monitoring patients' adherence to ARV therapy in PHC facilities, experience of external challenges influencing patient's adherence to ARV therapy, experiences in internal challenges that influence patients' ARV therapy adherence, and the consequences of non-monitoring and poor adherence.

CONCLUSION

 Non-adhering patients were seen to be the greatest challenge. More awareness regarding the central chronic medicine dispensing and distribution (CCMDD) programme and the development of guidelines on the support of PHC nurses and patients are recommended.Contribution: The findings of the study may guide recommendations to assist PHC nurses, PHC management and policy makers at large to address challenges in the monitoring and adherence of patients on ARV therapy.

Quantitative outcomes of a type 2 single arm hybrid effectiveness implementation pilot study for hypertension-HIV integration in Botswana

BACKGROUND

Successful HIV treatment programs have turned HIV into a chronic condition, but noncommunicable diseases such as hypertension jeopardize this progress. Hypertension control rates among people with HIV (PWH) are low owing to gaps in patient awareness, diagnosis, effective treatment, and management of both conditions at separate clinic visits. Integrated management, such as in our study, InterCARE, can enhance HIV-hypertension integration and blood pressure (BP) control.

METHODS

Our pilot study was conducted in two Botswana HIV clinics between October 2021 and November 2022. Based on our formative work, we adopted three main strategies; Health worker training on HTN/cardiovascular disease (CVD) management, adaptation of HIV Electronic Health Record (EHR) for HTN/CVD care, and use of treatment partners to support PWH with hypertension for implementation. We employed the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework to assess implementation effectiveness and outcomes for BP control at baseline, 6 and 12 months. HIV viral load (VL) suppression was also measured to assess impact of integration on HIV care.

RESULTS

We enrolled 290 participants; 35 (12.1%) were lost to follow-up, leaving 255 (87.9%) at 12-months. Median age was 54 years (IQR 46-62), and 77.2% were females. Our interventions significantly improved BP control to < 140/90 mmHg (or < 130/80 mmHg if diagnosis of diabetes or chronic kidney disease), from 137/290 participants, 47.2% at baseline to 206/290 participants, 71.0%, at 12 months (p < 0.001). Among targeted providers, 94.7% received training, with an associated significant increase in counseling on exercise, diet, and medication (all p < 0.001) but EHR use for BP medication prescribing and cardiovascular risk factor evaluation showed no adoption. In the intention-to-treat analysis, HIV VL suppression at 12 months decreased (85.5% vs 93.8%, p = 0.002) due to loss to follow-up but the per protocol analysis showed no difference in VL suppression between baseline and 12 months (97.3% vs 93.3%, p = 0.060).

CONCLUSION

The InterCARE pilot study demonstrated that low-cost practical support measures involving the integration of HIV and hypertension/CVD management could lead to improvements in BP control. These results support the need for a large implementation and effectiveness trial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05414526. Registered 18th May 2022.

A mixed methods approach identifying facilitators and barriers to guide adaptations to InterCARE strategies: an integrated HIV and hypertension care model in Botswana

BACKGROUND

Botswana serves as a model of success for HIV with 95% of people living with HIV (PLWH) virally suppressed. Yet, only 19% of PLWH and hypertension have controlled blood pressure. To address this gap, InterCARE, a care model that integrates HIV and hypertension care through a) provider training; b) adapted electronic health record; and c) treatment partners (peer support), was designed. This study presents results from our baseline assessment of the determinants and factors used to guide adaptations to InterCARE implementation strategies prior to a hybrid type 2 effectiveness-implementation study.

METHODS

This study employed a convergent mixed methods design across two clinics (one rural, one urban) to collect quantitative and qualitative data through facility assessments, 100 stakeholder surveys (20 each PLWH and hypertension, existing HIV treatment partners, clinical healthcare providers (HCPs), and 40 community leaders) and ten stakeholder key informative interviews (KIIs). Data were analyzed using descriptive statistics and deductive qualitative analysis organized by the Consolidated Framework for Implementation Research (CFIR) and compared to identify areas of convergence and divergence.

RESULTS

Although 90.3% of 290 PLWH and hypertension at the clinics were taking antihypertensive medications, 52.8% had uncontrolled blood pressure. Results from facility assessments, surveys, and KIIs identified key determinants in the CFIR innovation and inner setting domains. Most stakeholders (> 85%) agreed that InterCARE was adaptable, compatible and would be successful at improving blood pressure control in PLWH and hypertension. HCPs agreed that there were insufficient resources (40%), consistent with facility assessments and KIIs which identified limited staffing, inconsistent electricity, and a lack of supplies as key barriers. Adaptations to InterCARE included a task-sharing strategy and expanded treatment partner training and support.

CONCLUSIONS

Integrating hypertension services into HIV clinics was perceived as more advantageous for PLWH than the current model of hypertension care delivered outside of HIV clinics. Identified barriers were used to adapt InterCARE implementation strategies for more effective intervention delivery.

TRIAL REGISTRATION

ClinicalTrials.gov, ClinicalTrials.gov Identifier: NCT05414526 . Registered 18 May 2022 - Retrospectively registered.

Universal Health Coverage for Antiretroviral Treatment: A Review

Universal health coverage is essential for the progress to end threats of the acquired immunodeficiency syndrome epidemic. The current review assesses the publication rate, strategies and barriers for antiretroviral therapy (ART) coverage, equity, quality of care, and financial protection. We searched Web of Science, PubMed, and Google Scholar. Of the available articles, 43.13% were on ART coverage, 40.28% were on financial protection, 10.43% were on quality of care, and 6.16% were on equity. A lack of ART, fear of unwanted disclosure, lack of transportation, unaffordable health care costs, long waiting time to receive care, and poverty were barriers to ART coverage. Catastrophic health care costs were higher among individuals who were living in rural settings, walked greater distances to reach health care institutions, had a lower socioeconomic status, and were immunocompromised. There were challenges to the provision of quality of care, including health care providers' inadequate salary, high workload and inadequate health workforce, inappropriate infrastructure, lack of training opportunities, unclear division of responsibility, and the presence of strict auditing. In conclusion, ART coverage was below the global average, and key populations were disproportionally less covered with ART in most countries. Huge catastrophic health expenditures were observed. UHC contexts of ART will be improved by reaching people with poor socioeconomic status, delivering appropriate services, establishing a proper health workforce and service stewardship.