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Meek CJ, Munkhondya TEM, Mphande M, Tembo TA, Chitani M, Jean-Baptiste M, Vansia D, Kumbuyo C, Wang J, Simon KR, Rutstein SE, Barrington C, Kim MH, Go VF, Rosenberg NE. Examining the feasibility of assisted index case testing for HIV case-finding: a qualitative analysis of barriers and facilitators to implementation in Malawi. BMC Health Serv Res 2024; 24:606. [PMID: 38720312 PMCID: PMC11080127 DOI: 10.1186/s12913-024-10988-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 04/12/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Assisted index case testing (ICT), in which health care workers take an active role in referring at-risk contacts of people living with HIV for HIV testing services, has been widely recognized as an evidence-based intervention with high potential to increase status awareness in people living with HIV. While the available evidence from eastern and southern Africa suggests that assisted ICT can be an effective, efficient, cost-effective, acceptable, and low-risk strategy to implement in the region, it reveals that feasibility barriers to implementation exist. This study aims to inform the design of implementation strategies to mitigate these feasibility barriers by examining "assisting" health care workers' experiences of how barriers manifest throughout the assisted ICT process, as well as their perceptions of potential opportunities to facilitate feasibility. METHODS In-depth interviews were conducted with 26 lay health care workers delivering assisted ICT in Malawian health facilities. Interviews explored health care workers' experiences counseling index clients and tracing these clients' contacts, aiming to inform development of a blended learning implementation package. Transcripts were inductively analyzed using Dedoose coding software to identify and describe key factors influencing feasibility of assisted ICT. Analysis included multiple rounds of coding and iteration with the data collection team. RESULTS Participants reported a variety of barriers to feasibility of assisted index case testing implementation, including sensitivities around discussing ICT with clients, privacy concerns, limited time for assisted index case testing amid high workloads, poor quality contact information, and logistical obstacles to tracing. Participants also reported several health care worker characteristics that facilitate feasibility (knowledge, interpersonal skills, non-stigmatizing attitudes and behaviors, and a sense of purpose), as well as identified process improvements with the potential to mitigate barriers. CONCLUSIONS Maximizing assisted ICT's potential to increase status awareness in people living with HIV requires equipping health care workers with effective training and support to address and overcome the many feasibility barriers that they face in implementation. Findings demonstrate the need for, as well as inform the development of, implementation strategies to mitigate barriers and promote facilitators to feasibility of assisted ICT. TRIAL REGISTRATION NCT05343390. Date of registration: April 25, 2022.
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Affiliation(s)
- Caroline J Meek
- RTI International, Research Triangle Park, NC, USA.
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | | | - Mtisunge Mphande
- Baylor College of Medicine Children's Foundation, Lilongwe, Malawi
| | - Tapiwa A Tembo
- Baylor College of Medicine Children's Foundation, Lilongwe, Malawi
| | - Mike Chitani
- Baylor College of Medicine Children's Foundation, Lilongwe, Malawi
| | - Milenka Jean-Baptiste
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Dhrutika Vansia
- Baylor College of Medicine Children's Foundation, Lilongwe, Malawi
| | - Caroline Kumbuyo
- Baylor College of Medicine Children's Foundation, Lilongwe, Malawi
| | - Jiayu Wang
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Sarah E Rutstein
- Department of Medicine, Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Clare Barrington
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Maria H Kim
- Baylor College of Medicine Children's Foundation, Lilongwe, Malawi
| | - Vivian F Go
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Nora E Rosenberg
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Aheron S, Paredes-Vincent A, Patton ME, Gross J, Medley A, Mona G, Mtimkulu N, Nkuna K, Grund JM. Improving HIV Case Finding Through Index Testing: Findings from Health Facilities in 12 Districts of South Africa, October 2019-September 2021. AIDS Behav 2024; 28:1708-1718. [PMID: 38358586 PMCID: PMC11070287 DOI: 10.1007/s10461-024-04269-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2024] [Indexed: 02/16/2024]
Abstract
To assess the importance of index testing in HIV case finding, we analyzed quarterly data from October 2019 to September 2021 from 371 facilities in 12 districts in South Africa. Index testing accounted for 2.6% of all HIV tests (index and non-index) (n = 163,633), but 17.8% of all HIV-positive results, with an HIV-positivity 4-times higher than non-index testing modalities (4.1%). Despite twice as many adult females ≥ 15 years accepting index testing (n = 206,715) compared to adult males ≥ 15 years (n = 102,180), females identified fewer contacts (n = 91,123) than males (n = 113,939). Slightly more than half (51.2%) of all contacts elicited were tested (n = 163,633/319,680), while 19.7% (n = 62,978) of elicited contacts were previously diagnosed as HIV-positive and not eligible for further testing. These findings indicate index testing can be effective in increasing HIV diagnoses in South Africa. Further operational research is needed to address gaps identified in the index testing cascade, including elicitation and testing of contacts.
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Affiliation(s)
- Sarah Aheron
- Division of Global HIV and TB, Centers for Disease Control & Prevention, Pretoria, South Africa.
| | - Ariana Paredes-Vincent
- Division of Global HIV and TB, Centers for Disease Control & Prevention, Pretoria, South Africa
| | - Monica E Patton
- Division of Global HIV and TB, Centers for Disease Control & Prevention, Pretoria, South Africa
| | - Jessica Gross
- Division of Global HIV and TB, Centers for Disease Control & Prevention, Atlanta, GA, USA
| | - Amy Medley
- Division of Global HIV and TB, Centers for Disease Control & Prevention, Atlanta, GA, USA
| | - Gugu Mona
- Division of Global HIV and TB, Centers for Disease Control & Prevention, Pretoria, South Africa
| | | | - Khensani Nkuna
- Wits Reproductive Health and HIV Institute (WRHI), Johannesburg, South Africa
| | - Jonathan M Grund
- Division of Global HIV and TB, Centers for Disease Control & Prevention, Pretoria, South Africa
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Meek CJ, Munkhondya TEM, Mphande M, Tembo TA, Chitani M, Jean-Baptiste M, Vansia D, Kumbuyo C, Simon KR, Rutstein SE, Barrington C, Kim MH, Go VF, Rosenberg NE. Examining the feasibility of assisted index case testing for HIV case-finding: a qualitative analysis of barriers and facilitators to implementation in Malawi. RESEARCH SQUARE 2023:rs.3.rs-3314925. [PMID: 37720011 PMCID: PMC10503858 DOI: 10.21203/rs.3.rs-3314925/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
Background Assisted index case testing, in which health care workers take an active role in referring at-risk contacts of people living with HIV for HIV testing services, has been widely recognized as an evidence-based intervention with high potential to increase PLHIV status awareness. Promising evidence for the approach has led to several attempts to scale assisted index case testing throughout eastern and southern Africa in recent years. However, despite effective implementation being at the heart of any assisted index case testing strategy, there is limited implementation science research from the perspective of the HCWs who are doing the "assisting". This study examines the feasibility of assisted index case testing from the perspective of health care workers implementing the approach in Malawi. Methods In-depth interviews were conducted with 26 lay health care workers delivering assisted index case testing in Malawian health facilities. Interviews explored health care workers' experiences counselling index clients and tracing these clients' contacts, aiming to inform development of a blended learning implementation package. Transcripts were inductively analyzed using Dedoose coding software to identify and describe key factors influencing feasibility of assisted index case testing. Analysis included multiple rounds of coding and iteration with the data collection team. Results Participants reported a variety of barriers to feasibility of assisted index case testing implementation, including privacy concerns, limited time for assisted index case testing amid high workloads, poor quality contact information, logistical obstacles to tracing, and challenges of discussing sexual behavior with clients. Participants also reported several health care worker characteristics that facilitate feasibility: robust understanding of assisted index case testing's rationale and knowledge of procedures, strong interpersonal skills, positive attitudes towards clients, and sense of purpose in their work. Conclusions Findings demonstrate that maximizing assisted index case testing's potential to increase HIV status awareness requires adequately equipping health care workers with appropriate knowledge, skills, and support to address and overcome the many feasibility challenges that they face in implementation. Trial Registration Number NCT05343390 Date of registration: April 25, 2022.
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Affiliation(s)
- Caroline J Meek
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill
| | | | | | | | - Mike Chitani
- Baylor College of Medicine Children's Foundation
| | - Milenka Jean-Baptiste
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill
| | | | | | | | - Sarah E Rutstein
- Department of Medicine, Division of Infectious Diseases, University of North Carolina at Chapel Hill
| | - Clare Barrington
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill
| | - Maria H Kim
- Baylor College of Medicine Children's Foundation
| | - Vivian F Go
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill
| | - Nora E Rosenberg
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill
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Kiyingi M, Nankabirwa JI, Wiltshire CS, Nangendo J, Kiweewa JM, Katahoire AR, Semitala FC. Perspectives of people living with HIV on barriers to timely ART initiation following referral for antiretroviral therapy: A qualitative study at an urban HIV clinic in Kampala, Uganda. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001483. [PMID: 37494338 PMCID: PMC10370709 DOI: 10.1371/journal.pgph.0001483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 06/20/2023] [Indexed: 07/28/2023]
Abstract
Early initiation of antiretroviral therapy (ART) after HIV diagnosis prevents HIV transmission, progression of HIV to AIDS and improves quality of life. However, little is known about the barriers to timely ART initiation among patients who test HIV positive in settings different from where they will receive HIV treatment, hence are referred in the routine setting. Therefore, we explored the perspectives of people living with HIV on barriers faced to initiate ART following HIV testing and referral for treatment. In this qualitative study, we purposively sampled and enrolled 17 patients attending the Mulago ISS clinic. We selected patients (≥18 years) who previously were received as referrals for HIV treatment and had delayed ART initiation, as ascertained from their records. We conducted in-depth interviews, which were audio recorded, transcribed and translated. We used Atlas.ti version 9 software for data management. Data analysis followed thematic and framework analysis techniques and we adopted the socio-ecological model to categorize final themes. Key themes were found at organizational level including; negative experiences at the place of HIV diagnosis attributed to inadequate counselling and support, unclear communication of HIV-positive results and ambiguous referral procedures; and, long waiting time when patients reached the HIV clinic. At individual level, the themes identified were; immediate denial with late acceptance of HIV-positive results attributed to severe emotional and psychological distress at receiving results, fear of perceived side effects and long duration on ART. At interpersonal level, we found that anticipated and enacted stigma after HIV diagnosis resulted in non-disclosure, discrimination and lack of social support. We found that challenges at entry (during HIV test) and navigation of the HIV care system in addition to individual and interpersonal factors contributed to delayed ART initiation. Interventions during HIV testing would facilitate early ART initiation among patients referred for HIV care.
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Affiliation(s)
- Micheal Kiyingi
- Department of Medicine, Makerere University, Kampala, Uganda
- Makerere University Joint AIDS Program, Makerere University, Kampala, Uganda
| | - Joaniter I Nankabirwa
- Department of Medicine, Makerere University, Kampala, Uganda
- Infectious Diseases Research Collaboration, Kampala Uganda
| | | | - Joan Nangendo
- Infectious Diseases Research Collaboration, Kampala Uganda
| | - John M Kiweewa
- Education Department, Fairfield University, Fairfield, Connecticut, United States of America
| | - Anne R Katahoire
- Child Health Development Center, Makerere University, Kampala, Uganda
| | - Fred C Semitala
- Department of Medicine, Makerere University, Kampala, Uganda
- Makerere University Joint AIDS Program, Makerere University, Kampala, Uganda
- Infectious Diseases Research Collaboration, Kampala Uganda
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Kiyingi M, Nankabirwa JI, Sekaggya-Wiltshire C, Nangendo J, Kiweewa JM, Katahoire AR, Semitala FC. Predictors of delayed Anti-Retroviral Therapy initiation among adults referred for HIV treatment in Uganda: a cross-sectional study. BMC Health Serv Res 2023; 23:40. [PMID: 36647104 PMCID: PMC9843953 DOI: 10.1186/s12913-023-09052-z] [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: 08/19/2022] [Accepted: 01/09/2023] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Uganda's current guidelines recommend immediate initiation of Anti-Retroviral Therapy (ART) for persons living with HIV in order to reduce HIV/AIDS related morbidity and mortality. However, not all eligible PLHIV initiate ART within the recommended time following HIV diagnosis. We assessed the prevalence and factors associated with delayed ART initiation among PLHIV referred for ART initiation, five years since rolling out the test and treat guidelines. METHODS In this cross-sectional study, we enrolled adult patients referred to Mulago Immune Suppressive Syndrome (Mulago ISS) clinic for ART initiation from January 2017 to May 2021. We collected data on socio-demographics, HIV diagnosis and referral circumstances, and time to ART initiation using a questionnaire. The outcome of interest was proportion of patients that delayed ART, defined as spending more than 30 days from HIV diagnosis to ART initiation. We performed multivariable logistic regression and identified significant factors. RESULTS A total of 312 patients were enrolled of which 62.2% were female. The median (inter-quartile range [IQR]) age and baseline CD4 count of the patients were 35 (28-42) years and 315 (118.8-580.5) cells/μL respectively. Forty-eight (15.4%) patients delayed ART initiation and had a median (IQR) time to ART of 92 (49.0-273.5) days. The factors associated with delayed ART initiation were; 1) having had the HIV diagnosis made from a private health facility versus public, (adjusted odds ratio [aOR] = 2.4 (95% confidence interval [CI] 1.1-5.5); 2) initial denial of positive HIV test results, aOR = 5.4 (95% CI: 2.0-15.0); and, 3) having not received a follow up phone call from the place of HIV diagnosis, aOR = 2.8 (95% CI: 1.2-6.8). CONCLUSION There was significant delay of ART initiation among referred PLHIV within 5 years after the rollout of test and treat guidelines in Uganda. Health system challenges in the continuity of HIV care services negatively affects timely ART initiation among referred PLHIV in Uganda.
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Affiliation(s)
- Micheal Kiyingi
- grid.11194.3c0000 0004 0620 0548Department of Medicine, Makerere University College of Health Sciences, Makerere University, Box 7062, Kampala, Uganda ,grid.11194.3c0000 0004 0620 0548Makerere University Joint AIDS Program, Makerere University, Kampala, Uganda
| | - Joaniter I. Nankabirwa
- grid.11194.3c0000 0004 0620 0548Department of Medicine, Makerere University College of Health Sciences, Makerere University, Box 7062, Kampala, Uganda ,grid.463352.50000 0004 8340 3103Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Joan Nangendo
- grid.11194.3c0000 0004 0620 0548Department of Medicine, Makerere University College of Health Sciences, Makerere University, Box 7062, Kampala, Uganda ,grid.463352.50000 0004 8340 3103Infectious Diseases Research Collaboration, Kampala, Uganda
| | - John M. Kiweewa
- grid.255794.80000 0001 0727 1047Education Department, Fairfield University, Fairfield, CT USA
| | - Anne R. Katahoire
- grid.11194.3c0000 0004 0620 0548Child Health and Development Center, Makerere University, Kampala, Uganda
| | - Fred C. Semitala
- grid.11194.3c0000 0004 0620 0548Department of Medicine, Makerere University College of Health Sciences, Makerere University, Box 7062, Kampala, Uganda ,grid.11194.3c0000 0004 0620 0548Makerere University Joint AIDS Program, Makerere University, Kampala, Uganda ,grid.463352.50000 0004 8340 3103Infectious Diseases Research Collaboration, Kampala, Uganda
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Endalamaw A, Gilks CF, Ambaw F, Habtewold TD, Assefa Y. Universal Health Coverage for Antiretroviral Treatment: A Review. Infect Dis Rep 2022; 15:1-15. [PMID: 36648855 PMCID: PMC9844463 DOI: 10.3390/idr15010001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 12/16/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
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.
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Affiliation(s)
- Aklilu Endalamaw
- School of Public Health, The University of Queensland, Brisbane, QLD 4072, Australia
- College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar P.O. Box 79, Ethiopia
- Correspondence: ; Tel.: +61-424-690-121
| | - Charles F Gilks
- School of Public Health, The University of Queensland, Brisbane, QLD 4072, Australia
| | - Fentie Ambaw
- School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar P.O. Box 79, Ethiopia
| | - Tesfa Dejenie Habtewold
- Branch of Epidemiology, Division of Population Health Research, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, 9712 CP Groningen, The Netherlands
| | - Yibeltal Assefa
- School of Public Health, The University of Queensland, Brisbane, QLD 4072, Australia
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