Poor-quality health services and lack of programme support leads to low uptake of HIV testing in rural Mozambique

Dyadic Validation of Relational Processes in Seroconcordant Mozambican Couples: Social Support, Physician Trust, and Stigma

Psychometric instruments can quantify how people living with HIV experience three key barriers to antiretroviral therapy (ART) and retention: partner support, trust in medical professionals, and internalized HIV-related stigma. However, two challenges arise when using these instruments to measure and interpret relational processes among Mozambican couples, especially those participating in a couples intervention. First, relational measures have almost exclusively been developed and normed with Western, middle-class, and/or White adults. Second, traditional measurement approaches neglect the relational processes between partners. Using dyadic modeling, this paper demonstrates metric and scalar invariance for instruments measuring partner support (CFI = 0.964, TLI = 0.965, RMSEA = 0.034, SRMR = 0.052), trust in medical professionals (CFI = 0.978, TLI = 0.980, RMSEA = 0.033, SRMR = 0.039), and internalized HIV-related stigma (CFI = 0.960, TLI = 0.961, RMSEA = 0.050, SRMR = 0.060) within the novel context of seroconcordant HIV+ couples in Zambézia province.

"If it weren't for my traditional healer, I would be dead": Engaging traditional healers to support people living with HIV in rural Mozambique

Across rural sub-Saharan Africa, people living with HIV (PLHIV) commonly seek out treatment from traditional healers. We report on the clinical outcomes of a community health worker intervention adapted for traditional healers with insight into our results from qualitative interviews. We employed a pre-post intervention study design and used sequential mixed methods to assess the impact of a traditional healer support worker intervention in Zambézia province, Mozambique. After receiving a positive test result, 276 participants who were newly enrolled in HIV treatment and were interested in receiving home-based support from a traditional healer were recruited into the study. Those who enrolled from February 2016 to August 2016 received standard of care services, while those who enrolled from June 2017 to May 2018 received support from a traditional healer. We conducted interviews among healers and participants to gain insight into fidelity of study activities, barriers to support, and program improvement. Medication possession ratio at home (based on pharmacy pick-up dates) was not significantly different between pre- and post-intervention participants (0.80 in the pre-intervention group compared to 0.79 in the post-intervention group; p = 0.96). Participants reported receiving educational and psychosocial support from healers. Healers adapted their support protocol to initiate directly observed therapy among participants with poor adherence. Traditional healers can provide community-based psychosocial support, education, directly observed therapy, and disclosure assistance for PLHIV. Multiple factors may hinder patients' desire and ability to remain adherent to treatment, including poverty, confusion about medication side effects, and frustration with wait times at the health facility.

Leveraging HIV Care Infrastructures for Integrated Chronic Disease and Pandemic Management in Sub-Saharan Africa

In Sub-Saharan Africa, communicable and other tropical infectious diseases remain major challenges apart from the continuing HIV/AIDS epidemic. Recognition and prevalence of non-communicable diseases have risen throughout Africa, and the reimagining of healthcare delivery is needed to support communities coping with not only with HIV, tuberculosis, and COVID-19, but also cancer, cardiovascular disease, diabetes, and depression. Many non-communicable diseases can be prevented or treated with low-cost interventions, yet implementation of such care has been limited in the region. In this Perspective piece, we argue that deployment of an integrated service delivery model is an urgent next step, propose a South African model for integration, and conclude with recommendations for next steps in research and implementation. An approach that is inspired by South African experience would build on existing HIV-focused infrastructure that has been developed by Ministries of Health with strong support from the U.S. President’s Emergency Response for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria. An integrated chronic healthcare model holds promise to sustainably deliver infectious disease and non-communicable disease care. Integrated care will be especially critical as health systems seek to cope with the unprecedented challenges associated with COVID-19 and future pandemic threats.

Adolescent perceptions about participating in HIV-related research studies

The rising incidence of infection among youth in sub-Saharan Africa makes HIV-related research among younger people a top priority. There remains, however, a lack of consistent and unambiguous ethical principles and guidance for researchers wishing to conduct HIV studies with adolescents. The overarching aim of our research was to better understand youths' experiences with HIV studies. The present study explored four questions: (1) What strategies are effective for recruiting youth for HIV studies? (2) What motivates youth to participate in these studies? (3) How do study participants perceive HIV testing within the context of a research study? (4) What do participants understand about the risks of study participation? These data are essential to inform guidelines for the responsible conduct of research with young people. We interviewed 82 adolescents (aged 15-19) in Kenya taking part in a study examining ethical issues pertaining to their involvement in HIV-related research. Pursuant to our research questions, we found that direct study recruitment combined with encouragement from female relatives was the greatest facilitator to study enrolment among young people. Most young participants expressed that they were motivated to join the study in order to (1) learn their HIV status (n = 49) and (2) receive HIV-related education (n = 26), even though both are already free and widely available. Participants largely preferred testing in a place they deemed "private," although both the health clinic and home were regarded by adolescents as locations with greater privacy. Adolescents largely did not accurately perceive risks of the study two months after baseline, although they could remember the benefits with great clarity. This work can inform researchers, policymakers, and ethics review committees on approaches to maximize efficiency in recruitment and data collection, and to enhance understanding of risks and benefits in HIV-related research among adolescents. While further research is needed, these data may be used by others conducting HIV research in this region to improve recruitment strategies and more effectively engage and appeal to young people.

Partners-based HIV treatment for seroconcordant couples attending antenatal and postnatal care in rural Mozambique: A cluster randomized trial protocol

BACKGROUND

In resource-limited rural settings, scale-up of services to eliminate mother-to-child transmission of HIV has not been as effective as in better resourced urban settings. In sub-Saharan Africa, women often require male partner approval to access and remain engaged in HIV care. Our study will evaluate a promising male engagement intervention ("Homens para Saúde Mais" (HoPS+) [Men for Health Plus]) targeting the elimination of mother-to-child transmission in rural Mozambique.

DESIGN

We will use a cluster randomized clinical trial design to engage 24 health facilities (12 intervention and 12 standard of care), with 45 HIV-infected seroconcordant couples per clinic. The planned intervention will engage male partners to address social-structural and cultural factors influencing eMTCT based on new couple-centered integrated HIV services.

CONCLUSIONS

The HoPS+ study will evaluate the effectiveness of engaging male partners in antenatal care to improve outcomes among HIV-infected pregnant women, their HIV-infected male partners, and their newborn children. Our objectives are to: (1) Implement and evaluate the impact of male-engaged, couple-centered services on partners' retention in care, adherence to antiretroviral therapy, early infant diagnosis uptake, and mother-to-child transmission throughout pregnancy and breastfeeding; (2) Investigate the impact of HoPS+ intervention on hypothesized mechanisms of change; and (3) Use validated simulation models to evaluate the cost-effectiveness of the HoPS+ intervention with the use of routine clinical data from our trial. We expect the intervention to lead to strategies that can improve outcomes related to partners' retention in care, uptake of services for HIV-exposed infants, and reduced MTCT.

Adapting an adherence support workers intervention: engaging traditional healers as adherence partners for persons enrolled in HIV care and treatment in rural Mozambique

BACKGROUND

Systematic adaptation of evidence-informed interventions that increase retention in care and improve adherence to antiretroviral therapy (ART) are essential to ending the HIV epidemic in rural sub-Saharan Africa. We selected and adapted an adherence support worker intervention employed in Malawi for use by traditional healers in rural Mozambique. Given the levels of trust and dependence previously expressed by persons living with HIV (PLHIV) for traditional medicine, we adapted the program to engage traditional healers within the allopathic health system.

METHODS

Adaption followed a theoretically driven approach to intervention adaption: the Assessment-Decision-Administration-Production-Topical Experts-Integration-Training-Testing (ADAPT-ITT) model. Three rounds of performance feedback, based on theater presentations of the adapted intervention for stakeholders and idea generation, were completed with 12 groups from March to July 2016 to develop the final model. We offered healer support to 180 newly diagnosed HIV-infected patients.

RESULTS

Traditional healers were an acceptable group of community health workers to assist with patient adherence and retention. Traditional healers, clinicians, and interested community members suggested novel strategies to tailor the adherence support worker intervention, revealing a local culture of HIV denialism, aversion to the health system, and dislike of healthcare providers, as well as a preference for traditional treatments. Proposed changes to the intervention included modifications to the training language and topics, expanded community-based activities to support acceptability of an HIV diagnosis and to facilitate partner disclosure, and accompaniment to the health facility by healers to encourage delivery of respectful clinical care. PLHIV, healers, and clinicians deemed the intervention socially acceptable during focus groups. We subsequently recruited 180 newly diagnosed HIV-infected patients into the program: 170 (94%) accepted.

CONCLUSIONS

Systematic translation of interventions, even between regions with similar social and economic environments, is an important first step to successful program implementation. Efforts previously limited to community health workers can be tailored for use by traditional healers-an underutilized and often maligned health workforce. It proved feasible to use theater-based performances to demonstrate delivery of the intervention in low-literacy populations, generating discussions about social norms, community concerns, and the merits of an acceptable strategy to improve retention and adherence to ART.

Adapting an adherence support workers intervention: engaging traditional healers as adherence partners for persons enrolled in HIV care and treatment in rural Mozambique

BACKGROUND

Systematic adaptation of evidence-informed interventions that increase retention in care and improve adherence to antiretroviral therapy (ART) are essential to ending the HIV epidemic in rural sub-Saharan Africa. We selected and adapted an adherence support worker intervention employed in Malawi for use by traditional healers in rural Mozambique. Given the levels of trust and dependence previously expressed by persons living with HIV (PLHIV) for traditional medicine, we adapted the program to engage traditional healers within the allopathic health system.

METHODS

Adaption followed a theoretically driven approach to intervention adaption: the Assessment-Decision-Administration-Production-Topical Experts-Integration-Training-Testing (ADAPT-ITT) model. Three rounds of performance feedback, based on theater presentations of the adapted intervention for stakeholders and idea generation, were completed with 12 groups from March to July 2016 to develop the final model. We offered healer support to 180 newly diagnosed HIV-infected patients.

RESULTS

Traditional healers were an acceptable group of community health workers to assist with patient adherence and retention. Traditional healers, clinicians, and interested community members suggested novel strategies to tailor the adherence support worker intervention, revealing a local culture of HIV denialism, aversion to the health system, and dislike of healthcare providers, as well as a preference for traditional treatments. Proposed changes to the intervention included modifications to the training language and topics, expanded community-based activities to support acceptability of an HIV diagnosis and to facilitate partner disclosure, and accompaniment to the health facility by healers to encourage delivery of respectful clinical care. PLHIV, healers, and clinicians deemed the intervention socially acceptable during focus groups. We subsequently recruited 180 newly diagnosed HIV-infected patients into the program: 170 (94%) accepted.

CONCLUSIONS

Systematic translation of interventions, even between regions with similar social and economic environments, is an important first step to successful program implementation. Efforts previously limited to community health workers can be tailored for use by traditional healers-an underutilized and often maligned health workforce. It proved feasible to use theater-based performances to demonstrate delivery of the intervention in low-literacy populations, generating discussions about social norms, community concerns, and the merits of an acceptable strategy to improve retention and adherence to ART.

Impact of a primary care national policy on HIV screening in France: a longitudinal analysis between 2006 and 2013

BACKGROUND

Early diagnosis of HIV infection is a major public health issue worldwide. In 2009, the French National Authority for Health (Haute Autorité de Santé) developed specific guidelines and recommended mass screening of 15-70-year-olds across the general population. The guidelines were supported by communication directed at healthcare professionals, especially GPs.

AIM

To assess the impact of the national mass screening policy on HIV testing.

DESIGN AND SETTING

The study used data from the French National Health Insurance Fund database, from January 2006 to December 2013. Males and females aged 15-70 years, excluding HIV-positive individuals and pregnant females, were followed up throughout the 2006-2013 period. During the study period, 2 176 657 person-years and a total of 329 748 different individuals were followed up.

METHOD

Standardised and non-standardised rates of HIV screening were calculated for each year; the impact of the policy was assessed using adjusted segmented regression analyses.

RESULTS

Overall, annual HIV screening rates increased over the study period, from 4.2% (95% confidence interval [CI] = 4.2 to 4.3) in 2006 to 5.8% (95% CI = 5.7 to 5.9) in 2013 with a more pronounced trend after 2010 (P<0.0001). This increase was more significant for those who regularly consulted a GP. For these individuals, the policy led to a 20.4% increase (95% CI = 17.0 to 23.8) in HIV screening in 2013 compared with only a 4.5% increase (95% CI = 4.4 to 4.5) for those who did not consult a GP regularly in 2013.

CONCLUSION

The results show that the mass screening policy coordinated by GPs had a significant impact on HIV testing in France, which could result in positive impacts on public and individual health outcomes.

Assessing the Impact of Community Engagement Interventions on Health Worker Motivation and Experiences with Clients in Primary Health Facilities in Ghana: A Randomized Cluster Trial

Background

Health worker density per 1000 population in Ghana is one of the lowest in the world estimated to be 2.3, below the global average of 9.3. Low health worker motivation induced by poor working conditions partly explain this challenge. Albeit the wage bill for public sector health workers is about 90% of domestic government expenditure on health in countries such as Ghana, staff motivation and performance output remain a challenge, suggesting the need to complement financial incentives with non-financial incentives through a community-based approach. In this study, a systematic community engagement (SCE) intervention was implemented to engage community groups in healthcare quality assessment to promote mutual collaboration between clients and healthcare providers, and enhance health worker motivation levels. SCE involves structured use of existing community groups and associations to assess healthcare quality in health facilities. Identified quality gaps are discussed with healthcare providers, improvements made and rewards given to best performing facilities for closing quality care gaps.

Purpose

To evaluate the effect of SCE interventions on health worker motivation and experiences with clients.

Methods

The study is a cluster randomized trial involving health workers in private (n = 38) and public (n = 26) primary healthcare facilities in two administrative regions in Ghana. Out of 324 clinical and non-clinical staff randomly interviewed at baseline, 234 (72%) were successfully followed at end-line and interviewed on workplace motivation factors and personal experiences with clients. Propensity score matching and difference-in-difference estimations were used to estimate treatment effect of the interventions on staff motivation.

Results

Intrinsic (non-financial) work incentives including cordiality with clients and perceived career prospects appeared to be prime sources of motivation for health staff interviewed in intervention health facilities while financial incentives were ranked lowest. Intervention health facilities that were assessed by female community groups (Coef. = 0.2720, p = 0.0118) and informal groups with organized leadership structures like Artisans (Coef. = 0.2268, p = 0.0368) associated positively with higher intrinsic motivation levels of staff.

Conclusion

Community-based approach to health worker motivation is a potential complementary strategy that needs policy deliberation to explore its prospects. Albeit financial incentives remain critical sources of staff motivation, innovative non-financial approaches like SCE should complement the latter.

Engagement of Traditional Healers and Birth Attendants as a Controversial Proposal to Extend the HIV Health Workforce

"Medical pluralism" is the use of multiple health systems and is common among people living with HIV/AIDS in sub-Saharan Africa. Healers and traditional birth attendants (TBAs) often are a patient's first and/or preferred line of treatment; this often results in delayed, interrupted, or abandoned diagnosis and therapy. Literature from the study of medical pluralism suggests that HIV care and treatment programs are infrequently and inconsistently engaging healers around the world. Mistrust and misunderstanding among patients, clinical providers, and traditional practitioners make the development of effective partnerships difficult, particularly regarding early HIV diagnosis and antiretroviral therapy. We provide recommendations for the development of successful collaboration health workforce efforts based on both published articles and case studies from our work in rural Mozambique.

Poor clinical outcomes for HIV infected children on antiretroviral therapy in rural Mozambique: need for program quality improvement and community engagement

INTRODUCTION

Residents of Zambézia Province, Mozambique live from rural subsistence farming and fishing. The 2009 provincial HIV prevalence for adults 15-49 years was 12.6%, higher among women (15.3%) than men (8.9%). We reviewed clinical data to assess outcomes for HIV-infected children on combination antiretroviral therapy (cART) in a highly resource-limited setting.

METHODS

We studied rates of 2-year mortality and loss to follow-up (LTFU) for children <15 years of age initiating cART between June 2006-July 2011 in 10 rural districts. National guidelines define LTFU as >60 days following last-scheduled medication pickup. Kaplan-Meier estimates to compute mortality assumed non-informative censoring. Cumulative LTFU incidence calculations treated death as a competing risk.

RESULTS

Of 753 children, 29.0% (95% CI: 24.5, 33.2) were confirmed dead by 2 years and 39.0% (95% CI: 34.8, 42.9) were LTFU with unknown clinical outcomes. The cohort mortality rate was 8.4% (95% CI: 6.3, 10.4) after 90 days on cART and 19.2% (95% CI: 16.0, 22.3) after 365 days. Higher hemoglobin at cART initiation was associated with being alive and on cART at 2 years (alive: 9.3 g/dL vs. dead or LTFU: 8.3-8.4 g/dL, p<0.01). Cotrimoxazole use within 90 days of ART initiation was associated with improved 2-year outcomes Treatment was initiated late (WHO stage III/IV) among 48% of the children with WHO stage recorded in their records. Marked heterogeneity in outcomes by district was noted (p<0.001).

CONCLUSIONS

We found poor clinical and programmatic outcomes among children taking cART in rural Mozambique. Expanded testing, early infant diagnosis, counseling/support services, case finding, and outreach are insufficiently implemented. Our quality improvement efforts seek to better link pregnancy and HIV services, expand coverage and timeliness of infant diagnosis and treatment, and increase follow-up and adherence.

Symptomatic HIV-positive persons in rural Mozambique who first consult a traditional healer have delays in HIV testing: a cross-sectional study

OBJECTIVE

Delays in HIV diagnosis and initiation of antiretroviral therapy are common even among symptomatic individuals in Africa. We hypothesized that antiretroviral therapy delays might be more common if traditional healers (THs) were the first practitioners consulted.

DESIGN

Cross-sectional study.

METHODS

We interviewed 530 newly diagnosed HIV-infected adults (≥18 years of age) who were clinically symptomatic at the time of HIV testing in 2 rural districts in Zambézia Province, Mozambique. We ascertained their previous health care seeking behavior, duration of their symptoms, CD4 cell counts at the time of entry into care, and treatment provided by TH(s).

RESULTS

Of 517 patients (97.5%) with complete histories, 62% sought care from a healer before presenting to the local health facility. The median time to first health facility visit from first relevant symptom was 2 months [interquartile range (IQR): 1-4.5] for persons who had not visited a healer, 3 months (IQR: 2-6) for persons visiting 1 healer, and 9 months (IQR: 5-12) for persons visiting >1 healer (P < 0.001). Healers diagnosed 56% of patients with a social or ancestral curse and treated 66% with subcutaneous herbal remedies. A nonsignificant trend toward lower CD4 cells for persons who had seen multiple healers was noted.

CONCLUSIONS

Seeking initial care from healers was associated with delays in HIV testing among symptomatic HIV-seropositive persons. We had no CD4 evidence that sicker patients bypass THs, a potential inferential bias. Engaging THs in a therapeutic alliance may facilitate the earlier diagnosis of HIV/AIDS.