Barriers and facilitators of interventions for improving antiretroviral therapy adherence: a systematic review of global qualitative evidence

Barriers and facilitators of adherence to long-term antiretroviral treatment in Kampala, Uganda

Few qualitative studies have evaluated adherence to long-term antiretroviral treatment (ART) in sub-Saharan Africa. We explored adherence barriers and facilitators among PLWH on long-term ART (≥10 years in Kampala)., We conducted 22 in-depth interviews with 16 purposively selected PLWHs on long-term ART and six purposively selected healthcare providers at the Infectious Diseases Institute ART clinic.,. Interviews with PLWH explored their perspectives regarding; comprehension of ART adherence, ART adherence experiences, and adherence barriers and facilitators. Provider interviews covered: perceived ART adherence barriers and facilitators and how to reinforce and support ART adherence. Qualitative data were analyzed using a deductive content analytic approach. The median age of PLWH was 52 years [IQR] 39 - 65). Most (63%) had been on ART for 15-20 years, 50% were male, and 38% had treatment supporters. Both providers and PLWH on long-term ART emphasized the importance of adhering to prescribed medication to suppress HIV. Adherence facilitators: (i) Achieving sustained viral suppression improved overall health and motivated PLWH to maintain long-term adherence. (ii) Spousal treatment partners, financial support from adult children for transportation to clinic appointments, and the desire to fulfill social responsibilities were also adherence motivators. (iii) Policy changes, such as providing multi-month drug refills and community ART delivery, were effective strategies for promoting adherence. Adherence barriers: (i) Financial constraints - lack of money for transportation - often resulting in delayed or missed appointments to the clinic. (ii) Work obligations that conflicted with clinic appointments negatively impacted long-term ART adherence. (iii) Pill fatigue and avoidance of adherence counseling sessions by PLWH with detectable viral load exacerbated non-adherence. Familial support and differentiated ART delivery had a mutually beneficial effect on long-term adherence. Future studies should evaluate the unique adherence needs of this rapidly growing ART-experienced population and identify the most efficient strategies for adherence support.

Perceived neighborhood disorder and achieving HIV viral suppression among adults living with HIV: A cross-sectional study

Adherence to antiretroviral therapy (ART) is crucial for achieving and maintaining viral suppression in people living with HIV (PLWH). While individual factors affecting HIV viral suppression have been extensively studied, there is less attention on community-level factors, specifically perceived neighborhood disorder. This study aims to assess the relationship between perceived neighborhood disorder and achieving virologic suppression among people living with HIV. One hundred and eighty-eight PLWH 18 years of age and older from two HIV clinics completed a cross-sectional study. We assessed perceptions of neighborhood disorder, ART self-efficacy, social support, alcohol and drug use, depression, HIV stigma, provider-patient relationship, demographics, and length at the zip code. HIV viral loads were obtained from the clinical record. The analysis involved the use of Fisher's Exact test, Spearman's Rank test, Wilcoxon rank sum test, and Firth logistic regression. All analyses were conducted using STATA 17. Most participants were male (79%), white (62%), and identified as non-Hispanic (66%). Individuals with no perceived neighborhood disorder had median scores of 10 for integration and perseverance in ART self-efficacy. Those with high perceived disorder displayed decreased scores of 8.4 and 8.3 for integration and perseverance respectively. Both integration and perseverance showed statistically significant negative correlations with perceived neighborhood disorder, (Spearman's rho -0.2966; p<0.000 and -0.2387; p = 0.0010 respectively). Individuals with virologic suppression (n = 167) reported significantly lower perceived neighborhood disorder scores (median = 0.9 [IQR: 0.2-2.0]) compared to those without virologic suppression (n = 10, median = 3.2 [IQR: 2.4-4], p = 0.0012). The study highlights a notable correlation between perceived neighborhood disorder, ART adherence self-efficacy, and virologic suppression. This indicates that improving HIV treatment outcomes needs to extend beyond individual-level factors and include strategies to address neighborhood-level conditions. Public health policies and programs should consider the broader social and environmental contexts in which people living with HIV reside.

Acceptability, Feasibility, and Appropriateness of the B-OK Bottles as an Implementation Strategy for Treatment Adherence Support by Medical Case Managers

Antiretroviral therapy treatment adherence support by medical case managers is an evidence-based practice, but effectiveness may be constrained by limited understanding of antiretroviral therapy's benefits among people with HIV. We used mixed methods to evaluate the pre-implementation context of the B-OK Bottles ("B-OK") - a visual aid designed to correct HIV mental models - as an implementation strategy for treatment adherence support by medical case managers in Philadelphia. We assessed outcomes of acceptability, feasibility, and appropriateness among medical case managers and people with HIV. We conducted case manager focus groups at four agencies, and enrolled clients of case managers at these agencies. Clients received the B-OK intervention, a survey, and individual interviews. Among clients, we assessed implementation scales: Acceptability of Intervention Measure, Feasibility of Intervention Measure, and Intervention Appropriateness Measure. During focus groups, medical case managers (N = 29) found B-OK to be highly acceptable and feasible, and that it would be appropriate as a conversation starter. Individual interviews (N = 52) also demonstrated high degrees of B-OK acceptability, feasibility, and appropriateness for use by case managers. Medical case managers and people with HIV felt that B-OK could improve individual motivation for medication adherence. However, participants also identified other substantial barriers to adherence besides knowledge and understanding. Quantitative results were consistent with our qualitative findings, with high scores on implementation scales. This study suggests that B-OK would be acceptable, feasible, and appropriate as an implementation strategy for treatment adherence support by medical case managers, but that a multifaceted approach is likely needed to achieve optimal adherence.

Shifting roles of community health workers in the prevention and management of noncommunicable disease during the COVID-19 pandemic: a scoping review

Community Health Workers (CHWs) play a crucial role in the prevention and management of noncommunicable diseases (NCDs). The COVID-19 pandemic triggered the implementation of crisis-driven responses that involved shifts in the roles of CHWs in terms of delivering services for people with NCDs. Strategically aligning these shifts with health systems is crucial to improve NCD service delivery. The aim of this review was to identify and describe COVID-19-triggered shifting roles of CHWs that are promising in terms of NCD service delivery. We searched Ovid Medline, Embase, CINAHL, Web of Science and CABI for Global Health for relevant articles published between 1 January 2020 and 22 February 2022. Studies that were conducted within a COVID-19 context and focused on the shifted roles of CHWs in NCD service delivery were included. We used Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines to report the findings. A total of 25 articles from 14 countries were included in this review. We identified 12 shifted roles of CHWs in NCD service delivery during COVID-19, which can be categorized in three dimensions: 'enhanced' role of CHWs that includes additional tasks such as medication delivery; 'extended' roles such as the delivery of NCD services at household level and in remote communities; and 'enabled' roles through the use of digital health technologies. Health and digital literacy of people with NCDs, access to internet connectivity for people with NCDs, and the social and organizational context where CHWs work influenced the implementation of the shifted roles of CHWs. In conclusion, the roles of CHWs have shifted during the COVID-19 pandemic to include the delivery of additional NCD services at home and community levels, often supported by digital technologies. Given the importance of the shifting roles in the prevention and management of NCDs, adaptation and integration of these shifted roles into the routine activities of CHWs in the post-COVID period is recommended.

HIV-1 low-level viraemia predicts virological failure in first-line and second-line ART-experienced individuals in India: A retrospective longitudinal study

OBJECTIVE

To study the prevalence of low-level viraemia (LLV) and its association with virological failure (VF).

METHODS

We conducted a retrospective analysis of 3498 participants at YRG CARE, Chennai, India (2013-2018) on antiretroviral therapy (ART) for ≥6 months with two or more plasma viral load (pVL) measurements. Results were stratified for those with pVL <1000 copies/mL: fully suppressed (FS) (pVL <40), low-LLV (pVL 40-199), mid-LLV (pVL 200-399), and high-LLV (pVL 400-999). The study assessed the association with VF (pVL >1000 copies/mL) using Cox proportional hazard model.

RESULTS

Among 3498 participants, 2965 (84.8%) were FS and 533 (15.2%) were LLV. During the follow-up, 348 (10%) experienced VF, with 222 (6.3%) experienced after LLV (42% of LLV) and 126 (3.6%) experienced after FS (4.3% of FS). When compared with FS, those with LLV had a greater risk of VF [adjusted hazard ratio (aHR) = 12.7; 95% confidence interval (CI): 10.2-15.9]. First-line participants had a higher VF incidence (aHR = 15.8, 95% CI: 11.4-21.9) than second-line participants (aHR = 5.6, 95% CI: 4.1-7.7). Those with high-LLV had the highest VF risk (aHR = 22.856, 95% CI: 15.204-34.359 vs. aHR = 8.186, 95% CI: 5.564-12.043, for first-line vs. second-line participants, respectively), followed by those with mid-LLV (aHR = 13.375, 95% CI: 8.327-21.483 vs. aHR = 6.261, 95% CI: 4.044-9.695) and low-LLV (aHR = 12.976, 95% CI: 7.974-21.118 vs. aHR = 4.158, 95% CI: 2.826-6.119).

CONCLUSIONS

The prevalence of LLV was intermediate in our study population. There was a higher risk of VF among individuals with LLV, and this risk increased with the increasing levels of LLV. Close monitoring of individuals experiencing LLV could help in the early identification of VF.

Perceptions of HIV patients on the use of cell phones as a tool to improve their antiretroviral adherence in Northwest, Ethiopia: a cross-sectional study

BACKGROUND

Human immuno deficiency virus (HIV) is one of the most infectious diseases that cause death. A Medication non-adherence in HIV patient has been caused by factors such as not taking medications as prescribed by a physician, withdrawing from medication, missing appointments, and forgetfulness. To improve patients' antiretroviral adherence, supporting them with mobile phone applications is advisable. This study aimed to assess HIV patients' perceptions towards the use of cell phones to improve antiretroviral adherence.

METHODS AND MATERIALS

An institutional-based cross-sectional study was conducted among 423 HIV patients at a comprehensive specialized hospital in northwest Ethiopia from June to July 2022. Study participants were selected using systematic random sampling techniques and the data collection tool was adopted and modified for different literatures. Data were collected through an online data collection tool, and STATA-14 software was used for analysis. Descriptive statistics and binary logistic regression were used. The variables with a P-value equal to or less than 0.2 in bivariable logistic regression were entered into a multivariable logistic regression, and model fitness was assessed.

RESULTS

A total of 410 study subjects have participated, making a response rate of 97%. In this study, 62% (95% CI: 57-67%) of HIV patients had a positive perception regarding the use of mobile phones to improve antiretroviral adherence. Perceived usefulness of mobile phones [AOR = 4.5, (95% CI: 2.2-9.1)], perceived ease of mobile phone use [AOR = 3.9, (95% CI: 2.0-7.5), age [AOR = 3.0, (95% CI: 1.5-6.2)], and educational status [AOR = 5.0, (95% CI: 2.3-10.0)] were significantly associated with HIV patients' perception of mobile phones' use to improve antiretroviral adherence.

CONCLUSIONS

More than half of the respondents had positive perception regarding the use of mobile phones to enhance their adherence to treatment. Perceived usefulness, perceived ease of use, age, and educational status was significantly associated with perception of mobile phone use to enhance antiretroviral therapy adherence. Therefore, the government have to encourage and support patients in incorporating mobile phones into their antiretroviral therapy (ART) follow-up through training.

Safety and efficacy of long-acting intramuscular cabotegravir and rilpivirine in adults with HIV-1 infection: a systematic review and meta-analysis protocol

BACKGROUND

Current antiretroviral regimens have, for the most part, achieved optimal antiretroviral efficacy and tolerability, transforming HIV infection from a deadly disease into a manageable chronic condition. However, adherence to daily oral drug intake remains an issue, as it is the most important determinant for sustained viral suppression and prevention of the emergence of drug-resistant viral strains. The long-acting injection antiretroviral cabotegravir and rilpivirine combination, a novel drug delivery approach, is about to revolutionise the therapy for people living with HIV. In this protocol, we aim to generate a clinically useful summary of the interventions based on their efficacy.

METHODS AND ANALYSIS

We searched the literature for eligible studies published from inception up to 16 August 2022 through PubMed, EMBASE, Cochrane Library, Scopus and ClinicalTrials.gov. Two methodologically trained researchers will select the qualified studies for data extraction independently. Cochrane Risk of Bias tool will be used to assess the risk of bias in included studies. Statistical heterogeneity will be computed by Cochrane X² and I² tests. Sensitivity analysis will be conducted to evaluate the stability of the results. Publication biases will be evaluated by Begg's and Egger's tests. The quality of evidence will be assessed by the Grading of Recommendations Assessment, Development and Evaluation system. The RevMan V.5.3 and Stata V.14.0 software will be applied for statistical analyses.

ETHICS AND DISSEMINATION

Ethical approval will not be required for this systematic review because the data used are not linked to the individual patient. The results of this review will be disseminated by being published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42022310414.

Low-level viraemia among people living with HIV in Nigeria: a retrospective longitudinal cohort study

BACKGROUND

HIV transmission can occur with a viral load of at least 200 copies per mL of blood and low-level viraemia can lead to virological failure; the threshold level at which risk for virological failure is conferred is uncertain. To better understand low-level viraemia prevalence and outcomes, we analysed retrospective longitudinal data from a large cohort of people living with HIV on antiretroviral therapy (ART) in Nigeria.

METHODS

In this retrospective cohort study using previously collected longitudinal patient data, we estimated rates of virological suppression (≤50 copies per mL), low-level viraemia (51-999 copies per mL), virological non-suppression (≥1000 copies per mL), and virological failure (≥2 consecutive virological non-suppression results) among people living with HIV aged 18 years and older who initiated and received at least 24 weeks of ART at 1005 facilities in 18 Nigerian states. We analysed risk for low-level viraemia, virological non-suppression, and virological failure using log-binomial regression and mixed-effects logistic regression.

FINDINGS

At first viral load for 402 668 patients during 2016-21, low-level viraemia was present in 64 480 (16·0%) individuals and virological non-suppression occurred in 46 051 (11·4%) individuals. Patients with low-level viraemia had increased risk of virological failure (adjusted relative risk 2·20, 95% CI 1·98-2·43; p<0·0001). Compared with patients with virological suppression, patients with low-level viraemia, even at 51-199 copies per mL, had increased odds of low-level viraemia and virological non-suppression at next viral load; patients on optimised ART (ie, integrase strand transfer inhibitors) had lower odds than those on non-integrase strand transfer inhibitors for the same low-level viraemia range (eg, viral load ≥1000 copies per mL following viral load 400-999 copies per mL, integrase strand transfer inhibitor: odds ratio 1·96, 95% CI 1·79-2·13; p<0·0001; non-integrase strand transfer inhibitor: 3·21, 2·90-3·55; p<0·0001).

INTERPRETATION

Patients with low-level viraemia had increased risk of virological non-suppression and failure. Programmes should revise monitoring benchmarks and targets from less than 1000 copies per mL to less than 50 copies per mL to strengthen clinical outcomes and track progress to epidemic control.

FUNDING

None.

Scientific Publication Patterns of Systematic Reviews on Psychosocial Interventions Improving Well-being: Bibliometric Analysis

Background

Despite numerous empirical studies and systematic reviews conducted on the effectiveness of interventions improving psychological well-being, there is no holistic overview of published systematic reviews in this field.

Objective

This bibliometric study explored the scientific patterns of the effectiveness of different psychosocial interventions improving well-being among various categories of individuals with mental and physical diseases, to synthesize well-being intervention studies, and to suggest gaps and further studies in this emerging field.

Methods

The bibliometric analysis included identifying the most productive authors, institutions, and countries; most explored fields and subjects of study; most active journals and publishers; and performing citation analysis and analyzing publication trends between 2014 and 2022. We focused on data retrieved from known databases, and the study was conducted with a proven bibliometric approach.

Results

In total, 156 studies were found concerning the research domains and retrieved using LENS software from high-ranking databases (Crossref, Microsoft Academic, PubMed, and Core). These papers were written in English by 100 authors from 24 countries, among which, the leading country was the United Kingdom. Descriptive characteristics of the publications involved an increased number of publications in 2017 (n=35) and 2019 (n=34) and a decreased number in 2021 (n=4). The top 2 leading authors by citation score are James Thomas (3 papers and 260 citations) and Chris Dickens (3 papers and 182 citations). However, the most cited study had 592 citations. BMJ Open (n=6 articles) is the leading journal in the field of medicine; Clinical Psychology Review (n=5), in psychology; and Frontiers in Psychology, in psychological intervention (n=5) and psychology (n=5). The top 2 publishers were Wiley (n=28) and Elsevier (n=25).

Conclusions

This study indicates an overall interest in the declared domains within the last decade. Our findings primarily indicate that psychosocial interventions (PIs) were evaluated as being effective in managing mental and physical problems and enhancing well-being. Cognitive behavioral therapy was assessed as being effective in treating anxiety, psychoeducation in relapse prevention, and gratitude interventions in improving overall health, and the mindfulness approach had a positive impact on decreasing distress and depression. Moreover, all these intervention types resulted in an overall increase in an individuals’ well-being and resilience. Integrating social and cultural factors while considering individual differences increases the efficiency of PIs. Furthermore, PIs were evaluated as being effective in managing symptoms of eating disorders, dementia, and cancer. Our findings could help provide researchers an overview of the publication trends on research domains of focus for further studies, since it shows current findings and potential research needs in these fields, and would also benefit practitioners working on increasing their own and their patients' well-being.

How Do Psychosocial Interventions for Adolescents and Young People Living With HIV Improve Adherence and Viral Load? A Realist Review

PURPOSE

Psychosocial interventions have the potential to support adolescents and young people living with HIV (AYPLHIV) to achieve better HIV outcomes. However, more evidence is needed to understand which interventions are most effective, and the mechanisms driving how they work in practice.

METHODS

We used realist methodologies to generate statements based on evidence from intervention studies and linked evidence included in a systematic review of psychosocial interventions for AYPLHIV. Key data were extracted from available sources to generate cases, including context-mechanism-outcome pathways. Higher level themes were refined iteratively to create a mid-range theory of how these interventions may work.

RESULTS

From 26 resulting cases, 8 statements were crafted, grouped into 3 overarching categories, to describe how these interventions worked. Interventions were overall found to set off mechanisms to improve adherence when (1) responding to individual-level factors to support AYPLHIV (via incorporating agency and empowerment, personalized and/or contextualized approaches, and self-care skills); (2) tailoring delivery strategies to address specific needs (via diverse strategies, longer duration, and digital delivery); and (3) providing supportive resources (via peer and broader support, and structural support and integration into existing services).

DISCUSSION

A collection of diverse mechanisms may individually or collectively drive improved outcomes for AYPLHIV engaged in psychosocial interventions. Recommendations for integrating our findings into practice are discussed.

Barriers and facilitators to scaling up Healthy Choices, a motivational interviewing intervention for youth living with HIV

Background

This study included Community Health Workers and their supervisors from HIV clinical care teams who participated in the Healthy Choices intervention program. Healthy Choices is a Motivational Interviewing-based intervention aimed at improving medication adherence and reducing alcohol use for adolescents and emerging adults ages 16—24 living with HIV. In this study, the intervention was “scaled up” for delivery by local HIV care providers in real-world clinic settings.

Methods

Providers (N = 21) completed semi-structured interviews (N = 29) about their experiences with intervention scale-up. Rigorous thematic analyses were conducted within discussions of barriers and facilitators of intervention implementation.

Results

Three dominant thematic areas emerged from the data: (1) perceptions of the Healthy Choices intervention, (2) engaging high risk YLH in in-person behavior interventions, and (3) perspectives on implementation of the intervention using local staff. Results offer insights into implementation of MI-based interventions for adolescents and emerging adults in clinic settings using local clinical staff instead of dedicated research staff.

Conclusions

Overall, scaled-up intervention programs for youth are challenged to maintain scientific rigor, provide rigorous training and supports, and offer an attractive and engaging program.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08453-w.

Care engagement with healthcare providers and symptom management self-efficacy in women living with HIV in China: secondary analysis of an intervention study

Background

Symptom management self-efficacy is a prerequisite for individuals to fully manage their symptoms. The literature reports associations between engagement with healthcare providers (HCPs), internalized stigma, and types of self-efficacy other than symptom management. However, the factors of symptom management self-efficacy are not well understood. This study aimed to investigate the relationship among engagement with HCPs, internalized stigma, and HIV symptom management self-efficacy in Chinese women living with HIV (WLWH).

Methods

This current analysis was part of the original randomized control trial, we used data collected from 41 women living with HIV (WLWH) assigned to an intervention arm or a control arm from Shanghai and Beijing, China, at baseline, Week 4 and Week 12. The CONSORT checklist was used. The study was registered in the Clinical Trial Registry (#NCT03049332) on 10/02/2017.

Results

The results demonstrate that HCPs should increase engagement with WLWH when providing care, thereby improving their symptom management self-efficacy. The results suggested that participants’ engagement with HCPs was significantly positively correlated with their HIV symptom management self-efficacy in the latter two time points. Internalized stigma was significantly negatively correlated with HIV symptom management self-efficacy only at the 4-week follow-up.

Conclusions

This study demonstrated the positive effect of engagement with HCPs on WLWHs’ symptom management self-efficacy as well as the negative effect of internalized stigma on symptom management self-efficacy. Future research can further test the relationship between the three key concepts, as well as explore interventions to decrease internalized stigma.

Hearing From Men Living With HIV: Experiences With HIV Testing, Treatment, and Viral Load Suppression in Four High-Prevalence Countries in Sub-Saharan Africa

Engaging men in HIV services remains a challenge across sub-Saharan Africa. There is a critical need to better understand facilitators of men's successful engagement with HIV services and assess if there are similarities across contexts. We conducted in-depth interviews and focus group discussions with 92 men living with HIV (MLHIV) across Malawi, Uganda, South Africa, and Eswatini, most of whom had been diagnosed with HIV within the last 5 years. We coded interviews for themes using a constant-comparative approach. We contextualized our findings within a socioecological framework. HIV testing was primarily motivated by illness (individual level), though illness was sometimes accompanied by prompting and support from healthcare providers and/or intimate partners. Once diagnosed, nearly all participants reported immediate linkage to care, initiation of antiretroviral therapy (ART), and subsequent ART adherence. ART initiation and adherence were facilitated by men's sense of agency and ownership over their health (individual level), social support from intimate partners, friends, and family (interpersonal/network level), supportive-directive counseling from healthcare providers (institutional/health systems level), and male-friendly services, i.e., rapid, respectful, private (institutional/health systems level). Health literacy regarding viral suppression (individual level), strengthened by patient-provider communication (institutional/health systems level), was highest in Uganda, where most men could discuss viral load testing experiences, report their viral load status (most reported suppressed), and demonstrate an understanding of treatment as prevention. Elsewhere, few participants understood what viral load suppression was and even fewer knew their viral load status. Our findings reveal socioecological-level facilitators of men's progress across the HIV-care continuum. Programs may want to leverage facilitators of ART initiation and adherence that span socioecological levels—e.g., healthcare ownership and agency, social support, supportive-directive counseling—and apply them to each end of the continuum to encourage early HIV testing/diagnosis and improve health literacy to help men understand and achieve viral load suppression.

Role of religious beliefs on antiretroviral treatment adherence among Pentecostal Christians in sub-Saharan Africa: a scoping review protocol

INTRODUCTION

Sub-Saharan Africa continues to be disproportionately affected by HIV/AIDS. As such, several countries in sub-Saharan Africa are implementing the UNAIDS' recommendation to test and treat people living with HIV (PLHIV) irrespective of their CD4 count. However, most of the antiretroviral treatment (ART) programmes, in this region, continue to struggle with poor adherence to treatment stemming from patient-related factors including their religious beliefs. Unfortunately, the role of religious beliefs on ART adherence has been underexplored in the literature. In this study protocol, we propose the steps of a scoping review to explore, identify and map the literature on the impact of religious beliefs on adherence to ART among Pentecostals living with HIV in sub-Saharan Africa.

METHODS AND ANALYSIS

We will use Arksey and O'Malley's framework and the Joanna Briggs Institute methodology guidelines to conduct this scoping review. The following databases will be searched for relevant literature: Web of Science, PubMed/Medline, Psych-ARTICLES, Academic Search Complete, Cumulative Index of Nursing, Allied Health, Google Scholar and published articles from conference proceedings. Studies published between January 2010 and February 2022 will be eligible. The identified literature will be independently screened for eligibility by two reviewers based on predetermined inclusion and exclusion criteria. An Excel form will be designed to electronically capture data from studies that meet the inclusion criteria. Finally, we will use a narrative synthesis to summarise the data extracted to report on the nature of existing evidence and the impact of religious beliefs on ART adherence.

ETHICS AND DISSEMINATION

Ethical approval will not be required for the scoping review since it will entail synthesising information from already published articles and conference proceedings. The study findings will be disseminated through publication in a scientific journal and presented at conferences and workshops aimed at improving adherence to ART in PLHIV.

The Situated Information, Motivation, and Behavioral Skills Model of HIV Antiretroviral Therapy Adherence Among Persons Living With HIV in Haiti: A Qualitative Study Incorporating Culture and Context

ABSTRACT

To inform a clinic-based adherence-promotion intervention, this qualitative study applied the Situated Information, Motivation, and Behavioral Skills Model of Care Initiation and Maintenance to elucidate cultural and contextual factors affecting antiretroviral therapy adherence in Haiti. From the 23 focus group discussions with patients (n = 58) and health care workers (n = 57), culturally specific themes emerged relating to Information (e.g., conflicts with allopathic medicine and heuristics about how treatment failure occurs), Motivation (e.g., protecting family members, health and physical appearance, material advantages, and relationships with health workers), and Behavioral Skills (e.g., managing food intake and side effects, navigating health services utilization, accessing medication, and advocating for care needs). Recommendations include: provide therapeutic education on HIV drug resistance; promote the concept of "undetectable = untransmittable"; develop treatment buddy relationships; invest in training and enforcement of patient privacy, transparency, and fairness in access to services and resources; and provide patient-centered behavioral skills counseling.

Use of long-acting injectable antiretroviral agents for human immunodeficiency Virus: A review

The development of potent antiretroviral drugs has significantly reduced morbidity and mortality associated with human immunodeficiency virus infection, however, the effectiveness of these medications depends upon consistent daily oral intake. Non-adherence can lead to the emergence of resistance, treatment failure and disease progression. This has necessitated the development of long-acting antiretroviral formulations administrable via an infrequent dosing regimen. Long-acting injectable forms of cabotegravir and rilpivirine have reached various stages in clinical trials both for the treatment and prevention of HIV. Other long-acting agents are at various stages of development. This review evaluates the current research on the development of long-acting injectable antiretroviral agents for the treatment and prevention of HIV.

Association between adherence to Antiretroviral Therapy and place of residence among adult HIV infected patients in Ethiopia: A systematic review and meta-analysis

Background

According to the World Health Organization, optimal adherence to Antiretroviral Therapy (ART) improves quality of life. Patients who use ART have varying characteristics in terms of where they live. The effect of place of residence on ART adherence is unclear in Ethiopia. Therefore, the aim of this systematic review and meta-analysis was to estimate the pooled association between place of residence and adherence to ART.

Methods

Articles were retrieved from PubMed, Scopus, African Journals Online (AJOL), Journal Storage (JSTOR), and Web of Science. The data was extracted using Microsoft Excel 2016 spreadsheet. Review Manager 5.3 and STATA version 14 were used for the analysis. The Cochrane Q statistic was used to assess between-study heterogeneity. I² was used to quantify between-study heterogeneity. A weighted inverse variance random-effects model was used to calculate the pooled odds ratio with 95% confidence interval.

Results

Seven studies were included in this systematic review and meta-analysis. The Begg’s test (Z = 0.15, P = 0.881) and Egger’s test (t = 0.14, P = 0.894) revealed no evidence of publication bias. Urban residence was associated with an increased likelihood of good adherence (OR 2.07, 95%CI 1.22–3.51).

Conclusions

The study recommends that policy-makers should enact policies that increase access to ART services in a rural area in order to improve adherence. It is recommended that implementation studies be conducted in order to identify practical and affordable interventions.

Cultural considerations in health care capacity building: A qualitative study in Lesotho

International non-governmental organisations (NGOs) and academic institutions support health care capacity building to strengthen health systems in low and middle-income countries. We conducted a phenomenological study of foreign and Basotho clinicians who participated in clinical continuing professional development (CPD) in Lesotho. Clinicians included physicians, nurses, and a nutritionist. We sought to understand, through the lens of social cognitive theory, how cultural differences between foreign and Basotho clinicians affected bidirectional clinical education led by NGOs and academic institutions. We also assessed how Basotho clinical educators considered culture when leading NGO-sponsored clinical CPD for Basotho clinicians. After analysing 17 interviews with 24 total participants (four foreign educators, 11 Basotho educators, and nine Basotho learners), using an iterative and inductive approach, we identified 17 themes within the cognitive, environmental, and behavioural domains. Key findings highlighted: (1) cultural tensions between foreign and Basotho culture, including bias against traditional culture; (2) power structures which affected the efficacy of in-service training strategies; (3) perceptions among foreign educators that technical assistance was more effective than direct service delivery at promoting education and sustainability. Educators should map out key relationships and engage local and foreign stakeholders in culturally-focused targeted needs assessments to improve curricular design in capacity building.

Community and health system factors associated with antiretroviral therapy initiation among men and women in Malawi: a mixed methods study exploring gender-specific barriers to care

BACKGROUND

Although community and health system factors are known to be critical to timely antiretroviral therapy (ART) initiation, little is known about how they affect men and women.

METHODS

We examined community- and health system-level factors associated with ART initiation in Malawi and whether associations differ by gender; 312 ART initiates and 108 non-initiates completed a survey; a subset of 30 individuals completed an indepth interview. Quantitative data were analyzed using univariate and multivariate logistic regressions, with separate models by gender. Qualitative data were analyzed through constant comparison methods.

RESULTS

Among women, no community-level characteristics were associated with ART initiation in multivariable models; among men, receiving social support for HIV services (adjusted OR [AOR]=4.61; p<0.05) was associated with ART initiation. Two health system factors were associated with ART initiation among men and one for women: trust that accessing ART services would not lead to unwanted disclosure (women: AOR=4.51, p<0.01; men: AOR=1.71, p<0.01) and trust that clients were not turned away from ART services (men: 12.36, p=0.001).

CONCLUSIONS

Qualitative data indicate that men were concerned about unwanted disclosure due to engaging in ART services and long waiting times for services. Interventions to remove health system barriers to ART services should be explored to promote social support among men.

HIV Community-Level Stigmatizing Attitudes in Tanzania: Perspectives from Antenatal Care

INTRODUCTION

Stigma significantly impacts retention in HIV care and quality of life among people living with HIV. This study explored community-level HIV stigma from the perspective of patients and healthcare workers in antenatal care (ANC) in Moshi, Tanzania.

METHODS

We conducted in-depth interviews with 32 women (20 living with HIV), key-informant interviews with 7 ANC clinic employees, and two focus group discussions with 13 community health workers.

RESULTS

Themes emerged related to drivers and manifestations of stigma, resilience to stigmatizing attitudes, and opportunities to address stigma in ANC. Drivers of stigma included a fear of infection through social contact and associations of HIV with physical weakness (e.g., death, sickness) and immoral behaviour (e.g., sexual promiscuity). Manifestations included gossip, physical and social isolation, and changes in intimate relationships. At the same time, participants identified people who were resilient to stigmatizing attitudes, most notably individuals who worked in healthcare, family members with relevant life experiences, and some supportive male partners.

CONCLUSION/RECOMMENDATIONS

Supportive family members, partners, and healthcare workers can serve as role models for stigma-resilient behaviour through communication platforms and peer programs in ANC. Manifestations of HIV stigma show clear links to constructs of sexuality, gender, and masculinity, which may be particularly impactful during pregnancy care. The persistence of stigma emphasizes the need for innovation in addressing stigmatizing attitudes in the community. Campaigns and policies should go beyond dispelling myths about HIV transmission and immorality to innovate peer-led and couples-based stigma reduction programming in the ANC space.

Concerns of Parental HIV Disclosure in China

Although parental HIV disclosure has benefits for parents and children, the disclosure rate among parents remains low. This study aims to qualitatively examine parental concerns regarding disclosure of their HIV status to their children. Eighty parents were enrolled in a randomized controlled trial of a three-session disclosure-support intervention, with forty receiving the intervention and forty receiving treatment as usual. Intervention sessions were audio recorded, and transcriptions were qualitatively coded for content related to concerns of disclosure. Four themes emerged: Intention to disclose, disclosure approach, indicators for disclosure, and fears about disclosure. These themes reveal struggles that parents experience when considering HIV disclosure suggesting that an effective disclosure intervention must help parents assess pros and cons, discuss the emotions of the children after the disclosure, and monitor the impact on children's lives after disclosure over time. Future research is needed to implement interventions supporting HIV-positive parents' disclosure decision-making and actions.

"Most of what they do, we cannot do!" How lay health workers respond to barriers to uptake and retention in HIV care among pregnant and breastfeeding mothers in Malawi

BACKGROUND

In the era of Option B+ and 'treat all' policies for HIV, challenges to retention in care are well documented. In Malawi, several large community-facility linkage (CFL) models have emerged to address these challenges, training lay health workers (LHW) to support the national prevention of mother-to-child transmission (PMTCT) programme. This qualitative study sought to examine how PMTCT LHW deployed by Malawi's three most prevalent CFL models respond to known barriers to access and retention to antiretroviral therapy (ART) and PMTCT.

METHODS

We conducted a qualitative study, including 43 semi-structured interviews with PMTCT clients; 30 focus group discussions with Ministry of Health (MOH)-employed lay and professional providers and PMTCT LHWs; a facility CFL survey and 2-4 hours of onsite observation at each of 8 sites and in-depth interviews with 13 programme coordinators and MOH officials. Thematic analysis was used, combining inductive and deductive approaches.

RESULTS

Across all three models, PMTCT LHWs carried out a number of 'targeted' activities that respond directly to a range of known barriers to ART uptake and retention. These include: (i) fulfilling counselling and educational functions that responded to women's fears and uncertainties; (ii) enhancing women's social connectedness and participation in their own care and (iii) strengthening service function by helping clinic-based providers carry out duties more efficiently and effectively. Beyond absorbing workload or improving efficiency, however, PMTCT LHWs supported uptake and retention through foundational but often intangible work to strengthen CFL, including via efforts to strengthen facility-side responsiveness, and build community members' recognition of and trust in services.

CONCLUSION

PMTCT LHWs in each of the CFL models examined, addressed social, cultural and health system factors influencing client access to, and engagement with, HIV care and treatment. Findings underscore the importance of person-centred design in the 'treat-all' era and the contribution LHWs can make to this, but foreground the challenges of achieving person-centredness in the context of an under-resourced health system. Further work to understand the governance and sustainability of these project-funded CFL models and LHW cadres is now urgently required.

"When I receive the message, it is a sign of love": symbolic connotations of SMS messages for people living with HIV in Burkina Faso

Mobile health (mHealth) has gained considerable interest recently due to its potential to improve health outcomes in developing countries with high outreach yet low costs. Several studies have explored the use of short message service (SMS) reminders to improve antiretroviral (ARV) retention and adherence, with mixed results. The majority of these studies has a quantitative nature and employs randomized designs, which do not provide further qualitative insights about other possible impacts of the messages. Based on the qualitative assessment of an SMS intervention in Burkina Faso, which complemented a (quantitative) Randomized Controlled Trial (RCT), we show that beyond the functional role of improving ARV retention and adherence, SMS messages can also play important symbolic roles in offering psychosocial support to people living with HIV (PLHIV) and improving their perception of life. Concomitantly, we show that sufficient (ICT) literacy skills cannot be taken for granted in resource-poor settings. Yet, regardless of (ICT) literacy skills, the symbolism of care was perceived. Furthermore, we highlight the importance of complementing quantitative evidence of mHealth interventions with qualitative assessments.

Qualitative exploration of perceived benefits of care and barriers influencing HIV care in trans Nzoia, Kenya

Background

Substantial efforts have been made to ensure people living with HIV (PLHIV) are linked to and retained in care but many challenges deter care utilization. We report perceived benefits of seeking HIV care and barriers to HIV care that were identified through a formative assessment conducted to advise the development of an alternative care model to deliver antiretroviral treatment therapy (ART) in Trans Nzoia County, Kenya.

Methods

Data were collected in 2015 through key informant interviews (KIIs), in-depth interviews (IDIs), and focus group discussions (FGDs). The study involved 55 participants of whom 53% were female. Ten KIIs provided community contextual information and viewpoints on the HIV epidemic in Trans Nzoia County while 20 PLHIV (10 male and 10 female) participated in IDIs. Twenty-five individuals living with HIV participated in four FGDs - two groups for men and two for women. Key informants were purposively selected, while every third patient above 18 years at the Kitale HIV Clinic was invited to share their HIV care experience through IDIs or FGDs. Trained research assistants moderated all sessions and audio recordings were transcribed and analyzed thematically.

Results

Findings showed that PLHIV in Trans Nzoia County used both conventional and complementary alternative care for HIV; however, public health facilities were preferred. Popular perceived benefits of adopting care were relief from symptoms and the chance to live longer. Benefits of care uptake included weight gain, renewed energy, and positive behavior change. Individual-level barriers to HIV care included lack of money and food, use of alternative care, negative side effects of ART, denial, and disclosure difficulties. At the community level, stigma, limited social support for conventional HIV treatment, and poor means of transport were reported. The health system barriers were limited supplies and staff, long distance to conventional HIV care, and unprofessional providers.

Conclusions

Diverse individual, community and health system barriers continue to affect HIV care-seeking efforts in Kenya. Appreciation of context and lived experiences allows for development of realistic care models.

Preliminary Effects of a Mobile Interactive Supervised Therapy Intervention on People Living With HIV: Pilot Randomized Controlled Trial

BACKGROUND

As people living with HIV infection require lifelong treatment, nonadherence to medication will reduce their chance of maintaining viral suppression and increase the risk of developing drug resistance and HIV transmission.

OBJECTIVE

This study aimed to evaluate the efficacy of a mobile app, Mobile Interactive Supervised Therapy (MIST), for improving adherence to oral HIV medications among HIV-infected adults in Singapore.

METHODS

We conducted a two-group pilot randomized controlled trial (RCT) with a process evaluation, in which 40 HIV-infected participants with once-daily medication regimes were recruited from a public tertiary hospital in Singapore and randomly assigned equally to either the intervention (receiving MIST and routine care) or control (receiving routine care only) groups. The intervention lasted for 2 months. The outcome of antiretroviral therapy (ART) adherence was measured by a 7-day recall self-report (SR), pill count (PC), an electronic medical device-Medication Event Monitoring System (MEMS)-and a mobile app-MIST (for the intervention group only). In total, 20 participants from the intervention group were interviewed at the end of the intervention to assess the acceptability of MIST. Data were collected at baseline and at 1-month and 2-month postintervention.

RESULTS

All participants had excellent medication adherence at baseline (median 100, IQR 100-100). The use of MIST did not result in a significant improvement in ART adherence when measured by the SR, PC, and MEMS, as compared with the control group at 1-month (P values >.99, .86, and .74, respectively) and 2-month (P values=.80, .84, and .82, respectively) postintervention. ART adherence also did not improve in each group over the same period. MIST was perceived to be a beneficial tool based on the process evaluation results.

CONCLUSIONS

Although MIST did not enhance medication adherence to HIV treatments, mainly owing to the ceiling effect, it was perceived to be beneficial among the participants of this study. Our process evaluation provided useful data to further develop MIST for bigger and long-term mobile phone app-assisted intervention RCTs in the future.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03794648; https://clinicaltrials.gov/ct2/show/NCT03794648.

Barriers to Professional Mental Health Help-Seeking Among Chinese Adults: A Systematic Review

BACKGROUND

A large number of Chinese suffer from common mental disorders (e.g., depression, anxiety, stress, and post-traumatic stress disorder), but treatment seeking is typically low in this population. It is unclear what barriers influence professional mental health help-seeking behavior within the Chinese population. Identifying these barriers could assist in implementation science efforts to reach this population.

OBJECTIVE

This review systematically synthesizes findings related to the barriers to professional mental health help-seeking among Chinese adults.

METHODS

Two English language databases (PubMed and PsycINFO) and two Chinese databases (WANFANGDATA and CNKI) were searched to find relevant studies. Quality assessment was conducted in identified studies. Quantitative findings were tabulated and frequently reported barriers were ranked. Primary data obtained from qualitative studies were thematically analyzed.

RESULTS

Of 6,933 citations identified, 17 met inclusion criteria. There were 11 (64%) studies that reported quantitative methods; 3 (18%) employed qualitative research, and 3 (18%) mixed methods. Results indicated that frequently reported barriers to mental health help seeking among Chinese adults included a preference on self-reliance, seeking help from alternative sources, low perceived need toward help-seeking, a lack of affordability, negative attitude toward, or poor experiences with help-seeking. Less frequently mentioned barriers included stigma, families' opposition, limited knowledge about mental illness, a lack of accessibility, unwillingness to disclose mental illness, and fear of burdening family.

CONCLUSIONS

The current review identified a number of key barriers to help-seeking behavior. Effective strategies are needed to promote professional help-seeking among Chinese adults. Additional factors influencing professional mental health help-seeking need to be further investigated, as they may contribute to a better understanding the help-seeking behavior among Chinese.

Assessing mobile health feasibility and acceptability among HIV-infected cocaine users and their healthcare providers: guidance for implementing an intervention

BACKGROUND

Mobile health (mHealth) can provide innovative, cost-effective strategies to improve medication adherence and optimize HIV treatment outcomes. Very little, however, is known about the acceptability and feasibility of mHealth among people with HIV (PWH) who use drugs. Our study objective was to assess feasibility, acceptability, and barriers and facilitators of implementing an mHealth intervention among PWH who are cocaine users, a group for whom no pharmacological treatment to reduce cocaine use is available.

METHODS

Five focus groups (FGs) (N=20) were conducted with PWH who self-reported cocaine use in the past 30 days, with 3 groups (N=8) of healthcare providers. Topics included previous experience with smartphones; barriers and facilitators of mobile technology for health purposes; and attitudes toward receiving types of feedback about adherence.

RESULTS

Patients preferred text reminders over phone calls for reasons of privacy, accessibility and economizing phone minutes. Direct communication via text messages and phone calls was considered more appropriate for social workers and case managers, who have greater frequency of communication and deeper relationships with patients, and less so for doctors, who see patients less regularly than community health workers. Patients seem particular about who has what information, and overall, they seem to prefer that their medical information, especially HIV-related, stay within the confines of patient-provider relationships.

CONCLUSIONS

HIV still provokes stigma and makes health information particularly sensitive for both providers and patients. The rise of mobile technology and related applications such as mHealth, means that new norms have to be established for its use. Participants' suggestions and feedback informed the design of a subsequent mHealth pilot randomized control trial to improve medication adherence.

A global bibliometric analysis of antiretroviral treatment adherence: implications for interventions and research development (GAPRESEARCH)

The introduction of antiretroviral therapy (ART) has helped HIV population to live longer, but they could face not only AIDS-related morbidity but also other non-communicable diseases. Paying attention to ART adherence requires a system thinking with the life-long factors, individual-environment interactions and contextualized dynamics. Although several quantitative research had been conducted, they were not able to fully demonstrate the development of research approaches and scopes of previous studies. Essential and practical public health policy should be based on the most accessible and strategically analyzed evidence. Therefore, our study uses a scientometric approach to supplement previous reviews research covering until the end of 2017. Using a combination of two quantitative approaches to supplement previous reviews, we attempt to identify the research trends and potential research gaps which could be very helpful for policies and practices enhancements to inform evidence-based strategies. Our result indicates countries tend to collaborate in traditional models rather than prioritize severity and characteristics of HIV epidemics. Further ART research should highlight the incorporation of newly developed technology to examine long-term impacts, combine multiple measures, address contextual factors, and involve available technologies and resources, e.g., family, community.

Acceptability and feasibility of short message service to improve ART medication adherence among people living with HIV/AIDS receiving antiretroviral treatment at Adama hospital medical college, Central Ethiopia

Background

People living with HIV/AIDS are facing sub-optimal adherence to antiretroviral therapy. Short message service innovative strategies have been recommended by the national strategy to support medication adherence among HIV positive people. Thus, this study was conducted to examine the feasibility and acceptability of a short message service to improve medication adherence among people living with HIV/AIDS receiving Antiretroviral Treatment.

Methods

We conducted a cross-sectional survey, from February 5 to 30, 2018, among 422 randomly selected adults living with HIV/AIDS receiving antiretroviral treatment at Adama Hospital. Interviewer administered structured questionnaire was used to collect quantitative data on the feasibility and acceptability of short message services, socio-demographic and clinical characteristics of participants. Qualitative data were also collected from two focus groups to supplement the quantitative findings. Logistic regression analysis was performed to identify factors associated with the feasibility and acceptability of short message services.

Results

Of 420 participants responded to our questionnaire, about nine of ten patients (93.8%) possessed had a mobile phone. Most of the patients (90.9%) were willing to accept SMS to improve their medication adherence. Patients who were in young age, early adult, disclosed their HIV status, having cell phone always and believe short message service aid adherence were more likely to accept short messages on adherence. On the other hand, frequent ART Clinic visit and perceived low confidentiality of short message service were negatively associated with acceptability of short message service.

Conclusion

The acceptability of short message service on adherence to antiretroviral therapy was high among people living with HIV/AIDS central Ethiopia. Authors recommend further studies, piloting or experimenting, that validate the acceptability, feasibility, effectiveness, and scalability of the intervention.

Enablers and barriers to treatment adherence in heterozygous familial hypercholesterolaemia: a qualitative evidence synthesis

OBJECTIVES

Individuals with heterozygous familial hypercholesterolaemia (FH) are at high risk of developing cardiovascular disease (CVD). This risk can be substantially reduced with lifelong pharmacological and lifestyle treatment; however, research suggests adherence is poor. We synthesised the qualitative research to identify enablers and barriers to treatment adherence.

DESIGN

This study conducted a thematic synthesis of qualitative studies.

DATA SOURCES

MEDLINE, Embase, PsycINFO via OVID, Cochrane library and CINAHL databases and grey literature sources were searched through September 2018.

ELIGIBILITY CRITERIA

We included studies conducted in individuals with FH, and their family members, which reported primary qualitative data regarding their experiences of and beliefs about their condition and its treatment.

DATA EXTRACTION AND SYNTHESIS

Quality assessment was undertaken using the Critical Appraisal Skills Programme for qualitative studies. A thematic synthesis was conducted to uncover descriptive and generate analytical themes. These findings were then used to identify enablers and barriers to treatment adherence for application in clinical practice.

RESULTS

24 papers reporting the findings of 15 population samples (264 individuals with FH and 13 of their family members) across 8 countries were included. Data captured within 20 descriptive themes were considered in relation to treatment adherence and 6 analytical themes were generated: risk assessment; perceived personal control of health; disease identity; family influence; informed decision-making; and incorporating treatment into daily life. These findings were used to identify seven enablers (eg, 'commencement of treatment from a young age') and six barriers (eg, 'incorrect and/or inadequate knowledge of treatment advice') to treatment adherence. There were insufficient data to explore if the findings differed between adults and children.

CONCLUSIONS

The findings reveal several enablers and barriers to treatment adherence in individuals with FH. These could be used in clinical practice to facilitate optimal adherence to lifelong treatment thereby minimising the risk of CVD in this vulnerable population.

PROSPERO REGISTRATION NUMBER

CRD42018085946.

"I take my pills every day, but then it goes up, goes down. I don't know what's going on": Perceptions of HIV virological failure in a rural context in Mozambique. A qualitative research study

Background

HIV prevalence in Mozambique is estimated to be 13.2%. Routine viral load for HIV monitoring was first implemented in the rural area of Tete in 2014. Programmatic data showed an unexpected high proportion of high viral load results, with up to 40% of patients having a viral load above 1000 copies/ml.

Objectives

This qualitative study aimed to explore perceptions about virological failure and viral load monitoring from the perspective of HIV positive patients on first-line antiretroviral therapy (ART) and health-care workers.

Methods

The study was conducted in seven rural communities in Changara-Marara district, Tete province, Mozambique. A total of 91 participants took part in in-depth interviews (IDIs) and focus group discussions (FGDs), including health-care workers (n = 18), patients on ART in individual care or Community Adherence Groups (CAGs) who experienced virological failure and virological re-suppression (n = 39) and CAG focal points (n = 34). Purposive sampling was used to select participants. Interviews and FGDs were conducted in Nhuengue and Portuguese. IDIs and FGDs were translated and transcribed before being coded and thematically analysed.

Results

Emergent themes showed that patients and health-care workers attributed great importance to viral load monitoring. A supressed viral load was viewed by participants as a predictor of good health and good adherence. However, some patients were confused and appeared distressed when confronted with virological failure. Viral load results were often little understood, especially when virological failure was detected despite good adherence. Inadequate explanations of causes of virological failure, delayed follow-up viral load results, repeated blood tests and lack of access to second-line ART resulted in reduced confidence in the effectiveness of ART, challenged the patient-provider relationship and disempowered patients and providers.

Conclusion

In this rural context undetectable viral load is recognized as a predictor of good health by people living with HIV and health-care workers. However, a lack of knowledge and health system barriers caused different responses in patients and health-care workers. Adapted counselling strategies, accelerated viral load follow-up and second-line ART initiation in patients with virological failure need to be prioritized.

A triaged real-time alert intervention to improve antiretroviral therapy adherence among young African American men who have sex with men living with HIV: focus group findings

BACKGROUND

Among persons living with HIV, poorer antiretroviral therapy adherence has been reported in African Americans and disproportionate mortality reported in young African American men who have sex with men (AAMSM) compared to whites. We report the results of focus groups with young AAMSM living with HIV that explore their opinions about the acceptability and feasibility of a triaged real-time missed dose alert intervention to improve treatment adherence. The purpose of this study is to develop a theory-driven triaged real-time adherence monitoring intervention to promote HIV medication adherence in young AAMSM.

METHODS

We performed five focus groups and two individual interviews among young HIV-positive AAMSM (n = 25) in Chicago guided by the Technology Acceptance Model and explored perceptions regarding the monitoring concept including device issues and concerns about inclusion of support persons whose involvement is triggered by sustained missed doses. The purpose was to inform the development of this intervention in this population.

RESULTS

Generally, the participants found the proposed intervention acceptable and useful. Privacy was a major concern for participants especially with attention to possible disclosure of their HIV status by receiving a medication-related text that someone else might view and could lead to unwanted attention. There was concern that the device could be confused with a taser. Approximately half of the men already had a close personal contact that helped them with medication taking. Some participants acknowledged that the notification might lead to friction.

CONCLUSIONS

A triaged real-time alert intervention to improve treatment adherence is acceptable and feasible among young AAMSM living with HIV.

Challenges and support for quality of life of youths living with HIV/AIDS in schools and larger community in East Africa: a systematic review

BACKGROUND

Youths living with HIV/AIDS (YLWHA) experience innumerable challenges within schools and the larger community. Nonetheless, these environments are potential sources of support for such youths. This review provides a synthesis of evidence about these challenges and support available for YLWHA to inform the design and implementation of interventions that support the wellbeing of youths living with HIV/AIDS in an East African context.

METHODS

We searched MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, and Cochrane central registry of systematic reviews and randomized control trials for studies conducted in East Africa and published in English in the last 10 years (March 2007 to March 2017). We also searched Google Scholar and reference lists of all included studies. We purposed to include both qualitative and quantitative data but no quantitative data merited inclusion. We analyzed qualitative data using a framework thematic analysis.

RESULTS

We included 16 primary studies conducted in clinic and community settings that used qualitative or mixed methods. Three overarching themes-psychosocial wellbeing, treatment and health, and disclosure of HIV status together with a sub-theme of stigma that was important across the three overarching themes-were the basis for analysis. In each overarching theme, a duality of challenges versus support was reported. Psychosocial wellbeing included subthemes of challenges in schools and larger community, financial challenges, domestic violence, sexual and reproductive health challenges, and psychosocial support.

CONCLUSION

YLWHA experience numerous challenges and support needs, some of which occur in schools and affect their QoL. The effects of these challenges are poor health and educational outcomes as well as school dropout. The schools in which youths spend most of their formative years have not provided adequate support for YLWHA. This review identified that although most of the challenges that studies identified arose from within schools and that a few supportive approaches were available, none of the studies explored how these supportive approaches would work in schools. It was additionally identified that stigma complicates challenges of living with HIV/AIDS necessitating interventions for the wellbeing of YLWHA to understand and address HIV-stigma and its ramifications. Such interventions ought to be sustainable in schools, culturally appropriate, and multidisciplinary in order to promote the general health of all students.

Impact of lay health worker programmes on the health outcomes of mother-child pairs of HIV exposed children in Africa: A scoping review

BACKGROUND

Increased demand for healthcare services in countries experiencing high HIV disease burden and often coupled with a shortage of health workers, has necessitated task shifting from professional health workers to Lay Health Workers (LHWs) in order to improve healthcare delivery. Maternal and Child Health (MCH) services particularly benefit from task-shifting to LHWs or similar cadres. However, evidence on the roles and usefulness of LHWs in MCH service delivery in Sub-Saharan Africa (SSA) is not fully known.

OBJECTIVES

To examine evidence of the roles and impact of lay health worker programmes focusing on Women Living with HIV (WLH) and their HIV-exposed infants (HEIs).

METHODS

A scoping review approach based on Arksey and O'Malley's guiding principles was used to retrieve, review and analyse existing literature. We searched for articles published between January 2008 and July 2018 in seven (7) databases, including: MEDLINE, Embase, PsycINFO, Joanna Briggs, The Cochrane Library, EBM reviews and Web of Science. The critical constructs used for the literature search were "lay health worker", "community health worker", "peer mentor", "mentor mother," "Maternal and Child health worker", "HIV positive mothers", "HIV exposed infants" and PMTCT.

RESULTS

Thirty-three (33) full-text articles meeting the eligibility criteria were identified and included in the final analysis. Most (n = 13, 39.4%) of the included studies were conducted in South Africa and used a cluster RCT design (n = 13, 39.4%). The most commonly performed roles of LHWs in HIV specific MCH programmes included: community engagement and sensitisation, psychosocial support, linkage to care, encouraging women to bring their infants back for HIV testing and supporting default tracing. Community awareness on Mother to Child Transmission of HIV (MTCT), proper and consistent use of condoms, clinic attendance and timely HIV testing of HEIs, as well as retention in care for infected persons, have all improved because of LHW programmes.

CONCLUSION

LHWs play significant roles in the management of WLH and their HEIs, improving MCH outcomes in the process. LHW interventions are beneficial in increasing access to PMTCT services and reducing MTCT of HIV, though their impact on improving adherence to ART remains scanty. Further research is needed to evaluate ART adherence in LHW interventions targeted at WLH. LHW programmes can be enhanced by increasing supportive supervision and remuneration of LHWs.

"We need them as much as they need us": A systematic review of the qualitative evidence for possible mechanisms of effectiveness of animal-assisted intervention (AAI)

OBJECTIVE

Although Animal-Assisted Interventions (AAI) are effective treatments for a variety of psychological problems, the mechanism of treatment effectiveness remains unclear. Qualitative studies of AAI may reveal possible mechanisms. This review aims to synthesize qualitative research and identify factors that might contribute to the effectiveness of AAI.

METHODS

A literature search of qualitative evidence published before August 8th, 2018 was conducted using the following databases: PubMed, ERIC, PsycARTICLES, PsycINFO, and HABRI, with the aim of identifying qualitative research conducted with individuals undergoing AAI. Quality assessment was undertaken by CASP and the certainty of the evidence was evaluated using CERQual.

RESULTS

A total of 1866 articles were reviewed, and seven were included in the final analysis. A total of six themes were identified as factors relating to the effectiveness of AAI: 1. Fostering feelings of normalcy, 2. Improving behavioral activation, 3. Self-esteem enhancement, 4. Physical contact, belonging, and companionship, 5. Calming and comforting, and 6. Distraction. Barriers to AAI effectiveness were also identified.

CONCLUSION

The results of these studies suggest that AAI was viewed as a positive and highly accepted intervention across populations and settings. AAI might be a useful intervention among people who suffer from a variety of mental disorders. All themes consistently demonstrated that contact with a live animal is more important than the appearance of the animal. Additional investigations of AAI treatment mechanisms are needed.

"If you are here at the clinic, you do not know how many people need help in the community": Perspectives of home-based HIV services from health care workers in rural KwaZulu-Natal, South Africa in the era of universal test-and-treat

Background

Limited engagement in clinic-based care is affecting the HIV response. We explored the field experiences and perceptions of local health care workers regarding home-based strategies as opportunities to improve the cascade of care of people living with HIV in rural South Africa as part of a Universal Test-and-Treat approach.

Methods

In Hlabisa sub-district, home-based HIV services, including rapid HIV testing and counselling, and support for linkage to and retention in clinic-based HIV care, were implemented by health care workers within the ANRS 12249 Treatment-as-Prevention (TasP) trial. From April to July 2016, we conducted a mixed-methods study among health care workers from the TasP trial and from local government clinics, using self-administrated questionnaires (n = 90 in the TasP trial, n = 56 in government clinics), semi-structured interviews (n = 13 in the TasP trial, n = 5 in government clinics) and three focus group discussions (n = 6–10 health care workers of the TasP trial per group). Descriptive statistics were used for quantitative data and qualitative data were analysed thematically.

Results

More than 90% of health care workers assessed home-based testing and support for linkage to care as feasible and acceptable by the population they serve. Many health care workers underlined how home visits could facilitate reaching people who had slipped through the cracks of the clinic-based health care system and encourage them to successfully access care. Health care workers however expressed concerns about the ability of home-based services to answer the HIV care needs of all community members, including people working outside their home during the day or those who fear HIV-related stigmatization. Overall, health care workers encouraged policy-makers to more formally integrate home-based services in the local health system. They promoted reshaping the disease-specific and care-oriented services towards more comprehensive goals.

Conclusion

Because home-based services allow identification of people early during their infection and encourage them to take actions leading to viral suppression, HCWs assessed them as valuable components within the panel of UTT interventions, aiming to reach the 90-90-90 UNAIDS targets, especially in the rural Southern African region.

Trial registration

The registration number of the ANRS 12249 TasP trial on ClinicalTrials.gov is NCT01509508.

What do we know about community-based health worker programs? A systematic review of existing reviews on community health workers

OBJECTIVE

To synthesize current understanding of how community-based health worker (CHW) programs can best be designed and operated in health systems.

METHODS

We searched 11 databases for review articles published between 1 January 2005 and 15 June 2017. Review articles on CHWs, defined as non-professional paid or volunteer health workers based in communities, with less than 2 years of training, were included. We assessed the methodological quality of the reviews according to AMSTAR criteria, and we report our findings based on PRISMA standards.

FINDINGS

We identified 122 reviews (75 systematic reviews, of which 34 are meta-analyses, and 47 non-systematic reviews). Eighty-three of the included reviews were from low- and middle-income countries, 29 were from high-income countries, and 10 were global. CHW programs included in these reviews are diverse in interventions provided, selection and training of CHWs, supervision, remuneration, and integration into the health system. Features that enable positive CHW program outcomes include community embeddedness (whereby community members have a sense of ownership of the program and positive relationships with the CHW), supportive supervision, continuous education, and adequate logistical support and supplies. Effective integration of CHW programs into health systems can bolster program sustainability and credibility, clarify CHW roles, and foster collaboration between CHWs and higher-level health system actors. We found gaps in the review evidence, including on the rights and needs of CHWs, on effective approaches to training and supervision, on CHWs as community change agents, and on the influence of health system decentralization, social accountability, and governance.

CONCLUSION

Evidence concerning CHW program effectiveness can help policymakers identify a range of options to consider. However, this evidence needs to be contextualized and adapted in different contexts to inform policy and practice. Advancing the evidence base with context-specific elements will be vital to helping these programs achieve their full potential.

Experiences of HIV-positive postpartum women and health workers involved with community-based antiretroviral therapy adherence clubs in Cape Town, South Africa

Background

The rollout of universal, lifelong treatment for all HIV-positive pregnant and breastfeeding women (“Option B+”) has rapidly increased the number of women initiating antiretroviral treatment (ART) and requiring ART care postpartum. In a pilot project in South Africa, eligible postpartum women were offered the choice of referral to the standard of care, a local primary health care clinic, or a community-based model of differentiated ART services, the adherence club (AC). ACs have typically enrolled only non-pregnant and non-postpartum adults; postpartum women had not previously been referred directly from antenatal care. There is little evidence regarding postpartum women’s preferences for and experiences of differentiated models of care, or the capacity of this particular model to cater to their specific needs. This qualitative paper reports on feedback from both postpartum women and health workers who care for them on their respective experiences of the AC.

Methods

One-on-one in-depth qualitative interviews were conducted with 19 (23%) of the 84 postpartum women who selected the AC and were retained at approximately 12 months postpartum, and 9 health workers who staff the AC. Data were transcribed and thematically analysed using NVivo 11.

Results

Postpartum women’s inclusion in the AC was acceptable for both participants and health workers. Health workers were welcoming of postpartum women but expressed concerns about prospects for longer term adherence and retention, and raised logistical issues they felt might compromise trust with AC members in general.

Conclusions

Enrolling postpartum women in mixed groups with the general adult population is feasible and acceptable. Preliminary recommendations are offered and may assist in supporting the specific needs of postpartum women transitioning from antenatal ART care.

Trial registration

Number NCT02417675 clinicaltrials.gov/ct2/show/record/NCT02417675 (retrospective reg.)

Beyond mere pill taking: SMS reminders for HIV treatment adherence delivered to mobile phones of clients in a community support network in Australia

SMS reminders sent to personal mobiles are increasingly used by clinical services to promote patient engagement, including adherence to antiretroviral treatment (ART) for HIV. From August to September 2015, a 6-week, randomised SMS reminder for ART adherence intervention was implemented among 98 HIV-positive clients of Australian's largest HIV charitable organisation located in Sydney. This was followed by a mixed-method evaluation, comprising a self-completed online survey and a one-to-one interview. Of the 62 survey participants, all being men, the majority were gay (85.5%) and living long-term with HIV (median year of HIV diagnosis = 1998). While everyone was on ART, a substantial proportion (n = 27, 43.5%) had interrupted treatment in the past. At the end of the intervention, based on the standard SMAQ measure, 82% had consistently adhered to ART in the previous week. While there was no statistically significant intervention effect, perceiving less stigma were independently associated with better ART adherence (adjusted odds ratio = 0.37; 95% CI 0.16-0.89; P = .026). Of the 11 interviewees, despite limited add-on effects on individual ART adherence, the campaign was well-received as a unique community support service. This study underscores the essential role of empowerment through enhancing disease self-management, increasing social support and reducing stigma, particularly for long-term HIV survivors. SMS messaging, part of mHealth, delivered by community services could have broader impacts on reducing health and social inequity.

Interactive Two-Way mHealth Interventions for Improving Medication Adherence: An Evaluation Using The Behaviour Change Wheel Framework

BACKGROUND

Medication adherence is an important but highly complex set of behaviors, which for life-threatening and infectious diseases such as HIV carry critical consequences for individual and public health. There is growing evidence that mobile phone text messaging interventions (mHealth) connecting providers with patients positively impact medication adherence, particularly two-way engagement platforms that require bidirectional communication versus one-way in which responses are not mandatory. However, mechanisms of action have not been well defined. The Behavior Change Wheel is a comprehensive framework for behavior change that includes an all-encompassing model of behavior known as Capability Opportunity Motivation-Behavior and is complemented by a taxonomy of behavior change techniques. Evaluating mHealth interventions for medication adherence using these tools could provide useful insights that may contribute to optimizing their integration into the healthcare system and successful scaling-up.

OBJECTIVE

This study aimed to help address the current knowledge gap regarding how two-way mHealth interventions for medication adherence may work by applying the Behavior Change Wheel to characterize WelTel: an interactive digital health outreach platform with robust evidence for improving adherence to antiretroviral therapy.

METHODS

To characterize how WelTel may promote medication adherence, we applied the Behavior Change Wheel to systematically (1) generate a behavioral diagnosis through mapping known antiretroviral therapy adherence barriers onto the Capability Opportunity Motivation-Behavior model of behavior, (2) specify the behavior change techniques that WelTel delivers, (3) link identified behavior change techniques to corresponding intervention functions of the Behavior Change Wheel, and (4) connect these behavior change techniques and intervention functions to respective Capability Opportunity Motivation-Behavior influences on behavior to determine potential mechanisms of action.

RESULTS

Our evaluation of WelTel using the Behavior Change Wheel suggests that most of its impact is delivered primarily through its personalized communication component, in which 8 different behavior change techniques were identified and linked with 5 intervention functions (environmental restructuring, enablement, education, persuasion, and training). Its mechanisms of action in promoting antiretroviral therapy adherence may involve addressing all Capability Opportunity Motivation-Behavior influences on behavior (physical and psychological capability, physical and social opportunity, reflective and automatic motivation).

CONCLUSIONS

Systematically unpacking the potential active ingredients of effective interventions facilitates the creation and implementation of more parsimonious, tailored, and targeted approaches. Evaluating WelTel using the Behavior Change Wheel has provided valuable insights into how and why such interactive two-way mHealth interventions may produce greater impact than one-way in addressing both nonintentional and intentional forms of nonadherence. The application of the Behavior Change Wheel for evidence synthesis across mHealth interventions targeting various conditions would contribute to strengthening the knowledge base regarding how they may work to impact medication adherence behavior.

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.

Experiences using and organizing HIV self-testing

OBJECTIVE

HIV self-testing (HIVST) is now officially recommended by the WHO, yet much of HIVST evidence to date has focused on quantitative data and hypothetical concerns. Effective scale-up of HIVST in diverse local contexts requires qualitative data from experiences using and organizing HIVST. This qualitative systematic review aims to appraise and synthesize research evidence on experiences using and organizing HIVST.

METHODS

We conducted a systematic search of seven primary literature databases, four gray literature sources, and reference lists reporting qualitative evidence on HIVST. Data extraction and thematic analysis were used to synthesize findings. Quality of studies was assessed using the Critical Appraisal Skills Programme tool. Confidence in review findings was evaluated using the Confidence in the Evidence from Reviews of Qualitative Research approach. The review protocol was registered (CRD42015027607).

RESULTS

From 1266 potential articles, we included 18. Four studies were conducted in low-income countries, three in middle-income countries, 10 in high-income countries, and one in multiple countries. Generally, HIVST increased capacity to reach priority populations and expanded opportunities for service delivery. Self-testing was preferred to facility-based testing due to increased convenience and confidentiality, especially among stigmatized populations. HIVST decreased test-associated stigma compared with facility-based testing. HIVST generally empowered people because it provided greater control over individual testing needs. At the same time, HIVST rarely allowed husbands to coerce their wives to test.

CONCLUSIONS

This review suggests that HIVST should be offered as an additional HIV testing option to expand testing and empower testers. Adapting national policies to incorporate HIVST will be necessary to guide scale-up.

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.

Electronic health, telemedicine, and new paradigms for training and care

PURPOSE OF REVIEW

HIV prevention and care is changing rapidly; guideline revisions and programmatic scale-up require innovative approaches to in-service training and care extension to improve provider practice and care access. We assessed recent (≤12 months) peer-reviewed publications on electronic health (eHealth), telemedicine, and other innovative provider-targeted interventions for HIV-related care.

RECENT FINDINGS

Key developments included systems merging electronic medical records (EMR) with provider clinical decision aids to prompt action, demonstration eHealth, and telemedicine projects, reviews or descriptions of technology to improve connectivity in lower resource settings, and a few trials on provider-centered interventions. Most publications were program reports and few data were available regarding efficacy of eHealth interventions for providers on patient HIV-related outcomes, notably identification and management of antiretroviral treatment failure in Kenya. Better evidence is needed for strategies to train providers and care extenders with the goal to improve impact of HIV prevention and care interventions.

SUMMARY

Rapid technology introduction and expansion may change the paradigm for improving provider knowledge and practice. Although new, the developments are promising for HIV provider-targeted eHealth and innovations for traditional training. More rigorous testing with randomized trials is needed to demonstrate impact on services for people living with HIV.

"Poems in the Entrance Area": Using Photo-Stories to Promote HIV Medication Adherence

Adherence to antiretroviral medication among people living with HIV (PL-HIV) is critical to individual and public health. By some estimates only a quarter of PL-HIV are sufficiently adherent, underscoring a continued need for adherence-promoting strategies. In this analysis we explore the effect of adherence education posters developed via Photovoice. A group of PL-HIV generated images and captions to describe their adherence experiences and used their photo-stories to design 10 posters. We assessed viewers' ( N = 111) adherence knowledge, self-efficacy, and communication changes quantitatively and qualitatively before and 3 months after poster placement in the clinic. We analyzed quantitative data with an independent groups t test or a Mann-Whitney test, and qualitative interviews via theme analysis. Quantitative findings indicated no significant differences. Qualitative interviewees said that posters enhanced knowledge with nonthreatening, relatable information; self-efficacy by motivating patients to take medicine and disclose HIV to others; and communication by facilitating adherence conversations and creating a visually supportive clinic. Divergent quantitative and qualitative findings can be partially explained by inquiry methods. The posters may be more effective as part of discussions about their content, like those facilitated by qualitative interviews. Additional research regarding the application of Photovoice to health promotion is warranted.

Beyond "Option B+": Understanding Antiretroviral Therapy (ART) Adherence, Retention in Care and Engagement in ART Services Among Pregnant and Postpartum Women Initiating Therapy in Sub-Saharan Africa

BACKGROUND

Several studies from sub-Saharan Africa have highlighted significant challenges in providing antiretroviral therapy (ART) to pregnant and postpartum women, with specific concerns around maintaining optimal levels of adherence to ART and/or retaining women in long-term services. However, there are few conceptual frameworks to help understand nonadherence and nonretention, as well as the drivers of these, among HIV-infected women, particularly in the postpartum period.

METHODS

This review provides an overview of the key issues involved in thinking about ART adherence, retention in care and engagement in ART services among pregnant and postpartum women.

RESULTS

The related behaviors of adherence and retention may be understood as components of effective engagement of patients in ART services, which share the goal of achieving and maintaining suppressed maternal viral load on ART. Under this framework, the existing literature indicates that disengagement from care is widespread among postpartum women, with strikingly similar data emerging from ART services around the globe and indications that similar challenges may be encountered by postpartum care services outside the context of HIV. However, the drivers of disengagement require further research, and evidence-based intervention strategies are limited.

CONCLUSIONS

The challenges of engaging women in ART services during pregnancy and the postpartum period seem pervasive, although the determinants of these are poorly understood. Looking forward, a host of innovative intervention approaches are needed to help improve women's engagement, and in turn, promote maternal and child health in the context of HIV.

Exploring 'generative mechanisms' of the antiretroviral adherence club intervention using the realist approach: a scoping review of research-based antiretroviral treatment adherence theories

BACKGROUND

Poor retention in care and non-adherence to antiretroviral therapy (ART) continue to undermine the success of HIV treatment and care programmes across the world. There is a growing recognition that multifaceted interventions - application of two or more adherence-enhancing strategies - may be useful to improve ART adherence and retention in care among people living with HIV/AIDS. Empirical evidence shows that multifaceted interventions produce better results than interventions based on a singular perspective. Nevertheless, the bundle of mechanisms by which multifaceted interventions promote ART adherence are poorly understood. In this paper, we reviewed theories on ART adherence to identify candidate/potential mechanisms by which the adherence club intervention works.

METHODS

We searched five electronic databases (PubMed, EBSCOhost, CINAHL, PsycARTICLES and Google Scholar) using Medical Subject Headings (MeSH) terms. A manual search of citations from the reference list of the studies identified from the electronic databases was also done. Twenty-six articles that adopted a theory-guided inquiry of antiretroviral adherence behaviour were included for the review. Eleven cognitive and behavioural theories underpinning these studies were explored. We examined each theory for possible 'generative causality' using the realist evaluation heuristic (Context-Mechanism-Outcome) configuration, then, we selected candidate mechanisms thematically.

RESULTS

We identified three major sets of theories: Information-Motivation-Behaviour, Social Action Theory and Health Behaviour Model, which explain ART adherence. Although they show potential in explaining adherence bebahiours, they fall short in explaining exactly why and how the various elements they outline combine to explain positive or negative outcomes. Candidate mechanisms indentified were motivation, self-efficacy, perceived social support, empowerment, perceived threat, perceived benefits and perceived barriers. Although these candidate mechanisms have been distilled from theories employed to explore adherence to ART in various studies, the theories by themselves do not provide an explanatory model of adherence based on the realist logic.

CONCLUSIONS

The identified theories and candidate mechanisms offer possible generative mechanisms to explain how and why patients adhere (or not) to antiretroviral therapy. The study provides crucial insights to understanding how and why multifaceted adherence-enhancing interventions work (or not). These findings have implications for eliciting programme theories of group-based adherence interventions such as the adherence club intervention.

Enhancing Public Health HIV Interventions: A Qualitative Meta-Synthesis and Systematic Review of Studies to Improve Linkage to Care, Adherence, and Retention

Although HIV services are expanding, few have reached the scale necessary to support universal viral suppression of individuals living with HIV. The purpose of this systematic review was to summarize the qualitative evidence evaluating public health HIV interventions to enhance linkage to care, antiretroviral drug (ARV) adherence, and retention in care. We searched 19 databases without language restrictions. The review collated data from three separate qualitative evidence reviews addressing each of the three outcomes along the care continuum. 21,738 citations were identified and 24 studies were included in the evidence review. Among low and middle-income countries in Africa, men living with HIV had decreased engagement in interventions compared to women and this lack of engagement among men also influenced the willingness of their partners to engage in services. Four structural issues (poverty, unstable housing, food insecurity, lack of transportation) mediated the feasibility and acceptability of public health HIV interventions. Individuals living with HIV identified unmet mental health needs that interfered with their ability to access HIV services. Persistent social and cultural factors contribute to disparities in HIV outcomes across the continuum of care, shaping the context of service delivery among important subpopulations.