1
|
Molemans M, Reis R, Shabalala F, Dlamini N, Masilela N, Simelane N, Pell C, Chao A, Spiegelman D, Vernooij E, van Leth F. Reasons for using traditional and complementary care by people living with HIV on antiretroviral therapy and association with interrupted care: a mixed methods study in Eswatini. BMC Complement Med Ther 2023; 23:350. [PMID: 37794359 PMCID: PMC10548651 DOI: 10.1186/s12906-023-04184-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 09/26/2023] [Indexed: 10/06/2023] Open
Abstract
The use of traditional, complementary, and alternative medicine (TCAM) can lead to delays and interruptions in the HIV continuum of care. This study explores reasons for TCAM use in people living with HIV on antiretroviral therapy (ART) in Eswatini and compares interrupted care between different types of TCAM users. Data were collected using surveys in the MaxART study (a test-and-treat trial) between 2014 and 2017 to assess the exposure, namely visiting a TCAM provider. Additionally, visit dates were retrieved from clinic records to assess the outcome, interrupted care. Open-ended questions were analysed with qualitative content analysis (n = 602) and closed questions with bivariable and multivariable analysis (n = 202). Out of 202 participants, 145 (72%) never used TCAM, 40 (20%) ever used, and 17 (8%) is currently using TCAM (diviners, herbalists, and religious healers). No differences in interrupted care were found comparing never (reference category), past (Odds Ratio: 1.31, 95% confidence interval: 0.63-2.72), and current users (1.34, 0.47-3.77), while adjusting for gender, time since HIV diagnosis, and time on ART. Contextual factors affecting the choice for TCAM were the influence of family, advice from the health facility, and religious beliefs. Individual factors include trust in biomedical care, type of illness, no need for additional care, and practical reasons such as financial means. In conclusion, individual and contextual factors influence the choice for TCAM. Interrupted care does not differ between never, past, and current users.
Collapse
Affiliation(s)
- Marjan Molemans
- Amsterdam Institute for Social Science Research, Department of Anthropology, University of Amsterdam, Amsterdam, The Netherlands.
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands.
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands.
| | - Ria Reis
- Amsterdam Institute for Social Science Research, Department of Anthropology, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
- Department of Public Health and Primary Care, Leiden University Medical Centre, Leiden, The Netherlands
- The Children's Institute, School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Fortunate Shabalala
- Department of Community Health Nursing, Faculty of Health Sciences, University of Eswatini, Mbabane, Eswatini, Swaziland
| | - Njabuliso Dlamini
- National Emergency Response Council on HIV and AIDS (NERCHA), Mbabane, Eswatini, Swaziland
| | - Nelisiwe Masilela
- Department of Community Health Nursing, Faculty of Health Sciences, University of Eswatini, Mbabane, Eswatini, Swaziland
| | - Njabulo Simelane
- Ministry of Foreign Affairs and Trade, Mbabane, Eswatini, Swaziland
| | - Christopher Pell
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
- Department of Global Health, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - Ariel Chao
- Yale School of Public Health, New Haven, USA
| | | | - Eva Vernooij
- Amsterdam Institute for Social Science Research, Department of Anthropology, University of Amsterdam, Amsterdam, The Netherlands
- Department of Interdisciplinary Social Sciences, Utrecht University, Utrecht, The Netherlands
| | - Frank van Leth
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
- Department of Health Sciences, Vrije Universiteit, Amsterdam, The Netherlands
| |
Collapse
|
2
|
Theilmann M, Ginindza N, Myeni J, Dlamini S, Cindzi BT, Dlamini D, Dlamini TL, Greve M, Harkare HV, Hleta M, Khumalo P, Kolbe LM, Lewin S, Marowa LR, Masuku S, Mavuso D, Molemans M, Ntshalintshali N, Nxumalo N, Osetinsky B, Pell C, Reis R, Shabalala F, Simelane BR, Stehr L, Tediosi F, van Leth F, De Neve JW, Bärnighausen T, Geldsetzer P. Strengthening primary care for diabetes and hypertension in Eswatini: study protocol for a nationwide cluster-randomized controlled trial. Trials 2023; 24:210. [PMID: 36949485 PMCID: PMC10031170 DOI: 10.1186/s13063-023-07096-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 01/12/2023] [Indexed: 03/24/2023] Open
Abstract
BACKGROUND Diabetes and hypertension are increasingly important population health challenges in Eswatini. Prior to this project, healthcare for these conditions was primarily provided through physician-led teams at tertiary care facilities and accessed by only a small fraction of people living with diabetes or hypertension. This trial tests and evaluates two community-based healthcare service models implemented at the national level, which involve health care personnel at primary care facilities and utilize the country's public sector community health worker cadre (the rural health motivators [RHMs]) to help generate demand for care. METHODS This study is a cluster-randomized controlled trial with two treatment arms and one control arm. The unit of randomization is a primary healthcare facility along with all RHMs (and their corresponding service areas) assigned to the facility. A total of 84 primary healthcare facilities were randomized in a 1:1:1 ratio to the three study arms. The first treatment arm implements differentiated service delivery (DSD) models at the clinic and community levels with the objective of improving treatment uptake and adherence among clients with diabetes or hypertension. In the second treatment arm, community distribution points (CDPs), which previously targeted clients living with human immunodeficiency virus, extend their services to clients with diabetes or hypertension by allowing them to pick up medications and obtain routine nurse-led follow-up visits in their community rather than at the healthcare facility. In both treatment arms, RHMs visit households regularly, screen clients at risk, provide personalized counseling, and refer clients to either primary care clinics or the nearest CDP. In the control arm, primary care clinics provide diabetes and hypertension care services but without the involvement of RHMs and the implementation of DSD models or CDPs. The primary endpoints are mean glycated hemoglobin (HbA1c) and systolic blood pressure among adults aged 40 years and older living with diabetes or hypertension, respectively. These endpoints will be assessed through a household survey in the RHM service areas. In addition to the health impact evaluation, we will conduct studies on cost-effectiveness, syndemics, and the intervention's implementation processes. DISCUSSION This study has the ambition to assist the Eswatini government in selecting the most effective delivery model for diabetes and hypertension care. The evidence generated with this national-level cluster-randomized controlled trial may also prove useful to policy makers in the wider Sub-Saharan African region. TRIAL REGISTRATION NCT04183413. Trial registration date: December 3, 2019.
Collapse
Affiliation(s)
- Michaela Theilmann
- Heidelberg Institute of Global Health, Heidelberg University, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany.
- Assistant Professorship of Behavioral Science for Disease Prevention and Health Care, Technical University of Munich, Munich, Germany.
| | - Ntombifuthi Ginindza
- Ministry of Health in Eswatini, Ministry of Justice & Constitutional Affairs Building, Mhlambanyatsi Road, Mbabane, Eswatini
| | - John Myeni
- Ministry of Health in Eswatini, Ministry of Justice & Constitutional Affairs Building, Mhlambanyatsi Road, Mbabane, Eswatini
| | - Sijabulile Dlamini
- Ministry of Health in Eswatini, Ministry of Justice & Constitutional Affairs Building, Mhlambanyatsi Road, Mbabane, Eswatini
| | - Bongekile Thobekile Cindzi
- Clinton Health Access Initiative, Mbhilibhi House, Plot 170, Corner Tsekwane/Mbhilibhi Street, Mbabane, Eswatini
| | | | - Thobile L Dlamini
- Eswatini Business Health and Wellness, Malagwane Hill, Mbabane, Eswatini
| | - Maike Greve
- University of Göttingen, Humboldtallee 3, 37073, Göttingen, Germany
| | - Harsh Vivek Harkare
- Swiss Tropical and Public Health Institute, Kreuzstrasse 2, 4123, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Mbuso Hleta
- Eswatini Business Health and Wellness, Malagwane Hill, Mbabane, Eswatini
| | | | - Lutz M Kolbe
- University of Göttingen, Humboldtallee 3, 37073, Göttingen, Germany
| | - Simon Lewin
- Division of Health Services, Norwegian Institute of Public Health, Oslo, Norway
- Department of Health Sciences Ålesund, Norwegian University of Science and Technology (NTNU), Ålesund, Norway
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Lisa-Rufaro Marowa
- Clinton Health Access Initiative, Mbhilibhi House, Plot 170, Corner Tsekwane/Mbhilibhi Street, Mbabane, Eswatini
| | | | | | - Marjan Molemans
- Amsterdam Institute for Global Health and Development, Paasheuvelweg 25, 1105 BP, Amsterdam, Netherlands
- Amsterdam Institute for Social Science Research, Amsterdam, Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Nyasatu Ntshalintshali
- Clinton Health Access Initiative, Mbhilibhi House, Plot 170, Corner Tsekwane/Mbhilibhi Street, Mbabane, Eswatini
| | | | - Brianna Osetinsky
- Swiss Tropical and Public Health Institute, Kreuzstrasse 2, 4123, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Christopher Pell
- Amsterdam Institute for Global Health and Development, Paasheuvelweg 25, 1105 BP, Amsterdam, Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, Netherlands
- Amsterdam UMC, location University of Amsterdam, Department of Global Health, Amsterdam, The Netherlands
| | - Ria Reis
- Amsterdam Institute for Global Health and Development, Paasheuvelweg 25, 1105 BP, Amsterdam, Netherlands
- Amsterdam Institute for Social Science Research, Amsterdam, Netherlands
- Dept. of Public Health & Primary Care, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- School of Child and Adolescent Health, Children's Institute, University of Cape Town, Cape Town, South Africa
| | | | | | - Lisa Stehr
- Heidelberg Institute of Global Health, Heidelberg University, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Fabrizio Tediosi
- Swiss Tropical and Public Health Institute, Kreuzstrasse 2, 4123, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Frank van Leth
- Amsterdam Public Health Research Institute, Amsterdam, Netherlands
- Department of Health Sciences, Vrije Universiteit, De Boelelaan 1105, 1081 HV, Amsterdam, The Netherlands
| | - Jan-Walter De Neve
- Heidelberg Institute of Global Health, Heidelberg University, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, Heidelberg University, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
- Harvard Center for Population and Development Studies, Cambridge, USA
- Africa Health Research Institute, KwaZulu-Natal, 3935, South Africa
| | - Pascal Geldsetzer
- Division of Primary Care and Population Health, Stanford University, 291 Campus Drive, Stanford, CA, 94305-5101, USA.
- Chan Zuckerberg Biohub, San Francisco, CA, 94158, USA.
| |
Collapse
|
3
|
Olislagers Q, van Leth F, Shabalala F, Dlamini N, Simelane N, Masilela N, Gomez GB, Pell C, Vernooij E, Reis R, Molemans M. Reasons for, and factors associated with, positive HIV retesting: a cross-sectional study in Eswatini. AIDS Care 2022:1-8. [PMID: 36449635 DOI: 10.1080/09540121.2022.2142930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Eswatini has a high HIV prevalence but has made progress towards improving HIV-status awareness, ART uptake and viral suppression. However, there is still a delay in ART initiation, which could partly be attributed to positive HIV-retesting. This study examines reasons for, and factors associated with, positive HIV-retesting among MaxART participants in Eswatini. Data from 601 participants is included in this cross-sectional study. Descriptive statistics and logistic regressions were used. Of the participants, 32.8% has ever retested after a previous positive result. Most participants who retested did this because they could not accept their results (61.9% of all retesters). Other main reasons are related to external influences, gender or the progression of their HIV infection (respectively 18.3%, 10.2%, and 6.1% of all retesters). Participants without a current partner and participants with less time since their first positive test have lower odds of retesting. To decrease retesting and reduce the delay in ART initiation resulting from it, efforts could be made on increasing the acceptance of positive HIV results. Providing more information on the process of testing and importance of early ART initiation, could be part of the solution.
Collapse
Affiliation(s)
- Quint Olislagers
- Amsterdam Institute for Global Health and Development, Amsterdam, Netherlands
| | - Frank van Leth
- Department of health sciences, VU University, Amsterdam, Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Fortunate Shabalala
- Department of Community Health Nursing Sciences, Faculty of Health Sciences, University of Eswatini, Mbabane, Eswatini
| | - Njabuliso Dlamini
- National Emergency Response Council on HIV and AIDS (NERCHA), Mbabane, Eswatini
| | | | - Nelisiwe Masilela
- Department of Community Health Nursing Sciences, Faculty of Health Sciences, University of Eswatini, Mbabane, Eswatini
| | - Gabriela B. Gomez
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Christopher Pell
- Amsterdam Institute for Global Health and Development, Amsterdam, Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, Netherlands
- Department of Global Health Amsterdam, Amsterdam UMC, Location University of Amsterdam, Amsterdam, Netherlands
| | - Eva Vernooij
- Amsterdam Institute for Social Science Research, University of Amsterdam, Amsterdam, Netherlands
| | - Ria Reis
- Amsterdam Institute for Global Health and Development, Amsterdam, Netherlands
- Amsterdam Institute for Social Science Research, University of Amsterdam, Amsterdam, Netherlands
- Department of Public Health and Primary Care, Leiden University Medical Centre, Leiden, Netherlands
- The Children’s Institute, School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Marjan Molemans
- Amsterdam Institute for Global Health and Development, Amsterdam, Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, Netherlands
- Amsterdam Institute for Social Science Research, University of Amsterdam, Amsterdam, Netherlands
| |
Collapse
|
4
|
Moyer E, Baas R, Shabalala F. Social complexities of informed consent and assent among young males undergoing voluntary medical male circumcision in Eswatini. BMJ Glob Health 2022; 7:bmjgh-2021-007918. [PMID: 35609919 PMCID: PMC9131107 DOI: 10.1136/bmjgh-2021-007918] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 04/22/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction As part of an effort to meet ambitious male circumcision targets in Eswatini, programme implementers have increasingly focused on young males, raising questions about informed consent. Males aged 10–19 years account for more than two-thirds of those circumcised since 2008 when internationally funded circumcision campaigns began in Eswatini. The ethical guidelines of these programmes conform to international standards, requiring that informed consent or assent be obtained prior to surgery. This article examines clients’ levels of circumcision-related knowledge following the assent process, as well as how ethical guidelines were enacted in everyday practice in a setting where family dynamics and norms relating to autonomy and consensus make obtaining informed consent complex, especially when clients are incentivised with football kits and other material goods to encourage circumcision. Methods We conducted qualitative research in a health clinic where circumcision services for HIV prevention were being offered. Methods included focus group discussions, in-depth interviews, participant observation and informal interviews with young men undergoing circumcision in the clinic. Results Implementers paid little attention to risks, focusing more on benefits of circumcision. Incentives, usually in the form of sporting goods, increased participation, while also limiting autonomy. We also found that parental authority overpowers young males’ preferences regarding circumcision. Young males’ understanding of the risks associated with circumcision was poor. Most assumed HIV testing was obligatory. Conclusion The drive to eliminate HIV infections in Eswatini has opened the door for interventions such as targeted circumcision campaigns. In contradiction to international ethical guidelines and the policies of the Ministry of Health and voluntary medical male circumcision (VMMC) implementers, we conclude that, in practce, respect for young males’ rights and decision-making in the VMMC consent process is limited by complex social, economic and political realities.
Collapse
Affiliation(s)
- Eileen Moyer
- Department of Anthropology, University of Amsterdam, Amsterdam, The Netherlands .,Amsterdam Institute for Global Health and Development, University of Amsterdam, Amsterdam, The Netherlands
| | - Rufus Baas
- Department of Anthropology, University of Amsterdam, Amsterdam, The Netherlands
| | | |
Collapse
|
5
|
Abstract
Sexual assault on university campuses has attracted growing attention, but there is little data available on the scope of the problem in Southern Africa. We sought to measure the prevalence of campus sexual assault among female university students at the University of Eswatini and describe the experience of survivors using a mixed-methods study design. Women were randomly sampled from a list of all full-time female university students provided by the office of the registrar, and participants completed a brief behavioral survey in a private study office using a tablet with computer-assisted self-interview software. Women who indicated experiences of sexual violence during the survey were invited to self-identify themselves to study staff to participate in a follow-up qualitative interview. We measured sexual assault using the Sexual Experiences Survey-Short Form Version (SES-SFV). We found that women in University were over 6 times more likely to report forced or coerced sex in the previous 12 months than has been previously reported in the general population. Sixty percent of participants reported experiencing an attempted or completed sexual assault in their lifetime, and a total of 38% reported an assault in the past 12 months. The vast majority (93%) of assailants were known to their victim, and the majority (56%) of perpetrators were romantic partners. The majority of participants had never disclosed their assault, and victim blaming and stigma emerged as highly salient themes during in-depth qualitative interviews. Food insecurity, losing a parent before age 21, and hazardous drinking were all significantly associated with experiencing sexual assault in the previous 12 months, as was experiencing a previous assault before the age of 18. To our knowledge, this is the first generalizable study of campus sexual assault prevalence conducted in the Southern African region.
Collapse
Affiliation(s)
| | | | - Sakhile Masuku
- Faculty of Health Sciences, University of Eswatini, Mbabane, Eswatini
| | - Anita Raj
- University of California, San Diego School of Medicine, USA
| |
Collapse
|
6
|
Hay K, McDougal L, Percival V, Henry S, Klugman J, Wurie H, Raven J, Shabalala F, Fielding-Miller R, Dey A, Dehingia N, Morgan R, Atmavilas Y, Saggurti N, Yore J, Blokhina E, Huque R, Barasa E, Bhan N, Kharel C, Silverman JG, Raj A. Disrupting gender norms in health systems: making the case for change. Lancet 2019; 393:2535-2549. [PMID: 31155270 PMCID: PMC7233290 DOI: 10.1016/s0140-6736(19)30648-8] [Citation(s) in RCA: 131] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 03/06/2019] [Accepted: 03/11/2019] [Indexed: 12/21/2022]
Abstract
Restrictive gender norms and gender inequalities are replicated and reinforced in health systems, contributing to gender inequalities in health. In this Series paper, we explore how to address all three through recognition and then with disruptive solutions. We used intersectional feminist theory to guide our systematic reviews, qualitative case studies based on lived experiences, and quantitative analyses based on cross-sectional and evaluation research. We found that health systems reinforce patients' traditional gender roles and neglect gender inequalities in health, health system models and clinic-based programmes are rarely gender responsive, and women have less authority as health workers than men and are often devalued and abused. With regard to potential for disruption, we found that gender equality policies are associated with greater representation of female physicians, which in turn is associated with better health outcomes, but that gender parity is insufficient to achieve gender equality. We found that institutional support and respect of nurses improves quality of care, and that women's empowerment collectives can increase health-care access and provider responsiveness. We see promise from social movements in supporting women's reproductive rights and policies. Our findings suggest we must view gender as a fundamental factor that predetermines and shapes health systems and outcomes. Without addressing the role of restrictive gender norms and gender inequalities within and outside health systems, we will not reach our collective ambitions of universal health coverage and the Sustainable Development Goals. We propose action to systematically identify and address restrictive gender norms and gender inequalities in health systems.
Collapse
Affiliation(s)
| | - Lotus McDougal
- Center on Gender Equity and Health, Department of Medicine, School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Valerie Percival
- Norman Paterson School of International Affairs, Carleton University, Ottawa, ON Canada
| | - Sarah Henry
- Department of Pediatrics, Stanford University School of Medicine, Stanford University, Stanford, CA, USA
| | - Jeni Klugman
- Georgetown Institute for Women, Peace and Security, Georgetown University, Washington, DC, USA; Women and Public Policy Program, Harvard Kennedy School, Cambridge, MA, USA
| | - Haja Wurie
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Joanna Raven
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Rebecca Fielding-Miller
- Center on Gender Equity and Health, Department of Medicine, School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Arnab Dey
- Sambodhi Research & Communications, Noida, Uttar Pradesh, India
| | | | - Rosemary Morgan
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, MD, USA
| | | | | | - Jennifer Yore
- Center on Gender Equity and Health, Department of Medicine, School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Elena Blokhina
- Vladman Institute of Pharmacology, Department of Psychiatry, First Pavlov State Medical University of St Petersburg, Saint Petersburg, Russia
| | | | - Edwine Barasa
- Kemri-Wellcome Trust, Kenya Research Programme, Nairobi, Kenya
| | - Nandita Bhan
- Center on Gender Equity and Health, Department of Medicine, School of Medicine, University of California San Diego, La Jolla, CA, USA
| | | | - Jay G Silverman
- Center on Gender Equity and Health, Department of Medicine, School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Anita Raj
- Center on Gender Equity and Health, Department of Medicine, School of Medicine, University of California San Diego, La Jolla, CA, USA.
| |
Collapse
|
7
|
Pell C, Vernooij E, Masilela N, Simelane N, Shabalala F, Reis R. False starts in 'test and start': a qualitative study of reasons for delayed antiretroviral therapy in Swaziland. Int Health 2018; 10:78-83. [PMID: 29342259 DOI: 10.1093/inthealth/ihx065] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 11/30/2017] [Indexed: 11/14/2022] Open
Abstract
Background Test and start, antiretroviral therapy (ART) for all HIV-positive individuals, is a WHO-recommended treatment guideline. In Swaziland, test and start has been evaluated through the MaxART implementation study. This article examines why, in MaxART, some newly diagnosed HIV-positive clients delayed initiating ART. Methods Thirteen HIV-positive clients who delayed ART for ≥90 d after testing were identified from the MaxART study database and interviewed. Interviews were audio recorded, transcribed and translated into English for qualitative content analysis. Results Respondents had often tested positive several times before initiating ART, with the initial diagnosis sometimes completely unexpected. Repeat testing-and delayed ART-was linked to a desire to come to terms with their diagnosis and prepare for a lifelong treatment course. Clients previously enrolled in pre-ART, particularly with high CD4 counts, had internalized past messages about ART as being non-essential and taking care of oneself through other means. Concerns about ART-related adverse events were weighed against these messages. Worries about inadvertent disclosure and its impact on social and economic relationships also discouraged initiation. Conclusion Although potentially reducing logistical barriers, expedited ART initiation does not necessarily accommodate some clients' need for time to come to terms with the diagnosis and the prospect of lifelong treatment.
Collapse
Affiliation(s)
- Christopher Pell
- Amsterdam Institute for Social Science Research, University of Amsterdam, Nieuwe Achtergracht 166, 1018 WV, The Netherlands.,Amsterdam Institute for Global Health and Development (AIGHD), AHTC, Tower C4, Paasheuvelweg 25, 1105 BP, Amsterdam, The Netherlands
| | - Eva Vernooij
- Amsterdam Institute for Social Science Research, University of Amsterdam, Nieuwe Achtergracht 166, 1018 WV, The Netherlands.,Theory and History of Psychology, Faculty of Behavioural and Social Sciences, University of Groningen, Groningen, The Netherlands
| | | | | | - Fortunate Shabalala
- Amsterdam Institute for Social Science Research, University of Amsterdam, Nieuwe Achtergracht 166, 1018 WV, The Netherlands.,Department of Community Health Nursing Sciences, Faculty of Health Sciences, University of Swaziland, Mbabane, Swaziland
| | - Ria Reis
- Amsterdam Institute for Social Science Research, University of Amsterdam, Nieuwe Achtergracht 166, 1018 WV, The Netherlands.,Department of Public Health and Primary Care, Leiden University Medical Centre, Leiden, The Netherlands.,Children's Institute, School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
8
|
Abstract
Drawing from 18 months of ethnographic fieldwork in one urban and one rural setting in Swaziland, involving 13 case studies of adolescents living with HIV, in this article we explore the meaning of the family as it applies to Swazi adolescents' everyday life. Our findings suggest that the meaning of the family is constantly evolving and transforming based on changing needs of, and expectations by, adolescents in different contexts and moments of the care continuum. Central to the meaning of the family is a strong desire for belonging - that is, being accepted, welcomed and appreciated. Traditional institutions that used to regulate where children belong still shape adolescents' perceptions, hopes and desires, but may also prevent their realisation. Support groups are important but do not substitute for the familial belongings adolescents living with HIV have lost, and long for. Policymakers, programme managers and health providers working with adolescents living with HIV need to embrace the complexity and dynamism of the meaning of family and base their policies, programmes, standards and guidelines not only on the factual care arrangements that adolescents find themselves in, nor on legal definitions of rights and responsibilities, but also on what adolescents want.
Collapse
Affiliation(s)
- Fortunate Shabalala
- a Amsterdam Institute for Social Science Research , University of Amsterdam , Amsterdam , The Netherlands.,b Faculty of Health Sciences, Department of Community Health Nursing Sciences , University of Swaziland , Mbabane , Swaziland
| | - Ariane De Lannoy
- c Poverty and Inequality Initiative, Southern Africa Labour and Development Research Unit , University of Cape Town , Cape Town , South Africa
| | - Eileen Moyer
- a Amsterdam Institute for Social Science Research , University of Amsterdam , Amsterdam , The Netherlands
| | - Ria Reis
- a Amsterdam Institute for Social Science Research , University of Amsterdam , Amsterdam , The Netherlands.,d Department of Public Health and Primary Care , Leiden University Medical Centre , Leiden , The Netherlands.,e The Children's Institute , University of Cape Town , Cape Town , South Africa
| |
Collapse
|