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Mokhele I, Sineke T, Vujovic M, Ruiter RAC, Miot J, Onoya D. Improving patient-centred counselling skills among lay healthcare workers in South Africa using the Thusa-Thuso motivational interviewing training and support program. PLOS Glob Public Health 2024; 4:e0002611. [PMID: 38656958 PMCID: PMC11042703 DOI: 10.1371/journal.pgph.0002611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 03/15/2024] [Indexed: 04/26/2024]
Abstract
We developed a motivational interviewing (MI) counselling training and support program for lay counsellors in South Africa-branded "Thusa-Thuso-helping you help", commonly referred to as Thusa-Thuso. We present the results of a pilot study to determine the program's impact on MI technical skills and qualitatively assess the feasibility of a training-of-trainers (TOT) scale-up strategy among counselling staff of non-governmental (NGO) support partners of the human immunodeficiency virus (HIV) treatment program in South Africa. We enrolled adult (≥ 18 years) lay counsellors from ten primary healthcare clinics in Johannesburg (South Africa) selected to participate in the Thusa-Thuso training and support program. Counsellors attended the ten-day baseline and quarterly refresher training over 12 months (October 2018-October 2019). Each counsellor submitted two audio recordings of mock counselling sessions held during the ten-day baseline training and two additional recordings of sessions with consenting patients after each quarterly contact session. We reviewed the recordings using the MI treatment integrity (MITI) coding system to determine MI technical (cultivating change talk and softening sustain talk) and relational (empathy and partnership) competency scores before and after training. After 12 months of support with pilot site counsellors, we were asked to scale up the training to NGO partner team trainers in a once-off five-day Training of trainers (TOT) format (n = 127 trainees from November 2020 to January 2021). We report TOT training experiences from focus group discussions (n = 42) conducted six months after the TOT sessions. Of the 25 enrolled lay counsellors from participating facilities, 10 completed the 12-month Thusa-Thuso program. Attrition over the 12 months was caused by death (n = 3), site exclusion/resignations (n = 10), and absence (n = 2). MI competencies improved as follows: the technical skills score increased from a mean of 2.5 (standard deviation (SD): 0.8) to 3.1 (SD: 0.5), with a mean difference of 0.6 (95% confidence interval (CI): 0.04, 0.9). The MI relational skills score improved from a mean of 3.20 (SD: 0.7) to 3.5 (SD: 0.6), with a mean difference of 0.3 (95% CI: -0.3, 8.5). End-point qualitative data from the counsellors highlighted the value of identifying and addressing specific skill deficiencies and the importance of counsellors being able to self-monitor skill development using the MITI review process. Participants appreciated the ongoing support to clarify practical MI applications. The TOT program tools were valuable for ongoing on-the-job development and monitoring of quality counselling skills. However, the MITI review process was perceived to be too involved for large-scale application and was adapted into a scoring form to document sit-in mentoring sessions. The Thusa-Thuso MI intervention can improve counsellor motivation and skills over time. In addition, the program can be scaled up using an adapted TOT process supplemented with fidelity assessment tools, which are valuable for skills development and ongoing maintenance. However, further studies are needed to determine the effect of the Thusa-Thuso program on patient ART adherence and retention in care. Trial registration: Pan African Clinical Trials Registry No: PACTR202212796722256 (12 December 2022).
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Affiliation(s)
- Idah Mokhele
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Tembeka Sineke
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Robert A. C. Ruiter
- Department of Work and Social Psychology, Maastricht University, Maastricht, the Netherlands
| | - Jacqui Miot
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Dorina Onoya
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Sineke T, Bor J, King R, Mokhele I, Dukashe M, Bokaba D, Inglis R, Kgowedi S, Richman B, Kinker C, Blandford J, Ruiter RAC, Onoya D. Integrating 'undetectable equals untransmittable' into HIV counselling in South Africa: the development of locally acceptable communication tools using intervention mapping. BMC Public Health 2024; 24:1052. [PMID: 38622528 PMCID: PMC11020191 DOI: 10.1186/s12889-024-18471-4] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 03/28/2024] [Indexed: 04/17/2024] Open
Abstract
BACKGROUND The global campaign for "Undetectable equals Untransmittable" (U = U) seeks to spread awareness of HIV treatment as prevention, aiming to enhance psychological well-being and diminish stigma. Despite its potential benefits, U = U faces challenges in Sub-Saharan Africa, with low awareness and hesitancy to endorse it. We sought to develop a U = U communications intervention to support HIV counselling in primary healthcare settings in South Africa. METHODS We used Intervention Mapping (IM), a theory-based framework to develop the "Undetectable and You" intervention for the South African context. The six steps of the IM protocol were systematically applied to develop the intervention including a needs assessment consisting of a systematic review and qualitative research including focus group discussions (FGD) and key informant (KI) interviews. Program objectives and target population were determined before designing the intervention components and implementation plan. RESULTS The needs assessment indicated low global U = U awareness, especially in Africa, and scepticism about its effectiveness. Lay counsellors and clinic managers stressed the need for a simple and standardized presentation of U = U addressing both patients' needs for encouragement and modelling of U = U success but also clear guidance toward ART adherence behaviour. Findings from each step of the process informed successive steps. Our final intervention consisted of personal testimonials of PLHIV role models and their partners, organized as an App to deliver U = U information to patients in primary healthcare settings. CONCLUSIONS We outline an intervention development strategy, currently in evaluation stage, utilizing IM with formative research and input from key U = U stakeholders and people living with HIV (PLHIV).
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Affiliation(s)
- Tembeka Sineke
- Health Economics and Epidemiology Research Office, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Jacob Bor
- Health Economics and Epidemiology Research Office, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Rachel King
- Institute for Global Health Sciences, University of California, San Francisco, USA
| | - Idah Mokhele
- Health Economics and Epidemiology Research Office, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mandisa Dukashe
- South African National AIDS Council (SANAC), Johannesburg, South Africa
| | - Dorah Bokaba
- Tshwane Department of Health, City of Tshwane, South Africa, City of Tshwane, South Africa
| | | | - Sharon Kgowedi
- Health Economics and Epidemiology Research Office, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Bruce Richman
- Prevention Access Campaign, United States of America, New York City, USA
| | - Cameron Kinker
- Prevention Access Campaign, United States of America, New York City, USA
| | - John Blandford
- Centers for Disease Control and Prevention, Johannesburg, South Africa
| | - Robert A C Ruiter
- Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Dorina Onoya
- Health Economics and Epidemiology Research Office, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
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Mokhele I, Huber A, Rosen S, Kaiser JL, Lekodeba N, Ntjikelane V, Hendrickson C, Scott N, Pascoe S. Satisfaction with service delivery among HIV treatment clients enrolled in differentiated and conventional models of care in South Africa: a baseline survey. J Int AIDS Soc 2024; 27:e26233. [PMID: 38528370 DOI: 10.1002/jia2.26233] [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: 08/28/2023] [Accepted: 03/01/2024] [Indexed: 03/27/2024] Open
Abstract
INTRODUCTION Differentiated service delivery (DSD) models aim to increase the responsiveness of HIV treatment programmes to the individual needs of antiretroviral therapy (ART) clients to improve treatment outcomes and quality of life. Little is known about how DSD client experiences differ from conventional care. METHODS From May to November 2021, we interviewed adult (≥18) ART clients at 21 primary clinics in four districts of South Africa. Participants were enrolled consecutively at routine visits and stratified into four groups: conventional care-not eligible for DSD (conventional-not-eligible); conventional care eligible for but not enrolled in DSD (conventional-not-enrolled); facility pickup point DSD model; and external pickup point DSD model. Satisfaction was assessed using questions with 5-point Likert-scale responses. Mean scores were categorized as not satisfied (score ≤3) or satisfied (>3). We used logistic regression to assess differences and report crude and adjusted odds ratios (aORs). Qualitative themes were identified through content analysis. RESULTS Eight hundred and sixty-seven participants (70% female, median age 39) were surveyed: 24% facility pick-up points; 27% external pick-up points; 25% conventional-not-eligible; and 24% conventional-not-enrolled. Seventy-four percent of all study participants expressed satisfaction with their HIV care. Those enrolled in DSD models were more likely to be satisfied, with an aOR of 6.24 (95% CI [3.18-12.24]) for external pick-up point versus conventional-not-eligible and an aOR of 3.30 (1.95-5.58) for facility pick-up point versus conventional-not-eligible. Conventional-not-enrolled clients were slightly but not significantly more satisfied than conventional-not-eligible clients (1.29, 0.85-1.96). Those seeking outside healthcare (crude OR 0.57, 0.41-0.81) or reporting more annual clinic visits (0.52, 0.29-0.93) were less likely to be satisfied. Conventional care participants reporting satisfaction with their current model of care perceived providers as helpful, respectful, and friendly and were satisfied with care despite long queues. DSD model participants emphasized ease and convenience, particularly not having to queue. CONCLUSIONS Most adult ART clients in South Africa were satisfied with their care, but those enrolled in DSD models expressed slightly greater satisfaction than those remaining in conventional care. Efforts should focus on enrolling more eligible patients into DSD models, expanding eligibility criteria to cover a wider client base, and further improving the models' desirable characteristics.
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Affiliation(s)
- Idah Mokhele
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Amy Huber
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sydney Rosen
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Jeanette L Kaiser
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Nkgomeleng Lekodeba
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Vinolia Ntjikelane
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Cheryl Hendrickson
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Nancy Scott
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Sophie Pascoe
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Onoya D, Sineke T, King R, Mokhele I, Sharma S, Dukashe M, Cele R, Bokaba D, Inglis R, Sigasa S, Bor J. Designing effective U = U communication strategies considering the needs of PLHIV, their partners, and healthcare worker constraints in South African clinics. PLoS One 2023; 18:e0295920. [PMID: 38117817 PMCID: PMC10732369 DOI: 10.1371/journal.pone.0295920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 12/04/2023] [Indexed: 12/22/2023] Open
Abstract
INTRODUCTION We sought to understand the Undetectable = Untransmittable (U = U) communication needs of persons living with HIV (PLHIV) and barriers to U = U communication among healthcare providers (HCPs) in South Africa. METHODS We conducted five focus group discussions (FGDs) with HCPs (N = 42) including nurses and counsellors from primary healthcare clinics (PHCs) in the Gauteng and Free State Provinces of South Africa, three FGDs (N = 27) with PLHIV recruited by snowball sampling from civil society organizations, and 27 in-depth interviews (IDIs) with recently diagnosed PLHIV in Johannesburg. IDIs and FGDs were audio recorded, transcribed, translated to English, and analysed thematically. RESULTS PLHIV were largely unaware and sceptical of U = U as the message appeared to contradict the mainstream HIV prevention clinical guidance. The low viral load (VL) knowledge further reduced confidence in U = U. PLHIV need support and guidance on the best approaches for sharing U = U information and disclosing their VL status to their partners, highlighting the central role of community understanding of U = U and VL to mediate the desired stigma reduction, social acceptance and emotional benefits of U = U for PLHIV. HCPs were uneasy about sharing U = U due to concerns about risk compensation and ART non-adherence and worried about enabling any ensuing HIV transmission. HCPs also need a simple, unambiguous, and consistent narrative for U = U, integrated with other HIV prevention messages. PLHIV and HCPs alike recommended a patient-centred approach to communicating U = U, focusing primarily on attaining viral suppression and emphasizing that condomless sex is only safe during periods of ART adherence. CONCLUSIONS These data highlight the need for simple U = U communication support targeting both HCP and PLHIV. Culturally appropriate communication materials, with training and ongoing mentorship of the clinic staff, are essential to improve patient-centred U = U communication in clinics.
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Affiliation(s)
- Dorina Onoya
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Tembeka Sineke
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, The Netherlands
| | - Rachel King
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, United States of America
| | - Idah Mokhele
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Shubhi Sharma
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
| | - Mandisa Dukashe
- South African National AIDS Council (SANAC), Pretoria, South Africa
| | - Refiloe Cele
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Dorah Bokaba
- Tshwane Department of Health, Tshwane, South Africa
| | | | - Simangele Sigasa
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jacob Bor
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
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Mokhele I, Sineke T, Vujovic M, Ruiter RAC, Onoya D. Who is providing HIV testing services? The profile of lay counsellors providing HIV testing services in Johannesburg, South Africa in the treat-all era. BMC Health Serv Res 2023; 23:1372. [PMID: 38062396 PMCID: PMC10702037 DOI: 10.1186/s12913-023-10331-y] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 11/15/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Lay counsellors are critical in sustaining access to HIV testing services (HTS) and psychosocial support for persons living with HIV (PLHIV). We aimed to describe the professional and psychosocial profiles of lay counsellors in primary healthcare (PHC) clinics in Johannesburg, South Africa under the universal-test-and-treat (UTT) policy context. METHODS We conducted a descriptive analysis of a cross-sectional survey among adult (≥ 18 years) lay counsellors from 20 PHC facilities (2-3/ clinic) in Johannesburg, South Africa. Consenting counsellors were interviewed between June 2018 and March 2019. We report on counsellors' demographic profiles, training, work experience, and mental and emotional well-being. RESULTS Overall, 55 consenting adult (≥ 18 years) lay counsellors (92.7% female, median age 37 years, interquartile range [IQR]: 33-44, and 27.3% HIV diagnosed) were surveyed. Most (85.5%) were Department of Health lay counsellors receiving a volunteer stipend at the time. Overall, 56.4% had been working as counsellors for five years or longer. The majority (87%) had completed the National HIV Testing Services Policy Guidelines-recommended 10-day basic counselling training, but 45.2% had not completed refresher training within the guideline's required 24 months. Reported operational barriers include lack of designated space for counselling (56.4%), inadequate professional supervision and support (40.7%) and insufficient emotional support (over 56.4%), and 60% were overwhelmed by their workload. A total of 18.2% had major depressive symptoms, and the same proportion scored low for psychological well-being. While most (87.3%) reported moderate job satisfaction, 50.9% actively sought alternative employment. CONCLUSION Despite lay counsellors' significant role in delivering HIV care in South Africa, there has been minimal investment in their skills development, emotional support, and integration into the formal health workforce. Counsellors' persisting unmet psychosocial, training, and professional needs could impact their efficacy in the UTT era.
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Affiliation(s)
- Idah Mokhele
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Tembeka Sineke
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Robert A C Ruiter
- Faculty of Psychology and Neuroscience , Maastricht University, Maastricht, the Netherlands
| | - Dorina Onoya
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
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Sineke T, Onoya D, Mokhele I, Cele R, Sharma S, Sigasa P, Dukashe M, Hansrod L, Inglis R, King R, Bor J. "I was scared dating… who would take me with my status?"-Living with HIV in the era of UTT and U = U: A qualitative study in Johannesburg, South Africa. PLOS Glob Public Health 2023; 3:e0000829. [PMID: 37831644 PMCID: PMC10575521 DOI: 10.1371/journal.pgph.0000829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 08/16/2023] [Indexed: 10/15/2023]
Abstract
South Africa rolled out Universal Test-and-Treat (UTT) in 2016, extending treatment eligibility to all persons living with HIV (PLHIV). We sought to understand how PLHIV in Johannesburg, South Africa, interpret and experience their HIV status, five years into the UTT era. In May 2021, we conducted in-depth interviews (IDI) (N = 27) with adult (≥18 years) PLHIV referred by HIV counsellors at three peri-urban primary healthcare clinics. We also conducted three focus group discussions (FGDs) (N = 27) with adult PLHIV recruited from clinics or from civil society organisations through snowball sampling. Follow-up interviews were conducted with 29 IDI and FGD participants. Participants were asked to reflect on their HIV diagnosis, what their HIV status meant to them and how, if at all, being HIV-positive affected their lives. Interviews and focus group discussions were audio-recorded, transcribed, translated to English, and analysed using a grounded theory approach. Participants perceived that HIV was common, that PLHIV could live a normal life with antiretroviral therapy (ART), and that ART was widely accessible. However, HIV elicited feelings of guilt and shame as a sexually transmitted disease. Participants used the language of "blame" in discussing HIV transmission, citing their own reckless behaviour or blaming their partner for infecting them. Participants feared transmitting HIV to others and felt responsible for avoiding transmission. To manage transmission anxiety, participants avoided sexual relationships, chose HIV-positive partners, and/or insisted on using condoms. Many participants feared-or had previously experienced-rejection by partners due to their HIV status and reported hiding their medication, avoiding disclosure, or avoiding relationships altogether. Most participants were not aware that undetectable HIV is untransmittable (U = U). Participants who were aware of U = U expressed less anxiety about transmitting HIV to others and greater confidence in having relationships. Despite perceiving HIV as a manageable chronic condition, PLHIV still faced transmission anxiety and fears of rejection by their partners. Disseminating information on U = U could reduce the psychosocial burdens of living with HIV, encourage open communication with partners, and remove barriers to HIV testing and treatment adherence.
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Affiliation(s)
- Tembeka Sineke
- Faculty of Health Sciences, Department of Internal Medicine, Health Economics and Epidemiology Research Office, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Dorina Onoya
- Faculty of Health Sciences, Department of Internal Medicine, Health Economics and Epidemiology Research Office, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Idah Mokhele
- Faculty of Health Sciences, Department of Internal Medicine, Health Economics and Epidemiology Research Office, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Refiloe Cele
- Faculty of Health Sciences, Department of Internal Medicine, Health Economics and Epidemiology Research Office, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Shubhi Sharma
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Patience Sigasa
- Faculty of Health Sciences, Department of Internal Medicine, Health Economics and Epidemiology Research Office, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | | | - Rachel King
- Institute for Global Health Sciences, University of California, San Francisco, California, United States of America
| | - Jacob Bor
- Faculty of Health Sciences, Department of Internal Medicine, Health Economics and Epidemiology Research Office, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
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Pascoe S, Huber A, Mokhele I, Lekodeba N, Ntjikelane V, Sande L, Tchereni T, Haimbe P, Rosen S. The SENTINEL study of differentiated service delivery models for HIV treatment in Malawi, South Africa, and Zambia: research protocol for a prospective cohort study. BMC Health Serv Res 2023; 23:891. [PMID: 37612720 PMCID: PMC10463463 DOI: 10.1186/s12913-023-09813-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 07/13/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND Many countries in sub-Saharan Africa are rapidly scaling up "differentiated service delivery" (DSD) models for HIV treatment to improve the quality of care, increase access, reduce costs, and support the continued expansion and sustainability of antiretroviral therapy (ART) programs. Although there is some published evidence about the health outcomes of patients in DSD models, little is known about their impacts on healthcare providers' job satisfaction, patients' quality of life, costs to providers or patients, or how DSD models affect resource allocation at the facility level. METHODS SENTINEL is a multi-year observational study that will collect detailed data about DSD models for ART delivery and related services from 12 healthcare facilities in Malawi, 24 in South Africa, and 12 in Zambia. The first round of SENTINEL included a patient survey, provider survey, provider time-and-motion observations, and facility resource use inventory. A survey of clients testing for HIV and a supplement to the facility resource use component to describe service delivery integration will be added for the second round. The patient survey will ask up to 10 patients enrolled in each DSD model at each study site about their experiences in HIV care and in DSD models, costs incurred seeking treatment, and preferences for HIV service delivery. The provider survey will ask up to 10 providers per site about the impact of DSD models on their positions and clinics. The time-and-motion component will directly observe the time use of a sample of providers implementing DSD models. Finally, the resource utilization component will collect facility-level data about DSD model availability and enrollment and the human and other resources needed to implement them. SENTINEL is planned to include four or more approximately annual rounds of data collection between 2021 and 2026. DISCUSSION As national DSD programs for HIV treatment mature, it is important to understand how individual healthcare facilities are interpreting and implementing national guidelines and how healthcare workers and clients are adapting to new models of service delivery. SENTINEL will help policy makers and program managers understand the benefits and costs of differentiated service delivery and improve resource allocation going forward.
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Affiliation(s)
- Sophie Pascoe
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Sunnyside Office Park, Building C, First Floor, 32 Princess of Wales Terrace, Parktown, Johannesburg, 2193, South Africa
| | - Amy Huber
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Sunnyside Office Park, Building C, First Floor, 32 Princess of Wales Terrace, Parktown, Johannesburg, 2193, South Africa
| | - Idah Mokhele
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Sunnyside Office Park, Building C, First Floor, 32 Princess of Wales Terrace, Parktown, Johannesburg, 2193, South Africa
| | - Nkgomeleng Lekodeba
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Sunnyside Office Park, Building C, First Floor, 32 Princess of Wales Terrace, Parktown, Johannesburg, 2193, South Africa
| | - Vinolia Ntjikelane
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Sunnyside Office Park, Building C, First Floor, 32 Princess of Wales Terrace, Parktown, Johannesburg, 2193, South Africa
| | - Linda Sande
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Sunnyside Office Park, Building C, First Floor, 32 Princess of Wales Terrace, Parktown, Johannesburg, 2193, South Africa
| | - Timothy Tchereni
- Clinton Health Access Initiative-Malawi, Private Bag 68, Lilongwe, Malawi
| | - Prudence Haimbe
- Clinton Health Access Initiative-Zambia, P.O. Box 51071, Ridgeway, Lusaka, Zambia
| | - Sydney Rosen
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Sunnyside Office Park, Building C, First Floor, 32 Princess of Wales Terrace, Parktown, Johannesburg, 2193, South Africa.
- Department of Global Health, School of Public Health, Boston University, 801 Massachusetts Ave, 3rd Fl, Boston, MA, 02118, USA.
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Sineke T, Mokhele I, Langa J, Mngoma B, Onoya D. HIV and ART related knowledge among newly diagnosed patients with HIV under the universal-test-and-treat (UTT) policy in Johannesburg, South Africa. AIDS Care 2022; 34:655-662. [PMID: 33749453 DOI: 10.1080/09540121.2021.1902927] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
South Africa implemented Universal Test & Treat (UTT) guidelines in September 2016. We examine HIV/ART knowledge among newly diagnosed from a prospective study enrolling newly diagnosed HIV-positive adults, under same-day ART policy, at four primary health clinics in Johannesburg, South Africa. We describe factors associated with high HIV/ART related knowledge score among newly diagnosed patients using Poisson regression. We included 652 HIV positive adults (64.1% female; median age 33 years (IQR: 28-39). Overall, 539 (82.7%) patients were classified as having high HIV/ART knowledge, 14.7% medium knowledge and 2.6% had low knowledge. HIV/ART knowledge was mainly associated to high English literacy (aRR 0.9 Medium vs High, 95% CI: 0.8-0.9; aRR 0.7 for Low vs High: 95% CI: 0.6-0.9). However, patients who did not disclose their intentions for HIV test (aRR 0.9, not disclosed intentions vs having disclosed intentions to test, 95% CI: 0.8-0.9), participants who indicated concerns with ART (aRR 0.9 moderate to high vs low concerns, 95% CI: 0.8-0.9) were less likely to have high knowledge. Our results highlight a correlation between English literacy and good knowledge. There is a need to make information more accessible in a non-English language. Addressing this gap is critical in achieving the WHO targets.
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Affiliation(s)
- Tembeka Sineke
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Idah Mokhele
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Dorina Onoya
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Bor J, Fischer C, Modi M, Richman B, Kinker C, King R, Calabrese SK, Mokhele I, Sineke T, Zuma T, Rosen S, Bärnighausen T, Mayer KH, Onoya D. Changing Knowledge and Attitudes Towards HIV Treatment-as-Prevention and "Undetectable = Untransmittable": A Systematic Review. AIDS Behav 2021; 25:4209-4224. [PMID: 34036459 PMCID: PMC8147591 DOI: 10.1007/s10461-021-03296-8] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2021] [Indexed: 12/12/2022]
Abstract
People on HIV treatment with undetectable virus cannot transmit HIV sexually (Undetectable = Untransmittable, U = U). However, the science of treatment-as-prevention (TasP) may not be widely understood by people with and without HIV who could benefit from this information. We systematically reviewed the global literature on knowledge and attitudes related to TasP and interventions providing TasP or U = U information. We included studies of providers, patients, and communities from all regions of the world, published 2008–2020. We screened 885 papers and abstracts and identified 72 for inclusion. Studies in high-income settings reported high awareness of TasP but gaps in knowledge about the likelihood of transmission with undetectable HIV. Greater knowledge was associated with more positive attitudes towards TasP. Extant literature shows low awareness of TasP in Africa where 2 in 3 people with HIV live. The emerging evidence on interventions delivering information on TasP suggests beneficial impacts on knowledge, stigma, HIV testing, and viral suppression. Review was pre-registered at PROSPERO: CRD42020153725
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Affiliation(s)
- Jacob Bor
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA, 02119, USA.
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, GP, South Africa.
| | - Charlie Fischer
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA, 02119, USA
| | - Mirva Modi
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA, 02119, USA
| | | | | | - Rachel King
- UCSF Institute for Global Health Sciences, University of California, San Francisco, 550 16th Street, San Francisco, CA, 94158, USA
| | | | - Idah Mokhele
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, GP, South Africa
| | - Tembeka Sineke
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, GP, South Africa
| | - Thembelihle Zuma
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- University of KwaZulu-Natal, Durban, South Africa
- Division of Infection and Immunity, University College London, London, UK
| | - Sydney Rosen
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA, 02119, USA
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, GP, South Africa
| | - Till Bärnighausen
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Kenneth H Mayer
- Fenway Health Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Dorina Onoya
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, GP, South Africa
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Mokhele I, Jinga N, Berhanu R, Dlamini T, Long L, Evans D. Treatment and pregnancy outcomes of pregnant women exposed to second-line anti-tuberculosis drugs in South Africa. BMC Pregnancy Childbirth 2021; 21:453. [PMID: 34182944 PMCID: PMC8240388 DOI: 10.1186/s12884-021-03956-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 06/14/2021] [Indexed: 11/10/2022] Open
Abstract
Background Multi-drug resistant and rifampicin-resistant tuberculosis (MDR/RR-TB) in pregnant women is a cause for concern globally; few data have described the safety of second-line anti-TB medications during pregnancy. We aim to describe TB treatment and pregnancy outcomes among pregnant women receiving second-line anti-tuberculosis treatment for MDR/RR-TB in Johannesburg, South Africa. Methods We conducted a retrospective record review of pregnant women (≥ 18 years) who received treatment for MDR/RR-TB between 01/2010–08/2016 at three outpatient treatment sites in Johannesburg, South Africa. Demographic, treatment and pregnancy outcome data were collected from available medical records. Preterm birth (< 37 weeks), and miscarriage were categorized as adverse pregnancy outcomes. Results Out of 720 women of child-bearing age who received MDR/RR-TB treatment at the three study sites, 35 (4.4%) pregnancies were identified. Overall, 68.7% (24/35) were HIV infected, 83.3% (20/24) were on antiretroviral therapy (ART). Most women, 88.6% (31/35), were pregnant at the time of MDR/RR-TB diagnosis and four women became pregnant during treatment. Pregnancy outcomes were available for 20/35 (57.1%) women, which included 15 live births (11 occurred prior to 37 weeks), 1 neonatal death, 1 miscarriage and 3 pregnancy terminations. Overall, 13/20 (65.0%) women with known pregnancy outcomes had an adverse pregnancy outcome. Of the 28 women with known TB treatment outcomes 17 (60.7%) completed treatment successfully (4 were cured and 13 completed treatment), 3 (10.7%) died and 8 (28.6%) were lost-to-follow-up. Conclusions Pregnant women with MDR/RR-TB suffer from high rates of adverse pregnancy outcomes and about 60% achieve a successful TB treatment outcome. These vulnerable patients require close monitoring and coordinated obstetric, HIV and TB care.
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Affiliation(s)
- Idah Mokhele
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Nelly Jinga
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Rebecca Berhanu
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | | | - Lawrence Long
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Denise Evans
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Mokhele I, Sineke T, Langa J, Onoya D. Self-reported motivators for HIV testing in the treat-all era among HIV positive patients in Johannesburg, South Africa. Medicine (Baltimore) 2021; 100:e25286. [PMID: 33847626 PMCID: PMC8052053 DOI: 10.1097/md.0000000000025286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 03/08/2021] [Indexed: 11/01/2022] Open
Abstract
To explore associations between self-reported ill-health as a primary motivator for HIV-testing and socio-demographic factors.Four local primary healthcare clinics in Johannesburg, South Africa.A total of 529 newly HIV diagnosed adults (≥18 years) enrolled from October 2017 to August 2018, participated in the survey on the same day of diagnosis.Testing out of own initiative or perceived HIV exposure was categorized as asymptomatic. Reporting ill-health as the main reason for testing was categorized as symptomatic. Modified Poisson regression was used to evaluate predictors of motivators for HIV testing.Overall, 327/520 (62.9%) participants reported symptoms as the main motivator for testing. Among the asymptomatic, 17.1% reported potential HIV exposure as a reason for testing, while 20.0% just wanted to know their HIV status. Baseline predictors of symptom-related motivators for HIV testing include disclosing intention to test (aPR 1.4 for family/friend/others vs partners/spouse, 95% CI: 1.1-1.8; aPR 1.4 for not disclosing vs partners/spouse, 95% CI: 1.1-1.7), and HIV testing history (aPR 1.2 for last HIV test >12-months ago vs last test 12-months prior, 95% CI: 1.0-1.5; aPR 1.3 for never tested for HIV before vs last test 12-months prior, 95%CI:1.0-1.6).Findings indicate that newly diagnosed HIV positive patients still enter care because of ill-health, not prevention purposes. Increasing early HIV testing remains essential to maximize the benefits of expanded ART access.
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Affiliation(s)
- Idah Mokhele
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand
| | - Tembeka Sineke
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand
| | | | - Dorina Onoya
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand
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Onoya D, Mokhele I, Sineke T, Mngoma B, Moolla A, Vujovic M, Bor J, Langa J, Fox MP. Health provider perspectives on the implementation of the same-day-ART initiation policy in the Gauteng province of South Africa. Health Res Policy Syst 2021; 19:2. [PMID: 33407574 PMCID: PMC7789550 DOI: 10.1186/s12961-020-00673-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 12/16/2020] [Indexed: 12/27/2022] Open
Abstract
Background In September 2016, South Africa (SA) began implementing the universal-test-and-treat (UTT) policy in hopes of attaining the UNAIDS 90-90-90 targets by 2020. The SA National Department of Health provided a further directive to initiate antiretroviral therapy (ART) on the day of HIV diagnosis in September 2017. We conducted a qualitative study to determine the progress in implementing UTT and examine health providers' perspectives on the implementation of the same-day initiation (SDI) policy, six months after the policy change. Methods We conducted in-depth interviews with three professional nurses, and four HIV lay counsellors of five primary health clinics in the Gauteng province, between October and December 2017. In September 2018, we also conducted a focus group discussion with ten professional nurses/clinic managers from ten clinic facilities. The interviews and focus groups covered the adoption and implementation of UTT and SDI policies. Interviews were conducted in English, Sotho or Zulu and audio-recorded with participant consent. Audio-recordings were transcribed verbatim, translated to English and analysed thematically using NVivo 11. Results The data indicates inconsistencies across facilities and incongruities between counsellor and nursing provider perspectives regarding the SDI policy implementation. While nurses highlighted the clinical benefits of early ART initiation, they expressed concerns that immediate ART may be overwhelming for some patients, who may be unprepared and likely to disengage from care soon after the initial acceptance of ART. Accordingly, the SDI implementation was slow due to limited patient demand, provider ambivalence to the policy implementations, as well as challenges with infrastructure and human resources. The process for assessing patient readiness was poorly defined by health providers across facilities, inconsistent and counsellor dependent. Providers were also unclear on how to ensure that patients who defer treatment return for ongoing counselling. Conclusions Our results highlight important gaps in the drive to achieve the ART initiation target and demonstrate the need for further engagement with health care providers around the implementation of same-day ART initiation, particularly with regards to infrastructural/capacity needs and the management of patient readiness for lifelong ART on the day of HIV diagnosis. Additionally, there is a need for improved promotion of the SDI provision both in health care settings and in media communications to increase patient demand for early and lifelong ART.
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Affiliation(s)
- Dorina Onoya
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Idah Mokhele
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Tembeka Sineke
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Aneesa Moolla
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Jacob Bor
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Departments of Global Health, Boston University School of Public Health, Boston, MA, United States of America.,Departments of Epidemiology, Boston University School of Public Health, Boston, MA, United States of America
| | | | - Matthew P Fox
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Departments of Global Health, Boston University School of Public Health, Boston, MA, United States of America.,Departments of Epidemiology, Boston University School of Public Health, Boston, MA, United States of America
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13
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Mokhele I, Sineke T, Vujovic M, Fox MP, Ruiter RA, Onoya D. Using intervention mapping in motivational interviewing training to improve ART uptake in Gauteng, South Africa. J Health Psychol 2020; 27:589-600. [PMID: 33047638 DOI: 10.1177/1359105320962241] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
In South Africa, lay HIV counsellors are at the forefront of many HIV-related behavioural interventions. However, they have limited formal counselling training and little ongoing in-service support, leading to considerable variability in approaches to counselling. We describe the use of Intervention Mapping to develop a motivational interviewing counselling training and support program, titled "Thusa-Thuso - helping you help", for lay HIV counsellors practising in primary health care clinics in South Africa. The program is contextually relevant, locally-produced, scalable, and is designed to impart sustained motivational interviewing counselling skills in lay HIV counsellors for improved antiretroviral therapy (ART) uptake in the universal-test-and-treat era.
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Affiliation(s)
- Idah Mokhele
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Tembeka Sineke
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Matthew P Fox
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa.,Boston University School of Public Health, Boston, MA, USA
| | - Robert Ac Ruiter
- Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Dorina Onoya
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
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14
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Onoya D, Sineke T, Hendrickson C, Mokhele I, Maskew M, Long LC, Fox M. Impact of the test and treat policy on delays in antiretroviral therapy initiation among adult HIV positive patients from six clinics in Johannesburg, South Africa: results from a prospective cohort study. BMJ Open 2020; 10:e030228. [PMID: 32213514 PMCID: PMC7170559 DOI: 10.1136/bmjopen-2019-030228] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVES To assess delays to antiretroviral therapy (ART) initiation before and after the Universal Test and Treat (UTT) and the same-day initiation (SDI) of ART policy periods in Johannesburg, South Africa. DESIGN Prospective cohort study. SETTING Patients were recruited from six primary health clinics in Johannesburg. PARTICIPANTS Overall, 1029 newly diagnosed HIV positive adults (≥18 years) were consecutively enrolled by referral from the testing counsellor between April and December 2015 (pre-UTT n=146), July and August 2017 (UTT, n=141) and October 2017 and August 2018 (SDI, n=742). MAIN OUTCOME MEASURES Cox proportional hazards regression was used to assess predictors of 30 days ART initiation. Additionally, predictors of immediate ART initiation were evaluated using Poisson regression. RESULTS Overall, 30 days ART proportions were 71.9% overall, 36.9% pre-UTT (44.3% of those eligible), 65.9% under UTT and 79.9% under the SDI policy. The median days to ART initiation declined from 21 pre-UTT (IQR: 15-30) to 8 (IQR: 6-16) under UTT and 5 days (IQR: 0-8) under the SDI policy. However, only 150 (20.2%) of the SDI cohort-initiated ART immediately after HIV diagnosis. Living in a two-adult home (adjusted HR (aHR) 1.2 vs living alone, 95% CI 1.0 to 1.5) increased the likelihood of 30-day ART. Missing baseline cluster of differentiation four (CD4) data decreased the likelihood of 30 days ART by 40% (aHR 0.6 vs CD4 <350 cells/µL, 95% CI 0.5 to 0.7). More women took up immediate ART (adjusted relative risk (aRR) 1.3, 95% CI 1.0 to 1.9). Participants ≥40 years (aRR 0.6 vs 18-24 years, 95% CI 0.4 to 0.9) were less likely to start ART immediately after HIV diagnosis. However, immediate ART rates increased with longer policy implementation time (aRR 0.2 for <3 months vs >10 months, 95% CI 0.1 to 0.4). CONCLUSIONS The study results highlight a positive move towards earlier ART initiation during the UTT and SDI periods and emphasise a need to increase same-day ART implementation further.
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Affiliation(s)
- Dorina Onoya
- Health Economics & Epidemiology Research Office, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Tembeka Sineke
- Health Economics & Epidemiology Research Office, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Cheryl Hendrickson
- Health Economics & Epidemiology Research Office, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Idah Mokhele
- Health Economics & Epidemiology Research Office, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Mhairi Maskew
- Health Economics & Epidemiology Research Office, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Lawrence C Long
- Health Economics & Epidemiology Research Office, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts, USA
| | - Matthew Fox
- Health Economics & Epidemiology Research Office, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts, USA
- Department of Epidemiology, School of Public Health, Boston University, Boston, Massachusetts, USA
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Mokhele I, Mashamaite S, Majuba P, Xulu T, Long L, Onoya D. Effective public-private partnerships for sustainable antiretroviral therapy: outcomes of the Right to Care health services GP down-referral program. BMC Public Health 2019; 19:1471. [PMID: 31699063 PMCID: PMC6836664 DOI: 10.1186/s12889-019-7660-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 09/20/2019] [Indexed: 11/14/2022] Open
Abstract
Background The recently increased access to antiretroviral therapy (ART) in South Africa has placed additional strain on human and infrastructure resources of the public health sector. Capacity from private-sector General Practitioners (GPs) could be leveraged to ease the current burden on the public health sector. Methods We conducted a retrospective record review of routine electronic medical record data on a systematic sample of HIV-infected adults (≥18 years old) initiated on ART at a tertiary hospital outpatient HIV clinic in Johannesburg, South Africa and down-referred to private-GPs for continued care after stabilization on ART. We compared these patients (“GP down-referred”) to a control-cohort who remained at the referring site (“Clinic A”) and patients from a regional hospital outpatient HIV clinic not offering down-referral to GPs (“Clinic B”). Study outcomes assessed are viral load suppression (VL < 50 copies/ml) and attrition from care (all-cause-mortality or > 90-days late for a last-scheduled visit) by 12 months of follow-up following down-referral or eligibility. Results A total of 3685 patients, comprising 373 (10.1%) GP down-referred, 2599 (70.5%) clinic A controls, and 713 (19.4%) clinic B controls were included in the analysis. Overall, 1535 patients (53.3%) had a suppressed viral load. A higher portion of GP down-referred patients had a suppressed viral load compared to clinic A and B patients (65.7% vs 49.1% vs 58.9%). After adjusting for demographic and baseline clinical covariates, we found no difference in viral load suppression between GP down-referred and control patients (adjusted relative risk [aRR] for clinic A vs GP down-referred 1.0; 95% CI: 0.9–1.1), (aRR for clinic B vs GP down-referred 1.0; 95% CI: 0.9–1.2). Clinic B controls experienced the highest attrition compared to GP down-referred and clinic A controls (33.2% vs 11.3% vs 5.9%) and had a higher risk of attrition compared to GP down-referred patients (adjusted hazard ratio [aHR] 4.2; 95% CI: 2.8–6.5), whereas clinic B controls had a lower risk of attrition (aHR 0.5; 95% CI: 0.3–0.7). Conclusions and recommendations Our results show that private-GPs can contribute to caring for stabilized public sector HIV patients on life-long ART. However, they require special efforts to improve retention in care.
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Affiliation(s)
- Idah Mokhele
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | | | | | | | - Lawrence Long
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Dorina Onoya
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Mokhele I, Nattey C, Jinga N, Mongwenyana C, Fox MP, Onoya D. Prevalence and predictors of postpartum depression by HIV status and timing of HIV diagnosis in Gauteng, South Africa. PLoS One 2019; 14:e0214849. [PMID: 30947293 PMCID: PMC6448929 DOI: 10.1371/journal.pone.0214849] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 03/17/2019] [Indexed: 12/03/2022] Open
Abstract
Background Postpartum depression (PPD) is a common mental health condition that can compromise the quality of life and functional capacity of mothers and cause health and developmental problems in children born to affected mothers. Objectives We set out to measure the prevalence of PPD comparing postpartum HIV-1 infected women with pre-pregnancy HIV care experience, newly diagnosed (in latest pregnancy) HIV-1 infected women and HIV negative women, and to identify predictors of major PPD among these women in a peri-urban clinic in South Africa. Methods We conducted a cross-sectional survey of 1151 adult (≥18 years) postpartum HIV-1 infected (690) and HIV negative (461) women who delivered up to 30 days before study enrolment, interviewed after their first post-natal visit (3–6 days post- delivery) at Midwife Obstetric Units in Gauteng, South Africa. PPD was categorised into no depression (CES-D 10 total score <5), low to medium depression (CES-D 10 total score ≥5 and <10) and major depressive symptoms (CES-D 10 total score≥10). We used ordered logistic regression to identify predictors of postpartum depression and report adjusted odds ratio (aOR) and 95% confidence intervals (CIs). Results Overall 288 (25.0%) women screened positive for postpartum depression, a total of 168 (14.6%) women had low to medium PPD and 120 (10.4%) had major PPD. A higher proportion of HIV negative women experienced PPD, 129/461 (28.0%) among HIV negative vs. 159/690 (23.0%) among HIV-1 infected. Among HIV positive women, there was no meaningful difference in PPD between newly HIV diagnosed and those diagnosed before the most recent pregnancy (aOR 1.3, 95% confidence interval (CI): 0.9–1.8). Predictors of PPD among HIV positive women were living with friends/in a house-share (aOR 0.5 for house-share vs. own home, 95% CI: 0.3–0.9), and attending antenatal care (ANC) for the most recent pregnancy (aOR 0.2 for ANC attendance vs. no ANC attendance, 95% CI: 0.0–0.5). Living with friends/in a house-share was also a predictor of PPD among HIV negative women (aOR 0.4 for house-share vs. own home, 95% CI: 0.2–0.8). Conclusions and recommendations Targeted symptom screening based on identified risk factors should be considered for postpartum women to increase PPD case-finding and referral to specialised social support services.
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Affiliation(s)
- Idah Mokhele
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Cornelius Nattey
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nelly Jinga
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Constance Mongwenyana
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Matthew P. Fox
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Dorina Onoya
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- * E-mail:
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Nattey C, Jinga N, Mongwenyana C, Mokhele I, Mohomi G, Fox MP, Onoya D. Understanding Predictors of Early Antenatal Care Initiation in Relationship to Timing of HIV Diagnosis in South Africa. AIDS Patient Care STDS 2018; 32:251-256. [PMID: 29851501 DOI: 10.1089/apc.2018.0023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [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] [Indexed: 11/12/2022] Open
Abstract
Effective prevention of mother-to-child transmission benefits from early presentation to antenatal care (ANC). It is, however, unclear whether a previous HIV diagnosis results in earlier initiation of ANC. We estimated the probability of early ANC initiation among women with a previous HIV-positive diagnosis compared to those who first tested for HIV during ANC and explored determinants of early ANC among HIV-positive women. We conducted an analysis of a cross-sectional survey among 411 HIV-positive adult (>18 years) women who gave birth at midwife obstetrics units in Gauteng between October 2016 and May 2017. Predictors of early ANC (defined as initiating ANC before or at 14 weeks of gestation) were assessed by multivariate log-binomial regression model. Overall, 51% (210) were diagnosed during pregnancy with 89% (188) initiating antiretroviral therapy on the same day of diagnosis. There was no meaningful difference in the timing of ANC initiation between women with previous HIV diagnosis [adjusted risk ratio (aRR) = 1.2; 95% confidence interval (95% CI): 0.9-1.7] compared with those diagnosed during pregnancy. Early ANC was predicted by planned pregnancy [aRR = 1.3; 95% CI: 1.1-1.7], parity (>2 children) [aRR = 0.6; 95% CI: 0.2-0.9] compared to not having a child, and tuberculosis diagnosis [aRR = 2.9; 95% CI: 1.4-6.1]. Our results suggest the need for a targeted intervention among HIV-positive women by improving the quality, content and outreach of ANC services to enhance early ANC uptake, and minimize mother-to-child transmission risk.
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Affiliation(s)
- Cornelius Nattey
- 1 Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand , Johannesburg, South Africa
| | - Nelly Jinga
- 1 Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand , Johannesburg, South Africa
| | - Constance Mongwenyana
- 1 Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand , Johannesburg, South Africa
| | - Idah Mokhele
- 1 Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand , Johannesburg, South Africa
| | - Given Mohomi
- 1 Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand , Johannesburg, South Africa
| | - Matthew P Fox
- 1 Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand , Johannesburg, South Africa
- 2 Department of Global Health, Boston University School of Public Health , Boston, Massachusetts
- 3 Department of Epidemiology, Boston University School of Public Health , Boston, Massachusetts
| | - Dorina Onoya
- 1 Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand , Johannesburg, South Africa
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Spencer K, Mokhele I, Firnhaber C. Congenital genital abnormalities detected during routine circumcision at a South African institution: a retrospective record review. Afr Health Sci 2018; 18:352-358. [PMID: 30602962 PMCID: PMC6306973 DOI: 10.4314/ahs.v18i2.20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Due to the reduction in HIV transmission through male medical circumcisions (MMC), numerous clinics throughout South Africa offer a voluntary free service to boys from the age of ten years and above. An examination prior to the procedure may detect congenital abnormalities missed after birth. OBJECTIVES The aim of this study was to measure the incidence of these abnormalities, determine the demographic and clinical characteristics of this group and determine what referral systems, interventions, and follow-up is available to them. METHODS The study was a descriptive, observational, retrospective analysis of de-identified medical records at a routine MMC service at a Johannesburg clinic in 2015. The participants were male patients between the ages of 10 - 49. RESULTS Out of 1548 participants, 91.0% (n=1409) had a normal genital examination while 3.7% (n=57) had an abnormal examination and 5.1% (n=79) had no examination recorded. Thirty five congenital anomalies were detected and only 2 patients (diagnosed with hypospadias) were seen at the urology out-patient's department. CONCLUSION The incidence of congenital genital abnormalities of males presenting for routine circumcision is low. Despite the low incidence the effect on fertility, sexuality, ability to urinate and on psychological wellbeing is significant. Referral services to the urology department should be restructured to improve all outcomes.
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