Changes in disclosure, adherence and healthcare interactions after the introduction of immediate ART initiation: an analysis of patient experiences in Swaziland

Introduction

There are concerns that immediate ART initiation (regardless of CD4 count) negatively affects HIV status disclosure, ART adherence and healthcare interactions. We assessed changes in these factors after the ‘Early access to ART for all’ intervention, a universal test‐and‐treat study in Swaziland.

Methods

We recruited two samples of participants between 2014 and 2017. The first group was interviewed before the intervention (control); the second group at the implementation and 6 months thereafter (intervention).

Results

High levels of disclosure to partners (controls and intervention: 94%) and family members (controls: 78%, intervention: 79%) were reported, and high levels of adherence (85% did not miss a dose among the controls, 84% in the intervention group). There were no changes in patients reporting feeling pressured to initiate ART (controls: 10%, intervention: 11%). The quality of interaction with healthcare workers improved after the intervention; healthcare workers explained more often the choice of ART initiation (controls: 88%, intervention: 93%) and the meaning of both CD4 and viral load test results (controls: 15%, intervention: 47%). More patients in the intervention group reported receiving test results (controls: 13%, intervention: 46%). We observed no changes in disclosure, adherence or patient experiences 6 months into the intervention compared to its start.

Conclusion

Our results suggest that both reported adherence and disclosure levels remain high after the introduction of immediate ART in Swaziland. We observed an improvement in the healthcare interactions, possibly due to training at participating facilities, which will be an important element for a successful roll‐out of immediate ART.

"I don't want them to know": how stigma creates dilemmas for engagement with Treat-all HIV care for people living with HIV in Eswatini

"Treat-all" programmes aim to improve clinical outcomes and to reduce HIV transmission through regular HIV testing and immediate offer of antiretroviral therapy (ART) for those diagnosed HIV-positive, irrespective of immunological status and symptoms of disease. Global narratives on the benefits of Treat-all anticipate reduced HIV-related stigma and increased "normalisation" of HIV with Treat-all implementation, whereby HIV is remoulded as a manageable, chronic condition where stigmatising symptoms can be concealed. Drawing on Goffman's stigma work, we aimed to investigate how stigma may influence the engagement of clinically asymptomatic people living with HIV (PLHIV) with Treat-all HIV care in Shiselweni, Eswatini (formerly Swaziland). This longitudinal research comprised 106 interviews conducted from August 2016 to September 2017, including repeated interviews with 30 PLHIV, and one-off interviews with 20 healthcare workers. Data were analysed thematically using NVivo 11, drawing upon principles of grounded theory to generate findings inductively from participants' accounts. Stigma was pervasive within the narratives of PLHIV, framing their engagement with treatment and care. Many asymptomatic PLHIV were motivated to initiate ART in order to maintain a "discreditable" status, by preventing the development of visible and exposing symptoms. However, engagement with treatment and care services could itself be exposing. PLHIV described the ways in which these "invisibilising" benefits and exposing risks of ART were continually assessed and navigated over time. Where the risk of exposure was deemed too great, this could lead to intermittent treatment-taking, and disengagement from care. Addressing HIV related stigma is crucial to the success of Treat-all, and should thus be a core component of HIV responses.

"Is it making any difference?" A qualitative study examining the treatment-taking experiences of asymptomatic people living with HIV in the context of Treat-all in Eswatini

INTRODUCTION

Treat-all is being implemented in several African settings, in accordance with 2015 World Health Organisation guidelines. The factors known to undermine adherence to antiretroviral therapy (ART) may change in the context of Treat-all, where people living with HIV (PLHIV) increasingly initiate ART at earlier, asymptomatic stages of disease, soon after diagnosis. This paper aimed to examine the asymptomatic PLHIV's experiences engaging with early ART initiation under the Treat-all policy, including how they navigate treatment-taking over the longer term.

METHODS

A longitudinal qualitative study was conducted within a Médecins Sans Frontières/Ministry of Health Treat-all pilot in Shiselweni, southern Eswatini. The Treat-all pilot began in October 2014, adopted into national policy in October 2016. Participants were recruited purposively to include newly diagnosed, clinically asymptomatic PLHIV with a range of treatment-taking experiences, and healthcare workers (HCW) with various roles. This analysis drew upon a sub-sample of 17 PLHIV who had been on ART for at least 12 months, with mean 20 months on ART at first interview, and who undertook three interviews each. Additionally, 20 HCWs were interviewed once. Interviews were conducted from August 2016 to September 2017. Data were analysed thematically using coding, drawing upon principles of grounded theory, and aided by Nvivo 11.

RESULTS

It was important for PLHIV to perceive the need for treatment, and to have evidence of its effectiveness to motivate their treatment-taking, thereby supporting engagement with care. For some, coming to terms with a HIV diagnosis or re-interpreting past illnesses as signs of HIV could point to the need for ART to prevent health deterioration and prolong life. However, others doubted the accuracy of an HIV diagnosis and the need for treatment in the absence of symptoms or signs of ill health, with some experimenting with treatment-taking as a means of seeking evidence of their need for treatment and its effect. Viral load monitoring appeared important in offering a view of the effect of treatment on the level of the virus, thereby motivating continued treatment-taking.

CONCLUSIONS

These findings highlight the importance of PLHIV perceiving need for treatment and having evidence of the difference that ART is making to them for motivating treatment-taking. Patient support should be adapted to address these concerns, and viral load monitoring made routinely available within Treat-all care, with communication of suppressed results emphasized to patients.

Field suitability and diagnostic accuracy of the Biocentric® open real-time PCR platform for plasma-based HIV viral load quantification in Swaziland

BACKGROUND

Viral load (VL) testing is being scaled up in resource-limited settings. However, not all commercially available VL testing methods have been evaluated under field conditions. This study is one of a few to evaluate the Biocentric platform for VL quantification in routine practice in Sub-Saharan Africa.

METHODS

Venous blood specimens were obtained from patients eligible for VL testing at two health facilities in Swaziland from October 2016 to March 2017. Samples were centrifuged at two laboratories (LAB-1, LAB-2) to obtain paired plasma specimens for VL quantification with the national reference method and on the Biocentric platform. Agreement (correlation, Bland-Altman) and accuracy (sensitivity, specificity) indicators were calculated at the VL thresholds of 416 (2.62 log₁₀) and 1000 (3.0 log₁₀) copies/mL. Leftover samples from patients with discordant VL results were re-quantified and accuracy indicators recalculated. Logistic regression was used to compare laboratory performance.

RESULTS

A total of 364 paired plasma samples (LAB-1: n = 198; LAB-2: n = 166) were successfully tested using both methods. The correlation was high (R = 0.82, p < 0.01), and the Bland-Altman analysis showed a minimal mean difference (- 0.03 log₁₀ copies/mL; 95% CI: -1.15 to 1.08). At the clinical threshold level of 3.0 log₁₀ copies/mL, the sensitivity was 88.6% (95% CI: 78.7 to 94.9) and the specificity was 98.3% (95% CI: 96.1 to 99.4). Sensitivity was higher in LAB-1 (100%; 95% CI: 71.5 to 100) than in LAB-2 (86.4%; 95% CI: 75.0 to 94.0). Most upward (n = 8, 2.2%) and downward (n = 11, 3.0%) misclassifications occurred at the 2.62 log threshold, with LAB-2 having a 16 (95% CI: 2.26 to 113.27; p = 0.006) times higher odds of downward misclassification. After retesting of discordant leftover samples (n = 17), overall sensitivity increased to 93.5% (95% CI: 85.5 to 97.9) and 97.1% (95% CI: 90.1 to 99.7) at the 2.62 and 3.0 thresholds, and specificity increased to 98.6% (95% CI: 96.5 to 99.6) and 99.0% (95% CI: 97.0 to 99.8) respectively.

CONCLUSIONS

The test characteristics of the Biocentric platform were overall comparable to the national reference method for VL quantification. One laboratory tended to misclassify VL results downwards, likely owing to unmet training needs and lack of previous hands-on practice.

Knowledge and practices of parents about child eye health care in the public sector in Swaziland

BACKGROUND

 Swaziland, like many other developing countries, lacks appropriate eye health services, particularly for children.

AIM

 To determine the knowledge and practices of parents about child eye health care in the public sector in Swaziland.

SETTING

 The setting for this study was Swaziland.

METHODS

 A descriptive study involving cross-sectional sampling methodology and quantitative analysis was employed with 173 randomly selected parents whose children attended public schools in Swaziland.

RESULTS

 Out of 173 participants, 104 (60.1%) parents reported that they have never taken their children for an eye test and 69 (31.7%) felt that their children's vision was fine. Ninety-seven (53.1%) parents indicated having no knowledge about child eye conditions and no significant association was found between level of education and knowledge of eye conditions affecting children (p = 0.112). Having an immediate family member who wore spectacles increased the likelihood of a child being taken for eye testing (p = 0.001), but decreased the likelihood of being well informed about eye health (p = 0.218). Of those parents who reported taking their children for eye tests, 34 (49.3%) reported that they were given eye drops and 31 (44.9%) stated that their children were prescribed spectacles. Eighty-seven (50.3%) parents accepted the idea of their children wearing spectacles.

CONCLUSION

 The findings of the study suggest the need for parents to be informed about basic child eye health care and the importance of their children having regular eye examinations.

Access to assistive technology in two Southern African countries

BACKGROUND

Millions of people in Southern Africa are deprived of basic human rights such as the right to education and work because of the large and growing unmet demand for assistive technologies (AT). Evidence is needed to better characterize the lack of AT access.

METHODS

This study serves to identify the sociodemographic factors that are associated with access to AT in two countries in Southern Africa, Botswana and Swaziland. To achieve this aim, logistics regression was applied to a subset of variables from two Living Conditions Studies, nationally representative surveys that were conducted in Southern Africa (2014 and 2010).

RESULTS

In Botswana, 44% of people who needed AT did not receive it, while in Swaziland the unmet need was 67%. Among the sociodemographic variables tested, the type of disability was the most important factor in determining AT access in both countries. The likelihood of AT access was highest in both countries for those who had mobility limitations (i.e., difficulty walking/climbing stairs) [Botswana: 6.4 odds ratio (OR) = 6.4., 95% confidence internal (CI) (3.6-11.3); Swaziland: OR = 3.2, CI (1.4-7.3)], in comparison to those with non-mobility types of disabilities.

CONCLUSIONS

These findings provide support for governments and other stakeholders in the AT sector to prioritize AT to address the large unmet demand, and expand the range of AT products provided so that people with hearing, seeing, self-care, communication and cognition difficulties have equal access to AT as those with mobility impairments. A step toward achieving these aims is to inventory AT product types that are commonly covered through the public sector in each country, and identify common gaps (e.g., daily living aids). Advancing the AT sector as a whole within Southern Africa will require large scale qualitative studies that achieve a comprehensive understanding of the bottlenecks in regional AT supply, procurement, and delivery systems.

Retention on ART and predictors of disengagement from care in several alternative community-centred ART refill models in rural Swaziland

INTRODUCTION

A broad range of community-centred care models for patients stable on anti-retroviral therapy (ART) have been proposed by the World Health Organization to better respond to patient needs and alleviate pressure on health systems caused by rapidly growing patient numbers. Where available, often a single alternative care model is offered in addition to routine clinical care. We operationalized several community-centred ART delivery care models in one public sector setting. Here, we compare retention in care and on ART and identify predictors of disengagement with care.

METHODS

Patients on ART were enrolled into three community-centred ART delivery care models in the rural Shiselweni region (Swaziland), from 02/2015 to 09/2016: Community ART Groups (CAGs), comprehensive outreach care and treatment clubs. We used Kaplan-Meier estimates to describe crude retention in care model and retention on ART (including patients who returned to clinical care). Multivariate Cox proportional hazard models were used to determine factors associated with all-cause attrition from care model and disengagement with ART.

RESULTS

A total of 918 patients were enrolled. CAGs had the most participants with 531 (57.8%). Median age was 44.7 years (IQR 36.3 to 54.4), 71.8% of patients were female, and 62.6% fulfilled eligibility criteria for community ART. The 12-month retention in ART was 93.7% overall; it was similar between model types (p = 0.52). A considerable proportion of patients returned from community ART to clinical care, resulting in lower 12 months retention in care model (82.2% overall); retention in care model was lowest in CAGs at 70.4%, compared with 86.3% in outreach and 90.4% in treatment clubs (p < 0.001). In multivariate Cox regression models, patients in CAGs had a higher risk of disengaging from care model (aHR 3.15, 95% CI 2.01 to 4.95, p < 0.001) compared with treatment clubs. We found, however, no difference in attrition in ART between alternative model types.

CONCLUSIONS

Concurrent implementation of three alternative community-centred ART models in the same region was feasible. Although a considerable proportion of patients returned back to clinical care, overall ART retention was high and should encourage programme managers to offer community-centred care models adapted to their specific setting.

The Prevalence and Correlates of Physical and Sexual Violence Affecting Female Sex Workers in Swaziland

Female sex workers (FSW) have a heightened vulnerability to violence and negative sexual/reproductive health outcomes. Limited research has examined how experiencing physical and sexual violence (PSV) mediates risk for poor health outcomes among FSW in Swaziland. The present analyses aim to contribute to literature linking violence with poor health outcomes, high-risk behaviors, and reduced health service-seeking among FSW. Data were analyzed from a cross-sectional study conducted in Swaziland between July and September 2011 with 325 adult women who reported exchanging sex for money, goods, or favors in the last 12 months, recruited through respondent-driven sampling (RDS). Logistic regression was used to assess the relationship between PSV and ancillary violence/abuse exposures, risk behaviors, and sexual/reproductive and mental health outcomes. PSV was conceptualized as either ever having been beaten up as a result of selling sex or ever being forced to have sex since the age of 18, or both. Prevalence of PSV in this sample was 59.0% in crude estimation, and 48.4% (95% confidence interval [CI]:[39.2,57.6]) with RDS weighting. Separate RDS-weighted estimates of being beaten up as a result of sex work and ever being forced to have sex were 32.4% (95%CI=[24.4,40.4]) and 33.1% (95%CI =[25.0,41.2%]), respectively. Experiencing PSV was associated with being blackmailed (adjusted odds ratio [aOR]= 1.93, 95%CI= [1.07,3.52]), non-injection drug use in the last 12 months (aOR= 1.84, 95%CI= [1.02,3.33]), and feeling afraid to seek health services as a result of selling sex (aOR = 1.74, 95%CI= [1.01,2.99]). Given these findings, violence prevention strategies should be prioritized in programs that address Swazi FSW health, empowerment, and safety.

Understanding reasons for discontinued antiretroviral treatment among clients in test and treat: a qualitative study in Swaziland

INTRODUCTION

Retention on antiretroviral therapy (ART) is critical for the successful adoption of the test and treat policy by sub-Saharan African countries, and for realizing the United Nations programme on HIV and AIDS target of 90-90-90. This qualitative study explores HIV positive clients' reasons for discontinuing ART under the MaxART test and treat implementation study in Swaziland.

METHODS

Clients identified as lost to follow-up (LTFU) in the programme database, who had initiated ART under the intervention arm of the MaxART study, were purposively selected from two facilities. LTFU was defined as stopping ART refill for three months or longer from the date of last appointment, and not being classified as transferred out or deceased. Semi-structured face-to-face interviews were conducted with nine clients and one treatment supporter between July and August 2017. All interviews were conducted in the local language, audio-recorded, summarized or transcribed and translated to English for thematic analysis.

RESULTS

Respondents described mobility as the first step in a chain of events that affected retention in care. It was entwined with precarious employment, care delivery, interactions with health workers, lack of social support, anticipated stigma and ART-related side-effects, including the exacerbation of hunger. The chains of events involved several intersecting reasons that occurred one after the other as a series of contiguous and linked events that led to clients' eventual discontinuation of ART. The individual accounts of step-by-step decision-making revealed the influence of multi-layered contexts and the importance of critical life-events.

CONCLUSIONS

Clients' reasons for abandoning ART are a complex, inextricably interwoven chain of events rather than a single occurrence. Mobility is often the first step in the process and commonly results from precarious economic and social circumstances. Currently the health system poorly caters to the reality of people's mobile lives. Interventions should seek to increase healthcare workers' understanding of the chain of events leading up to discontinuation on ART and the social dilemmas that clients face.

Global Health Education for Medical Students: When Learning Objectives Include Research

BACKGROUND

The Luke Commission, a provider of comprehensive mobile health outreach in rural Swaziland, focuses on human immunodeficiency virus testing and prevention, including the performance of over 100 circumcisions weekly. Educational objectives for medical student global health electives are essential. Learning research methodology while engaging in clinical activities reinforces curriculum goals. Medical care databases can produce clinically significant findings affecting international health policy. Engaging in academic research exponentially increased the educational value of student experiences during an international medical elective.

METHODS

Staff of the Luke Commission, a nongovernmental organization, collected and deidentified information from 1500 Swazi male patients undergoing circumcision from January through June of 2014. Medical students designed studies and analyzed these data to produce research projects on adverse event rates, pain perception, and penile malformations. Institutional review board approval was obtained from the home institution and accompanying senior surgical faculty provided mentorship.

RESULTS

First-year medical students enrolled in an international medical elective to explore resource availability, cultural awareness, health care provision, and developing world endemic diseases. While in country, students learned research methodology, collected data, and engaged in research projects. Following the trip, students presented posters at over 10 regional and national meetings. All 4 articles are accepted or under consideration for publication by major journals.

CONCLUSIONS

During international medical electives the combination of clinical experiences and access to databases from health aid organizations provides the foundation for productive medical student research. All participants benefit from the relationships formed by aid organizations, medical students, and patient populations. Global health research has many complexities, but through careful planning and cultural awareness, medical students can increase their research skills and contribute to the medical literature, bringing attention to and improving health care policies around the world. In sum, the educational experience of medical students is enhanced through the interaction of delivering patient care and completing clinical research studies.

Projected cervical Cancer incidence in Swaziland using three methods and local survey estimates

BACKGROUND

The scarcity of country data (e.g. a cancer registry) for the burden of cervical cancer (CC) in low-income countries (LCIs) such as Swaziland remains a huge challenge. Such data are critical to inform local decision-making regarding resource allocation [1]. We aimed to estimate likely cervical cancer incidence in Swaziland using three different methodologies (triangulation), to help better inform local policy guidance regarding likely higher "true" burden and increased resource allocation required for treatment, cervical cancer screening and HPV vaccine implementation.

METHODS

Three methods were applied to estimate CC incidence, namely: 1) application of age-specific CC incidence rates for Southern African region from GLOBOCAN 2012 extrapolated to the 2014 Swaziland female population; 2) a linear regression based model with transformed age-standardised CC incidence against hr-HPV (with and without HIV as a covariate) prevalence among women with normal cervical cytology; and 3) a mathematical model, using a natural history approach based on parameter estimates from various available literature and local survey estimates. We then triangulated estimates and uncertainty from the three models to estimate the most likely CC incidence rate for Swaziland in 2015.

RESULTS

The projected incidence estimates for models 1-3 were 69.4 (95% CI: 66.7-72.1), 62.6 per 100,000 (95%CI: 53.7-71.8) and 44.6 per 100,000 (41.5 to 52.1) respectively. Model 2 with HIV prevalence as covariate estimated a higher CC incidence rate estimate of 101.1 per 100,000 (95%CI: 90.3-112.2). The triangulated ('averaged') age-standardized CC incidence based across the 3 models for 2015 was estimated at 69.4 per 100,000 (95% CI: 63.0-77.1) in Swaziland.

CONCLUSION

It is widely accepted that cancer incidence (and in this case CC) is underestimated in settings with poor and lacking registry data. Our findings suggest that the projected burden of CC is higher than that suggested from other sources. Local health policy decisions and decision-makers need to re-assess resource allocation to prevent and treat CC effectively, which is likely to persist given the very high burden of hr-HPV within the country.

Marginalization and social change processes among lesbian, gay, bisexual and transgender persons in Swaziland: implications for HIV prevention

Swaziland has among the highest national adult HIV prevalence globally. There is limited knowledge of HIV vulnerabilities and prevention engagement among lesbian, gay, bisexual and transgender (LGBT) persons in the context of Swaziland's criminalization of consensual same-sex practices. This study explored social processes of marginalization to assess how they could potentiate HIV vulnerabilities and limit engagement in HIV prevention services. Additionally, we assessed positive change to better understand existing strategies employed by LGBT persons to challenge these HIV prevention barriers. Guided by community-based research methodology and conducted in Mbabane and Manzini, Swaziland, data were collected by LGBT peer-research assistants (PRA) in collaboration with an LGBT community organization in Manzini. Semi-structured interviews were conducted by trained PRAs and explored HIV prevention, including experiences of stigma and coping. Audio files were transcribed verbatim, translated to English, and analyzed using thematic techniques. Among participants (n = 51; mean age: 26.47, SD: 4.68), 40 self-identifed as gay or lesbian (78.4%), 11 bisexual (22.6%), and 12 (23.5%) identified as transgender. Findings highlighted three primary processes of marginalization and positive change in structural, community, and internal domains. First, structural marginalization, which included criminalization, healthcare discrimination, and a scarcity of LGBT tailored HIV prevention resources was challenged by grassroots networks created to access and share specific HIV resources with LGBT persons and the Ministry of Health. Second, community marginalization included stigma and multi-dimensional forms of violence, however, this was met with LGBT persons providing mutual peer support, including for accessing HIV testing services. Thirdly, internal marginalization comprised of self-stigma and associated sexual risk practices was contrasted with coping strategies focused on self-acceptance, stemming from social support and leading to healthcare utilization. Jointly, these findings can inform the implementation of community-based and rights affirming HIV prevention and care cascade strategies that improve coverage of services with LGBT persons in Swaziland.

Case management of malaria in Swaziland, 2011-2015: on track for elimination?

Objective: To assess adherence to malaria diagnosis and treatment guidelines (2010 and 2014) in all health care facilities in Swaziland between 2011 and 2015. Methods: This was a cross-sectional descriptive study involving all health care facilities that diagnosed and managed malaria cases in Swaziland. Patients' age, sex, diagnosis method and type of treatment were analysed. Results: Of 1981 records for severe and uncomplicated malaria analysed, 56% of cases were uncomplicated and 14% had severe malaria. The type of malaria was not recorded for 30% of cases. Approximately 71% of cases were confirmed by rapid diagnostic tests (RDT) alone, 3% by microscopy alone and 26% by both RDT and microscopy. Of the uncomplicated cases, 93% were treated with artemether-lumefantrine (AL) alone, 5% with quinine alone and 2% with AL and quinine. Amongst the severe cases, 11% were treated with AL alone, 44% with quinine alone and 45% with AL and quinine. For severe malaria, clinics and health centres prescribed AL alone more often than hospitals (respectively 13%, 12% and 4%, P = 0.03). Conclusion: RDTs and/or microscopy results are used at all facilities to inform treatment. Poor recording of malaria type causes difficulties in assessing the prescription of antimalarial drugs.

Exploring the Potential of Participatory Theatre to Reduce Stigma and Promote Health Equity for Lesbian, Gay, Bisexual, and Transgender (LGBT) People in Swaziland and Lesotho

Stigma and discrimination affecting lesbian, gay, bisexual, and transgender (LGBT) people compromise health and human rights and exacerbate the HIV epidemic. Scant research has explored effective LGBT stigma reduction strategies in low- and middle-income countries. We developed and pilot-tested a participatory theatre intervention (PTI) to reduce LGBT stigma in Swaziland and Lesotho, countries with the world's highest HIV prevalence. We collected preliminary data from in-depth interviews with LGBT people in Lesotho and Swaziland to enhance understanding of LGBT stigma. Local LGBT and theatre groups worked with these data to create a 2-hour PTI composed of three skits on LGBT stigma in health care, family, and community settings in Swaziland (Manzini) and Lesotho (Maseru, Mapoteng). Participants ( n = 106; nursing students, health care providers, educators, community members) completed 12 focus groups following the PTI. We conducted thematic analysis to understand reactions to the PTI. Focus groups revealed the PTI increased understanding of LGBT persons and issues, increased empathy, and fostered self-reflection of personal biases. Increased understanding included enhanced awareness of the negative impacts of LGBT stigma, and of LGBT people's lived experiences and issues. Participants discussed changes in attitude and perspective through self-reflection and learning. The format of the theatre performance was described as conducive to learning and preferred over more conventional educational methods. Findings indicate changed attitudes and awareness toward LGBT persons and issues following a PTI in Swaziland and Lesotho. Stigma reduction interventions may help mitigate barriers to HIV prevention, treatment, and care in these settings with a high burden of HIV.

A time-motion study of cardiovascular disease risk factor screening integrated into HIV clinic visits in Swaziland

INTRODUCTION

Screening of modifiable cardiovascular disease (CVD) risk factors is recommended but not routinely provided for HIV-infected patients, especially in low-resource settings. Potential concerns include limited staff time and low patient acceptability, but little empirical data exists. As part of a pilot study of screening in a large urban HIV clinic in Swaziland, we conducted a time-motion study to assess the impact of screening on patient flow and HIV service delivery and exit interviews to assess patient acceptability.

METHODS

A convenience sample of patients ≥40 years of age attending routine HIV clinic visits was screened for hypertension, diabetes, hyperlipidemia and tobacco smoking. We observed HIV visits with and without screening and measured time spent on HIV and CVD risk factor screening activities. We compared screened and unscreened patients on total visit time and time spent receiving HIV services using Wilcoxon rank-sum tests. A separate convenience sample of screened patients participated in exit interviews to assess their satisfaction with screening.

RESULTS

We observed 172 patient visits (122 with CVD risk factor screening and 50 without). Screening increased total visit time from a median (range) of 4 minutes (2 to 11) to 15 minutes (9 to 30) (p < 0.01). Time spent on HIV care was not affected: 4 (2 to 10) versus 4 (2 to 11) (p = 0.57). We recruited 126 patients for exit interviews, all of whom indicated that they would recommend screening to others.

CONCLUSION

Provision of CVD risk factor screening more than tripled the length of routine HIV clinic visits but did not reduce the time spent on HIV services. Programme managers need to take longer visit duration into account in order to effectively integrate CVD risk factor screening and counselling into HIV programmes.

Constrained relationship agency as the risk factor for intimate partner violence in different models of transactional sex

Women who engage in transactional sex are more likely to experience intimate partner violence (IPV) and are at higher risk of HIV. However, women engage in transactional sex for a variety of reasons and the precise mechanism linking transactional sex and IPV is not fully understood. We conducted a behavioural survey with a cross-sectional sample of 401 women attending 1 rural and 1 urban public antenatal clinic in Swaziland between February and June 2014. We used structural equation modelling to identify and measure constrained relationship agency (CRA) as a latent variable, and then tested the hypothesis that CRA plays a significant role in the pathway between IPV and transactional sex. After controlling for CRA, receiving more material goods from a sexual partner was not associated with higher levels of physical or sexual IPV and was protective against emotional IPV. CRA was the single largest predictor of IPV, and more education was associated with decreased levels of constrained relationship agency. Policies and interventions that target transactional sex as a driver of IPV and HIV may be more successful if they instead target the broader social landscape that constrains women’s agency and drives the harmful aspects of transactional sex.

"I will take ARVs once my body deteriorates": an analysis of Swazi men's perceptions and acceptability of Test and Start

Swaziland has the highest HIV prevalence in the world. To mitigate the spread and devastation caused by HIV and to improve the wellbeing of people living with HIV, the country has adopted the latest available HIV prevention campaigns, including "Test and Start". Because evidence from randomised controlled trials has demonstrated a significant risk reduction in HIV transmission when HIV-positive people start antiretroviral therapy (ART) early, Swaziland aims to find these people and link them to treatment. This study presents findings regarding the perceptions of this promising HIV-prevention intervention among men aged 17-69 years. A combination of qualitative methods including focus group discussions (12), in-depth interviews (17), informal conversations and participant observation (21) were used to collect data in two peri-urban communities in 2013-2014. Findings illustrate that men still fear taking an HIV test because of a relatively high probability of a positive test which some still interpret as a death sentence. Other potential barriers to the effectiveness of Test and Start programmes include lack of hospitality in hospitals, fear of starting treatment early related to side effects of ART, poverty, and lack of trust in the financial stability of the Swazi government. We argue that several social factors need to be considered for the Test and Start programme to be more effective.

Screening for Antepartum Depression Through Community Health Outreach in Swaziland

Maternal depression, including antepartum and postpartum depression, is a neglected public health issue with potentially far-reaching effects on maternal and child health. We aimed to measure the burden of antepartum depression and identify risk factors among women in a peri-urban community in Swaziland. We conducted a cross-sectional study within the context of a community outreach peer support project involving "Mentor Mothers". We used of the Edinburgh Postnatal Depression Scale (EPDS) to screen women for depression during the third trimester of pregnancy, using a cut-off score of ≥13 to indicate depression. We also collected demographic and socioeconomic factors, and assessed the association of these factors with EPDS score using logistic regression models. A total of 1038 pregnant women were screened over a period of 9 months. Almost a quarter (22.7 %) had EPDS scores ≥13 and 41.2 % were HIV positive. A fifth, 17.5 % were teenagers and 73.7 % were unemployed. Depression was not associated with HIV status, age or employment status. However, women with multiple socioeconomic stressors were found to be more likely to score highly on the EPDS. Depression was common among pregnant women in the peri-urban areas of Swaziland. Screening for depression using the EPDS is feasible and can be included in the community health worker standard tool box as a way to improve early detection of depression and to highlight the importance of maternal mental health as a core public health concern.

Prolonged Exclusive Breastfeeding Through Peer Support: A Cohort Study From a Community Outreach Project in Swaziland

Swaziland faces great public health challenges, including suboptimal breastfeeding practices and the world's highest prevalence of HIV. The objective of this study was to estimate neonatal and infant mortality rate and rate of exclusive breastfeeding for clients enrolled in a community-based peer support project in peri-urban areas of Swaziland. The intervention builds on the so called "Philani-model" with Mentor Mothers in the community under high level of supervision. Cohort data was collected from journals kept by the Mentor Mothers. Kaplan-Meier and Cox regression were used to analyse data. Neonatal and infant mortality were estimated to 15 respectively 57 per 1000 live births. High level of social vulnerability was associated with risk of neonatal mortality (HR 1.12, CI 95 % 1.01-1.24) while the mother's positive HIV status was associated with infant mortality (HR 2.05, CI 95 % 1.15-3.65). More visits by a Mentor Mother could not be shown to result in lower mortality. The chance to practice exclusive breastfeeding for 6 months was estimated to 50 %. The risk of discontinuing exclusive breastfeeding before 6 months was lower for mothers being unemployed (HR 0.55, CI 95 % 0.44-0.69) or socially vulnerable (HR 0.95, CI 95 % 0.92-0.99) and higher for mothers being HIV positive (HR 1.22, CI 95 % 1.01-1.48). Receiving at least four visits by a Mentor Mother during pregnancy decreased the risk of discontinuing exclusive breastfeeding prematurely (HR 0.82, CI 95 % 0.67-0.99). Peer support with Mentor Mothers thus had a positive impact on exclusive breastfeeding rates in this disadvantaged population.

Identification of misdiagnosed HIV clients in an Early Access to ART for All implementation study in Swaziland

Introduction: Rapid diagnostic testing has made HIV diagnosis and subsequent treatment more accessible. However, multiple factors, including improper implementation of testing strategies and clerical errors, have been reported to lead to HIV misdiagnosis. The World Health Organization has recommended HIV retesting prior to antiretroviral therapy (ART) initiation which has become pertinent with scaling up of Early Access to ART for All (EAAA). In this analysis, misdiagnosed clients are identified from a subgroup of clients enrolled in EAAA implementation study in Swaziland.

Methods: The subgroup to assess misdiagnosis was identified from enrolled EAAA study clients, who had an undetectable viral load prior to ART initiation between September 1, 2014 and May 31, 2016. One hundred and five of 2533 (4%) clients had an undetectable viral load prior to initiation to ART (pre-ART). The HIV status of clients was confirmed using the Determine HIV 1/2 and Uni-Gold HIV 1/2 rapid tests performed serially as recommended by the national testing algorithm. The status of clients on ART was additionally confirmed by fourth-generation HIV Ag/Ab combo tests, Architect and Genscreen Ultra.

Results: Fourteen of the 105 (13%) clients were false positive (HIV negative) on confirmation testing, of whom five (36%) were still in pre-ART care, while nine (64%) were in ART care. Overall, proportion of false positive was 0.6% (14/2533). The false-positive clients had a median CD4 of 791 cells/ml (interquartile range (IQR): 628, 967) compared to 549 cells/ml (IQR: 387, 791) for true positives (HIV positive) (p = 0.0081) and were nearly 20 years older (p = 0.0008).

Conclusions: Overall 0.6% of all enrolled EAAA clients were misdiagnosed, and 64% of misdiagnosed clients were initiated on ART. With adoption of EAAA guidelines by national governments, ART initiation regardless of immunological criteria, strengthening of proficiency testing and adoption of retesting prior to ART initiation would allow identification of misdiagnosed clients and further reduce potential of initiating misdiagnosed clients on ART.

An assessment of financial catastrophe and impoverishment from out-of-pocket health care payments in Swaziland

BACKGROUND

As the drive towards universal coverage is gaining momentum globally, the need for assessing levels of financial health protection in countries, particularity the developing world, has increasingly become important. In Swaziland, the level of financial health protection is not clearly understood.

OBJECTIVE

To assess financial catastrophe and impoverishment from out-of-pocket payments for health services in Swaziland.

METHODS

The nationally representative Swaziland Household Income and Expenditure Survey (2009/2010) dataset is used for the analyses. Data are collected by the Central Statistics Office in Swaziland. The final dataset contains information on 3,167 households (i.e. about 14,145 individuals) out of the anticipated 3,750 households. Financial catastrophe is assessed using an initial threshold that is adjusted to increase with household income (i.e. rank-dependent). Payment for health services is considered catastrophic when they exceed the threshold. Impoverishment is assessed using a national poverty line and an international poverty line ($1.25/day).

RESULTS

Using an initial threshold of 10.0% of household expenditure, 9.7% of Swazi households experience financial catastrophe while the proportion is estimated at 2.7% using an initial threshold of 40.0% of non-food expenditure. Between 1.0% and 1.6% of the Swazi population, representing between 10,000 and 16,000 people are pushed below the poverty line because of out-of-pocket payments. These findings indicate that financial health protection is not adequate in Swaziland.

CONCLUSION

If Swaziland is to move towards achieving universal health coverage, there is a need to address the burden created by direct out-of-pocket payments. Among other things, this means that the country needs to consider financing mechanisms that guarantee equitable access to needed quality health services, which do not place undue hardship on the poor and vulnerable.

Retention of children under 18 months testing HIV positive in care in Swaziland: a retrospective study

INTRODUCTION

Significant progress has been made with respect to the initiation of children on antiretroviral therapy (ART) in Southern Africa including Swaziland, however retention of these children in care poses a major challenge. The aim of the study was to assess retention to care in children testing HIV positive taking into account the number of return child welfare care (CWC) visits the child made.

METHODS

A retrospective cross sectional study and was conducted at 4 facilities in Swaziland. All children who were HIV infected from 0 to 18 months were identified using the child welfare register (CWC). Infant characteristics were obtained from the child welfare register and early infant diagnosis logbooks. Proportion of patients retained in care were calculated at three, six, nine and twelve months.

RESULTS

Of the 32 HIV positive children identified tested between December 2014 up to July 2016, sixty eight percent (n = 22) of the children that tested HIV positive were retained at three months, 40.6% at six months, 18.8% at nine months and 12.5% at twelve months. Children that resided in urban areas, more male than female children, children from mothers who were on antiretroviral treatment, children initiated on antiretroviral treatment, mothers on antiretroviral treatment for more than one year and children who received Infant Nevirapine were more likely to be retained.

CONCLUSION

Facilities are performing well in terms of identifying HIV positive children within the first two months of life and linking them into care. However, as time progresses the retention of children in care declines. Innovative strategies need to be developed to enhance patient retention.

Distrusting community health workers with confidential health information: a convergent mixed-methods study in Swaziland

Background

Patients are unlikely to share the personal information that is critical for effective healthcare, if they do not trust that this information will remain confidential. Trust in confidentiality may be particularly low in interactions with community health workers (CHW) because CHW deliver healthcare outside the clinic setting. This study aims to determine the proportion of Swaziland's population that does not trust the national CHW cadre with confidential medical information, and to identify reasons for distrust.

Methods

Using two-stage cluster random sampling, we carried out a household survey covering 2000 households across 100 census enumeration areas in two of Swaziland's four regions. To confirm and explain the quantitative survey results, we used qualitative data from 19 semi-structured focus group discussions in the same population.

Results

49% of household survey participants stated that they distrust the national CHW cadre with confidential health information. Having ever been visited by a CHW was positively associated with trust (aOR: 2.11; P  < 0.001), while higher levels of schooling of the respondent were negatively associated (aOR for more than secondary schooling versus no schooling: 0.21; P  < 0.001). The following three primary reasons for distrusting CHW with confidential health information emerged in the qualitative analyses: (1) CHW are members of the same community as their clients and may thus share information with people who know the client, (2) CHW are mostly women and several focus group participants assumed that women are more likely than men to share information with other community members, and (3) CHW are not sufficiently trained in confidentiality issues.

Conclusion

Our findings suggest that confidentiality concerns could be a significant obstacle to the successful rollout of CHW services for stigmatized conditions in Swaziland. Increasing coverage of the CHW program, raising the population's confidence in CHWs' training, assigning CHW to work in communities other than the ones in which they live, changing the CHW gender composition, and addressing gender biases may all increase trust with regards to confidentiality.

Suicidal ideation and associated factors among school going adolescents in Swaziland

Background and objective

Suicide among children has been a major issue and the statistics are considerably alarming. However, no studies have been conducted in Swaziland on suicidal ideation which is a starting point for committing suicide. The objective of the study was to determine the prevalence of suicidal ideation and its correlates.

Methods

A secondary analysis of data was conducted using data collected in a Swaziland 2013 Global School-based Student Health Survey (GSHS). The survey assessed among other factors, mental health of the students using a self-administered questionnaire. We considered factors that have been reported to be associated with suicidal ideation in the literature. Unadjusted odds ratios (OR) and adjusted odds ratios (AOR) together with their 95 confidence intervals (CI) are reported.

Results

The overall proportions of students who considered suicide were 18.3% of 1866 females and 15.6% of 1672 males. In bivariate models the risk factors for suicidal ideation were feeling lonely, anxiety, using drugs and smoking marijuana. In multivariate model to include age, gender, food security, close friends, truancy, bullied, attacked, physical fight, drugs, marijuana, parental understanding anxiety and loneliness, all the considered factors were significantly associated with suicide except close friends.

Conclusion

The rate of suicidal ideation was high among adolescents in Swaziland and intervention considering violence, social support from friends and parents, and drug abuse should be designed to prevent suicidal thoughts.

Agency as a mediator in the pathway from transactional sex to HIV among pregnant women in Swaziland: a multigroup path analysis

Introduction: Transactional sex is a structural driver of HIV for women and girls in sub-Saharan Africa. In transactional relationships, sexual and economic obligations intertwine and may have positive and negative effects on women’s financial standing and social status. We conducted a clinic-based survey with pregnant women in Swaziland using a locally validated transactional sex scale to measure the association between subjective social status, transactional sex, and HIV status, and to assess whether this association differed according to a woman’s agency within her relationship.

Methods: We recruited a convenience sample of 406 pregnant women at one rural and one urban public antenatal clinic in Swaziland and administered a behavioural survey that was linked to participant HIV status using clinic records. We then conducted a multigroup path analysis to test three hypotheses: (1) that more engagement in transactional sex is associated with decreased condom use and increased subjective social status; (2) that subjective social status mediates the relationship between transactional sex and HIV status; and (3) that these relationships are different across groups according to whether or not a woman reported any indicator of constrained agency within her relationship.

Results: The amount and value of material goods received from a sexual partner was significantly and positively associated with higher subjective social status among all participants. As the amount of material goods received from a partner increased, women who reported no indicators of constrained agency were less likely to use condoms. Conversely, there was no relationship between transactional sex and condom use among women who reported any indicator of constrained relationship agency. Among women who reported any indicator of constrained agency, HIV was significantly associated with lower subjective social status.

Conclusions: Relationship agency likely plays a key role in determining which mechanisms create HIV risk for women in transactional relationships. Interventions to mitigate these risks must address social forces that penalize women who engage in sexual relationships as well as structural drivers of gendered economic disparity that reduce women’s agency within their sexual and romantic relationships.