51
|
|
52
|
Roy M, Bolton Moore C, Sikazwe I, Holmes CB. A Review of Differentiated Service Delivery for HIV Treatment: Effectiveness, Mechanisms, Targeting, and Scale. Curr HIV/AIDS Rep 2020; 16:324-334. [PMID: 31230342 DOI: 10.1007/s11904-019-00454-5] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE OF REVIEW Differentiated service delivery (DSD) models were initially developed as a means to combat suboptimal long-term retention in HIV care, and to better titrate limited health systems resources to patient needs, primarily in low-income countries. The models themselves are designed to streamline care along the HIV care cascade and range from individual to group-based care and facility to community-based health delivery systems. However, much remains to be understood about how well and for whom DSD models work and whether these models can be scaled, are sustainable, and can reach vulnerable and high-risk populations. Implementation science is tasked with addressing some of these questions through systematic, scientific inquiry. We review the available published evidence on the implementation of DSD and suggest further health systems innovations needed to maximize the public health impact of DSD and future implementation science research directions in this expanding field. RECENT FINDINGS While early observational data supported the effectiveness of various DSD models, more recently published trials as well as evaluations of national scale-up provide more rigorous evidence for effectiveness and performance at scale. Deeper understanding of the mechanism of effect of various DSD models and generalizability of studies to other countries or contexts remains somewhat limited. Relative implementability of DSD models may differ based on patient preference, logistical complexity of model adoption and maintenance, human resource and pharmacy supply chain needs, and comparative cost-effectiveness. However, few studies to date have evaluated comparative implementation or cost-effectiveness from a health systems perspective. While DSD represents an exciting and promising "next step" in HIV health care delivery, this innovation comes with its own set of implementation challenges. Evidence on the effectiveness of DSD generally supports the use of most DSD models, although it is still unclear which models are most relevant in diverse settings and populations and which are the most cost-effective. Challenges during scale-up highlight the need for accurate differentiation of patients, sustainable inclusion of a new cadre of health care worker (the community health care worker), and substantial strengthening of existing pharmacy supply chains. To maximize the public health impact of DSD, systems need to be patient-centered and adaptive, as well as employ robust quality improvement processes.
Collapse
Affiliation(s)
- Monika Roy
- Division of HIV, Infectious Diseases, and Global Medicine, San Francisco General Hospital, University of California, San Francisco, 995 Potrero Avenue, Bldg 80, San Francisco, CA, 94110, USA.
| | - Carolyn Bolton Moore
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.,University of Alabama, Birmingham, AL, USA
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Charles B Holmes
- Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Center for Global Health and Quality, Georgetown University School of Medicine, Washington, DC, USA
| |
Collapse
|
53
|
Lejone TI, Kopo M, Bachmann N, Brown JA, Glass TR, Muhairwe J, Matsela T, Scherrer R, Chere L, Namane T, Labhardt ND, Amstutz A. PEBRA trial - effect of a peer-educator coordinated preference-based ART service delivery model on viral suppression among adolescents and young adults living with HIV: protocol of a cluster-randomized clinical trial in rural Lesotho. BMC Public Health 2020; 20:425. [PMID: 32228531 PMCID: PMC7106615 DOI: 10.1186/s12889-020-08535-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 03/16/2020] [Indexed: 01/10/2023] Open
Abstract
Background Despite tremendous progress in controlling the HIV epidemic in sub-Saharan Africa, HIV-related mortality continues to increase among adolescents and young people living with HIV (AYPLHIV). Globally, sub-Saharan Africa accounts for 85% of the AYPLHIV. Overall outcomes along the HIV care cascade are worse among AYPLHIV as compared to all other age groups due to various challenges in accessing and adhering to antiretroviral therapy (ART). New, innovative multicomponent packages of differentiated service delivery (DSD) models, are required to address the specific needs of AYPLHIV. This study aims to evaluate the feasibility and effectiveness of a multicomponent DSD model (PEBRA model) designed for AYPLHIV and coordinated by a peer-educator. Methods PEBRA (Peer-Educator Based Refill of ART) is a cluster randomized, open-label, superiority trial conducted at 20 health facilities in three districts of Lesotho, Southern Africa. The clusters (health facilities) are randomly assigned to either the PEBRA model or standard of care in a 1:1 ratio, stratified by district. AYPLHIV aged 15–24 years old in care and on ART at one of the clusters are eligible. In the PEBRA model, a peer-educator coordinates the antiretroviral therapy (ART) services - such as medication pick-up, SMS notifications and support options - according to the preferences of the AYPLHIV. The peer-educator delivers this personalized model using a tablet-based application called PEBRApp. The control clusters continue to offer standard of care: ART services coordinated by the nurse. The primary endpoint is viral suppression at 12 months. Secondary endpoints include self-reported adherence to ART, quality of life, satisfaction with care and engagement in care. The target sample size is 300 AYPLHIV. Statistical analyses are conducted and reported in line with CONSORT guidelines for cluster randomized trials. Discussion The PEBRA trial will provide evidence on the feasibility and effectiveness of an inclusive, holistic and preference-based DSD model for AYPLHIV that is coordinated by a peer-educator. Many countries in SSA have an existing peer-educator program. If proven effective, the PEBRA model and PEBRApp have the potential to be scaled up to similar settings. Trial registration Clinicaltrials.gov, NCT03969030. Registered on 31 May 2019. More information: www.pebra.info
Collapse
Affiliation(s)
| | | | - Nadine Bachmann
- Department of Medicine, Clinical Research Unit, Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Jennifer Anne Brown
- Department of Medicine, Clinical Research Unit, Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051, Basel, Switzerland.,University of Basel, Basel, Switzerland.,Molecular Virology, Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Tracy Renée Glass
- Department of Medicine, Clinical Research Unit, Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | | | | | - Ramona Scherrer
- Department of Medicine, Clinical Research Unit, Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | | | - Tilo Namane
- Motebang Government Hospital, Leribe, Lesotho
| | - Niklaus Daniel Labhardt
- Department of Medicine, Clinical Research Unit, Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051, Basel, Switzerland.,University of Basel, Basel, Switzerland.,Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Alain Amstutz
- Department of Medicine, Clinical Research Unit, Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051, Basel, Switzerland. .,University of Basel, Basel, Switzerland. .,Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland.
| |
Collapse
|
54
|
Munyayi FK, van Wyk B. The effects of Teen Clubs on retention in HIV care among adolescents in Windhoek, Namibia. South Afr J HIV Med 2020; 21:1031. [PMID: 32158557 PMCID: PMC7059250 DOI: 10.4102/sajhivmed.v21i1.1031] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 10/30/2019] [Indexed: 11/12/2022] Open
Abstract
Background Adolescents living with HIV (ALHIV) are notably underserved by the national HIV programmes globally because of their unique needs. Of particular concern is limited access to and availability of adolescent-friendly antiretroviral therapy (ART) services, which contribute to poor retention in care in many sub-Saharan African countries. A Teen Club intervention was introduced in 2010 in Windhoek, Namibia, to improve retention in care among ALHIV through psychosocial support in a peer-group environment. Objectives To compare the effects of the Teen Club intervention against standard care on retention in HIV care amongst adolescents at a Paediatric ART clinic. Method A retrospective cohort analysis of adolescents aged 10–19 years receiving ART between July 2015 and June 2017 was conducted. Routine patient data were extracted from an electronic database and patient registers. A sample of 385 participants was analysed: 78 in the Teen Club and 307 in standard care. Retention was measured by assessing attendance to prescribed clinic visits up to 24 months. Comparisons were assessed with the Chi-square test, and Kaplan–Meier survival analysis was conducted to analyse differences in retention rates. Results The overall retention rate at 24 months among all adolescents was 90.1%, with no statistically significant difference between those in Teen Club (91%) and those in standard care (89%) (p = 0.956). Younger adolescents (10–14 years) had better retention rates at 24 months compared to older adolescents (15–19 years) (94% vs. 86%; p = 0.016). Retention rates were significantly higher for adolescents on first-line ART regimen (vs. second line: hazard ratio [HR] = 0.333; 95% confidence interval [CI] = 0.125–0.889); on ART ≥ 12 months (vs. < 12 months: HR =0.988; 95% CI = 0.977–0.999); and those to whom their HIV status was disclosed (HR = 0.131; 95% CI = 0.025–0.686). Conclusion Group-based adherence support interventions did not improve retention rates for younger adolescents in specialised paediatric ART clinics but may still hold the potential for improving retention rates of older adolescents.
Collapse
Affiliation(s)
- Farai K Munyayi
- School of Public Health, Faculty of Community and Health Sciences, University of the Western Cape, Cape Town, South Africa.,International Training and Education Center for Health, Windhoek, Namibia
| | - Brian van Wyk
- School of Public Health, Faculty of Community and Health Sciences, University of the Western Cape, Cape Town, South Africa
| |
Collapse
|
55
|
Enane LA, Eby J, Arscott-Mills T, Argabright S, Caiphus C, Kgwaadira B, Steenhoff AP, Lowenthal ED. TB and TB-HIV care for adolescents and young adults. Int J Tuberc Lung Dis 2020; 24:240-249. [PMID: 32127110 PMCID: PMC7307717 DOI: 10.5588/ijtld.19.0416] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING: Nine high-burden public tuberculosis (TB) clinics in Gaborone, Botswana.OBJECTIVE: To evaluate the challenges encountered, healthcare worker (HCW) approaches, and supported interventions in TB and TB-HIV (human immunodeficiency virus) care for adolescents and young adults (AYA, aged 10-24 years).DESIGN: Semi-structured interviews with HCW in TB clinics, analyzed using thematic analysis.RESULTS: Sixteen HCWs were interviewed. AYA developmental needs included reliance on family support for care, increasing autonomy, attending school or work, building trust in HCWs, and intensive TB education and adherence support. Stigma strongly influenced care engagement, including clinic attendance and HIV testing. Health system barriers to optimal AYA TB care included limited staffing and resources to follow-up or support. HCWs utilized intensive education and counseling, and transitioned AYA to community-based directly observed therapy whenever feasible. HCWs supported implementation of youth-friendly services, such as AYA-friendly spaces or clinic days, training in AYA care, use of mobile applications, and peer support interventions, in addition to health system strengthening.CONCLUSION: HCWs utilize dedicated approaches for AYA with TB, but have limited time and resources for optimal care. They identified several strategies likely to improve care and better retain AYAs in TB treatment. Further work is needed to study interventions to improve AYA TB care and outcomes.
Collapse
Affiliation(s)
- L A Enane
- Division of Infectious Diseases, Botswana-UPenn Partnership, Gaborone, Botswana
| | - J Eby
- Department of Pediatrics, Boston Children's Hospital and Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - T Arscott-Mills
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA, Botswana-UPenn Partnership, Gaborone, Botswana, University of Pennsylvania Perelman School of Medicine
| | - S Argabright
- University of Pennsylvania, Philadelphia, PA, USA
| | - C Caiphus
- Botswana National TB Programme, Ministry of Health, Gaborone, Botswana
| | - B Kgwaadira
- Botswana National TB Programme, Ministry of Health, Gaborone, Botswana
| | - A P Steenhoff
- Division of Infectious Diseases, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA, Botswana-UPenn Partnership, Gaborone, Botswana, University of Pennsylvania Perelman School of Medicine
| | - E D Lowenthal
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA, Botswana-UPenn Partnership, Gaborone, Botswana, Center for Clinical Epidemiology & Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| |
Collapse
|
56
|
Bartlett AW, Lumbiganon P, Kurniati N, Sudjaritruk T, Mohamed TJ, Hansudewechakul R, Ly PS, Truong KH, Puthanakit T, Nguyen LV, Chokephaibulkit K, Do VC, Kumarasamy N, Yusoff NKN, Fong MS, Watu DK, Nallusamy R, Sohn AH, Law MG. Use and Outcomes of Antiretroviral Monotherapy and Treatment Interruption in Adolescents With Perinatal HIV Infection in Asia. J Adolesc Health 2019; 65:651-659. [PMID: 31395514 PMCID: PMC7007807 DOI: 10.1016/j.jadohealth.2019.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 05/22/2019] [Accepted: 05/28/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Antiretroviral monotherapy and treatment interruption are potential strategies for perinatally HIV-infected adolescents (PHIVA) who face challenges maintaining effective combination antiretroviral therapy (ART). We assessed the use and outcomes for adolescents receiving monotherapy or undergoing treatment interruption in a regional Asian cohort. METHODS Regional Asian data (2001-2016) were analyzed to describe PHIVA who experienced ≥2 weeks of lamivudine or emtricitabine monotherapy or treatment interruption and trends in CD4 count and HIV viral load during and after episodes. Survival analyses were used for World Health Organization (WHO) stage III/IV clinical and immunologic event-free survival during monotherapy or treatment interruption, and a Poisson regression to determine factors associated with monotherapy or treatment interruption. RESULTS Of 3,448 PHIVA, 84 (2.4%) experienced 94 monotherapy episodes, and 147 (4.3%) experienced 174 treatment interruptions. Monotherapy was associated with older age, HIV RNA >400 copies/mL, younger age at ART initiation, and exposure to ≥2 combination ART regimens. Treatment interruption was associated with CD4 count <350 cells/μL, HIV RNA ≥1,000 copies/mL, ART adverse event, and commencing ART age ≥10 years compared with age <3 years. WHO clinical stage III/IV 1-year event-free survival was 96% and 85% for monotherapy and treatment interruption cohorts, respectively. WHO immunologic stage III/IV 1-year event-free survival was 52% for both cohorts. Those who experienced monotherapy or treatment interruption for more than 6 months had worse immunologic and virologic outcomes. CONCLUSIONS Until challenges of treatment adherence, engagement in care, and combination ART durability/tolerability are met, monotherapy and treatment interruption will lead to poor long-term outcomes.
Collapse
Affiliation(s)
- Adam W. Bartlett
- Kirby Institute, University of New South Wales Sydney, New South Wales, Australia,Address correspondence to: Adam W. Bartlett, M.B.B.S., Kirby Institute, University of New South Wales, Level 6,Wallace Wurth Building, Sydney, New South Wales 2052, Australia, (A.W. Bartlett)
| | - Pagakrong Lumbiganon
- Department of Pediatrics, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Nia Kurniati
- Cipto Mangunkusumo, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Tavitiya Sudjaritruk
- Department of Pediatrics, Faculty of Medicine, and Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | | | | | - Penh S. Ly
- National Centre for HIV/AIDS, Dermatology and STDs, Phnom Penh, Cambodia
| | | | - Thanyawee Puthanakit
- Department of Pediatrics, Faculty of Medicine and Research Unit in Pediatric and Infectious Diseases, Chulalongkorn University, Bangkok, Thailand
| | | | - Kulkanya Chokephaibulkit
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Viet C. Do
- Children’s Hospital 2, Ho Chi Minh City, Vietnam
| | | | | | | | - Dewi K. Watu
- Sanglah Hospital, Udayana University, Bali, Indonesia
| | | | - Annette H. Sohn
- TREAT Asia/amfAR - The Foundation for AIDS Research, Bangkok, Thailand
| | - Matthew G. Law
- Kirby Institute, University of New South Wales Sydney, New South Wales, Australia
| | | |
Collapse
|
57
|
Subramanian S, Edwards P, Roberts ST, Musheke M, Mbizvo M. Integrated Care Delivery for HIV Prevention and Treatment in Adolescent Girls and Young Women in Zambia: Protocol for a Cluster-Randomized Controlled Trial. JMIR Res Protoc 2019; 8:e15314. [PMID: 31584004 PMCID: PMC6797972 DOI: 10.2196/15314] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 08/14/2019] [Accepted: 08/17/2019] [Indexed: 01/26/2023] Open
Abstract
Background Among countries in sub-Saharan Africa, Zambia has one of the highest incidences of HIV. Adolescent girls and young women (AGYW) are a particularly affected group because of their social and economic vulnerability. Objective The goal of this study is to test a multilevel package of interventions at the community and health system levels in Zambia in order to connect AGYW with a source of regular care, which will in turn allow for sustainable, successful implementation of regular HIV testing and adherence to antiretroviral treatment. Methods We will adapt prior tools to create the SHIELD (Support for HIV Integrated Education, Linkages to Care, and Destigmatization) intervention to educate and empower Zambian AGYW of 10-24 years of age and their families and to create community-based youth clubs to foster peer support. We will also develop integrated wellness care clinics to offer a youth-friendly environment that provides tailored clinical services. We will perform formative research, including focus groups and in-depth interviews, among AGYW, caregivers, and stakeholders to help inform the development and tailoring of the interventions. A cluster-randomized controlled trial will be implemented in Lusaka, with six clinic catchment areas randomized into three groups: zones with integrated wellness care clinics and SHIELD intervention, zones with only SHIELD intervention, and control zones with no intervention. We will assess HIV testing among the HIV-negative or unknown (HIV-/u) cohort, and retention in care along with viral load suppression will be evaluated in the HIV-positive (HIV+) cohort. We will use in-depth interviews and surveys to collect staff and stakeholder feedback after the trial. Cost-effectiveness of the interventions and return-on-investment impacts will be quantified using a microsimulation model. Results Interim results are expected in 2021, and the final results are expected in 2022. If this multilevel intervention is successful in establishing a comprehensive care continuum for HIV-affected AGYW, the Zambian Ministry of Health may advocate for expansion to additional settings to support national scale-up. Conclusions This integrated service delivery model can also be a platform to implement additional preventive services, so HIV-/u and HIV+ AGYW can receive comprehensive, integrated services. Trial Registration ClinicalTrials.gov NCT03995953; https://clinicaltrials.gov/ct2/show/NCT03995953 International Registered Report Identifier (IRRID) PRR1-10.2196/15314
Collapse
Affiliation(s)
| | - Patrick Edwards
- RTI International, Research Triangle Park, NC, United States
| | | | | | | |
Collapse
|
58
|
Masese RV, Ramos JV, Rugalabamu L, Luhanga S, Shayo AM, Stewart KA, Cunningham CK, Dow DE. Challenges and facilitators of transition from adolescent to adult HIV care among young adults living with HIV in Moshi, Tanzania. J Int AIDS Soc 2019; 22:e25406. [PMID: 31651089 PMCID: PMC6813636 DOI: 10.1002/jia2.25406] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 10/02/2019] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Scale up of anti-retroviral therapy has enabled millions of children infected with HIV to survive into adulthood, requiring transition of care to the adult HIV clinic. This transition period is often met with anxiety and reluctance. Youth who fail to transition may create strain on capacity in the pediatric and adolescent clinics or result in individuals dropping out of care entirely. This study examined challenges and facilitators to the transition among young adults living with HIV in Moshi, Tanzania. METHODS From April to June 2017, in-depth interviews were conducted with young adults aged 18 to 27 years living with HIV in order to capture the spectrum of experiences from pre-transitioning youth to those who successfully transitioned to adult care. Young adults were purposively recruited based on prior study enrollees and recommendations from healthcare staff. Recruitment occurred in the adolescent, adult HIV and the prevention of mother to child transition clinics at Kilimanjaro Christian Medical Centre. Two separate in-depth interviews were conducted with eligible participants. Medical records were reviewed retrospectively to collect information on HIV-related outcomes. RESULTS In-depth interviews were held with 19 young adults. Participants mean age was 23.8 years (interquartile range 22.2 to 26.3 years); 53% were female. Most (78.9%) participants had been receiving anti-retroviral therapy for nearly a decade and 72.2% were virologically suppressed (HIV RNA <200 copies/mL). Barriers to transition included fear of losing peer networks formed in the adolescent clinic, the abrupt manner in which young adults were asked to transition, stigma, financial constraints and a lower quality of care in the adult clinic. Facilitators of transition included family and social support, positive perspectives on living with HIV and maintenance of good health. Recommendations for transition included transition preparation, transition as a group and adoption of desirable aspects of the adolescent clinic (peer networks and education) in the adult clinic. CONCLUSIONS Transition is a complex process influenced by many factors. As the number of young adults living with HIV continues to grow, it is vital to develop a transition protocol that addresses these challenges and is feasible to implement in low-resource settings.
Collapse
Affiliation(s)
- Rita V Masese
- Duke Global Health InstituteDuke UniversityDurhamNCUSA
| | - Julia V Ramos
- School of MedicineJohns Hopkins UniversityBaltimoreMDUSA
| | | | | | - Aisa M Shayo
- Kilimanjaro Christian Medical CentreMoshiTanzania
| | | | - Coleen K Cunningham
- Duke Global Health InstituteDuke UniversityDurhamNCUSA
- Division of Pediatric Infectious DiseaseDuke University Medical CenterDurhamNCUSA
| | - Dorothy E Dow
- Duke Global Health InstituteDuke UniversityDurhamNCUSA
- Kilimanjaro Christian Medical CentreMoshiTanzania
- Division of Pediatric Infectious DiseaseDuke University Medical CenterDurhamNCUSA
| |
Collapse
|
59
|
Maskew M, Bor J, MacLeod W, Carmona S, Sherman GG, Fox MP. Adolescent HIV treatment in South Africa's national HIV programme: a retrospective cohort study. Lancet HIV 2019; 6:e760-e768. [PMID: 31585836 DOI: 10.1016/s2352-3018(19)30234-6] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 06/12/2019] [Accepted: 06/24/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND The number of South African adolescents receiving HIV care and treatment in South Africa is growing. By use of routinely collected laboratory data from South Africa's National HIV Programme, we aimed to quantify the numbers of adolescents accessing HIV care and treatment over time, characterise the role of perinatal infection in these trends, and estimate proportions of adolescents seeking HIV care and antiretroviral therapy (ART) in South Africa's public sector. METHODS We did a retrospective, descriptive cohort study of children and adolescents aged 1-19 years accessing care in South Africa's public sector HIV treatment programme from 2005 to 2016 with a CD4 cell count or viral load recorded in South Africa's National Health Laboratory Service database. We estimated the total number of children and adolescents entering HIV care with a CD4 cell count or viral load test result by calendar period, as well as the proportion in care and receiving ART with at least one viral load test result. We stratified analyses by gender and by whether the patient entered care at younger than 15 years (probably perinatally infected) or at 15-19 years (probably infected in adolescence). FINDINGS We identified 730 882 patients aged 1-19 years at entry to care between Jan 1, 2005, and Dec 31, 2016. 209 205 (54%) of 388 439 patients entering care younger than 15 years and 301 242 (88%) of 342 443 patients entering care aged 15-19 were female. During the study period, the number of virologically monitored patients aged 15-19 years receiving ART increased from 7949 in 2005-08 to 80 918 in 2013-16. 92 783 (66%) of 140 028 patients aged 15-19 years seeking care started ART by 2016, well below UNAID's target of ART for 90% of those diagnosed. We project that the number of adolescents on ART will continue to rise. INTERPRETATION The many adolescents aged 15-19 years receiving ART reflect the ageing of children entering care at ages 1-14 years, and increases in care-seeking among horizontally infected adolescents aged 15-19 years. However, many adolescents seeking care do not start ART, suggesting an urgent need for interventions to increase uptake of ART and improve services for this population. FUNDING US National Institutes of Health, and the President's Emergency Plan for AIDS Relief through the US Agency for International Development.
Collapse
Affiliation(s)
- Mhairi Maskew
- 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; Department of Global Health, Boston University School of Public Health, Boston University, Boston, MA, USA; Department of Epidemiology, Boston University School of Public Health, Boston University, Boston, MA, USA
| | - William MacLeod
- 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 University, Boston, MA, USA
| | - Sergio Carmona
- National Health Laboratory Service, Johannesburg, South Africa
| | - Gayle G Sherman
- Department of Paediatrics and Child Health, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; National Institute for Communicable Disease, 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 University, Boston, MA, USA; Department of Epidemiology, Boston University School of Public Health, Boston University, Boston, MA, USA
| |
Collapse
|
60
|
McBride K, Parent J, Mmanga K, Chivwala M, Nyirenda MH, Schooley A, Mwambene JB, Dovel K, Lungu E, Balakasi K, Hoffman RM, Moucheraud C. ART Adherence Among Malawian Youth Enrolled in Teen Clubs: A Retrospective Chart Review. AIDS Behav 2019; 23:2629-2633. [PMID: 31292826 DOI: 10.1007/s10461-019-02580-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
To improve outcomes among HIV-positive adolescents, the Malawi Ministry of Health is supporting scale-up of "Teen Clubs," a facility-based antiretroviral treatment (ART) delivery model. Teen Clubs are monthly ART clinics for adolescents (10-19 years old) that provide clinical services and peer psychosocial support. This paper assesses ART adherence among Teen Club attendees in Malawi. We performed a retrospective analysis of medical records and Teen Club attendance data on 589 HIV-positive adolescents at 16 Partners in Hope (PIH)-Extending Quality Improvement for HIV/AIDS in Malawi (EQUIP) supported facilities across Malawi, from January to June of 2017, who attended at least two Teen Club sessions. Multi-level logistic regression models were used to examine the role of gender and age on optimal ART adherence (≥ 95% based on pill count) among HIV-positive adolescents enrolled in Teen Clubs. The median age of adolescents in this sample was 14 years, and 47% were male. Older adolescent males (15-19 years) were 64% more likely to achieve ≥ 95% ART adherence (aOR 1.64, 95% CI 1.16-2.31, p < 0.01) compared to younger (10-14 years) males. The effect of age on adherence was smaller and not significant among females (aOR 1.36, 95% CI 0.96-1.94, p = 0.08). In the full model including males and females, older adolescence was associated with higher odds of optimal adherence (aOR 1.48, 95% CI 1.16-1.90, p < 0.01). These results reinforce the need for age-specialized programming for adolescents, and future research should evaluate this in achieving optimal ART adherence.
Collapse
Affiliation(s)
- Kaitlyn McBride
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Campus Box 951772, Los Angeles, CA, 90095-1772, USA.
| | | | | | | | | | - Alan Schooley
- Partners in Hope, Lilongwe, Malawi
- Department of Medicine and Division of Infectious Diseases, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
| | | | - Kathryn Dovel
- Partners in Hope, Lilongwe, Malawi
- Department of Medicine and Division of Infectious Diseases, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
| | | | | | - Risa M Hoffman
- Department of Medicine and Division of Infectious Diseases, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
| | - Corrina Moucheraud
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Campus Box 951772, Los Angeles, CA, 90095-1772, USA
| |
Collapse
|
61
|
Casale M, Carlqvist A, Cluver L. Recent Interventions to Improve Retention in HIV Care and Adherence to Antiretroviral Treatment Among Adolescents and Youth: A Systematic Review. AIDS Patient Care STDS 2019; 33:237-252. [PMID: 31166783 PMCID: PMC6588099 DOI: 10.1089/apc.2018.0320] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Adolescents represent a growing proportion of people living with HIV worldwide and the highest risk population group for treatment attrition and AIDS-related mortality. There is an urgent need to design, implement, and test interventions that keep young people in HIV treatment and care. However, previous systematic reviews show scarce and inconclusive evidence of effective interventions for this age group. Recent years have seen an increase in focus on adolescent health and a rapidly changing programmatic environment. This systematic review article provides an evidence update by synthesizing empirical evaluations of interventions designed to improve antiretroviral therapy adherence and retention among adolescents (10-19) and youth (15-24) living with HIV, published between January 2016 and June 2018. A search of 11 health and humanities databases generated 2425 citations and 10 relevant studies, the large majority conducted in sub-Saharan Africa. These include six clinic-level interventions, one individual-level m-Health trial, and three community- or household-level interventions. Implications of their findings for future programming and research with young adults are discussed, in relation to previous reviews and the broader empirical evidence in this area. Findings highlight the need to further develop and test multi-faceted interventions that go beyond health facilities, to address broader social barriers to adherence and retention. In particular, further intervention studies with adolescents (10-19) should be a priority, if we are to retain these young people in treatment and care and aspire to achieve the United Nation's Sustainable Development Goals and 90-90-90 targets.
Collapse
Affiliation(s)
- Marisa Casale
- Department of Social Policy and Intervention, University of Oxford, Oxford, United Kingdom
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Anna Carlqvist
- Department of Social Policy and Intervention, University of Oxford, Oxford, United Kingdom
| | - Lucie Cluver
- Department of Social Policy and Intervention, University of Oxford, Oxford, United Kingdom
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
62
|
Youth-friendly services and differentiated models of care are needed to improve outcomes for young people living with HIV. Curr Opin HIV AIDS 2019; 13:249-256. [PMID: 29432230 DOI: 10.1097/coh.0000000000000454] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Outcomes among young people living with HIV (YPLWH) remain disturbingly poor. We summarize recent research on youth-friendly services (YFS) and adolescent-specific differentiated care models, which may improve outcomes across the HIV care continuum for this vulnerable population. We further emphasize unique complexities that characterize the transition from childhood through adolescence to adulthood which must be considered when caring for YPLWH. RECENT FINDINGS Studies suggest that YFS may improve outcomes in some but not all steps of the HIV care continuum. However, generalizability is compromised by the limited numbers of studies, frequent use of nonequivalent comparison groups, small sample sizes and/or short follow-up. Reproducibility and scale-up are further hindered by lack of insufficient details on operational aspects of YFS, an effective minimum package of YFS and contextual factors that may facilitate adoption of YFS. Differentiated models of care for YPLWH are in very early stages of development with positive preliminary outcomes, but most pilot models focus only on stable patients on antiretroviral therapy. SUMMARY YFS and adolescent-specific differentiated models of care are needed to improve health outcomes among YPLWH, but scale-up should be guided by rigorous research and address the unique complexities that characterize the vulnerable period of adolescence.
Collapse
|
63
|
Alhaj M, Amberbir A, Singogo E, Banda V, van Lettow M, Matengeni A, Kawalazira G, Theu J, Jagriti MR, Chan AK, van Oosterhout JJ. Retention on antiretroviral therapy during Universal Test and Treat implementation in Zomba district, Malawi: a retrospective cohort study. J Int AIDS Soc 2019; 22:e25239. [PMID: 30734510 PMCID: PMC6367572 DOI: 10.1002/jia2.25239] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 12/19/2018] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Since June 2016, the national HIV programme in Malawi has adopted Universal Test and Treat (UTT) guidelines requiring that all persons who test HIV positive will be referred to start antiretroviral therapy (ART). Although there is strong evidence from clinical trials that early initiation of ART leads to reduced morbidity and mortality, the impact of UTT on retention on ART in real-life programmatic settings in Africa is not yet known. METHODS We conducted a retrospective cohort study in Zomba district, Malawi to compare ART outcomes of patients who initiated ART under 2016 UTT guidelines and those who started ART prior to rollout of UTT (pre-UTT). We analysed data from 32 rural and urban health facilities of various sizes. Cox proportional hazards modelling was used to determine the independent risk factors of attrition from ART at 12 months. All analyses were adjusted for clustering by health facility using a robust standard errors approach. RESULTS Among 1492 patients (mean age 34.4 years, 933 (63%) female) who initiated ART during the study period, 501 were enrolled in the pre-UTT cohort and 911 during UTT. At 12 months, retention on ART in the UTT cohort was higher than in the pre-UTT cohort 83.0% (95% confidence interval (CI): 81.0% to 85.0%) versus 76.2% (95% CI 73.9% to 78.5%). Adolescents, aged 10 to 19 years (adjusted hazard ratio (aHR) 1.53; 95% CI 1.01 to 2.32), and women who were pregnant or breastfeeding at ART initiation (aHR 1.87; 95% CI 1.30 to 2.38) were at higher risk of attrition in the combined pre-UTT and UTT cohort. CONCLUSIONS Retention on ART was nearly 6% higher after UTT introduction. Young adults and women who were pregnant or breastfeeding at the start of ART were at increased risk of attrition, emphasizing the need for targeted interventions for these groups to achieve the 90-90-90 UNAIDS targets in the UTT era.
Collapse
Affiliation(s)
- Mohammad Alhaj
- Dalla Lana School of Public HealthUniversity of TorontoTorontoCanada
- Dignitas InternationalZombaMalawi
| | - Alemayehu Amberbir
- Dalla Lana School of Public HealthUniversity of TorontoTorontoCanada
- Dignitas InternationalZombaMalawi
| | | | | | - Monique van Lettow
- Dalla Lana School of Public HealthUniversity of TorontoTorontoCanada
- Dignitas InternationalZombaMalawi
| | | | - Gift Kawalazira
- Zomba District Health OfficeMalawi Ministry of HealthZombaMalawi
| | - Joe Theu
- Dignitas InternationalZombaMalawi
| | | | - Adrienne K Chan
- Dalla Lana School of Public HealthUniversity of TorontoTorontoCanada
- Dignitas InternationalZombaMalawi
- Division of Infectious DiseasesSunnybrook Health Sciences CentreUniversity of TorontoTorontoCanada
| | - Joep J van Oosterhout
- Dignitas InternationalZombaMalawi
- Department of MedicineCollege of MedicineUniversity of MalawiBlantyreMalawi
| |
Collapse
|
64
|
MacKenzie RK, van Lettow M, Gondwe C, Nyirongo J, Singano V, Banda V, Thaulo E, Beyene T, Agarwal M, McKenney A, Hrapcak S, Garone D, Sodhi SK, Chan AK. Greater retention in care among adolescents on antiretroviral treatment accessing "Teen Club" an adolescent-centred differentiated care model compared with standard of care: a nested case-control study at a tertiary referral hospital in Malawi. J Int AIDS Soc 2018; 20. [PMID: 29178197 PMCID: PMC5810310 DOI: 10.1002/jia2.25028] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 11/07/2017] [Indexed: 11/20/2022] Open
Abstract
Introduction There are numerous barriers to the care and support of adolescents living with HIV (ALHIV) that makes this population particularly vulnerable to attrition from care, poor adherence and virological failure. In 2010, a Teen Club was established in Zomba Central Hospital (ZCH), Malawi, a tertiary referral HIV clinic. Teen Club provides ALHIV on antiretroviral treatment (ART) with dedicated clinic time, sexual and reproductive health education, peer mentorship, ART refill and support for positive living and treatment adherence. The purpose of this study was to evaluate whether attending Teen Club improves retention in ART care. Methods We conducted a nested case–control study with stratified selection, using programmatic data from 2004 to 2015. Cases (ALHIV not retained in care) and controls (ALHIV retained in care) were matched by ART initiation age group. Patient records were reviewed retrospectively and subjects were followed starting in March 2010, the month in which Teen Club was opened. Follow‐up ended at the time patients were no longer considered retained in care or on 31 December 2015. Cases and controls were drawn from a study population of 617 ALHIV. Of those, 302 (48.9%) participated in at least two Teen Club sessions. From the study population, 135 (non‐retained) cases and 405 (retained) controls were selected. Results In multivariable analyses, Teen Club exposure, age at the time of selection and year of ART initiation were independently associated with attrition. ALHIV with no Teen Club exposure were less likely to be retained than those with Teen Club exposure (adjusted odds ratio (aOR) 0.27; 95% CI 0.16, 0.45) when adjusted for sex, ART initiation age, current age, reason for ART initiation and year of ART initiation. ALHIV in the age group 15 to 19 were more likely to have attrition from care than ALHIV in the age group 10 to 14 years of age (aOR 2.14; 95% CI 1.12, 4.11). Conclusions This study contributes to the limited evidence evaluating the effectiveness of service delivery interventions to support ALHIV within healthcare settings. Prospective evaluation of the Teen Club package with higher methodological quality is required for programmes and governments in low‐ and middle‐income settings to prioritize interventions for ALHIV and determine their cost‐effectiveness.
Collapse
Affiliation(s)
| | - Monique van Lettow
- Dignitas International, Zomba, Malawi.,Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | | | | | | | | | - Edith Thaulo
- Zomba Central Hospital, Malawi Ministry of Health, Zomba, Malawi
| | - Teferi Beyene
- Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Mansi Agarwal
- Dignitas International, Zomba, Malawi.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Allyson McKenney
- Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Susan Hrapcak
- Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | | | - Sumeet K Sodhi
- Dignitas International, Zomba, Malawi.,Department of Family and Community Medicine, University Health Network, University of Toronto, Toronto, Canada
| | - Adrienne K Chan
- Dignitas International, Zomba, Malawi.,Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.,Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| |
Collapse
|