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Mcinziba A, Bock P, Hoddinott G, Seeley J, Bond V, Fidler S, Viljoen L. Managing household income and antiretroviral therapy adherence among people living with HIV in a low-income setting: a qualitative data from the HPTN 071 (PopART) trial in South Africa. AIDS Res Ther 2023; 20:54. [PMID: 37542278 PMCID: PMC10401727 DOI: 10.1186/s12981-023-00549-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 07/18/2023] [Indexed: 08/06/2023] Open
Abstract
BACKGROUND South Africa is reported to have the highest burden of HIV with an estimated 8.2 million people living with HIV (PLHIV) in 2021- despite adopting the World Health Organisation (WHO) universal HIV test and treat (UTT) recommendations in 2016. As of 2021, only an estimated 67% (5.5 million) of all PLHIV were accessing antiretroviral therapy (ART), as per recorded clinic appointments attendance. Studies in sub-Saharan Africa show that people living in low-income households experience multiple livelihood-related barriers to either accessing or adhering to HIV treatment including lack of resources to attend to facilities and food insecurity. We describe the interactions between managing household income and ART adherence for PLHIV in low-income urban and semi-urban settings in the Western Cape, South Africa. METHODS We draw on qualitative data collected as part of the HPTN 071 (PopART) HIV prevention trial (2016 - 2018) to provide a detailed description of the interactions between household income and self-reported ART adherence (including accessing ART and the ability to consistently take ART as prescribed) for PLHIV in the Western Cape, South Africa. We included data from 21 PLHIV (10 men and 11 women aged between 18 and 70 years old) from 13 households. As part of the qualitative component, we submitted an amendment to the ethics to recruit and interview community members across age ranges. We purposefully sampled for diversity in terms of age, gender, and household composition. RESULTS We found that the management of household income interacted with people's experiences of accessing and adhering to ART in diverse ways. Participants reported that ART adherence was not a linear process as it was influenced by income stability, changing household composition, and other financial considerations. Participants reported that they did not have a fixed way of managing income and that subsequently caused inconsistency in their ART adherence. Participants reported that they experienced disruptions in ART access and adherence due to competing household priorities. These included difficulties balancing between accessing care and/or going to work, as well as struggling to cover HIV care-related costs above other basic needs. CONCLUSION Our analysis explored links between managing household income and ART adherence practices. We showed that these are complex and change over the course of treatment duration. We argued that mitigating negative impacts of income fluctuation and managing complex trade-offs in households be included in ART adherence support programmes.
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Affiliation(s)
- Abenathi Mcinziba
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
| | - Peter Bock
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Graeme Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Janet Seeley
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Virginia Bond
- School of Medicine, University of Zambia, Ridgeway Campus, Zambart, Lusaka, Zambia
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Sarah Fidler
- Department of Medicine, Imperial College, London, UK
| | - Lario Viljoen
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Sandoval M, Mtetwa G, Devezin T, Vambe D, Sibanda J, Dube GS, Dlamini-Simelane T, Lukhele B, Mandalakas AM, Kay A. Community-based tuberculosis contact management: Caregiver experience and factors promoting adherence to preventive therapy. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001920. [PMID: 37450473 PMCID: PMC10348572 DOI: 10.1371/journal.pgph.0001920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 06/19/2023] [Indexed: 07/18/2023]
Abstract
Delivery of tuberculosis preventive therapy (TPT) for children with household exposure to tuberculosis is a globally supported intervention to reduce the impact of tuberculosis disease (TB) in vulnerable children; however, it is sub-optimally implemented in most high-burden settings. As part of a community-based household contact management program, we evaluated predictors of adherence to community based TPT in children and performed qualitative assessments of caregiver experiences. The Vikela Ekhaya (Protect the Home) project was a community-based household contact management program implemented between 2019 and 2020 in the Hhohho Region of Eswatini. At home visits, contact management teams screened children for TB, initiated TPT when indicated and performed follow-up assessments reviewing TPT adherence. TPT non-adherence was defined as either two self-reported missed doses or a pill count indicating at least two missed doses, and risk factors were evaluated using multivariate clustered Cox regression models. Semi-structured interviews were performed with caregivers to assess acceptability of home visits for TPT administration. In total, 278 children under 15 years initiated TPT and 96% completed TPT through the Vikela Ekhaya project. Risk factors for TPT non-adherence among children initiating 3HR included low family income (adjusted hazard ratio (aHR) 2.3, 95%CI 1.2-4.4), female gender of the child (aHR 2.5, 95% CI 1.4-5.0) and an urban living environment (aHR 3.1, 95%CI 1.6-6.0). Children with non-adherence at the first follow-up visit were 9.1 fold more likely not to complete therapy. Caregivers indicated an appreciation for community services, citing increased comfort, reduced cost, and support from community members. Our results are supportive of recent World Health Organization (WHO) recommendations for decentralization of TB preventive services. Here, we identify populations that may benefit from additional support to promote TPT adherence, but overall demonstrate a clear preference for and excellent outcomes with community based TPT delivery.
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Affiliation(s)
- Micaela Sandoval
- The Global Tuberculosis Program, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas, United States of America
- Epidemiology, Human Genetics & Environmental Sciences, UTHealth School of Public Health, Houston, Texas, United States of America
| | - Godwin Mtetwa
- The Global Tuberculosis Program, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas, United States of America
- Baylor College of Medicine Children’s Foundation-Eswatini, Mbabane, Eswatini
| | - Tara Devezin
- The Global Tuberculosis Program, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas, United States of America
| | - Debrah Vambe
- Eswatini National Tuberculosis Control Program, Manzini, Eswatini
| | - Joyce Sibanda
- Eswatini National Tuberculosis Control Program, Manzini, Eswatini
| | - Gloria S. Dube
- Eswatini National Tuberculosis Control Program, Manzini, Eswatini
| | | | - Bhekumusa Lukhele
- Health Policy & Organization, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Anna M. Mandalakas
- The Global Tuberculosis Program, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas, United States of America
- Epidemiology, Human Genetics & Environmental Sciences, UTHealth School of Public Health, Houston, Texas, United States of America
- Clinical Infectious Disease Group, German Center for Infectious Research (DZIF), Clinical TB Unit, Research Center Borstel, Borstel, Germany
| | - Alexander Kay
- The Global Tuberculosis Program, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas, United States of America
- Baylor College of Medicine Children’s Foundation-Eswatini, Mbabane, Eswatini
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Mulholland GE, Herce ME, Bahemuka UM, Kwena ZA, Jeremiah K, Okech BA, Bukusi E, Okello ES, Nanyonjo G, Ssetaala A, Seeley J, Emch M, Pettifor A, Weir SS, Edwards JK. Geographic mobility and treatment outcomes among people in care for tuberculosis in the Lake Victoria region of East Africa: A multi-site prospective cohort study. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001992. [PMID: 37276192 PMCID: PMC10241360 DOI: 10.1371/journal.pgph.0001992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 05/04/2023] [Indexed: 06/07/2023]
Abstract
Geographic mobility may disrupt continuity of care and contribute to poor clinical outcomes among people receiving treatment for tuberculosis (TB). This may occur especially where health services are not well coordinated across international borders, particularly in lower and middle income country settings. In this work, we describe mobility and the relationship between mobility and unfavorable TB treatment outcomes (i.e., death, loss to follow-up, or treatment failure) among a cohort of adults who initiated TB treatment at one of 12 health facilities near Lake Victoria. We abstracted data from health facility records for all 776 adults initiating TB treatment during a 6-month period at the selected facilities in Kenya, Tanzania, and Uganda. We interviewed 301 cohort members to assess overnight travel outside one's residential district/sub-county. In our analyses, we estimated the proportion of cohort members traveling in 2 and 6 months following initiation of TB treatment, explored correlates of mobility, and examined the association between mobility and an unfavorable TB treatment outcome. We estimated that 40.7% (95% CI: 33.3%, 49.6%) of people on treatment for TB traveled overnight at least once in the 6 months following treatment initiation. Mobility was more common among people who worked in the fishing industry and among those with extra-pulmonary TB. Mobility was not strongly associated with other characteristics examined, however, suggesting that efforts to improve TB care for mobile populations should be broad ranging. We found that in this cohort, people who were mobile were not at increased risk of an unfavorable TB treatment outcome. Findings from this study can help inform development and implementation of mobility-competent health services for people with TB in East Africa.
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Affiliation(s)
- Grace E. Mulholland
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Michael E. Herce
- Institute for Global Health and Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Ubaldo M. Bahemuka
- Medical Research Council/Uganda Virus Research Institute & London School of Hygiene and Tropical Medicine, Uganda Research Unit, Entebbe, Uganda
| | | | - Kidola Jeremiah
- Mwanza Intervention Trials Unit, Mwanza Research Centre, National Institute for Medical Research, Mwanza, Tanzania
| | | | | | - Elialilia S. Okello
- Mwanza Intervention Trials Unit, Mwanza Research Centre, National Institute for Medical Research, Mwanza, Tanzania
| | | | - Ali Ssetaala
- UVRI-IAVI HIV Vaccine Program Limited, Entebbe, Uganda
| | - Janet Seeley
- Medical Research Council/Uganda Virus Research Institute & London School of Hygiene and Tropical Medicine, Uganda Research Unit, Entebbe, Uganda
- Global Health and Development Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Michael Emch
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Department of Geography, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Audrey Pettifor
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Sharon S. Weir
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Jessie K. Edwards
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
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Thorp M, Ayieko J, Hoffman RM, Balakasi K, Camlin CS, Dovel K. Mobility and HIV care engagement: a research agenda. J Int AIDS Soc 2023; 26:e26058. [PMID: 36943731 PMCID: PMC10029995 DOI: 10.1002/jia2.26058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 01/10/2023] [Indexed: 03/23/2023] Open
Abstract
INTRODUCTION Mobility is common and an essential livelihood strategy in sub-Saharan Africa (SSA). Mobile people suffer worse outcomes at every stage of the HIV care cascade compared to non-mobile populations. Definitions of mobility vary widely, and research on the role of temporary mobility (as opposed to permanent migration) in HIV treatment outcomes is often lacking. In this article, we review the current landscape of mobility and HIV care research to identify what is already known, gaps in the literature, and recommendations for future research. DISCUSSION Mobility in SSA is closely linked to income generation, though caregiving, climate change and violence also contribute to the need to move. Mobility is likely to increase in the coming decades, both due to permanent migration and increased temporary mobility, which is likely much more common. We outline three central questions regarding mobility and HIV treatment outcomes in SSA. First, it is unclear what aspects of mobility matter most for HIV care outcomes and if high-risk mobility can be identified or predicted, which is necessary to facilitate targeted interventions for mobile populations. Second, it is unclear what groups are most vulnerable to mobility-associated treatment interruption and other adverse outcomes. And third, it is unclear what interventions can improve HIV treatment outcomes for mobile populations. CONCLUSIONS Mobility is essential for people living with HIV in SSA. HIV treatment programmes and broader health systems must understand and adapt to human mobility, both to promote the rights and welfare of mobile people and to end the HIV pandemic.
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Affiliation(s)
- Marguerite Thorp
- Division of Infectious DiseasesDavid Geffen School of MedicineUniversity of California Los AngelesLos AngelesCaliforniaUSA
| | - James Ayieko
- Center for Microbiology ResearchKenya Medical Research InstituteKisumuKenya
| | - Risa M. Hoffman
- Division of Infectious DiseasesDavid Geffen School of MedicineUniversity of California Los AngelesLos AngelesCaliforniaUSA
| | | | - Carol S. Camlin
- Department of ObstetricsGynecology & Reproductive SciencesUniversity of California San FranciscoSan FranciscoCaliforniaUSA
- Center for AIDS Prevention StudiesDepartment of MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Kathryn Dovel
- Division of Infectious DiseasesDavid Geffen School of MedicineUniversity of California Los AngelesLos AngelesCaliforniaUSA
- Partners in HopeLilongweMalawi
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Leslie HH, Mooney AC, Gilmore HJ, Agnew E, Grignon JS, deKadt J, Shade SB, Ratlhagana MJ, Sumitani J, Barnhart S, Steward WT, Lippman SA. Prevalence, motivation, and outcomes of clinic transfer in a clinical cohort of people living with HIV in North West Province, South Africa. BMC Health Serv Res 2022; 22:1584. [PMID: 36572869 PMCID: PMC9791728 DOI: 10.1186/s12913-022-08962-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 12/13/2022] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Continuity of care is an attribute of high-quality health systems and a necessary component of chronic disease management. Assessment of health information systems for HIV care in South Africa has identified substantial rates of clinic transfer, much of it undocumented. Understanding the reasons for changing sources of care and the implications for patient outcomes is important in informing policy responses. METHODS In this secondary analysis of the 2014 - 2016 I-Care trial, we examined self-reported changes in source of HIV care among a cohort of individuals living with HIV and in care in North West Province, South Africa. Individuals were enrolled in the study within 1 year of diagnosis; participants completed surveys at 6 and 12 months including items on sources of care. Clinical data were extracted from records at participants' original clinic for 12 months following enrollment. We assessed frequency and reason for changing clinics and compared the demographics and care outcomes of those changing and not changing source of care. RESULTS Six hundred seventy-five (89.8%) of 752 study participants completed follow-up surveys with information on sources of HIV care; 101 (15%) reported receiving care at a different facility by month 12 of follow-up. The primary reason for changing was mobility (N=78, 77%). Those who changed clinics were more likely to be young adults, non-citizens, and pregnant at time of diagnosis. Self-reported clinic attendance and ART adherence did not differ based on changing clinics. Those on ART not changing clinics reported 0.66 visits more on average than were documented in clinic records. CONCLUSION At least 1 in 6 participants in HIV care changed clinics within 2 years of diagnosis, mainly driven by mobility; while most appeared lost to follow-up based on records from the original clinic, self-reported visits and adherence were equivalent to those not changing clinics. Routine clinic visits could incorporate questions about care at other locations as well as potential relocation, particularly for younger, pregnant, and non-citizen patients, to support existing efforts to make HIV care records portable and facilitate continuity of care across clinics. TRIAL REGISTRATION The original trial was registered with ClinicalTrials.gov , NCT02417233, on 12 December 2014.
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Affiliation(s)
- Hannah H. Leslie
- grid.266102.10000 0001 2297 6811Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th Street, San Francisco, CA 94158 USA
| | - Alyssa C. Mooney
- grid.266102.10000 0001 2297 6811Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA USA
| | - Hailey J. Gilmore
- grid.266102.10000 0001 2297 6811Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th Street, San Francisco, CA 94158 USA
| | - Emily Agnew
- grid.266102.10000 0001 2297 6811Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th Street, San Francisco, CA 94158 USA
| | - Jessica S. Grignon
- grid.34477.330000000122986657Department of Global Health, University of Washington, Seattle, WA USA ,International Training and Education Center for Health (I-TECH) South Africa, Pretoria, Republic of South Africa
| | - Julia deKadt
- International Training and Education Center for Health (I-TECH) South Africa, Pretoria, Republic of South Africa
| | - Starley B. Shade
- grid.266102.10000 0001 2297 6811Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th Street, San Francisco, CA 94158 USA
| | - Mary Jane Ratlhagana
- International Training and Education Center for Health (I-TECH) South Africa, Pretoria, Republic of South Africa
| | - Jeri Sumitani
- International Training and Education Center for Health (I-TECH) South Africa, Pretoria, Republic of South Africa
| | - Scott Barnhart
- grid.34477.330000000122986657Department of Global Health, University of Washington, Seattle, WA USA
| | - Wayne T. Steward
- grid.266102.10000 0001 2297 6811Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th Street, San Francisco, CA 94158 USA
| | - Sheri A. Lippman
- grid.266102.10000 0001 2297 6811Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th Street, San Francisco, CA 94158 USA
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Murphy JP, Shumba K, Jamieson L, Nattey C, Pascoe S, Fox MP, Miot J, Maskew M. Assessment of facility-level antiretroviral treatment patient status utilizing a national-level laboratory cohort: Toward an understanding of system-level tracking and clinic switching in South Africa. Front Public Health 2022; 10:959481. [PMID: 36590005 PMCID: PMC9798405 DOI: 10.3389/fpubh.2022.959481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 11/11/2022] [Indexed: 12/23/2022] Open
Abstract
Background Most estimates of HIV retention are derived at the clinic level through antiretroviral (ART) patient management systems, which capture ART clinic visit data, yet these cannot account for silent transfers across HIV treatment sites. Patient laboratory monitoring visits may also be observed in routinely collected laboratory data, which include ART monitoring tests such as CD4 count and HIV viral load, key to our work here. Methods In this analysis, we utilized the NHLS National HIV Cohort (a system-wide viewpoint) to investigate the accuracy of facility-level estimates of retention in care for adult patients accessing care (defined using clinic visit data on patients under ART recorded in an electronic patient management system) at Themba Lethu Clinic (TLC). Furthermore, we describe patterns of facility switching among all patients and those patients classified as lost to follow-up (LTFU) at the facility level. Results Of the 43,538 unique patients in the TLC dataset, we included 20,093 of 25,514 possible patient records (78.8%) in our analysis that were linked with the NHLS National Cohort, and we restricted the analytic sample to patients initiating ART between 1 January 2007 and 31 December 2017. Most (60%) patients were female, and the median age (IQR) at ART initiation was 37 (31-45) years. We found the laboratory records augmented retention estimates by a median of 860 additional active records (about 8% of all median active records across all years) from the facility viewpoint; this augmentation was more noticeable from the system-wide viewpoint, which added evidence of activity of about one-third of total active records in 2017. In 2017, we found 7.0% misclassification at the facility-level viewpoint, a gap which is potentially solvable through data integration/triangulation. We observed 1,134/20,093 (5.6%) silent transfers; these were noticeably more female and younger than the entire dataset. We also report the most common locations for clinic switching at a provincial level. Discussion Integration of multiple data sources has the potential to reduce the misclassification of patients as being lost to care and help understand situations where clinic switching is common. This may help in prioritizing interventions that would assist patients moving between clinics and hopefully contribute to services that normalize formal transfers and fewer silent transfers.
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Affiliation(s)
- Joshua P. Murphy
- Health Economics and Epidemiology Research Office (HERO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa,*Correspondence: Joshua P. Murphy
| | - Khumbo Shumba
- Health Economics and Epidemiology Research Office (HERO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lise Jamieson
- Health Economics and Epidemiology Research Office (HERO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Cornelius Nattey
- Health Economics and Epidemiology Research Office (HERO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sophie Pascoe
- Health Economics and Epidemiology Research Office (HERO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Matthew P. Fox
- Health Economics and Epidemiology Research Office (HERO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa,Department of Global Health, School of Public Health, Boston University, Boston, MA, United States
| | - Jacqui Miot
- Health Economics and Epidemiology Research Office (HERO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mhairi Maskew
- Health Economics and Epidemiology Research Office (HERO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Samba BO, Lewis-Kulzer J, Odhiambo F, Juma E, Mulwa E, Kadima J, Bukusi EA, Cohen CR. Exploring Estimates and Reasons for Lost to Follow-Up Among People Living With HIV on Antiretroviral Therapy in Kisumu County, Kenya. J Acquir Immune Defic Syndr 2022; 90:146-153. [PMID: 35213856 PMCID: PMC9203903 DOI: 10.1097/qai.0000000000002942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 02/11/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND A better understanding why people living with HIV (PLHIV) become lost to follow-up (LTFU) and determining who is LTFU in a program setting is needed to attain HIV epidemic control. SETTING This retrospective cross-sectional study used an evidence-sampling approach to select health facilities and LTFU patients from a large HIV program supporting 61 health facilities in Kisumu County, Kenya. METHODS Eligible PLHIV included adults 18 years and older with at least 1 clinic visit between September 1, 2016, and August 31, 2018, and were LTFU (no clinical contact for ≥90 days after their last expected clinic visit). From March to June 2019, demographic and clinical variables were collected from a sample of LTFU patient files at 12 health facilities. Patient care status and retention outcomes were determined through program tracing. RESULTS Of 787 LTFU patients selected and traced, 36% were male, median age was 30.5 years (interquartile range: 24.6-38.0), and 78% had their vital status confirmed with 560 (92%) alive and 52 (8%) deceased. Among 499 (89.0%) with a retention outcome, 233 (46.7%) had stopped care while 266 (53.3%) had self-transferred to another facility. Among those who had stopped care, psychosocial reasons were most common {65.2% [95% confidence interval (CI): 58.9 to 71.1]} followed by structural reasons [29.6% (95% CI: 24.1 to 35.8)] and clinic-based reasons [3.0% (95% CI: 1.4 to 6.2)]. CONCLUSION We found that more than half of patients LTFU were receiving HIV care elsewhere, leading to a higher overall patient retention rate than routinely reported. Similar strategies could be considered to improve the accuracy of reporting retention in HIV care.
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Affiliation(s)
- Benard O Samba
- Center for Microbiology Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Jayne Lewis-Kulzer
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA; and
| | - Francesca Odhiambo
- Center for Microbiology Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Eric Juma
- Center for Microbiology Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Edwin Mulwa
- Center for Microbiology Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Julie Kadima
- Center for Microbiology Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Elizabeth A Bukusi
- Center for Microbiology Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Craig R Cohen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA; and
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Understanding the Reasons for Deferring ART Among Patients Diagnosed Under the Same-Day-ART Policy in Johannesburg, South Africa. AIDS Behav 2021; 25:2779-2792. [PMID: 33534055 PMCID: PMC8373761 DOI: 10.1007/s10461-021-03171-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2021] [Indexed: 12/20/2022]
Abstract
We aimed to examine the correlates of antiretroviral therapy (ART) deferral to inform ART demand creation and retention interventions for patients diagnosed with HIV during the Universal Test and Treat (UTT) policy in South Africa. We conducted a cohort study enrolling newly diagnosed HIV-positive adults (≥ 18 years), at four primary healthcare clinics in Johannesburg between October 2017 and August 2018. Patients were interviewed immediately after HIV diagnosis, and ART initiation was determined through medical record review up to six-months post-test. ART deferral was defined as not starting ART six months after HIV diagnosis. Participants who were not on ART six-months post-test were traced and interviewed telephonically to determine reasons for ART deferral. Modified Poisson regression was used to evaluate correlates of six-months ART deferral. We adjusted for baseline demographic and clinical factors. We present crude and adjusted risk ratios (aRR) associated with ART deferral. Overall, 99/652 (15.2%) had deferred ART by six months, 20.5% men and 12.2% women. Baseline predictors of ART deferral were older age at diagnosis (adjusted risk ratio (aRR) 1.5 for 30-39.9 vs 18-29.9 years, 95% confidence intervals (CI): 1.0-2.2), disclosure of intentions to test for HIV (aRR 2.2 non-disclosure vs disclosure to a partner/spouse, 95% CI: 1.4-3.6) and HIV testing history (aRR 1.7 for > 12 months vs < 12 months/no prior test, 95% CI: 1.0-2.8). Additionally, having a primary house in another country (aRR 2.1 vs current house, 95% CI: 1.4-3.1) and testing alone (RR 4.6 vs partner/spouse support, 95% CI: 1.2-18.3) predicted ART deferral among men. Among the 43/99 six-months interviews, women (71.4%) were more likely to self-report ART initiation than men (RR 0.4, 95% CI: 0.2-0.8) and participants who relocated within SA (RR 2.1 vs not relocated, 95% CI: 1.2-3.5) were more likely to still not be on ART. Under the treat-all ART policy, nearly 15.2% of study participants deferred ART initiation up to six months after the HIV diagnosis. Our analysis highlighted the need to pay particular attention to patients who show little social preparation for HIV testing and mobile populations.
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Limbada M, Bwalya C, Macleod D, Floyd S, Schaap A, Situmbeko V, Hayes R, Fidler S, Ayles H. A comparison of different community models of antiretroviral therapy delivery with the standard of care among stable HIV+ patients: rationale and design of a non-inferiority cluster randomized trial, nested in the HPTN 071 (PopART) study. Trials 2021; 22:52. [PMID: 33430928 PMCID: PMC7802215 DOI: 10.1186/s13063-020-05010-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 12/29/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Following the World Health Organization's (WHO) 2015 guidelines recommending initiation of antiretroviral therapy (ART) irrespective of CD4 count for all people living with HIV (PLHIV), many countries in sub-Saharan Africa have adopted this strategy to reach epidemic control. As the number of PLHIV on ART rises, maintenance of viral suppression on ART for over 90% of PLHIV remains a challenge to government health systems in resource-limited high HIV burden settings. Non facility-based antiretroviral therapy (ART) delivery for stable HIV+ patients may increase sustainable ART coverage in resource-limited settings. Within the HPTN 071 (PopART) trial, two models, home-based delivery (HBD) or adherence clubs (AC), were offered to assess whether they achieved similar viral load suppression (VLS) to standard of care (SoC). In this paper, we describe the trial design and discuss the methodological issues and challenges. METHODS A three-arm cluster randomized non-inferiority trial, nested in two urban HPTN 071 trial communities in Zambia, randomly allocated 104 zones to SoC (35), HBD (35), or AC (34). ART and adherence support were delivered 3-monthly at home (HBD), adherence clubs (AC), or clinic (SoC). Adult HIV+ patients defined as "stable" on ART were eligible for inclusion. The primary endpoint was the proportion of PLHIV with virological suppression (≤ 1000 copies HIV RNA/ml) at 12 months (± 3months) after study entry across all three arms. Viral load measurement was done at the routine government laboratories in accordance with national guidelines, annually. The study was powered to determine if either of the community-based interventions would yield a viral suppression rate drop compared to SoC of no more than 5% in its absolute value. Both community-based interventions were delivered by community HIV providers (CHiPs). An additional qualitative study using observations, interviews with PLHIV, and FGDs with community HIV providers was nested in this study to complement the quantitative data. DISCUSSION This trial was designed to provide rigorous randomized evidence of safety and efficacy of non-facility-based delivery of ART for stable PLHIV in high-burden resource-limited settings. This trial will inform policy regarding best practices and what is needed to strengthen scale-up of differentiated models of ART delivery in resource-limited settings. TRIAL REGISTRATION ClinicalTrials.gov NCT03025165 . Registered on 19 January 2017.
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Affiliation(s)
- Mohammed Limbada
- Zambart, University of Zambia, School of Medicine, Zambart House, Ridgeway Campus, Off Nationalist Road, P.O. Box 50697, Lusaka, Zambia.
| | - Chiti Bwalya
- Zambart, University of Zambia, School of Medicine, Zambart House, Ridgeway Campus, Off Nationalist Road, P.O. Box 50697, Lusaka, Zambia
| | - David Macleod
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Sian Floyd
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Ab Schaap
- Zambart, University of Zambia, School of Medicine, Zambart House, Ridgeway Campus, Off Nationalist Road, P.O. Box 50697, Lusaka, Zambia
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Vasty Situmbeko
- Zambart, University of Zambia, School of Medicine, Zambart House, Ridgeway Campus, Off Nationalist Road, P.O. Box 50697, Lusaka, Zambia
| | - Richard Hayes
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Sarah Fidler
- Imperial College and Imperial College NIHR BRC, London, UK
| | - Helen Ayles
- Zambart, University of Zambia, School of Medicine, Zambart House, Ridgeway Campus, Off Nationalist Road, P.O. Box 50697, Lusaka, Zambia
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
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10
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Viljoen L, Bond VA, Reynolds LJ, Mubekapi‐Musadaidzwa C, Baloyi D, Ndubani R, Stangl A, Seeley J, Pliakas T, Bock P, Fidler S, Hayes R, Ayles H, Hargreaves JR, Hoddinott G. Universal HIV testing and treatment and HIV stigma reduction: a comparative thematic analysis of qualitative data from the HPTN 071 (PopART) trial in South Africa and Zambia. SOCIOLOGY OF HEALTH & ILLNESS 2021; 43:167-185. [PMID: 33085116 PMCID: PMC7894283 DOI: 10.1111/1467-9566.13208] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 09/16/2020] [Accepted: 09/24/2020] [Indexed: 06/11/2023]
Abstract
Despite continued development of effective HIV treatment, expanded access to care and advances in prevention modalities, HIV-related stigma persists. We examine how, in the context of a universal HIV-testing and treatment trial in South Africa and Zambia, increased availability of HIV services influenced conceptualisations of HIV. Using qualitative data, we explore people's stigma-related experiences of living in 'intervention' and 'control' study communities. We conducted exploratory data analysis from a qualitative cohort of 150 households in 13 study communities, collected between 2016 and 2018. We found that increased availability of HIV-testing services influenced conceptualisations of HIV as normative (non-exceptional) and the visibility of people living with HIV (PLHIV) in household and community spaces impacted opportunities for stigma. There was a shift in community narratives towards individual responsibility to take up (assumingly) widely available service - for PLHIV to take care of their own health and to prevent onward transmission. Based on empirical data, we show that, despite a growing acceptance of HIV-related testing services, anticipated stigma persists through the mechanism of shifting responsibilisation. To mitigate the responsibilisation of PLHIV, heath implementers need to adapt anti-stigma messaging and especially focus on anticipated stigma.
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Affiliation(s)
- Lario Viljoen
- Department of Paediatrics and Child HealthFaculty of Medicine and Health SciencesDesmond Tutu TB CentreStellenbosch UniversityStellenboschSouth Africa
- Department of Sociology and Social AnthropologyStellenbosch UniversityStellenboschSouth Africa
| | - Virginia A. Bond
- ZambartSchool of Public HealthRidgeway CampusUniversity of ZambiaLusakaZambia
- Global Health and Development DepartmentFaculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Lindsey J. Reynolds
- Department of Sociology and Social AnthropologyStellenbosch UniversityStellenboschSouth Africa
| | - Constance Mubekapi‐Musadaidzwa
- Department of Paediatrics and Child HealthFaculty of Medicine and Health SciencesDesmond Tutu TB CentreStellenbosch UniversityStellenboschSouth Africa
| | - Dzunisani Baloyi
- Department of Paediatrics and Child HealthFaculty of Medicine and Health SciencesDesmond Tutu TB CentreStellenbosch UniversityStellenboschSouth Africa
| | - Rhoda Ndubani
- ZambartSchool of Public HealthRidgeway CampusUniversity of ZambiaLusakaZambia
| | - Anne Stangl
- International Center for Research on WomenWashingtonDCUSA
| | - Janet Seeley
- Global Health and Development DepartmentFaculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Triantafyllos Pliakas
- Department of Public Health, Environments and SocietyFaculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Peter Bock
- Department of Paediatrics and Child HealthFaculty of Medicine and Health SciencesDesmond Tutu TB CentreStellenbosch UniversityStellenboschSouth Africa
| | - Sarah Fidler
- Imperial College NIHR BRCImperial College LondonLondonUK
| | - Richard Hayes
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Public HealthLondon School of Hygiene and Tropical MedicineLondonUK
| | - Helen Ayles
- ZambartSchool of Public HealthRidgeway CampusUniversity of ZambiaLusakaZambia
- Department of Public Health, Environments and SocietyFaculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
| | - James R. Hargreaves
- Department of Public Health, Environments and SocietyFaculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Graeme Hoddinott
- Department of Paediatrics and Child HealthFaculty of Medicine and Health SciencesDesmond Tutu TB CentreStellenbosch UniversityStellenboschSouth Africa
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11
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Viljoen L, Myburgh H, Reynolds L. "It Stays Between Us": Managing Comorbidities and Public/Private Dichotomies in HPTN071 (POPART) Trial Communities. Med Anthropol 2020; 40:280-293. [PMID: 33000972 DOI: 10.1080/01459740.2020.1820501] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
In contexts of scarcity, managing comorbidities is a complex process, shaped by divergent understandings of causes, prognoses, and social meanings of illness. Drawing on research with one young South African woman living with HIV and epilepsy, and 13 other people with comorbidities, we describe how concepts of "public" and "private" shape the management of co-morbid conditions. Despite narratives of HIV "normalization," participants labored to keep their HIV status private, while sharing other illness experiences more publicly. We challenge simple dichotomies between public and private spheres and emphasize the need for more fluid understandings of how people negotiate social space.
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Affiliation(s)
- Lario Viljoen
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University.,Department of Sociology and Social Anthropology, Stellenbosch University
| | - Hanlie Myburgh
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University.,Amsterdam Institute for Social Science Research
| | - Lindsey Reynolds
- Department of Sociology and Social Anthropology, Stellenbosch University
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12
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Hannaford A, Moll AP, Madondo T, Khoza B, Shenoi SV. Mobility and structural barriers in rural South Africa contribute to loss to follow up from HIV care. AIDS Care 2020; 33:1436-1444. [PMID: 32856470 DOI: 10.1080/09540121.2020.1808567] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Retention in HIV care is crucial to sustaining viral load suppression, and reducing HIV transmission, yet loss to follow-up (LTFU) in South Africa remains substantial. We conducted a mixed methods evaluation in rural South Africa to characterize ART disengagement in neglected rural settings. Using convenience sampling, surveys were completed by 102 PLWH who disengaged from ART (minimum 90 days) and subsequently resumed care. A subset (n = 60) completed individual in-depth interviews. Median duration of ART discontinuation was 9 months (IQR 4-22). Participants had HIV knowledge gaps regarding HIV transmission and increased risk of tuberculosis. The major contributors to LTFU were mobility and structural barriers. PLWH traveled for an urgent family need or employment, and were not able to collect ART while away. Structural barriers included inability to access care, due to lack of financial resources to reach distant clinics. Other factors included dissatisfaction with care, pill fatigue, lack of social support, and stigma. Illness was the major precipitant of returning to care. Mobility and structural barriers impede longitudinal HIV care in rural South Africa, threatening the gains made from expanded ART access. To achieve 90-90-90, future interventions, including emphasis on patient centered care, must address barriers relevant to rural settings.
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Affiliation(s)
- Alisse Hannaford
- Department of Internal Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Anthony P Moll
- Church of Scotland Hospital, Tugela Ferry, South Africa.,Philanjalo NGO, Tugela Ferry, South Africa
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Mobility and its Effects on HIV Acquisition and Treatment Engagement: Recent Theoretical and Empirical Advances. Curr HIV/AIDS Rep 2020; 16:314-323. [PMID: 31256348 DOI: 10.1007/s11904-019-00457-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE OF REVIEW We reviewed literature across multiple disciplines to describe issues with the measurement of population mobility in HIV research and to summarize evidence of causal pathways linking mobility to HIV acquisition risks and treatment engagement, with a focus on sub-Saharan Africa. RECENT FINDINGS While the literature on mobility and HIV remains hampered by problems and inconsistency in measures of mobility, the recent research reveals a turn towards a greater attentiveness to measurement and gender. Theoretical and heuristic models for the study of mobility and HIV acquisition and treatment outcomes have been published, but few studies have used longitudinal designs with clear ascertainment of exposures and outcomes for measurement of causal pathways. Notwithstanding these limitations, evidence continues to accumulate that mobility is linked to higher HIV incidence, and that it challenges optimal treatment engagement. Gender continues to be important: while men are more mobile than women, women's mobility particularly heightens their HIV acquisition risks. Recent large-scale efforts to find, test, and treat the individuals in communities who are most at risk of sustaining local HIV transmission have been severely challenged by mobility. Novel interventions, policies, and health systems improvements are urgently needed to fully engage mobile individuals in HIV care and prevention. Interventions targeting the HIV prevention and care needs of mobile populations remain few in number and urgently needed.
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14
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Phillips TK, Myer L. Shifting to the long view: engagement of pregnant and postpartum women living with HIV in lifelong antiretroviral therapy services. Expert Rev Anti Infect Ther 2019; 17:349-361. [PMID: 30978126 DOI: 10.1080/14787210.2019.1607296] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Introduction: The advent of policies promoting lifelong antiretroviral therapy (ART) for all pregnant and postpartum women living with HIV has shifted focus from short-term prevention of mother-to-child transmission (PMTCT) to lifelong engagement in ART services. However, disengagement from care threatens the long-term treatment and prevention benefits of lifelong ART. Areas covered: A framework for considering the unique aspects of ART for pregnant and postpartum women is presented along with a review of the literature on maternal engagement in care in sub-Saharan Africa and a discussion of potential interventions to sustain engagement in lifelong ART. Expert opinion: Engaging women and mothers in ART services for life is critical for maternal health, PMTCT, and prevention of sexual transmission. Evidence-based interventions exist to support engagement in care but most focus on periods of mother-to-child transmission risk. In the long term, life transitions and health-care transfers are inevitable. Thus, interventions that can reach beyond a single facility or provide a bridge between health services should be prioritized. Multicomponent interventions will also be essential to address the numerous intersecting barriers to sustained engagement in ART services.
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Affiliation(s)
- Tamsin K Phillips
- a Division of Epidemiology & Biostatistics and Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine , University of Cape Town , Cape Town , South Africa
| | - Landon Myer
- a Division of Epidemiology & Biostatistics and Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine , University of Cape Town , Cape Town , South Africa
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15
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Kuteesa MO, Weiss HA, Abaasa A, Nash S, Nsubuga RN, Newton R, Seeley J, Kamali A. Feasibility of conducting HIV combination prevention interventions in fishing communities in Uganda: A pilot cluster randomised trial. PLoS One 2019; 14:e0210719. [PMID: 30917121 PMCID: PMC6436767 DOI: 10.1371/journal.pone.0210719] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 01/01/2019] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE We assessed feasibility of an HIV-combination-prevention trial among fishing communities in Uganda. DESIGN Cluster randomised trial in four fishing communities on Lake Victoria, Uganda. Two intervention communities received a combination-prevention-package (behaviour change communication, condom promotion, HIV testing, voluntary male medical circumcision and referral for anti-retroviral therapy if HIV-positive). All four communities received routine government HIV care services. METHODS Using household census data we randomly selected a cohort of consenting residents aged ≥18 years. A baseline sero-survey in July 2014 was followed by two repeat surveys in March and December 2015. We measured uptake of HIV prevention methods, loss-to-follow-up and HIV incidence, accounting for multistage survey design. RESULTS A total of 862 participants were enrolled and followed for 15 months. Participation was 62% and 74% in the control and intervention arms respectively; Overall loss to follow up (LTFU) was 21.6% and was similar by arm. Self-reported abstinence/faithfulness increased between baseline and endline in both arms from 53% to 73% in the control arm, and 55% to 67% in the intervention arm. Reported condom use throughout the study period was 36% in the intervention arm vs 28% in the control arm; number of male participants reporting circumsicion in both arms from 58% to 79% in the intervention arm, and 39% to 46% in the control arm. Independent baseline predictors of loss-to-follow-up were: being HIV positive, residence in the community for <1 year, younger age, living in an urban area, and being away from the area for >1 month/year. CONCLUSIONS Recruitment and retention of participants in longitudinal trials in highly mobile HIV fishing communities is challenging. Future research should investigate modes for locating and retaining participants, and delivery of HIV-combination prevention.
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Affiliation(s)
- Monica O. Kuteesa
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe Uganda
- London School of Hygiene and Tropical Medicine, London United Kingdom
- * E-mail:
| | - Helen A. Weiss
- London School of Hygiene and Tropical Medicine, London United Kingdom
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London United Kingdom
| | - Andrew Abaasa
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe Uganda
- London School of Hygiene and Tropical Medicine, London United Kingdom
| | - Stephen Nash
- London School of Hygiene and Tropical Medicine, London United Kingdom
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London United Kingdom
| | | | - Rob Newton
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe Uganda
| | - Janet Seeley
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe Uganda
- London School of Hygiene and Tropical Medicine, London United Kingdom
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16
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Being HIV positive and staying on antiretroviral therapy in Africa: A qualitative systematic review and theoretical model. PLoS One 2019; 14:e0210408. [PMID: 30629648 PMCID: PMC6328200 DOI: 10.1371/journal.pone.0210408] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 12/21/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Adherence to antiretroviral therapy (ART) and long-term uninterrupted engagement in HIV care is difficult for HIV-positive people, and randomized trials of specific techniques to promote adherence often show small or negligible effects. Understanding what influences decision-making in HIV-positive people in Africa may help researchers and policy makers in the development of broader, more effective interventions and policies. METHODS We used thematic synthesis and a grounded theory approach to generate a detailed narrative and theoretical model reflecting life with HIV in Africa, and how this influences ART adherence and engagement decisions. We included qualitative primary studies that explored perspectives, perceptions and experiences of HIV-positive people, caregivers and healthcare service providers. We searched databases from 1 January 2013 to 9 December 2016, screened all studies, and selected those for inclusion using purposeful sampling methods. Included studies were coded with Atlas.ti, and we assessed methodological quality across five domains. RESULTS We included 59 studies from Africa in the synthesis. Nine themes emerged which we grouped under three main headings. First, people who are HIV-positive live in a complicated world where they must navigate the challenges presented by poverty, competing priorities, unpredictable life events, social identity, gender norms, stigma, and medical pluralism-these influences can make initiating and maintaining ART difficult. Second, the health system is generally seen as punishing and uninviting and this can drive HIV-positive people out of care. Third, long-term engagement and adherence requires adaptation and incorporation of ART into daily life, a process which is facilitated by: inherent self-efficacy, social responsibilities, previous HIV-related illnesses and emotional, practical or financial support. These factors together can lead to a "tipping point", a point in time when patients choose to either engage or disengage from care. HIV-positive people may cycle in and out of these care states in response to fluctuations in influences over time. CONCLUSION This analysis provides a practical theory, arising from thematic synthesis of research, to help understand the dynamics of adherence to ART and engagement in HIV care. This can contribute to the design of service delivery approaches, and informed thinking and action on the part of policy makers, providers, and society: to understand what it is to be HIV-positive in Africa and how attitudes and the health service need to shift to help those with HIV lead 'normal' lives.
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17
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Eshun-Wilson I, Rohwer A, Hendricks L, Oliver S, Garner P. Being HIV positive and staying on antiretroviral therapy in Africa: A qualitative systematic review and theoretical model. PLoS One 2019; 14:e0210408. [PMID: 30629648 PMCID: PMC6328200 DOI: 10.1371/journal.pone.0210408&type=printable] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 12/21/2018] [Indexed: 05/22/2023] Open
Abstract
BACKGROUND Adherence to antiretroviral therapy (ART) and long-term uninterrupted engagement in HIV care is difficult for HIV-positive people, and randomized trials of specific techniques to promote adherence often show small or negligible effects. Understanding what influences decision-making in HIV-positive people in Africa may help researchers and policy makers in the development of broader, more effective interventions and policies. METHODS We used thematic synthesis and a grounded theory approach to generate a detailed narrative and theoretical model reflecting life with HIV in Africa, and how this influences ART adherence and engagement decisions. We included qualitative primary studies that explored perspectives, perceptions and experiences of HIV-positive people, caregivers and healthcare service providers. We searched databases from 1 January 2013 to 9 December 2016, screened all studies, and selected those for inclusion using purposeful sampling methods. Included studies were coded with Atlas.ti, and we assessed methodological quality across five domains. RESULTS We included 59 studies from Africa in the synthesis. Nine themes emerged which we grouped under three main headings. First, people who are HIV-positive live in a complicated world where they must navigate the challenges presented by poverty, competing priorities, unpredictable life events, social identity, gender norms, stigma, and medical pluralism-these influences can make initiating and maintaining ART difficult. Second, the health system is generally seen as punishing and uninviting and this can drive HIV-positive people out of care. Third, long-term engagement and adherence requires adaptation and incorporation of ART into daily life, a process which is facilitated by: inherent self-efficacy, social responsibilities, previous HIV-related illnesses and emotional, practical or financial support. These factors together can lead to a "tipping point", a point in time when patients choose to either engage or disengage from care. HIV-positive people may cycle in and out of these care states in response to fluctuations in influences over time. CONCLUSION This analysis provides a practical theory, arising from thematic synthesis of research, to help understand the dynamics of adherence to ART and engagement in HIV care. This can contribute to the design of service delivery approaches, and informed thinking and action on the part of policy makers, providers, and society: to understand what it is to be HIV-positive in Africa and how attitudes and the health service need to shift to help those with HIV lead 'normal' lives.
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Affiliation(s)
- Ingrid Eshun-Wilson
- Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
- * E-mail:
| | - Anke Rohwer
- Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Lynn Hendricks
- Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Sandy Oliver
- UCL Institute of Education, University College London, London, United Kingdom
- Africa Centre for Evidence, University of Johannesburg, Johannesburg, South Africa
| | - Paul Garner
- Centre for Evidence Synthesis in Global Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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Masebo W. Accessing ART in Malawi while living in South Africa - a thematic analysis of qualitative data from undocumented Malawian migrants. Glob Public Health 2018; 14:621-635. [PMID: 30235977 DOI: 10.1080/17441692.2018.1524920] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The majority of international migrants from Malawi to South Africa are undocumented, and some of them are on ART. This study explored how these migrants manage to access ART. Qualitative data were collected using open-ended questions in semi-structured interviews. 23 returned undocumented Malawian migrants from South Africa participated in the study. Also, key informant discussions were held with three health workers. Data collection took place in April and May 2015 at a rural village of Namwera in Mangochi district in southern Malawi. Interviews were audio-recorded, transcribed and translated into English for thematic analysis. The guardians collected ART from health facilities in Malawi on behalf of the migrants. The guardians sent ART through truck and bus drivers to the migrants in South Africa. The migrants shared their ART. Others bought ART from the 'street pharmacies'. Others accessed ART from South African health facilities through the help of their South African friends. There are risks to dispensing ART to the migrants who do not themselves present at health facilities. There is value to more regular contacts between clients and health service system that is compromised by alternative strategies. It is better to deliver ART services in South Africa to the undocumented migrants.
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Affiliation(s)
- Wilfred Masebo
- a Health Economics and HIV and AIDS Research Division , University of KwaZulu-Natal , Durban , South Africa
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19
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Camlin CS, Cassels S, Seeley J. Bringing population mobility into focus to achieve HIV prevention goals. J Int AIDS Soc 2018; 21 Suppl 4:e25136. [PMID: 30027588 PMCID: PMC6053544 DOI: 10.1002/jia2.25136] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 05/22/2018] [Indexed: 11/08/2022] Open
Affiliation(s)
- Carol S Camlin
- Department of Obstetrics, Gynecology and Reproductive SciencesDepartment of MedicineUniversity of CaliforniaSan FranciscoUSA
| | - Susan Cassels
- Department of GeographyUniversity of CaliforniaSanta BarbaraUSA
| | - Janet Seeley
- Department of Global Health and DevelopmentLondon School of Hygiene and Tropical MedicineLondonUK
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20
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Cassels S, Camlin CS, Seeley J. One step ahead: timing and sexual networks in population mobility and HIV prevention and care. J Int AIDS Soc 2018; 21 Suppl 4:e25140. [PMID: 30027553 PMCID: PMC6053478 DOI: 10.1002/jia2.25140] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 05/22/2018] [Indexed: 11/07/2022] Open
Affiliation(s)
- Susan Cassels
- Department of GeographyUniversity of CaliforniaSanta BarbaraCAUSA
| | - Carol S Camlin
- Department of Obstetrics, Gynecology and Reproductive SciencesUniversity of CaliforniaSan FranciscoCAUSA
- Department of MedicineUniversity of CaliforniaSan FranciscoCAUSA
| | - Janet Seeley
- Department of Global Health and DevelopmentLondon School of Hygiene and Tropical MedicineLondonUK
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