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Koricha ZB, Abraha YG, Ababulgu SA, Abraham G, Morankar S. Community engagement in research addressing infectious diseases of poverty in sub-Saharan Africa: A qualitative systematic review. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003167. [PMID: 39008476 PMCID: PMC11249264 DOI: 10.1371/journal.pgph.0003167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 04/05/2024] [Indexed: 07/17/2024]
Abstract
Though engaging communities in research processes has several advantages and implications, research efforts are poorly embedded in and linked with communities, especially in low- and middle-income countries (LMICs). There is also a need for more empirical evidence on effectively engaging communities in research in LMICs, specifically in Sub-Saharan Africa (SSA). Thus, there is an urgent need to synthesize existing evidence on community engagement experiences in research in SSA. Therefore, this review aimed to synthesize the existing community engagement experiences and related barriers to engaging communities in health research focusing on infectious diseases of poverty in SSA. The systematic review was conducted following the JBI methodology for qualitative systematic reviews. The review included both published and unpublished studies. A thematic analysis approach was used for data synthesis. A total of 40 studies were included in the review. Community engagement in the conceptualization of the research project, analysis, dissemination, and interpretation of the result was rare. On top of this, almost all the research projects engaged the community at a lower level of engagement (i.e., informing or consulting the community at some point in the research process), suggesting the importance of integrating communities in the entire research cycle. The lack of shared control over the research by the community was one of the significant challenges mentioned. This review uncovered that community engagement in the research process is minimal. Nevertheless, the review generated valuable evidence that can inform researchers and research stakeholders to promote effective community engagement in the research process addressing infectious diseases of poverty. Despite these, it requires rigorous primary studies to examine the applicability and usefulness of community engagement, including developing valid metrics of engagement, standardizations of reporting community engagements, and views and understandings of communities and stakeholders on the values, expectations, and concepts of community engagement in research.
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Affiliation(s)
- Zewdie Birhanu Koricha
- Public Health Faculty, Department of Health, Behaviour and Society, Jimma University, Jimma, Ethiopia
- Ethiopian Evidence-Based Healthcare and Development Centre: a JBI Centre of Excellence, Jimma University, Jimma, Ethiopia
| | - Yosef Gebreyohannes Abraha
- Public Health Faculty, Department of Health, Behaviour and Society, Jimma University, Jimma, Ethiopia
- Ethiopian Public Health Institute, Knowledge Translation Directorate, Addis Ababa, Ethiopia
- The Ethiopian Public Health Institute, Ethiopian Knowledge Translation Group for Health: a JBI Affiliated Group, Addis Ababa, Ethiopia
| | - Sabit Ababor Ababulgu
- Public Health Faculty, Department of Health, Behaviour and Society, Jimma University, Jimma, Ethiopia
- Ethiopian Public Health Institute, Knowledge Translation Directorate, Addis Ababa, Ethiopia
- The Ethiopian Public Health Institute, Ethiopian Knowledge Translation Group for Health: a JBI Affiliated Group, Addis Ababa, Ethiopia
| | - Gelila Abraham
- Public Health Faculty, Department of Health, Behaviour and Society, Jimma University, Jimma, Ethiopia
- Ethiopian Evidence-Based Healthcare and Development Centre: a JBI Centre of Excellence, Jimma University, Jimma, Ethiopia
- Health Policy & Management Department, Jimma Institute of Health, Jimma University, Jimma, Ethiopia
| | - Sudhakar Morankar
- Public Health Faculty, Department of Health, Behaviour and Society, Jimma University, Jimma, Ethiopia
- Ethiopian Evidence-Based Healthcare and Development Centre: a JBI Centre of Excellence, Jimma University, Jimma, Ethiopia
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West NS, Nakubulwa R, Murray SM, Ddaaki W, Mayambala D, Nakyanjo N, Nalugoda F, Hutton HE, Surkan PJ, Kennedy CE. Okweraliikirira and Okwenyamira: Idioms of Psychological Distress Among People Living with HIV in Rakai, Uganda. RESEARCH SQUARE 2024:rs.3.rs-4656465. [PMID: 39011105 PMCID: PMC11247927 DOI: 10.21203/rs.3.rs-4656465/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/17/2024]
Abstract
Introduction Health and illness experiences are positioned within social and cultural contexts. Understanding the mental health and psychological distress of people living with HIV in highly affected communities is critical to addressing their needs and to ensure programming and interventions are targeted and appropriate. Methods Grounded in the ethnomedical theoretical perspective, we conducted qualitative interviews to understand the experience and expression of psychological distress by people living with HIV in Rakai, Uganda. Participants included adults living with HIV (n=20), health workers (counselors, peer health workers, nurses, n=10), and key informants (n=12). Interviews were audio recorded, transcribed/translated, coded, and analyzed using thematic analysis. Results Two idioms of distress, okweraliikirira (worry/apprehension) and okwenyamira (deep/manythoughts/lots of thoughts) were described as impacting people living with HIV. Both idioms were said to be alleviated by social support or counseling, but if left unaddressed could lead to more severe mental health problems and poor ART adherence. Conclusion People living with HIV understand their psychological distress through culturally specific idioms; such distress can have deleterious impacts on well-being. Incorporating idioms of distress into screening and treatment for people living with HIV may improve identification of individuals in need and overall health services to address this need.
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Affiliation(s)
- Nora S West
- Department of Medicine, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine
| | | | - Sarah M Murray
- Johns Hopkins Bloomberg School of Public Health, Department of Mental Health
| | | | | | | | | | - Heidi E Hutton
- Johns Hopkins School of Medicine, Division of Psychiatry and Behavioral Sciences
| | - Pamela J Surkan
- Johns Hopkins Bloomberg School of Public Health, Department of International Health
| | - Caitlin E Kennedy
- Johns Hopkins Bloomberg School of Public Health, Department of International Health
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Kadota JL, Packel LJ, Mlowe M, Ulenga N, Mwenda N, Njau PF, Dow WH, Wang J, Sabasaba A, McCoy SI. Rudi Kundini, Pamoja Kundini (RKPK): study protocol for a hybrid type 1 randomized effectiveness-implementation trial using data science and economic incentive strategies to strengthen the continuity of care among people living with HIV in Tanzania. Trials 2024; 25:114. [PMID: 38336793 PMCID: PMC10858527 DOI: 10.1186/s13063-024-07960-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 01/31/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Economic incentives can improve clinical outcomes among in-care people living with HIV (PLHIV), but evidence is limited for their effectiveness among out-of-care PLHIV or those at risk of disengagement. We propose a type 1 hybrid effectiveness-implementation study to advance global knowledge about the use of economic incentives to strengthen the continuity of HIV care and accelerate global goals for HIV epidemic control. METHODS The Rudi Kundini, Pamoja Kundini study will evaluate two implementation models of an economic incentive strategy for supporting two groups of PLHIV in Tanzania. Phase 1 of the study consists of a two-arm, cluster randomized trial across 32 health facilities to assess the effectiveness of a home visit plus one-time economic incentive on the proportion of out-of-care PLHIV with viral load suppression (< 1000 copies/ml) 6 months after enrollment (n = 640). Phase 2 is an individual 1:1 randomized controlled trial designed to determine the effectiveness of a short-term counseling and economic incentive program offered to in-care PLHIV who are predicted through machine learning to be at risk of disengaging from care on the outcome of viral load suppression at 12 months (n = 692). The program includes up to three incentives conditional upon visit attendance coupled with adapted counselling sessions for this population of PLHIV. Consistent with a hybrid effectiveness-implementation study design, phase 3 is a mixed methods evaluation to explore barriers and facilitators to strategy implementation in phases 1 and 2. Results will be used to guide optimization and scale-up of the incentive strategies, if effective, to the larger population of Tanzanian PLHIV who struggle with continuity of HIV care. DISCUSSION Innovative strategies that recognize the dynamic process of lifelong retention in HIV care are urgently needed. Strategies such as conditional economic incentives are a simple and effective method for improving many health outcomes, including those on the HIV continuum. If coupled with other supportive services such as home visits (phase 1) or with tailored counselling (phase 2), economic incentives have the potential to strengthen engagement among the subpopulation of PLHIV who struggle with retention in care and could help to close the gap towards reaching global "95-95-95" goals for ending the AIDS epidemic. TRIAL REGISTRATION Phase 1: ClinicalTrials.gov, NCT05248100 , registered 2/21/2022. Phase 2: ClinicalTrials.gov, NCT05373095 , registered 5/13/2022.
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Affiliation(s)
- Jillian L Kadota
- Division of Epidemiology, School of Public Health, University of California, Berkeley, CA, USA.
- Division of Pulmonary and Critical Care Medicine and Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA.
| | - Laura J Packel
- Division of Epidemiology, School of Public Health, University of California, Berkeley, CA, USA
| | - Matilda Mlowe
- Health for a Prosperous Nation, Dar Es Salaam, Tanzania
| | - Nzovu Ulenga
- Management and Development for Health, Dar Es Salaam, Tanzania
| | | | | | - William H Dow
- Division of Health Policy and Management, School of Public Health, University of California, Berkeley, USA
| | - Jingshen Wang
- Division of Biostatistics, School of Public Health, University of California, Berkeley, CA, USA
| | - Amon Sabasaba
- Health for a Prosperous Nation, Dar Es Salaam, Tanzania
| | - Sandra I McCoy
- Division of Epidemiology, School of Public Health, University of California, Berkeley, CA, USA
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Feldacker C, Mugwanya R, Irongo D, Kathumba D, Chiwoko J, Kitsao E, Sippell K, Wasunna B, Jonas K, Samala B, Mwakanema D, Oni F, Jafa K, Tweya H. A Community-Based, Mobile Electronic Medical Record System App for High-Quality, Integrated Antiretroviral Therapy in Lilongwe, Malawi: Design Process and Pilot Implementation. JMIR Form Res 2023; 7:e48671. [PMID: 37948102 PMCID: PMC10674144 DOI: 10.2196/48671] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 10/05/2023] [Accepted: 10/08/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Differentiated service delivery (DSD) increases antiretroviral therapy (ART) access in sub-Saharan Africa by moving clients out of congested ART clinics to communities for care. However, DSD settings challenge provider adherence to complex, chronic care treatment guidelines and have burdensome systems for client monitoring and evaluation (M&E), reducing data for decision-making. Electronic medical record systems (EMRS) improve client outcomes and reduce M&E workload. Traditional EMRS cannot operate in most DSD settings with unreliable power and poor connectivity. OBJECTIVE This study aims to detail the human-centered design (HCD) process of developing a mobile EMRS for community-based DSD services in Lilongwe, Malawi. METHODS Lighthouse Trust (LT) operates 2 Ministry of Health (MoH) clinics in Lilongwe, Malawi, with a combined total of >35,000 ART clients. LT's real-time, point-of-care EMRS collects complex client M&E data and provides decision-making support, ensuring adherence to integrated HIV and tuberculosis guidelines that optimize client and program outcomes. LT's EMRS scaled to all large MoH ART clinics. LT also implements a nurse-led community-based ART program (NCAP), a DSD model to provide ART and rapid assessment for 2400 stable LT clients in the community. LT, alongside collaborators, from the University of Washington's International Training and Education Center for Health and technology partner, Medic, used the open-source Community Health Toolkit (CHT) and HCD to develop an open-source, offline-first, mobile EMRS-like app, "community-based ART retention and suppression" (CARES). CARES aims to bring EMRS-like provider benefits to NCAP's DSD clients. RESULTS CARES design took approximately 12 months and used an iterative process of highly participatory feedback sessions with provider, data manager, and M&E team inputs to ensure CARES optimization for the NCAP and LT settings. The CARES mobile EMRS prototype supports NCAP providers with embedded prompts and alerts to ensure adherence to integrated MoH ART guidelines, aiming to improve the quality of client care. CARES facilitates improved data quality and flow for NCAP M&E, aiming to reduce data gaps between community and clinic settings. The CARES pilot demonstrates the potential of a mobile, point-of-care EMRS-like app that could benefit NCAP clients, providers, and program teams with integrated client care and complete M&E data for decision-making. CARES challenges include app speed, search features to align longitudinal records, and CARES to EMRS integration that supports timely care alerts. CONCLUSIONS Leveraging the CHT and HCD processes facilitated the design of a locally specified and optimized mobile app with the promise to bring EMRS-like benefits to DSD settings. Moving from the CARES prototype to routine NCAP implementation should result in improved client care and strengthened M&E while reducing workload. Our transparent and descriptive process shares the progress and pitfalls of the CARES design and development, helping others in this digital innovation area to learn from our experiences at this stage.
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Affiliation(s)
- Caryl Feldacker
- Department of Global Health, University of Washington, Seattle, WA, United States
- International Training and Education Center for Health, Seattle, WA, United States
| | | | | | | | | | | | | | | | | | | | - Daniel Mwakanema
- International Training and Education Center for Health, Lilongwe, Malawi
| | | | | | - Hannock Tweya
- Department of Global Health, University of Washington, Seattle, WA, United States
- International Training and Education Center for Health, Lilongwe, Malawi
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Lancaster KE, Remch M, Edmonds A, Ajeh R, Dzudie A, Adedimeji A, Nash D, Anastos K, Yotebieng M, Yone-Pefura EW, Nsame D, Parcesepe AM. Age-varying Associations of Depressive Symptoms and Heavy Episodic Drinking Throughout Adulthood Among People with HIV and Receiving care in Cameroon Within a National "treat all" Policy. AIDS Behav 2023; 27:2070-2078. [PMID: 36472684 PMCID: PMC10557023 DOI: 10.1007/s10461-022-03939-4] [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] [Accepted: 11/18/2022] [Indexed: 12/12/2022]
Abstract
Comorbid depression and heavy episodic drinking (HED) may threaten the success of "treat all" policies in sub-Saharan Africa as the population of people with HIV (PWH) ages. We investigated associations between depressive symptoms and heavy episodic drinking (HED) and the extent the relationship differed across ages among PWH receiving HIV care in Cameroon. We conducted a retrospective analysis of 18-60-year-old PWH on antiretroviral therapy in Cameroon from January 2016 to March 2020. Age-varying effect modelling was conducted to assess associations between depressive symptoms and HED across ages and by gender. Prevalence of depression and HED was highest at ages 20 and 25, respectively. After age 25, the magnitude of the association between depressive symptoms and HED was significant and increased until age 30 (aOR: 1.88, 95% CI: 1.48, 2.39), with associations remaining significant until age 55 (aOR: 1.64, 95% CI: 1.17, 2.29). Women had more variability and higher magnitudes of associations between depressive symptoms and HED than men. The interrelationship between depressive symptoms and HED was significant throughout most of adulthood for PWH receiving HIV care in Cameroon. Understanding age and gender trends in these associations can guide integration efforts in HIV care settings.
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Affiliation(s)
| | - Molly Remch
- Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Andrew Edmonds
- Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Rogers Ajeh
- Clinical Research Education Networking and Consultancy, Yaounde, Cameroon
| | - Anastase Dzudie
- Clinical Research Education Networking and Consultancy, Yaounde, Cameroon
| | - Adebola Adedimeji
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Denis Nash
- City University of New York, New York, NY, USA
| | - Kathryn Anastos
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Marcel Yotebieng
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Denis Nsame
- Bamenda Regional Hospital, Bamenda, Cameroon
| | - Angela M Parcesepe
- Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA
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Brazier E, Maruri F, Wester CW, Musick B, Freeman A, Parcesepe A, Hossmann S, Christ B, Kimmel A, Humphrey J, Freeman E, Enane LA, Lancaster KE, Ballif M, Golub JE, Nash D, Duda SN. Design and implementation of a global site assessment survey among HIV clinics participating in the International epidemiology Databases to Evaluate AIDS (IeDEA) research consortium. PLoS One 2023; 18:e0268167. [PMID: 36917598 PMCID: PMC10013879 DOI: 10.1371/journal.pone.0268167] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 02/28/2023] [Indexed: 03/15/2023] Open
Abstract
INTRODUCTION Timely descriptions of HIV service characteristics and their evolution over time across diverse settings are important for monitoring the scale-up of evidence-based program strategies, understanding the implementation landscape, and examining service delivery factors that influence HIV care outcomes. METHODS The International epidemiology Databases to Evaluate AIDS (IeDEA) consortium undertakes periodic cross-sectional surveys on service availability and care at participating HIV treatment sites to characterize trends and inform the scientific agenda for HIV care and implementation science communities. IeDEA's 2020 general site assessment survey was developed through a consultative, 18-month process that engaged diverse researchers in identifying content from previous surveys that should be retained for longitudinal analyses and in developing expanded and new content to address gaps in the literature. An iterative review process was undertaken to standardize the format of new survey questions and align them with best practices in survey design and measurement and lessons learned through prior IeDEA site assessment surveys. RESULTS The survey questionnaire developed through this process included eight content domains covered in prior surveys (patient population, staffing and community linkages, HIV testing and diagnosis, new patient care, treatment monitoring and retention, routine HIV care and screening, pharmacy, record-keeping and patient tracing), along with expanded content related to antiretroviral therapy (differentiated service delivery and roll-out of dolutegravir-based regimens); mental health and substance use disorders; care for pregnant/postpartum women and HIV-exposed infants; tuberculosis preventive therapy; and pediatric/adolescent tuberculosis care; and new content related to Kaposi's sarcoma diagnostics, the impact of COVID-19 on service delivery, and structural barriers to HIV care. The survey was distributed to 238 HIV treatment sites in late 2020, with a 95% response rate. CONCLUSION IeDEA's approach for site survey development has broad relevance for HIV research networks and other priority health conditions.
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Grants
- L40 HD103261 NICHD NIH HHS
- U01 AI096299 NIAID NIH HHS
- K23 HD095778 NICHD NIH HHS
- U01 AI069911 NIAID NIH HHS
- U01 AI069907 NIAID NIH HHS
- U01 AI069924 NIAID NIH HHS
- U01 AI069923 NIAID NIH HHS
- R24 AI124872 NIAID NIH HHS
- U01 AI069919 NIAID NIH HHS
- U01 AI069918 NIAID NIH HHS
- The International Epidemiology Databases to Evaluate AIDS (IeDEA) is supported by the U.S. National Institutes of Health’s National Institute of Allergy and Infectious Diseases, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Cancer Institute, the National Institute of Mental Health, the National Institute on Drug Abuse, the National Heart, Lung, and Blood Institute, the National Institute on Alcohol Abuse and Alcoholism, the National Institute of Diabetes and Digestive and Kidney Diseases, the Fogarty International Center, and the National Library of Medicine
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Affiliation(s)
- Ellen Brazier
- City University of New York, Institute for Implementation Science in Population Health, New York, NY, United States of America
- City University of New York, Graduate School of Public Health and Health Policy, New York, NY, United States of America
| | - Fernanda Maruri
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - C. William Wester
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, United States of America
- Vanderbilt Institute for Global Health, Nashville, TN, United States of America
| | - Beverly Musick
- School of Medicine, Indiana University, Indianapolis, IN, United States of America
| | - Aimee Freeman
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Angela Parcesepe
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Stefanie Hossmann
- Institute of Social and Preventive Medicine, University of Berne, Berne, Switzerland
| | - Benedikt Christ
- Institute of Social and Preventive Medicine, University of Berne, Berne, Switzerland
| | - April Kimmel
- Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine/VCU Health, Richmond, VA, United States of America
| | - John Humphrey
- Division of Infectious Diseases, Department of Medicine, Indiana University, Indianapolis, IN, United States of America
| | - Esther Freeman
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Leslie A. Enane
- The Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Kathryn E. Lancaster
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH, United States of America
| | - Marie Ballif
- Institute of Social and Preventive Medicine, University of Berne, Berne, Switzerland
| | - Jonathan E. Golub
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Denis Nash
- City University of New York, Institute for Implementation Science in Population Health, New York, NY, United States of America
- City University of New York, Graduate School of Public Health and Health Policy, New York, NY, United States of America
| | - Stephany N. Duda
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, United States of America
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Wiginton JM, Mathur S, Gottert A, Pilgrim N, Pulerwitz J. Hearing From Men Living With HIV: Experiences With HIV Testing, Treatment, and Viral Load Suppression in Four High-Prevalence Countries in Sub-Saharan Africa. Front Public Health 2022; 10:861431. [PMID: 35651865 PMCID: PMC9149263 DOI: 10.3389/fpubh.2022.861431] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/21/2022] [Indexed: 12/02/2022] Open
Abstract
Engaging men in HIV services remains a challenge across sub-Saharan Africa. There is a critical need to better understand facilitators of men's successful engagement with HIV services and assess if there are similarities across contexts. We conducted in-depth interviews and focus group discussions with 92 men living with HIV (MLHIV) across Malawi, Uganda, South Africa, and Eswatini, most of whom had been diagnosed with HIV within the last 5 years. We coded interviews for themes using a constant-comparative approach. We contextualized our findings within a socioecological framework. HIV testing was primarily motivated by illness (individual level), though illness was sometimes accompanied by prompting and support from healthcare providers and/or intimate partners. Once diagnosed, nearly all participants reported immediate linkage to care, initiation of antiretroviral therapy (ART), and subsequent ART adherence. ART initiation and adherence were facilitated by men's sense of agency and ownership over their health (individual level), social support from intimate partners, friends, and family (interpersonal/network level), supportive-directive counseling from healthcare providers (institutional/health systems level), and male-friendly services, i.e., rapid, respectful, private (institutional/health systems level). Health literacy regarding viral suppression (individual level), strengthened by patient-provider communication (institutional/health systems level), was highest in Uganda, where most men could discuss viral load testing experiences, report their viral load status (most reported suppressed), and demonstrate an understanding of treatment as prevention. Elsewhere, few participants understood what viral load suppression was and even fewer knew their viral load status. Our findings reveal socioecological-level facilitators of men's progress across the HIV-care continuum. Programs may want to leverage facilitators of ART initiation and adherence that span socioecological levels—e.g., healthcare ownership and agency, social support, supportive-directive counseling—and apply them to each end of the continuum to encourage early HIV testing/diagnosis and improve health literacy to help men understand and achieve viral load suppression.
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Affiliation(s)
- John Mark Wiginton
- Department of Health, Behavior and Society, Johns Hopkins University, Baltimore, MD, United States
| | | | - Ann Gottert
- Population Council, Washington, DC, United States
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Li C, Xiong Y, Muessig KE, Tang W, Huang H, Mu T, Tong X, Yu J, Yang Z, Sherer R, Hazra A, Lio J, Matthews DD, Fisher EB, Li L, Tucker JD. Community-engaged mHealth intervention to increase uptake of HIV pre-exposure prophylaxis (PrEP) among gay, bisexual and other men who have sex with men in China: study protocol for a pilot randomised controlled trial. BMJ Open 2022; 12:e055899. [PMID: 35537794 PMCID: PMC9092176 DOI: 10.1136/bmjopen-2021-055899] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 04/12/2022] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION The large number of key populations in China who would benefit from HIV pre-exposure prophylaxis (PrEP) in the context of limited health system capacity and public awareness will pose challenges for timely PrEP scale-up, suggesting an urgent need for innovative and accessible interventions. This study aims to develop and pilot test a theory-informed, tailored mobile phone intervention that was codeveloped by young gay men, HIV clinicians and public health researchers to increase engagement in PrEP education and initiation among Chinese gay, bisexual and other men who have sex with men (GBMSM), who bear a disproportionate burden of HIV infections and remain underserved in the healthcare system. METHODS AND ANALYSIS This two-phase study includes a formative assessment using in-depth interviews (N=30) and a 12-week experimental pilot study using a two-arm randomised controlled trial design (N=70). The primary intervention is delivered through a WeChat-based mini-app (a program built into a Chinese multipurpose social media application) developed by young GBMSM from a 2019 crowdsourcing hackathon. Using mixed methods, we will further investigate the specific needs and concerns among GBMSM in terms of using PrEP as an HIV prevention strategy, how their concerns and PrEP use behaviours may change with exposure to the mini-app intervention during the study period and how we can further refine this intervention tool to better meet GBMSM's needs for broader implementation. ETHICS AND DISSEMINATION This study and its protocols have been reviewed and approved by the Institutional Review Boards of the University of North Carolina at Chapel Hill, USA (19-3481), the Guangdong Provincial Dermatology Hospital, China (2020031) and the Guangzhou Eighth People's Hospital, China (202022155). Study staff will work with local GBMSM community-based organisations to disseminate the study results to participants and the community via social media, workshops and journal publications. TRIAL REGISTRATION NUMBER The study was prospectively registered on clinicaltrials.gov (NCT04426656) on 11 June 2020.
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Affiliation(s)
- Chunyan Li
- Department of Health Behavior, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Yuan Xiong
- University of North Carolina Project-China, Guangzhou, Guangdong, China
| | - Kathryn E Muessig
- Department of Health Behavior, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Weiming Tang
- University of North Carolina Project-China, Guangzhou, Guangdong, China
| | - Haojie Huang
- Wuhan Tongxing LGBTQ Center, Wuhan, Hubei, China
| | - Tong Mu
- Qingdao Eighth People's Hospital, Qingdao, Shandong, China
| | - Xiaokai Tong
- Xi'an Polytechnic University, Xi'an, Shaanxi, China
| | | | - Zeyu Yang
- University of North Carolina Project-China, Guangzhou, Guangdong, China
| | - Renslow Sherer
- Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Aniruddha Hazra
- Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Jonathan Lio
- Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Derrick D Matthews
- Department of Health Behavior, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Edwin B Fisher
- Department of Health Behavior, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Linghua Li
- Infectious Diseases Research Department, Guangzhou Eighth People's Hospital, Guangzhou, Guangdong, China
| | - Joseph D Tucker
- Institute of Global Health and Infectious Diseases, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
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Dzudie A, Tchounga B, Ajeh R, Kouanfack C, Ebasone PV, Djikeussi T, Nyoto LB, Fokam J, Ateudjieu J, Tchendjou P, Semengue ENJ, Kamgang FY, Anoubessi J, Varloteaux M, Youngui B, Tabala FN, Atanga B, Simo L, Zemsi A, Shu EN, Ndayisaba G, Nyenti A, Ntabe AC, Bwemba TA, Sobngwi E, Billong SC, Ditekemena J, Bissek ACZK, Njock LR. Research priorities for accelerating the achievement of three 95 HIV goals in Cameroon: a consensus statement from the Cameroon HIV Research Forum (CAM-HERO). Pan Afr Med J 2021; 40:124. [PMID: 34909092 PMCID: PMC8641633 DOI: 10.11604/pamj.2021.40.124.31068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 09/05/2021] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION the Treat-All remains the globally endorsed approach to attain the 95-95-95 targets and end the AIDS pandemic by 2030, but requires some country-level contextualization. In Cameroon, the specific research agenda to inform strategies for improving HIV policy was yet to be defined. METHODS under the patronage of the Cameroon Ministry of health, researchers, policy makers, implementing partners, and clinicians from 13 institutions, used the Delphi method to arrive at a consensus of HIV research priorities. The process had five steps: 1) independent literature scan by 5 working groups; 2) review of the initial priority list; 3) appraisal of priorities list in a larger group; 4) refinement and consolidation by a consensus group; 5) rating of top research priorities. RESULTS five research priorities and corresponding research approaches, resulted from the process. These include: 1) effectiveness, safety and active toxicity monitoring of new and old antiretrovirals; 2) outcomes of Antiretroviral Therapy (ART) with focus in children and adolescents; 3) impact of HIV and ART on aging and major chronic diseases; 4) ART dispensation models and impact on adherence and retention; 5) evaluations of HIV treatment and prevention programs. CONCLUSION the research priorities resulted from a consensus amongst a multidisciplinary team and were based on current data about the pandemic and science to prevent, treat, and ultimately cure HIV. These priorities highlighted critical areas of investigation with potential relevance for the country, funders, and regulatory bodies.
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Affiliation(s)
- Anastase Dzudie
- Clinical Research Education, Networking and Consultancy, Yaoundé, Cameroon
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
- Service of Internal Medicine and Subspecialities, Douala General Hospital, Douala, Cameroon
- Lown Scholars Program, Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, USA
| | - Boris Tchounga
- Elizabeth Glaser Pediatric AIDS Foundation, Yaoundé, Cameroon
| | - Rogers Ajeh
- Clinical Research Education, Networking and Consultancy, Yaoundé, Cameroon
| | - Charles Kouanfack
- HIV Day Hospital, Yaoundé Central Hospital, Yaoundé, Cameroon
- Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
| | - Peter Vanes Ebasone
- Clinical Research Education, Networking and Consultancy, Yaoundé, Cameroon
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | | | - Joseph Fokam
- International Reference Centre Chantal Biya (IRCCB), Yaoundé, Cameroon
- Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Jérôme Ateudjieu
- Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
| | | | | | - Fabrice Youbi Kamgang
- Division of the Fight against Diseases, Ministry of Public Health, Yaoundé, Cameroon
| | - Jean Anoubessi
- National AIDS Control Committee, Ministry of Public Health, Yaoundé, Cameroon
| | - Marie Varloteaux
- Cameroon office, National Agency for Research on AIDS (ANRS), Yaoundé, Cameroon
| | - Boris Youngui
- Elizabeth Glaser Pediatric AIDS Foundation, Yaoundé, Cameroon
| | - Felicite Naah Tabala
- Division of Health Operational Research, Ministry of Public Health, Yaoundé, Cameroon
| | - Benjamin Atanga
- Division of Health Operational Research, Ministry of Public Health, Yaoundé, Cameroon
| | - Leonie Simo
- Elizabeth Glaser Pediatric AIDS Foundation, Yaoundé, Cameroon
| | - Armel Zemsi
- Elizabeth Glaser Pediatric AIDS Foundation, Yaoundé, Cameroon
| | | | | | | | | | | | - Eugene Sobngwi
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
| | - Serge Clotaire Billong
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
- National AIDS Control Committee, Ministry of Public Health, Yaoundé, Cameroon
| | - John Ditekemena
- Elizabeth Glaser Pediatric AIDS Foundation, Yaoundé, Cameroon
| | - Anne Cecile Zoung-Kanyi Bissek
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
- Division of Health Operational Research, Ministry of Public Health, Yaoundé, Cameroon
| | - Louis Richard Njock
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
- General Secretariat, Ministry of Public Health, Yaoundé, Cameroon
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10
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Usability and Clinical Performance Characteristics of the Asante HIV1/2 Test by Trained Users in Two African Sites. Diagnostics (Basel) 2021; 11:diagnostics11091727. [PMID: 34574068 PMCID: PMC8465151 DOI: 10.3390/diagnostics11091727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 09/01/2021] [Accepted: 09/08/2021] [Indexed: 11/17/2022] Open
Abstract
HIV self-testing (HIVST) devices are acknowledged as having the potential to enable the acceleration of HIV diagnosis and linkage to care. How efficiently professional and trained users engaged with the Asante HIV-1/2 Oral Self-Test (Asante) (Sedia Biosciences, Portland, OR, USA), and the accuracy of the device in comparison to other HIV rapid diagnostic tests (RDT), was assessed to be able to guide the development and adoption of the device in Senegal and South Africa. Using convenience sampling, potential participants were recruited from catchment areas where HIV was prevalent. Trained users performed an HIV test on participants using an Oral HIVST. The professional user’s interpretation of results was then measured against the results of various other RDTs. The South African study had 1652 participants and the Senegalese, 500. Most of the participants in each study were 18–35 years old. Senegal had a higher number of females (346/500, 69.2%) compared to South Africa (699/1662, 42.1%). Asante displayed very high sensitivity and specificity when tested against other devices. In the final enzyme-linked immunosorbent assay (ELISA) comparison, in South Africa, the sensitivity: specificity was 99.1:99.9% and in Senegal, 98.4:100.0%. Senegal further identified 53/63 (84.1%) with HIV-1, 8/63 (12.7) with HIV-2 and 2/63 (3.2%) with HIV-1/2 co-infections. Professional or trained users’ interpretations of Asante results correlated strongly to results when using various RDTs, the ELISA assay and Western blot tests, making it a dependable HIV testing instrument.
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11
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King PR, Beehler GP, Donnelly K, Funderburk JS, Wray LO. A Practical Guide to Applying the Delphi Technique in Mental Health Treatment Adaptation: The Example of Enhanced Problem-Solving Training (E-PST). ACTA ACUST UNITED AC 2021; 52:376-386. [PMID: 34446984 DOI: 10.1037/pro0000371] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Expert consensus methods, such as the Delphi procedure, are commonly employed in consumer, education, and health services research. However, the utility of this methodology has not widely been described in relation to mental health treatment adaptation efforts. This gap is noteworthy given that evidence-based treatments are often modified in terms of core intervention content, method of delivery, and target populations. Expert consensus methods such as the Delphi procedure offer multiple practical benefits (e.g., flexibility, resource-efficiency) for psychologists who need to adapt existing treatments to meet new research and clinical practice needs. The purpose of this paper is to provide a brief overview of the Delphi procedure, and to offer a practical guide to using this method for treatment adaptation. An example is offered using our team's application of a three-round Delphi procedure to render content and context modifications to an existing problem-solving intervention to optimize its use with a new treatment population. Data were collected from Department of Veterans Affairs clinical subject matter experts. Round 1 utilized semi-structured interviews to determine necessary protocol features and modifications. Rounds 2-3 utilized a forced-choice survey and feedback loop to evaluate expert consensus. More than 91% of rated items reached consensus following Round 2, with the remainder following Round 3. Recommended modifications included minor structural and content edits, and re-balancing time allotments. We conclude that consensus methods may facilitate treatment adaptation efforts, enhance treatment feasibility, and promote content and ecological validity. Considerations for future Delphi-based treatment adaptations are offered.
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Affiliation(s)
- Paul R King
- VA Center for Integrated Healthcare, Buffalo, NY
- Department of Counseling, School, and Educational Psychology, Graduate school of Education, University at Buffalo, Buffalo, NY
| | - Gregory P Beehler
- VA Center for Integrated Healthcare, Buffalo, NY
- Department of Community Health and Health Behavior, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY
| | - Kerry Donnelly
- Department of Counseling, School, and Educational Psychology, Graduate school of Education, University at Buffalo, Buffalo, NY
- VA Western New York Healthcare System, Buffalo, NY
- Department of Psychiatry, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY
| | - Jennifer S Funderburk
- VA Center for Integrated Healthcare, Syracuse, NY
- Department of Psychology, Syracuse University, Syracuse, NY
| | - Laura O Wray
- VA Center for Integrated Healthcare, Buffalo, NY
- Division of Geriatrics/ Gerontology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY
- Department of Psychology, College of Arts and Sciences, University at Buffalo, Buffalo, NY
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12
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Zakumumpa H, Makobu K, Ntawiha W, Maniple E. A mixed-methods evaluation of the uptake of novel differentiated ART delivery models in a national sample of health facilities in Uganda. PLoS One 2021; 16:e0254214. [PMID: 34292984 PMCID: PMC8297836 DOI: 10.1371/journal.pone.0254214] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 06/22/2021] [Indexed: 11/18/2022] Open
Abstract
Introduction Since 2017, Uganda has been implementing five differentiated antiretroviral therapy (ART) delivery models to improve the quality of HIV care and to achieve health-system efficiencies. Community-based models include Community Client-Led ART Delivery and Community Drug Distribution Points. Facility-based models include Fast Track Drug Refill, Facility Based Group and Facility Based Individual Management. We set out to assess the extent of uptake of these ART delivery models and to describe barriers to uptake of either facility-based or community-based models. Methods Between December 2019 and February 2020, we conducted a mixed-methods study entailing a cross-sectional health facility survey (n = 116) and in-depth interviews (n = 16) with ART clinic managers in ten case-study facilities as well as six focus group discussions (56 participants) with patients enrolled in differentiated ART models. Facilities were selected based on the 10 geographic sub-regions of Uganda. Statistical analyses were performed in STATA (v13) while qualitative data were analysed by thematic approach. Results Most facilities 63 (57%) commenced implementation of differentiated ART delivery in 2018. Fast Track Drug Delivery was the most common facility-based model (implemented in 100 or 86% of health facilities). Community Client-Led ART Delivery was the most popular community model (63/116 or 54%). Community Drug Distribution Points had the lowest uptake with only 33 (24.88%) facilities implementing them. By ownership-type, for-profit facilities reported the lowest uptake of differentiated ART models. Barriers to enrolment in community-based models include HIV-related stigma and low enrolment of adult males in community models. Conclusion To the best of our knowledge this is the first study reporting national coverage of differentiated ART delivery models in Uganda. Overall, there has been a higher uptake of facility-based models. Interventions for enhancing the uptake of differentiated ART models in for-profit facilities are recommended.
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Affiliation(s)
- Henry Zakumumpa
- Makerere University, School of Public Health, Kampala, Uganda
- * E-mail:
| | - Kimani Makobu
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Everd Maniple
- Kabale University, School of Medicine, Kabale, Uganda
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Lawrence DS, Leeme T, Mosepele M, Harrison TS, Seeley J, Jarvis JN. Equity in clinical trials for HIV-associated cryptococcal meningitis: A systematic review of global representation and inclusion of patients and researchers. PLoS Negl Trop Dis 2021; 15:e0009376. [PMID: 34043617 PMCID: PMC8158913 DOI: 10.1371/journal.pntd.0009376] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background It is essential that clinical trial participants are representative of the population under investigation. Using HIV-associated cryptococcal meningitis (CM) as a case study, we conducted a systematic review of clinical trials to determine how inclusive and representative they were both in terms of the affected population and the involvement of local investigators. Methods We searched Medline, EMBASE, Cochrane, Africa-Wide, CINAHL Plus, and Web of Science. Data were extracted for 5 domains: study location and design, screening, participants, researchers, and funders. Data were summarised and compared over 3 time periods: pre-antiretroviral therapy (ART) (pre-2000), early ART (2000 to 2009), and established ART (post-2010) using chi-squared and chi-squared for trend. Comparisons were made with global disease burden estimates and a composite reference derived from observational studies. Results Thirty-nine trials published between 1990 and 2019 were included. Earlier studies were predominantly conducted in high-income countries (HICs) and recent studies in low- and middle-income countries (LMICs). Most recent studies occurred in high CM incidence countries, but some highly affected countries have not hosted trials. The sex and ART status of participants matched those of the general CM population. Patients with reduced consciousness and those suffering a CM relapse were underrepresented. Authorship had poor representation of women (29% of all authors), particularly as first and final authors. Compared to trials conducted in HICs, trials conducted in LMICs were more likely to include female authors (32% versus 20% p = 0.014) but less likely to have authors resident in (75% versus 100%, p < 0.001) or nationals (61% versus 93%, p < 0.001) of the trial location. Conclusions There has been a marked shift in CM trials over the course of the HIV epidemic. Trials are primarily performed in locations and populations that reflect the burden of disease, but severe and relapse cases are underrepresented. Most CM trials now take place in LMICs, but the research is primarily funded and led by individuals and institutions from HICs. It is essential that clinical trial participants are representative of the population under investigation. Similarly, research must meaningfully include researchers who are from and/or based in the location where the study is being conducted, both to ensure that the research matches the local need but also to promote equity in research. Using clinical trials in HIV-associated cryptococcal meningitis as a case study, we conducted a systematic review to determine how inclusive and representative trials have been across the course of the HIV epidemic. We identified 39 studies. There was a geographical shift with trials moving from the USA to Africa and Asia over time. We found that recent trials were conducted in areas heavily affected by cryptococcal meningitis, but we did identify geographical areas and patient groups that have been underrepresented. We also found inequality within authorship that was skewed towards male researchers from high-income countries. These findings outline areas for our discipline to focus on. We can also use this study as a benchmark from which to monitor our progress over time. This is a broad methodology that could be adopted and adapted by other research groups.
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Affiliation(s)
- David S. Lawrence
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Tshepo Leeme
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Mosepele Mosepele
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- University of Botswana, Gaborone, Botswana
| | - Thomas S. Harrison
- Institute for Infection and Immunity, St George’s University of London, and St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
- MRC Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
| | - Janet Seeley
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- MRC/UVRI & LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Joseph N. Jarvis
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
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14
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Raichur P, Salvi SP, Sangle S, Chavan A, Nimkar S, Gawande G, Rewari B, Mathad J, Mcintire K, Gupta A, Marbaniang I, Mave V. Trends and Sex Differences in Access to HIV Care with Scale Up of National HIV Treatment Guidelines in Pune, India. J Int Assoc Provid AIDS Care 2021; 19:2325958220931735. [PMID: 32573318 PMCID: PMC7313325 DOI: 10.1177/2325958220931735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Test and treat is the current global standard, yet sex differences persist in access to HIV care. We assessed the differences in presentation and antiretroviral therapy (ART) uptake by sex and ART-eligibility period among ART-naive adults registered at a public ART center in India. Four ART eligibility periods were defined by programmatically determined CD4 criteria (periods I-IV: CD4 <200, <350, ≤500 cells/μL, and any CD4) between January 2005 and December 2017. Of 23 957 participants, 12 510 were male. Men consistently presented with lower median CD4 count (period I-IV, P < .05) and higher median age (period I-III, P < .001) than women. From period I to IV, median age increased in women (P < .0001), ART initiation time decreased in both sexes (P < .001), and median CD4 remained <200 cells/µL in men. Advanced HIV disease and increasing age at presentation are persistent sex-specific trends which warrant innovative HIV testing strategies in both sexes.
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Affiliation(s)
- Priyanka Raichur
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
| | - Sonali Pankaj Salvi
- Department of Medicine, BJ Government Medical College and Sassoon General Hospitals, Pune, Maharashtra, India
| | - Shashikala Sangle
- Department of Medicine, BJ Government Medical College and Sassoon General Hospitals, Pune, Maharashtra, India
| | - Amol Chavan
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
| | - Smita Nimkar
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
| | - Gajanan Gawande
- Department of Medicine, BJ Government Medical College and Sassoon General Hospitals, Pune, Maharashtra, India
| | - Bharat Rewari
- National AIDS Control Organisation, New Delhi, New Delhi, India
| | - Jyoti Mathad
- Department of Medicine, Center for Global Health, Weill Cornell Medicine, New York, NY, USA
| | - Katherine Mcintire
- Department of Medicine and Infectious Diseases, Johns Hopkins University, Baltimore, MD, USA
| | - Amita Gupta
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India.,Department of Medicine and Infectious Diseases, Johns Hopkins University, Baltimore, MD, USA
| | - Ivan Marbaniang
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India.,Department of Epidemiology, McGill University, Montreal, Quebec, Canada
| | - Vidya Mave
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India.,Department of Medicine and Infectious Diseases, Johns Hopkins University, Baltimore, MD, USA
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15
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Enane LA, Christenson JC. Global emerging resistance in pediatric infections with TB, HIV, and gram-negative pathogens. Paediatr Int Child Health 2021; 41:65-75. [PMID: 33305992 PMCID: PMC8243638 DOI: 10.1080/20469047.2020.1853350] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 11/13/2020] [Indexed: 12/28/2022]
Abstract
Infants, children and adolescents are at risk of life-threatening, antimicrobial-resistant infections. Global burdens of drug-resistant TB, HIV and gram-negative pathogens have a particular impact on paediatric age groups, necessitating a paediatric-focused agenda to address emerging resistance. Dedicated approaches are needed to find, successfully treat and prevent resistant infections in paediatric populations worldwide. Challenges include the diagnosis and identification of resistant infections, limited access to novel antimicrobials or to paediatric-friendly formulations, limited access to research and clinical trials and implementation challenges related to prevention and successful completion of treatment. In this review, the particular complexities of emerging resistance in TB, HIV and gram-negative pathogens in children, with attention to both clinical and public health challenges, are highlighted. Key principles of a paediatric-focused agenda to address antimicrobial resistance are outlined. They include quality of care, increasing equitable access to key diagnostics, expanding antimicrobial stewardship and infection prevention across global settings, and health system strengthening. Increased access to research studies, including clinical trials, is needed. Further study and implementation of care models and strategies for child- or adolescent-centred management of infections such as HIV and TB can critically improve outcome and avoid development of resistance. As the current global pandemic of a novel coronavirus, SARS-CoV-2, threatens to disrupt health systems and services for vulnerable populations, this is a critical time to mitigate against a potential surge in the incidence of resistant infections.
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Affiliation(s)
- Leslie A Enane
- Department of Pediatrics Indiana University School of Medicine, Ryan White Center for Pediatric Infectious Disease and Global Health, Indianapolis, IN, USA
| | - John C Christenson
- Department of Pediatrics Indiana University School of Medicine, Ryan White Center for Pediatric Infectious Disease and Global Health, Indianapolis, IN, USA
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16
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Bernard C, Font H, Diallo Z, Ahonon R, Tine JM, N’guessan Abouo F, Tanon A, Messou E, Seydi M, Dabis F, de Rekeneire N. Prevalence and factors associated with severe depressive symptoms in older west African people living with HIV. BMC Psychiatry 2020; 20:442. [PMID: 32912173 PMCID: PMC7481548 DOI: 10.1186/s12888-020-02837-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 08/27/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Depression is one of the most common psychiatric disorders in people living with HIV (PLHIV). Depression has a negative impact on both mental and physical health and is mainly associated with suboptimal HIV treatment outcomes. To encourage successful aging and the achievement of the 3 × 90 objectives in older PLHIV, the psychological domain must not be neglected. In this context and as data are scarce in West Africa, this study aimed to evaluate the prevalence and the factors associated with severe depressive symptoms in older PLHIV living in this region of the world. METHODS Data from PLHIV aged ≥50 years and on ART since ≥6 months were collected in three clinics (two in Côte d'Ivoire, one in Senegal) participating in the West Africa International epidemiological Databases to Evaluate AIDS (IeDEA) collaboration. The severity of depressive symptoms was measured using the Center for Epidemiological Studies Depression scale (CES-D), and associated factors were identified using logistic regressions. RESULTS The median age of the 334 PLHIV included in the study was 56.7 (53.5-61.1), 57.8% were female, and 87.1% had an undetectable viral load. The prevalence of severe depressive symptoms was 17.9% [95% Confidence Interval (95% CI): 13.8-22.0]. PLHIV with severe depressive symptoms were more likely to be unemployed (adjusted Odd Ratio (aOR) = 2.8; 95% CI: 1.4-5.7), and to be current or former tobacco smokers (aOR = 2.6; 95% CI: 1.3-5.4) but were less likely to be overweight or obese (aOR = 0.4; 95% CI: 0.2-0.8). CONCLUSIONS The prevalence of severe depressive symptoms is high among older PLHIV living in West Africa. Unemployed PLHIV and tobacco smokers should be seen as vulnerable and in need of additional support. Further studies are needed to describe in more details the reality of the aging experience for PLHIV living in SSA. The integration of screening and management of depression in the standard of care of PLHIV is crucial.
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Affiliation(s)
- Charlotte Bernard
- Bordeaux Population Health Research Center, Univ. Bordeaux, Inserm, UMR 1219, F-33000, Bordeaux, France. .,Bordeaux Population Health Research Center, Univ. Bordeaux, ISPED, UMR 1219, F-33000, Bordeaux, France.
| | - Hélène Font
- grid.412041.20000 0001 2106 639XBordeaux Population Health Research Center, Univ. Bordeaux, Inserm, UMR 1219, F-33000 Bordeaux, France ,grid.412041.20000 0001 2106 639XBordeaux Population Health Research Center, Univ. Bordeaux, ISPED, UMR 1219, F-33000 Bordeaux, France
| | - Zélica Diallo
- grid.411387.80000 0004 7664 5497Service de maladies infectieuses et tropicales, CHU Treichville, Abidjan, Côte d’Ivoire
| | - Richard Ahonon
- Centre de prise en charge de recherche et de formation (CePReF), Yopougon Attié Hospital, Abidjan, Côte d’Ivoire
| | - Judicaël Malick Tine
- Service de maladies infectieuses et tropicales, CRCF, CHNU de Fann, Dakar, Senegal
| | - Franklin N’guessan Abouo
- grid.411387.80000 0004 7664 5497Service de maladies infectieuses et tropicales, CHU Treichville, Abidjan, Côte d’Ivoire
| | - Aristophane Tanon
- grid.411387.80000 0004 7664 5497Service de maladies infectieuses et tropicales, CHU Treichville, Abidjan, Côte d’Ivoire
| | - Eugène Messou
- Centre de prise en charge de recherche et de formation (CePReF), Yopougon Attié Hospital, Abidjan, Côte d’Ivoire
| | - Moussa Seydi
- Service de maladies infectieuses et tropicales, CRCF, CHNU de Fann, Dakar, Senegal
| | - François Dabis
- grid.412041.20000 0001 2106 639XBordeaux Population Health Research Center, Univ. Bordeaux, Inserm, UMR 1219, F-33000 Bordeaux, France ,grid.412041.20000 0001 2106 639XBordeaux Population Health Research Center, Univ. Bordeaux, ISPED, UMR 1219, F-33000 Bordeaux, France
| | - Nathalie de Rekeneire
- grid.412041.20000 0001 2106 639XBordeaux Population Health Research Center, Univ. Bordeaux, Inserm, UMR 1219, F-33000 Bordeaux, France ,grid.412041.20000 0001 2106 639XBordeaux Population Health Research Center, Univ. Bordeaux, ISPED, UMR 1219, F-33000 Bordeaux, France
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Abstract
We present recent literature describing interventions for linkage to HIV care in the era of Universal Test and Treat (UTT) policies. We also provide information for ongoing studies of linkage to care strategies registered with ClinicalTrials.gov.
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Abstract
Purpose of review To explore the comparative importance of HIV infections among key populations and their intimate partners as HIV epidemics evolve, and to review implications for guiding responses. Recent findings Even as concentrated epidemics evolve, new infections among current and former key population members and their intimate partners dominate new infections. Prevalent infections in the general population grow primarily because of key population turnover and infections among their intimate partners. In generalized epidemic settings, data and analysis on key populations are often inadequate to assess the impact of key population-focused responses, so they remain limited in coverage and under resourced. Models must incorporate downstream infections in comparing impacts of alternative responses. Summary Recognize that every epidemic is unique, moving beyond the overly simplistic concentrated/generalized epidemic paradigm that can misdirect resources. Guide HIV responses by gathering and using locally relevant data, understanding risk heterogeneity, and applying modeling at both national and sub-national levels to optimize resource allocations among different populations for greatest impact. Translate this improved understanding into clear, unequivocal advice for policymakers on where to focus for impact, breaking them free of the generalized/concentrated paradigm limiting their thinking and affecting their decisions.
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Abstract
Four of the largest HIV prevention trials have been conducted in sub-Saharan Africa, enrolling hundreds of thousands of participants in catchment areas of millions of people. The trials have focused on community-level interventions to increase diagnosis and initiation of antiretroviral therapy (ART) to improve health and reduce HIV transmission. Universal test-and-treat strategies are deployed to achieve viral suppression thereby reducing risk to uninfected persons, known as treatment as prevention (TasP).
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Chammartin F, Dao Ostinelli CH, Anastos K, Jaquet A, Brazier E, Brown S, Dabis F, Davies MA, Duda SN, Malateste K, Nash D, Wools-Kaloustian K, von Groote PM, Egger M. International epidemiology databases to evaluate AIDS (IeDEA) in sub-Saharan Africa, 2012-2019. BMJ Open 2020; 10:e035246. [PMID: 32414825 PMCID: PMC7232622 DOI: 10.1136/bmjopen-2019-035246] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 02/21/2020] [Accepted: 04/14/2020] [Indexed: 02/06/2023] Open
Abstract
PURPOSE The objectives of the International epidemiology databases to evaluate AIDS (IeDEA) are to (i) evaluate the delivery of combination antiretroviral therapy (ART) in children, adolescents and adults in sub-Saharan Africa, (ii) to describe ART regimen effectiveness, durability and tolerability, (iii) to examine HIV-related comorbidities and coinfections and (iv) to examine the pregnancy-related and HIV-related outcomes of women on ART and their infants exposed to HIV or ART in utero or via breast milk. PARTICIPANTS IeDEA is organised in four regions (Central, East, Southern and West Africa), with 240 treatment and care sites, six data centres at African, European and US universities, and almost 1.4 million children, adolescents and adult people living with HIV (PLWHIV) enrolled. FINDINGS TO DATE The data include socio-demographic characteristics, clinical outcomes, opportunistic events, treatment regimens, clinic visits and laboratory measurements. They have been used to analyse outcomes in PLWHIV-1 or PLWHIV-2 who initiate ART, including determinants of mortality, of switching to second-line and third-line ART, drug resistance, loss to follow-up and the immunological and virological response to different ART regimens. Programme-level estimates of mortality have been corrected for loss to follow-up. We examined the impact of coinfection with hepatitis B and C, and the epidemiology of different cancers and of (multidrug resistant) tuberculosis, renal disease and of mental illness. The adoption of 'Treat All', making ART available to all PLWHIV regardless of CD4+ cell count or clinical stage was another important research topic. FUTURE PLANS IeDEA has formulated several research priorities for the 'Treat All' era in sub-Saharan Africa. It recently obtained funding to set up sentinel sites where additional data are prospectively collected on cardiometabolic risks factors as well as mental health and liver diseases, and is planning to create a drug resistance database.
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Affiliation(s)
| | - Cam Ha Dao Ostinelli
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Kathryn Anastos
- Departments of Medicine and Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Antoine Jaquet
- French National Research Institute for Sustainable Development (IRD), Inserm, UMR 1219, University of Bordeaux, Bordeaux, France
| | - Ellen Brazier
- Institute for Implementation Science in Population Health, City University of New York, New York, New York, USA
- Graduate School of Public Health and Health Policy, City University of New York, New York, New York, USA
| | - Steven Brown
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Francois Dabis
- French National Research Institute for Sustainable Development (IRD), Inserm, UMR 1219, University of Bordeaux, Bordeaux, France
| | - Mary-Ann Davies
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Stephany N Duda
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Karen Malateste
- French National Research Institute for Sustainable Development (IRD), Inserm, UMR 1219, University of Bordeaux, Bordeaux, France
| | - Denis Nash
- Institute for Implementation Science in Population Health, City University of New York, New York, New York, USA
- Graduate School of Public Health and Health Policy, City University of New York, New York, New York, USA
| | - Kara Wools-Kaloustian
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Per M von Groote
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Rondebosch, Western Cape, South Africa
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Zakumumpa H, Rujumba J, Kwiringira J, Katureebe C, Spicer N. Understanding implementation barriers in the national scale-up of differentiated ART delivery in Uganda. BMC Health Serv Res 2020; 20:222. [PMID: 32183796 PMCID: PMC7077133 DOI: 10.1186/s12913-020-5069-y] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 03/04/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Although Differentiated Service Delivery (DSD) for anti-retroviral therapy (ART) has been rolled-out nationally in several countries since World Health Organization (WHO)'s landmark 2016 guidelines, there is little research evaluating post-implementation outcomes. The objective of this study was to explore patients' and HIV service managers' perspectives on barriers to implementation of Differentiated ART service delivery in Uganda. METHODS We employed a qualitative descriptive design involving 124 participants. Between April and June 2019 we conducted 76 qualitative interviews with national-level HIV program managers (n = 18), District Health Team leaders (n = 24), representatives of PEPFAR implementing organizations (11), ART clinic in-charges (23) in six purposively selected Uganda districts with a high HIV burden (Kampala, Luwero, Wakiso, Mbale, Budadiri, Bulambuli). Six focus group discussions (48 participants) were held with patients enrolled in DSD models in case-study districts. Data were analyzed by thematic approach as guided by a multi-level analytical framework: Individual-level factors; Health-system factors; Community factors; and Context. RESULTS Our data shows that multiple barriers have been encountered in DSD implementation. Individual-level: Individualized stigma and a fear of detachment from health facilities by stable patients enrolled in community-based models were reported as bottlenecks. Socio-economic status was reported to have an influence on patient selection of DSD models. Health-system: Insufficient training of health workers in DSD delivery and supply chain barriers to multi-month ART dispensing were identified as constraints. Patients perceived current selection of DSD models to be provider-intensive and not sufficiently patient-centred. Community: Community-level stigma and insufficient funding to providers to fully operationalize community drug pick-up points were identified as limitations. CONTEXT Frequent changes in physical addresses among urban clients were reported to impede the running of patient groups of rotating ART refill pick-ups. CONCLUSION This is one of the first multi-stakeholder evaluations of national DSD implementation in Uganda since initial roll-out in 2017. Multi-level interventions are needed to accelerate further DSD implementation in Uganda from demand-side (addressing HIV-related stigma, community engagement) and supply-side dimensions (strengthening ART supply chain capacities, increasing funding for community models and further DSD program design to improve patient-centeredness).
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Affiliation(s)
- Henry Zakumumpa
- Makerere University, School of Public Health, Kampala, Uganda.
| | - Joseph Rujumba
- Makerere University, School of Medicine, Kampala, Uganda
| | | | | | - Neil Spicer
- London School of Hygiene and Tropical Medicine, London, UK
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Esber AL, Coakley P, Ake JA, Bahemana E, Adamu Y, Kiweewa F, Maswai J, Owuoth J, Robb ML, Polyak CS, Crowell TA. Decreasing time to antiretroviral therapy initiation after HIV diagnosis in a clinic-based observational cohort study in four African countries. J Int AIDS Soc 2020; 23:e25446. [PMID: 32064776 PMCID: PMC7025087 DOI: 10.1002/jia2.25446] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 12/06/2019] [Accepted: 12/16/2019] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION World Health Organization (WHO) guidelines have shifted over time to recommend earlier initiation of antiretroviral therapy (ART) and now encourage ART initiation on the day of HIV diagnosis, if possible. However, barriers to ART access may delay initiation in resource-limited settings. We characterized temporal trends and other factors influencing the interval between HIV diagnosis and ART initiation among participants enrolled in a clinic-based cohort across four African countries. METHODS The African Cohort Study enrols adults engaged in care at 12 sites in Uganda, Kenya, Tanzania and Nigeria. Participants provide a medical history, complete a physical examination and undergo laboratory assessments every six months. Participants with recorded dates of HIV diagnosis were categorized by WHO guideline era (<2006, 2006 to 2009, 2010 to 2012, 2013 to 2015, ≥2016) at the time of diagnosis. Cox proportional hazard modelling was used to estimate hazard ratios (HRs) and 95% confidence intervals (95% CI) for time to ART initiation. RESULTS AND DISCUSSION From January 2013 to September 2019, a total of 2888 adults living with HIV enrolled with known diagnosis dates. Median time to ART initiation decreased from 22.0 months (interquartile range (IQR) 4.0 to 77.3) among participants diagnosed prior to 2006 to 0.5 months (IQR 0.2 to 1.8) among those diagnosed in 2016 and later. Comparing those same periods, CD4 nadir increased from a median of 166 cells/mm3 (IQR: 81 to 286) to 298 cells/mm3 (IQR: 151 to 501). In the final adjusted model, participants diagnosed in each subsequent WHO guideline era had increased rates of ART initiation compared to those diagnosed before 2006. CD4 nadir ≥500 cells/mm3 was independently associated with a lower rate of ART initiation as compared to CD4 nadir <200 cells/mm3 (HR: 0.32; 95% CI: 0.28 to 0.37). Age >50 years at diagnosis was independently associated with shorter time to ART initiation as compared to 18 to 29 years (HR: 1.38; 95% CI: 1.19 to 1.61). CONCLUSIONS Consistent with changing guidelines, the interval between diagnosis and ART initiation has decreased over time. Still, many adults living with HIV initiated treatment with low CD4, highlighting the need to diagnose HIV earlier while improving access to immediate ART after diagnosis.
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Affiliation(s)
- Allahna L Esber
- U.S. Military HIV Research ProgramWalter Reed Army Institute of ResearchSilver SpringMDUSA
- Henry M. Jackson Foundation for the Advancement of Military MedicineBethesdaMDUSA
| | - Peter Coakley
- U.S. Military HIV Research ProgramWalter Reed Army Institute of ResearchSilver SpringMDUSA
- Henry M. Jackson Foundation for the Advancement of Military MedicineBethesdaMDUSA
| | - Julie A Ake
- U.S. Military HIV Research ProgramWalter Reed Army Institute of ResearchSilver SpringMDUSA
| | - Emmanuel Bahemana
- U.S. Military HIV Research ProgramWalter Reed Army Institute of ResearchSilver SpringMDUSA
- Henry Jackson Foundation MRIMbeyaTanzania
| | - Yakubu Adamu
- U.S. Military HIV Research ProgramWalter Reed Army Institute of ResearchSilver SpringMDUSA
- U.S. Army Medical Research Directorate – AfricaNairobiKenya
- Henry Jackson Foundation MRIAbujaNigeria
| | | | - Jonah Maswai
- U.S. Military HIV Research ProgramWalter Reed Army Institute of ResearchSilver SpringMDUSA
- Kenya Medical Research Institute/U.S. Army Medical Research DirectorateNairobiKenya
- Henry Jackson Foundation MRIKerichoKenya
| | - John Owuoth
- U.S. Military HIV Research ProgramWalter Reed Army Institute of ResearchSilver SpringMDUSA
- Kenya Medical Research Institute/U.S. Army Medical Research DirectorateNairobiKenya
- Henry Jackson Foundation MRIKisumuKenya
| | - Merlin L Robb
- U.S. Military HIV Research ProgramWalter Reed Army Institute of ResearchSilver SpringMDUSA
- Henry M. Jackson Foundation for the Advancement of Military MedicineBethesdaMDUSA
| | - Christina S Polyak
- U.S. Military HIV Research ProgramWalter Reed Army Institute of ResearchSilver SpringMDUSA
- Henry M. Jackson Foundation for the Advancement of Military MedicineBethesdaMDUSA
| | - Trevor A Crowell
- U.S. Military HIV Research ProgramWalter Reed Army Institute of ResearchSilver SpringMDUSA
- Henry M. Jackson Foundation for the Advancement of Military MedicineBethesdaMDUSA
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Yotebieng M, Mpody C, Ravelomanana NLR, Tabala M, Malongo F, Kawende B, Ntangu P, Behets F, Okitolonda E. HIV viral suppression among pregnant and breastfeeding women in routine care in the Kinshasa province: a baseline evaluation of participants in CQI-PMTCT study. J Int AIDS Soc 2019; 22:e25376. [PMID: 31496051 PMCID: PMC6732557 DOI: 10.1002/jia2.25376] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 07/21/2019] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Published data on viral suppression among pregnant and breastfeeding women in routine care settings are scarce. Here, we report provincial estimates of undetectable and suppressed viral load among pregnant or breastfeeding women in HIV care in Kinshasa, Democratic Republic of Congo (DRC) and associated risk factors. METHODS This cross-sectional study was conducted as part of a baseline assessment for the CQI-PMTCT study: an ongoing cluster randomized trial to evaluate the effect of continuous quality interventions (CQI) on long-term ART outcomes among pregnant and breastfeeding women (NCT03048669). From November 2016 to June 2018, in each of the 35 Kinshasa provincial health zones (HZ), study teams visited the three busiest maternal and child health clinics, enrolled all HIV-positive pregnant or breastfeeding women (≤1 year post-delivery) receiving ART, and performed viral load testing. Log binomial models with generalized estimating equations to account for clustering at the HZ level, were used to estimate prevalence ratios comparing participants with undetected (<40 copies/mL) or suppressed (<1000 copies/mL) viral load across levels of individual and site characteristics. RESULTS Of the 1752 eligible women, 1623 had viral load results available, including 38% who had been on ART for <6 months and 74% were on tenofovir-lamivudine-efavirenz. Viral load was undetectable in 53% of women and suppressed in 62%. Among women who were on ART for ≥12 months, only 60% and 67% respectively, had undetectable or suppressed viral load. Viral load was undetectable in 53%, 48% and 58% of women testing during pregnancy, at delivery, and in postpartum respectively. In multivariable log binomial models, duration of ART >12 months, older age, being married, disclosure of HIV status, receiving care in an urban health zone or one supported by PEPFAR were all positively associated with viral suppression. CONCLUSIONS The observed high level of detectable viral load suggests that high ART coverage alone without substantial efforts to improve the quality of care for pregnant and breastfeeding women, will not be enough to achieve the goal of virtual elimination of vertical HIV transmission in high-burden and limited resources settings like DRC.
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Affiliation(s)
- Marcel Yotebieng
- Division of EpidemiologyCollege of Public HealthThe Ohio State UniversityColumbusOHUSA
| | - Christian Mpody
- Division of EpidemiologyCollege of Public HealthThe Ohio State UniversityColumbusOHUSA
| | - Noro LR Ravelomanana
- Division of EpidemiologyCollege of Public HealthThe Ohio State UniversityColumbusOHUSA
| | - Martine Tabala
- School of Public HealthThe University of KinshasaKinshasaDemocratic Republic of Congo
| | - Fathy Malongo
- School of Public HealthThe University of KinshasaKinshasaDemocratic Republic of Congo
| | - Bienvenu Kawende
- School of Public HealthThe University of KinshasaKinshasaDemocratic Republic of Congo
| | - Paul Ntangu
- National AIDS Control Program (PNLS)Provincial CoordinationKinshasaDemocratic Republic of Congo
| | - Frieda Behets
- Department of EpidemiologyGillings School of Global Public HealthThe University of North Carolina at Chapel HillChapel HillNCUSA
- Department of Social MedicineThe University of North Carolina at Chapel HillChapel HillNCUSA
| | - Emile Okitolonda
- School of Public HealthThe University of KinshasaKinshasaDemocratic Republic of Congo
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Nash D, Robertson M. How to Evolve the Response to the Global HIV Epidemic With New Metrics and Targets Based on Pre-Treatment CD4 Counts. Curr HIV/AIDS Rep 2019; 16:304-313. [PMID: 31278620 PMCID: PMC10938289 DOI: 10.1007/s11904-019-00452-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF THE REVIEW Early diagnosis and treatment of HIV following seroconversion improves individual and population health. Using published data on pre-treatment CD4 cell counts, we benchmarked the level of immunodeficiency at HIV diagnosis and ART initiation in the "real world" against those of the treatment and control arms of landmark controlled trials that successfully reduced HIV-related deaths (INSIGHT/START) and onward HIV transmission (HPTN 052). RECENT FINDINGS The median CD4 count in the treatment vs. control arms of the INSIGHT/START trial and HPTN 052 were 650 vs. 408 cells/μL and 442 vs. 221 cells/μL, respectively. In the real world, recent global estimates of the median CD4 count at start of ART range from 234 to 350 cells/μL, and only 25% of those initiating ART do so early (i.e., with CD4 > 500 cells/μL). Recent global data on trends in the median CD4 count at diagnosis and ART initiation are not encouraging. We identify a critical need for new targets and metrics for persons newly diagnosed with HIV, newly enrolling in HIV care, and newly initiating ART, based on pre-treatment CD4 counts, to help increase the focus of implementation efforts on achieving earlier diagnosis, linkage to care, and ART initiation.
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Affiliation(s)
- Denis Nash
- Institute for Implementation Science in Population Health (ISPH), City University of New York (CUNY), New York, NY, USA.
- Department of Epidemiology and Biostatistics, CUNY School of Public Health, New York, NY, USA.
- CUNY Institute for Implementation Science in Population Health, 55 W. 125th St., 6th Floor, New York, NY, USA.
| | - McKaylee Robertson
- Institute for Implementation Science in Population Health (ISPH), City University of New York (CUNY), New York, NY, USA
- Department of Epidemiology and Biostatistics, CUNY School of Public Health, New York, NY, USA
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Kelly N, Maokola W, Mudasiru O, McCoy SI. Interventions to Improve Linkage to HIV Care in the Era of "Treat All" in Sub-Saharan Africa: a Systematic Review. Curr HIV/AIDS Rep 2019; 16:292-303. [PMID: 31201613 PMCID: PMC10655251 DOI: 10.1007/s11904-019-00451-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE OF THE REVIEW In 2015, antiretroviral therapy (ART) was recommended for all people living with HIV (PLHIV) regardless of CD4 count ("Treat All"). To better understand how to improve linkage to care under these new guidelines, we conducted a systematic review of studies evaluating linkage interventions in Sub-Saharan Africa under Treat All. RECENT FINDINGS We identified 14 eligible articles and qualitatively analyzed the effectiveness of the interventions. Increases in linkage were reported by supply-side and counseling interventions. Mobile testing and economic incentives did not increase linkage. Given the lag time between adoption and implementation, only two of the studies were conducted in a Treat All setting. None of the interventions specifically focused on re-linking PLHIV who had disengaged from care. Future studies must design interventions that target not only newly diagnosed or treatment naïve PLHIV, but should explicitly focus on PLHIV who have disengaged from care.
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Affiliation(s)
- Nicole Kelly
- University of California, 2121 Berkeley Way, MC 7360, Berkeley, CA, 94720, USA.
| | - Werner Maokola
- University of California, 2121 Berkeley Way, MC 7360, Berkeley, CA, 94720, USA
- Community Development, Gender, Elderly, and Children, Ministry of Health, Dar es Salaam, Tanzania
| | - Omobola Mudasiru
- University of California, 2121 Berkeley Way, MC 7360, Berkeley, CA, 94720, USA
| | - Sandra I McCoy
- University of California, 2121 Berkeley Way, MC 7360, Berkeley, CA, 94720, USA
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Ross J, Sinayobye JD, Yotebieng M, Hoover DR, Shi Q, Ribakare M, Remera E, Bachhuber MA, Murenzi G, Sugira V, Nash D, Anastos K. Early outcomes after implementation of treat all in Rwanda: an interrupted time series study. J Int AIDS Soc 2019; 22:e25279. [PMID: 30993854 PMCID: PMC6468264 DOI: 10.1002/jia2.25279] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 03/29/2019] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Nearly all countries in sub-Saharan Africa have adopted policies to provide antiretroviral therapy (ART) to all persons living with HIV (Treat All), though HIV care outcomes of these programmes are not well-described. We estimated changes in ART initiation and retention in care following Treat All implementation in Rwanda in July 2016. METHODS We conducted an interrupted time series analysis of adults enrolling in HIV care at ten Rwandan health centres from July 2014 to September 2017. Using segmented linear regression, we assessed changes in levels and trends of 30-day ART initiation and six-month retention in care before and after Treat All implementation. We compared modelled outcomes with counterfactual estimates calculated by extrapolating baseline trends. Modified Poisson regression models identified predictors of outcomes among patients enrolling after Treat All implementation. RESULTS Among 2885 patients, 1803 (62.5%) enrolled in care before and 1082 (37.5%) after Treat All implementation. Immediately after Treat All implementation, there was a 31.3 percentage point increase in the predicted probability of 30-day ART initiation (95% CI 15.5, 47.2), with a subsequent increase of 1.1 percentage points per month (95% CI 0.1, 2.1). At the end of the study period, 30-day ART initiation was 47.8 percentage points (95% CI 8.1, 87.8) above what would have been expected under the pre-Treat All trend. For six-month retention, neither the immediate change nor monthly trend after Treat All were statistically significant. While 30-day ART initiation and six-month retention were less likely among patients 15 to 24 versus >24 years, the predicted probability of both outcomes increased significantly for younger patients in each month after Treat All implementation. CONCLUSIONS Implementation of Treat All in Rwanda was associated with a substantial increase in timely ART initiation without negatively impacting care retention. These early findings support Treat All as a strategy to help achieve global HIV targets.
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Affiliation(s)
- Jonathan Ross
- Department of MedicineMontefiore Medical Center/Albert Einstein College of MedicineBronxNYUSA
| | | | - Marcel Yotebieng
- Division of EpidemiologyCollege of Public HealthOhio State UniversityColumbusOHUSA
| | - Donald R Hoover
- Department of Statistics and Biostatistics and Institute for HealthHealth Care Policy and Aging ResearchRutgers the State University of New JerseyPiscatawayNJUSA
| | - Qiuhu Shi
- Department of Epidemiology and Community HealthNew York Medical CollegeValhallaNYUSA
| | | | | | - Marcus A Bachhuber
- Department of MedicineMontefiore Medical Center/Albert Einstein College of MedicineBronxNYUSA
| | - Gad Murenzi
- Research DivisionRwanda Military HospitalKigaliRwanda
| | | | - Denis Nash
- Institute for Implementation Science in Population HealthCity University of New YorkNew YorkNYUSA
| | - Kathryn Anastos
- Department of MedicineMontefiore Medical Center/Albert Einstein College of MedicineBronxNYUSA
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Nash D, Yotebieng M, Sohn AH. Treating all people living with HIV in sub-Saharan Africa: a new era calling for new approaches. J Virus Erad 2018; 4:1-4. [PMID: 30515307 PMCID: PMC6248848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Nearly all countries in sub-Saharan Africa (SSA) have adopted national policies to treat all persons with HIV, regardless of CD4 cell count or clinical stage ('treat all'). With 10.3 million people untreated and a projected 1.2 million new infections per year in SSA, the current and anticipated unmet need for HIV treatment in SSA is substantial. Evidence to date from SSA suggests that, once linked to care, timely ART initiation with retention and viral suppression is the norm. However, ART initiation in SSA usually occurs late in the course of infection, driving high mortality and incidence rates. The 'treat all' era presents strategic opportunities for health systems to substantially reduce AIDS-related mortality and HIV incidence. This special issue of the Journal of Virus Eradication contains eight articles focused on issues critical to ensuring the success and impact of 'treat all' implementation in SSA.
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Affiliation(s)
- Denis Nash
- Corresponding author: Denis Nash,
City University of New York,
Institute for Implementation Science in Population Health,
55 W 125th Street, 6th Floor,
New York,
NY10027,
USA
| | - Marcel Yotebieng
- College of Public Health, Division of Epidemiology, Ohio State University,
Columbus, OH,
USA
| | - Annette H Sohn
- TREAT Asia, amfAR – Foundation for AIDS Research,
Bangkok,
Thailand
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