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Beres LK, Underwood A, Le Tourneau N, Kemp CG, Kore G, Yaeger L, Li J, Aaron A, Keene C, Mallela DP, Khalifa BAA, Mody A, Schwartz SR, Baral S, Mwamba C, Sikombe K, Eshun‐Wilson I, Geng EH, Lavoie MC. Person-centred interventions to improve patient-provider relationships for HIV services in low- and middle-income countries: a systematic review. J Int AIDS Soc 2024; 27:e26258. [PMID: 38740547 PMCID: PMC11090778 DOI: 10.1002/jia2.26258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 04/16/2024] [Indexed: 05/16/2024] Open
Abstract
INTRODUCTION Person-centred care (PCC) has been recognized as a critical element in delivering quality and responsive health services. The patient-provider relationship, conceptualized at the core of PCC in multiple models, remains largely unexamined in HIV care. We conducted a systematic review to better understand the types of PCC interventions implemented to improve patient-provider interactions and how these interventions have improved HIV care continuum outcomes and person-reported outcomes (PROs) among people living with HIV in low- and middle-income countries. METHODS We searched databases, conference proceedings and conducted manual targeted searches to identify randomized trials and observational studies published up to January 2023. The PCC search terms were guided by the Integrative Model of Patient-Centeredness by Scholl. We included person-centred interventions aiming to enhance the patient-provider interactions. We included HIV care continuum outcomes and PROs. RESULTS We included 28 unique studies: 18 (64.3%) were quantitative, eight (28.6.%) were mixed methods and two (7.1%) were qualitative. Within PCC patient-provider interventions, we inductively identified five categories of PCC interventions: (1) providing friendly and welcoming services; (2) patient empowerment and improved communication skills (e.g. supporting patient-led skills such as health literacy and approaches when communicating with a provider); (3) improved individualized counselling and patient-centred communication (e.g. supporting provider skills such as training on motivational interviewing); (4) audit and feedback; and (5) provider sensitisation to patient experiences and identities. Among the included studies with a comparison arm and effect size reported, 62.5% reported a significant positive effect of the intervention on at least one HIV care continuum outcome, and 100% reported a positive effect of the intervention on at least one of the included PROs. DISCUSSION Among published HIV PCC interventions, there is heterogeneity in the components of PCC addressed, the actors involved and the expected outcomes. While results are also heterogeneous across clinical and PROs, there is more evidence for significant improvement in PROs. Further research is necessary to better understand the clinical implications of PCC, with fewer studies measuring linkage or long-term retention or viral suppression. CONCLUSIONS Improved understanding of PCC domains, mechanisms and consistency of measurement will advance PCC research and implementation.
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Affiliation(s)
- Laura K. Beres
- Johns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
- Centre for Infectious Disease Research in Zambia (CIDRZ)LusakaZambia
| | - Ashley Underwood
- Washington University in St. Louis School of MedicineSt LouisMissouriUSA
| | - Noelle Le Tourneau
- Washington University in St. Louis School of MedicineSt LouisMissouriUSA
| | | | - Gauri Kore
- Johns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Lauren Yaeger
- Washington University in St. Louis School of MedicineSt LouisMissouriUSA
| | - Jingjia Li
- Johns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Alec Aaron
- Johns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | | | | | | | - Aaloke Mody
- Centre for Infectious Disease Research in Zambia (CIDRZ)LusakaZambia
| | | | - Stefan Baral
- Johns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Chanda Mwamba
- Centre for Infectious Disease Research in Zambia (CIDRZ)LusakaZambia
| | | | | | - Elvin H. Geng
- Washington University in St. Louis School of MedicineSt LouisMissouriUSA
| | - Marie‐Claude C. Lavoie
- Center for International Health Education and BiosecurityUniversity of Maryland School of MedicineBaltimoreMarylandUSA
- Institute of Human VirologyUniversity of Maryland School of MedicineBaltimoreMarylandUSA
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Ntinga X, Musiello F, Pita T, Mabaso N, Celum C, Szpiro A, van Rooyen H, Barnabas R, van Heerden A. People living with HIV's perspectives of acceptability of fee for home delivery of ART: a qualitative study. BMC Health Serv Res 2024; 24:88. [PMID: 38233824 PMCID: PMC10792944 DOI: 10.1186/s12913-023-10533-4] [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] [Received: 08/18/2023] [Accepted: 12/27/2023] [Indexed: 01/19/2024] Open
Abstract
INTRODUCTION Significant progress has been made in the HIV response in South Africa; however, gaps remain in ensuring engagement in care to support life-long medication adherence and viral suppression. The National Department of Health (NDoH) has introduced community-based and clinic-based HIV differentiated service delivery (DSD) models to tackle suboptimal adherence and retention in care. Nevertheless, differentiated care models require adaptation to better serve clients who struggle with adherence. There is limited research on the acceptability of fee for home delivery of ART in resource-constrained settings. The current study investigates the acceptability of fee for home delivery of ART among people living with HIV in South Africa. METHODS Two mixed-gender focus group discussions (FGDs) took place between June and November 2019, consisting of 10 participants in each group. A purposive sampling strategy was employed to identify and select 10 people living with HIV who were ART-eligible but not in care, and 10 people living with HIV who were currently taking ART and in care. Participants were grouped according to their treatment status. A coding framework, informed by a priori categories and derived from topics in the interview guide, was developed and utilized to facilitate analysis. RESULTS Participants expressed enthusiasm for having ART home-delivered, as it would save the time spent waiting in long queues at the clinic. However, some participants raised concerns about potential payment difficulties due to high unemployment rates in the community. Some participants believed this would be acceptable, as patients already incur costs for travel and food when visiting the clinic. Participants in both FGDs expressed strong concerns about home delivery of their ART based on fear of accidental disclosure, especially for those who have not disclosed to their immediate families and partners. CONCLUSION Our study suggests that charging a fee for home delivery is an acceptable and innovative approach to supporting PLHIV in maintaining adherence to their medication and remaining in care.
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Affiliation(s)
- Xolani Ntinga
- Centre for Community Based Research, Human Sciences Research Council, Old Bus Depot, Sweetwaters, Pietermaritzburg, KZN, 3201, South Africa.
| | - Franco Musiello
- Centre for Community Based Research, Human Sciences Research Council, Old Bus Depot, Sweetwaters, Pietermaritzburg, KZN, 3201, South Africa
| | - Thembelihle Pita
- Centre for Community Based Research, Human Sciences Research Council, Old Bus Depot, Sweetwaters, Pietermaritzburg, KZN, 3201, South Africa
| | - Nomagugu Mabaso
- Centre for Community Based Research, Human Sciences Research Council, Old Bus Depot, Sweetwaters, Pietermaritzburg, KZN, 3201, South Africa
| | - Connie Celum
- Department of Global Health, University of Washington, Seattle, WA, USA
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Adam Szpiro
- Department of Biostatistics, School of Public Health, University of Washington, Seattle, WA, USA
| | - Heidi van Rooyen
- Centre for Community Based Research, Human Sciences Research Council, Old Bus Depot, Sweetwaters, Pietermaritzburg, KZN, 3201, South Africa
- MRC/Wits Developmental Pathways for Health Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Ruanne Barnabas
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Alastair van Heerden
- Centre for Community Based Research, Human Sciences Research Council, Old Bus Depot, Sweetwaters, Pietermaritzburg, KZN, 3201, South Africa
- MRC/Wits Developmental Pathways for Health Research Unit, University of the Witwatersrand, Johannesburg, South Africa
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GOVERE SABINAM, MANYANGADZE TAWANDA, KALINDA CHESTER, CHIMBARI MOSESJ. An assessment on the implementation of same day antiretroviral therapy initiation in eThekwini clinics, KwaZulu-Natal, South Africa. J Public Health Afr 2023; 14:2179. [PMID: 38162327 PMCID: PMC10755505 DOI: 10.4081/jphia.2023.2179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 07/05/2022] [Indexed: 01/03/2024] Open
Abstract
The World Health Organization (WHO) recommends same-day initiation (SDI) of antiretroviral therapy (ART) for all individuals diagnosed with HIV irrespective of CD4+ count or clinical stage. Implementation of program is still far from reaching its goals. This study assessed the level of implementation of same day ART initiation. A longitudinal study was conducted at four primary healthcare clinics in eThekwini municipality KwaZulu-Natal. Data was collected between June 2020 to October 2020 using a data extraction form. Data on individuals tested HIV positive, number of SDI of ART; and clinicians working on UTT program were compiled from clinic registers, and Three Interlinked Electronic Registers.Net (TIER.Net). Non-governmental organisations (NGO) supporting the facility and services information was collected. Among the 403 individuals who tested HIV positive, 279 (69.2%) were initiated on ART on the same day of HIV diagnosis from the four facilities. There was a significant association between health facility and number of HIV positive individuals initiated on SDI (chi-square=10.59; P-value=0.008). There was a significant association between facilities with support from all NGOs and ART SDI (chi-square=10.18; P-value=0.015. There was a significant association between staff provision in a facility and SDI (chi-square=7.51; P-value=0.006). Urban areas clinics were more likely to have high uptake of SDI compared to rural clinics (chi-square=11,29; P-value=0.003). Implementation of the Universal Test and Treat program varies by facility indicating the need for the government to monitor and standardize implementation of the policy if the program is to yield success.
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Affiliation(s)
- SABINA M. GOVERE
- School of Nursing and Public Health, Discipline of Public Health Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - TAWANDA MANYANGADZE
- School of Nursing and Public Health, Discipline of Public Health Medicine, University of KwaZulu-Natal, Durban, South Africa
- Geography Department, Faculty of Science and Engineering, Bindura University of Science Education, Private Bag, Bindura, Zimbabwe
| | - CHESTER KALINDA
- School of Nursing and Public Health, Discipline of Public Health Medicine, University of KwaZulu-Natal, Durban, South Africa
- Bill and Joyce Cummings Institute of Global Health and Institute of Global Health Equity Research (IGHER), University of Global Health Equity Kigali Heights, Kigali
| | - MOSES J. CHIMBARI
- School of Nursing and Public Health, Discipline of Public Health Medicine, University of KwaZulu-Natal, Durban, South Africa
- Department of Public Health, Great Zimbabwe University, Masvingo, Zimbabwe
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Nicol E, Jama NA, Mehlomakulu V, Hlongwa M, Pass D, Basera W, Bradshaw D. Enhancing linkage to HIV care in the "Universal Test and Treat" era: Barriers and enablers to HIV care among adults in a high HIV burdened district in KwaZulu-Natal, South Africa. BMC Public Health 2023; 23:1756. [PMID: 37689667 PMCID: PMC10492313 DOI: 10.1186/s12889-023-16576-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 08/21/2023] [Indexed: 09/11/2023] Open
Abstract
Ending AIDS by 2030 would depend on how successful health systems are in linking people living with HIV (PLHIV) into care. The World Health Organization recommended the 'Universal Test and Treat' (UTT) strategy - initiating all individuals testing positive on antiretroviral therapy (ART) irrespective of their CD4 count and clinical staging. This study aimed to explore the enablers and barriers to linkage to HIV care among adults with a new HIV diagnosis in a high-HIV prevalent rural district in South Africa. A qualitative study was undertaken to explore patients' perceptions of enablers and barriers of linkage-to-care, using a life-story narration and dialogue approach. In-depth interviews were conducted with 38 HIV-positive participants sampled from a cohort of 1194 HIV-positive patients recruited from December 2017 to June 2018. Participants were selected based on whether they had been linked to care or not within 3 months of positive HIV diagnosis. Interviews were thematically analysed using a general inductive approach. Of the 38 participants, 22 (58%) linked to care within three months of HIV-positive diagnosis. Factors that facilitated or inhibited linkage-to-care were found at individual, family, community, as well as health systems levels. Enablers included a positive HIV testing experience, and assistance from the fieldwork team. Support from family, and friends, as well as prior community-based education about HIV and ART were also noted. Individual factors such as acceptance of HIV status, previous exposure to PLHIV, and fear of HIV progressing, were identified. Barriers to linkage included, denial of HIV status, dislike of taking pills, and preference for alternative medicine. Negative experiences with counselling and health systems inefficiency were also noted as barriers. Perceived stigma and socio-economic factors, such as lack of food or money to visit the clinic were other barriers. Community-based and health system-level interventions would need to focus on clinic readiness in providing patients with necessary and effective health services such as proper and adequate counselling. This could increase the number of patients who link to care. Finally, interventions to improve linkage-to-care should consider a holistic approach, including training healthcare providers, community outreach and the provision of psychological, social, and financial support.
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Affiliation(s)
- Edward Nicol
- Burden of Disease Research Unit, South African Medical Research Council, P.O. Box 19070, TygerbergCape Town, 7505, South Africa.
- Division of Health Systems and Public Health, Stellenbosch University, Cape Town, South Africa.
| | - Ngcwalisa Amanda Jama
- Burden of Disease Research Unit, South African Medical Research Council, P.O. Box 19070, TygerbergCape Town, 7505, South Africa
- School of Public Health, University of the Western Cape, Bellville, South Africa
| | - Vuyelwa Mehlomakulu
- Burden of Disease Research Unit, South African Medical Research Council, P.O. Box 19070, TygerbergCape Town, 7505, South Africa
| | - Mbuzeleni Hlongwa
- Burden of Disease Research Unit, South African Medical Research Council, P.O. Box 19070, TygerbergCape Town, 7505, South Africa
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Public Health, Societies and Belonging, Human Sciences Research Council, Pretoria, South Africa
| | - Desiree Pass
- Burden of Disease Research Unit, South African Medical Research Council, P.O. Box 19070, TygerbergCape Town, 7505, South Africa
| | - Wisdom Basera
- Burden of Disease Research Unit, South African Medical Research Council, P.O. Box 19070, TygerbergCape Town, 7505, South Africa
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Debbie Bradshaw
- Burden of Disease Research Unit, South African Medical Research Council, P.O. Box 19070, TygerbergCape Town, 7505, South Africa
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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Govere SM, Kalinda C, Chimbari MJ. The impact of same-day antiretroviral therapy initiation on retention in care and clinical outcomes at four eThekwini clinics, KwaZulu-Natal, South Africa. BMC Health Serv Res 2023; 23:838. [PMID: 37553685 PMCID: PMC10408100 DOI: 10.1186/s12913-023-09801-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 07/11/2023] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND Same-day initiation (SDI) of antiretroviral therapy (ART) increases ART uptake, however retention in care after ART initiation remains a challenge. Public health behaviours, such as retention in HIV care and adherence to antiretroviral therapy (ART) pose major challenges to reducing new Human Immunodeficiency Virus (HIV) transmission and improving health outcomes among HIV patients. METHODS We evaluated 6-month retention in care, and clinical outcomes of an ART cohort comprising of SDI and delayed ART initiators. We conducted a 6 months' observational prospective cohort study of 403 patients who had been initiated on ART. A structured questionnaire was used to abstract data from patient record review which comprised the medical charts, laboratory databases, and Three Interlinked Electronic Registers.Net (TIER.Net). Treatment adherence was ascertained by patient visit constancy for the clinic scheduled visit dates. Retention in care was determined by status at 6 months after ART initiation. RESULTS Among the 403 participants enrolled in the study and followed up, 286 (70.97%) and 267 (66.25%) complied with scheduled clinics visits at 3 months and 6 months, respectively. One hundred and thirteen (28.04%) had been loss to follow-up. 17/403 (4.22%) had died and had been out of care after 6 months. 6 (1.49%) had been transferred to other health facilities and 113 (28.04%) had been loss to follow-up. Among those that had been lost to follow-up, 30 (33.63%) deferred SDI while 75 (66.37%) initiated ART under SDI. One hundred and eighty-nine (70.79%) participants who had remained in care were SDI patients while 78 (29.21%) were SDI deferred patients. In the bivariate analysis; gender (OR: 1.672; 95% CI: 1.002-2.791), number of sexual partners (OR: 2.092; 95% CI: 1.07-4.061), age (OR: 0.941; 95% CI: 0.734-2.791), ART start date (OR: 0.078; 95% CI: 0.042-0.141), partner HIV status (OR: 0.621; 95% CI: 0.387-0.995) and the number of hospitalizations after HIV diagnosis (OR: 0.173; 95% CI: 0.092-0.326). were significantly associated with viral load detection. Furthermore, SDI patients who defaulted treatment were 2.4 (95% CI: 1.165-4.928) times more likely to have increased viral load than those who had been returned in care. CONCLUSION Viral suppression under SDI proved higher but with poor retention in care. However, the results also emphasise a vital need, to not only streamline processes to increase immediate ART uptake further, but also to ensure retention in care.
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Affiliation(s)
- Sabina M Govere
- School of Nursing and Public Health, Discipline of Public Health Medicine, Howard College Campus, University of KwaZulu-Natal, Durban, South Africa.
| | - Chester Kalinda
- School of Nursing and Public Health, Discipline of Public Health Medicine, Howard College Campus, University of KwaZulu-Natal, Durban, South Africa
- Bill and Joyce Cummings Institute of Global Health and Institute of Global Health Equity Research (IGHER), University of Global Health Equity Kigali Heights, Kigali, Rwanda
| | - Moses J Chimbari
- School of Nursing and Public Health, Discipline of Public Health Medicine, Howard College Campus, University of KwaZulu-Natal, Durban, South Africa
- Department of Public Health, Great Zimbabwe University, P.O Box 1235, Masvingo, Zimbabwe
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Nicol E, Basera W, Mukumbang FC, Cheyip M, Mthethwa S, Lombard C, Jama N, Pass D, Laubscher R, Bradshaw D. Linkage to HIV Care and Early Retention in Care Rates in the Universal Test-and-Treat Era: A Population-based Prospective Study in KwaZulu-Natal, South Africa. AIDS Behav 2023; 27:1068-1081. [PMID: 36098845 PMCID: PMC10020822 DOI: 10.1007/s10461-022-03844-w] [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: 08/27/2022] [Indexed: 11/01/2022]
Abstract
HIV linkage, and retention are key weaknesses in South Africa's national antiretroviral therapy (ART) program, with the greatest loss of patients in the HIV treatment pathway occurring before ART initiation. This study investigated linkage-to and early-retention-in-care (LTRIC) rates among adults newly diagnosed with HIV in a high-HIV prevalent rural district. We conducted an observational prospective cohort study to investigate LTRIC rates for adults with a new HIV diagnosis in South Africa. Patient-level survey and clinical data were collected using a one-stage-cluster design from 18 healthcare facilities and triangulated between HIV and laboratory databases and registered deaths from Department of Home Affairs. We used Chi-square tests to assess associations between categorical variables, and results were stratified by HIV status, sex, and age. Of the 5,637 participants recruited, 21.2% had confirmed HIV, of which 70.9% were women, and 46.5% were aged 25-34 years. Although 82.7% of participants were linked-to-care within 3 months, only 46.1% remained-in-care 12 months after initiating ART and 5.2% were deceased. While a significantly higher proportion of men were linked-to-care at 3 months compared to women, a significant proportion of women (49.5%) remained-in-care at 12 months than men (38.0%). Post-secondary education and child support grants were significantly associated with retention. We found high linkage-to-care rates, but less than 50% of participants remained-in-care at 12 months. Significant effort is required to retain people living with HIV in care, especially during the first year after ART initiation. Our findings suggest that interventions could target men to encourage HIV testing.
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Affiliation(s)
- Edward Nicol
- Burden of Disease Research Unit, South African Medical Research Council, Tygerberg, 7505, Cape Town, P.O. Box 19070, South Africa.
- Division of Health Systems and Public Health, Stellenbosch University, Cape Town, South Africa.
| | - Wisdom Basera
- Burden of Disease Research Unit, South African Medical Research Council, Tygerberg, 7505, Cape Town, P.O. Box 19070, South Africa
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Ferdinand C Mukumbang
- Burden of Disease Research Unit, South African Medical Research Council, Tygerberg, 7505, Cape Town, P.O. Box 19070, South Africa
- School of Public Health, University of the Western Cape, Bellville, South Africa
| | - Mireille Cheyip
- Centers for Disease Control and Prevention, Pretoria, South Africa
| | | | - Carl Lombard
- Biostatistics, South African Medical Research Council, Cape Town, South Africa
| | - Ngcwalisa Jama
- Burden of Disease Research Unit, South African Medical Research Council, Tygerberg, 7505, Cape Town, P.O. Box 19070, South Africa
- School of Public Health, University of the Western Cape, Bellville, South Africa
| | - Desiree Pass
- Burden of Disease Research Unit, South African Medical Research Council, Tygerberg, 7505, Cape Town, P.O. Box 19070, South Africa
| | - Ria Laubscher
- Biostatistics, South African Medical Research Council, Cape Town, South Africa
| | - Debbie Bradshaw
- Burden of Disease Research Unit, South African Medical Research Council, Tygerberg, 7505, Cape Town, P.O. Box 19070, South Africa
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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Babatunde AO, Akin-Ajani OD, Abdullateef RO, Togunwa TO, Isah HO. Review of antiretroviral therapy coverage in 10 highest burden HIV countries in Africa: 2015-2020. J Med Virol 2023; 95:e28320. [PMID: 36397202 DOI: 10.1002/jmv.28320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 10/19/2022] [Accepted: 11/15/2022] [Indexed: 11/19/2022]
Abstract
Africa is responsible for two-thirds of the global total of new HIV infections. South Africa, Nigeria, Mozambique, Uganda, Tanzania, Zambia, Zimbabwe, Kenya, Malawi, and Ethiopia were responsible for 80% of HIV cases in Africa in 2014 according to the Joint United Nations Programme on HIV/AIDS (UNAIDS). This study assesses antiretroviral coverage strategies implemented by these countries after the initiation of the "Fast-Track strategy to end the AIDS epidemic by 2030." Data reported in this review were obtained from different e-bibliographic including PubMed, Google Scholar, and Research Gate. Key terms were "Antiretroviral therapy," "Antiretroviral treatment," "HIV treatment," "HIV medication," "HIV/AIDS therapy," "HIV/AIDS treatment" + each of the countries listed earlier. We also extracted data on antiretroviral therapy (ART) coverage from the UNAIDS database. About 50 papers published from 2015 to 2021 met the inclusion criteria. All 10 countries have experienced an increase in ART coverage from 2015 to 2020 with an average of 47.6% increment. Nigeria recorded the highest increase in the rate of ART coverage (72% increase) while Ethiopia had the least (30%). New strategies adopted to increase ART coverage and retention in most countries were community-based models and the use of mobile health technology rather than clinic-based. These strategies focus on promoting task shifting, door-to-door access to HIV services, and a long-term supply of antiretroviral medications. Most of these strategies are still in the piloting stage. However, some new strategies and frameworks have been adopted nationwide in countries like Mozambique, Tanzania, Zambia, Zimbabwe, Kenya, and Malawi. Identified challenges include lack of funding, inadequate testing and surveillance services, poor digital penetration, and cultural/religious beliefs. The adoption of community-based and digital health strategies could have contributed to increased ART coverage and retention. African countries should facilitate nationwide scaling of ART coverage strategies to attain the 95-95-95 goal by 2030.
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Affiliation(s)
- Abdulhammed O Babatunde
- Department of Medicine and Surgery, Faculty of Clinical Sciences, College of Medicine, University of Ibadan, Ibadan, Nigeria.,Healthy Africans Platform, Ibadan, Nigeria.,Federation of African Medical Students' Associations, Ibadan, Nigeria
| | - Oluwawapelumi D Akin-Ajani
- Department of Medicine and Surgery, Faculty of Clinical Sciences, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Ridwanullah O Abdullateef
- Department of Medicine and Surgery, Faculty of Clinical Sciences, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Taofeeq O Togunwa
- Department of Medicine and Surgery, Faculty of Clinical Sciences, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Haroun O Isah
- Department of Community Medicine and Primary Health Care, College of Medicine and Health Sciences, Bingham University, Jos, Nigeria
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Leveraging routine data in impact evaluation: Understanding data systems in primary healthcare prior to a matched cluster-randomised evaluation of adherence guidelines in South Africa. S Afr Med J 2022; 112:819-827. [PMID: 36472333 DOI: 10.7196/samj.2022.v112i10.14909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND An essential part of providing high-quality patient care and a means of efficiently conducting research studies relies upon high-quality routinely collected medical information. OBJECTIVES To describe the registers, paper records and databases used in a sample of primary healthcare clinics in South Africa (SA) with the view to conduct an impact evaluation using routine data. METHODS Between October 2015 and December 2015, we collected information on the presence, quality and completeness of registers, clinical stationery and databases at 24 public health facilities in SA. We describe each register and type of clinical stationery we encountered, their primary uses, and the quality of completion. We also mapped the ideal flow of data through a site to better understand how its data collection works. RESULTS We identified 13 registers (9 standard, 4 non-standard), 5 types of stationery and 4 databases as sources of medical information within a site. Not all clinics used all the standardised registers, and in those that did, registers were kept in various degrees of completeness: a common problem was inconsistent recording of folder numbers. The quality of patient stationery was generally high, with only the chronic patient record being considered of varied quality. The TIER.Net database had high-quality information on key variables, but national identification (ID) number was incompletely captured (42% complete). Very few evaluation sites used electronic data collection systems for conditions other than HIV/AIDS. CONCLUSION Registers, databases and clinical stationery were not implemented or completed consistently across the 24 evaluation sites. For those considering using routinely collected data for research and evaluation purposes, we would recommend a thorough review of clinic data collection systems for both quality and completeness before considering them to be a reliable data source.
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Enslin D, Mallya P. Factors influencing treatment adherence in hypertension and HIV management in South Africa: A comparative literature review. S Afr Fam Pract (2004) 2022; 64:e1-e10. [PMID: 36073101 PMCID: PMC10064525 DOI: 10.4102/safp.v64i1.5434] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 03/29/2022] [Accepted: 04/11/2022] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Hypertension (HTN) is the most significant risk factor for cardiovascular disease (CVD) in South Africa (SA), with one in three people over the age of 25 suffering from HTN. Whilst human immunodeficiency virus and acquired immunodeficiency syndrome (HIV/AIDS) are the leading causes of death in South Africa, CVD is in the top 10 causes of death, demonstrating the importance of detecting and controlling blood pressure early on. This study aimed to review adherence factors to antihypertensive medication and antiretroviral therapy (ART) and evaluate the resulting factors influencing adherence discrepancies within the South African population. METHODS A comprehensive literature review was carried out. PubMed, ScienceDirect, Cochrane and Embase were searched for English publications between 2000 and 2021. RESULTS A total of 50 articles covering quantitative and qualitative studies were included. Many studies identified poor adherence levels to antihypertensive treatment, reaching a substandard adherence rate of 41.9%, whilst most studies on the HIV-positive population reported good levels of adherence, with adherence rates of more than 90%. Being of the male gender, advanced age, low socioeconomic status and a low level of education were associated with unsatisfactory adherence rates in both groups. Within the HIV group, more participants had better knowledge concerning the extent of their disease and its required treatments. CONCLUSION The results present substandard adherence levels to antihypertensives compared with antiretroviral (ARV) adherence, despite the influence of more non-adherence factors in the HIV group. The authors recommend better adherence counselling for patients with HTN during every clinic visit, regular healthcare worker training and the implementation of ART adherence programmes in patients with hypertension.
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Affiliation(s)
- Dimitra Enslin
- Department of Health Sciences, Faculty of Life Sciences and Education, University of South Wales, Pontypridd.
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10
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Coetzee LM, Cassim N, Glencross DK. Newly implemented community CD4 service in Tshwaragano, Northern Cape province, South Africa, positively impacts result turn-around time. Afr J Lab Med 2022; 11:1376. [PMID: 35811752 PMCID: PMC9257740 DOI: 10.4102/ajlm.v11i1.1376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 02/25/2022] [Indexed: 11/17/2022] Open
Abstract
Background The Northern Cape is South Africa’s largest province with an HIV prevalence of 7.1% versus a 13.5% national prevalence. CD4 testing is provided at three of five National Health Laboratory Service district laboratories, each covering a 250 km precinct radius. Districts without a local service report prolonged CD4 turn-around times (TAT). Objective This study documented the impact of a new CD4 laboratory in Tshwaragano in the remote John Taolo Gaetsewe district of the Northern Cape, South Africa. Methods CD4 test volumes and TAT (total, pre-analytical, analytical, and post-analytical) data for the Northern Cape province were extracted for June 2018 to October 2019. The percentage of CD4 results within the stipulated 40-h TAT cut-off and the median and 75th percentiles of all TAT parameters were calculated. Pre-implementation, samples collected at Tshwaragano were referred to Kimberley or Upington, Northern Cape, South Africa. Results Pre-implementation, 95.4% of samples at Tshwaragano were referred to Kimberley for CD4 testing (36.3% of Kimberley’s test volumes). Only 7.5% of Tshwaragano’s total samples were referred post-implementation. The Tshwaragano laboratory’s CD4 median total TAT decreased from 24.7 h pre-implementation to 12 h post-implementation (p = 0.003), with > 95.0% of results reported within 40 h. The Kimberley laboratory workload decreased by 29.0%, and testing time significantly decreased from 10 h to 4.3 h. Conclusion The new Tshwaragano CD4 service significantly decreased local TAT. Upgrading existing community laboratories to include CD4 testing can alleviate provincial service load and improve local access, TAT and efficiency in the centralised reference laboratory.
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Affiliation(s)
- Lindi-Marie Coetzee
- National Priority Programme, National Health Laboratory Service, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
- Department of Molecular Medicine and Haematology, University of the Witwatersrand, Johannesburg, South Africa
| | - Naseem Cassim
- National Priority Programme, National Health Laboratory Service, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
- Department of Molecular Medicine and Haematology, University of the Witwatersrand, Johannesburg, South Africa
| | - Deborah K. Glencross
- National Priority Programme, National Health Laboratory Service, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
- Department of Molecular Medicine and Haematology, University of the Witwatersrand, Johannesburg, South Africa
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11
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Joseph Davey DL, Wall KM, Naidoo N, Naidoo D, Xaba G, Serao C, Malone T, Dovel K. HIV testing and linkage to ART following secondary distribution of HIV self-test kits to male partners of women living with HIV: a pilot randomized control trial in Mpumalanga, South Africa. J Int AIDS Soc 2022; 25:e25937. [PMID: 35690880 PMCID: PMC9188623 DOI: 10.1002/jia2.25937] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 05/12/2022] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION South African men are underrepresented in HIV testing and treatment services. Secondary distribution of oral HIV self-test (HIVST) kits by women living with HIV (WLHIV) to their male partners (i.e. index partner HIVST) may increase men's testing and treatment but has been understudied. METHODS Between March and July 2021, we evaluated the effectiveness of index partner HIVST versus the standard of care (SOC) (invitations for men's facility-based testing) on men's testing in a 1:1 randomized control trial. Eligibility criteria included: WLHIV; ≥18 years of age; attending one of four high-density rural clinics; have a working cell phone; and self-reported having a primary male partner of unknown serostatus. The primary outcome was the proportion of WLHIV reporting that her partner tested for HIV within 3 months after enrolment. RESULTS We enrolled 180 WLHIV and 176 completed an endline survey (mean age = 35 years, 15% pregnant, 47% unmarried or non-cohabiting). In the HIVST arm, 78% of male partners were reported to have tested for HIV versus 55% in SOC (RR = 1.41; 95% CI = 1.14-1.76). In the HIVST arm, nine men were reactive with HIVST (14% positivity), six were confirmed HIV positive with standard testing (67%) and all of those started antiretroviral therapy (ART), and four HIV-negative men started pre-exposure prophylaxis (PrEP) (5%). In SOC, six men were diagnosed with HIV (12% positivity), 100% started ART and seven HIV-negative men started PrEP (16%). One case of verbal intimate partner violence was reported in the HIVST arm. CONCLUSIONS Secondary distribution of HIVST to partners of WLHIV was acceptable and effective for improving HIV testing among men in rural South Africa in our pilot study. Interventions are needed to link reactive HIVST users to confirmatory testing and ART.
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Affiliation(s)
- Dvora L Joseph Davey
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA.,Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Los Angeles, California, USA.,Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Kristin M Wall
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | | | | | - Gugu Xaba
- BroadReach Healthcare, Johannesburg, South Africa
| | - Claire Serao
- BroadReach Healthcare, Johannesburg, South Africa
| | - Todd Malone
- BroadReach Healthcare, Johannesburg, South Africa
| | - Kathryn Dovel
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
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12
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Reynolds Z, McCluskey SM, Moosa MYS, Gilbert RF, Pillay S, Aturinda I, Ard KL, Muyindike W, Musinguzi N, Masette G, Moodley P, Brijkumar J, Rautenberg T, George G, Johnson BA, Gandhi RT, Sunpath H, Marconi VC, Bwana MB, Siedner MJ. Who's slipping through the cracks? A comprehensive individual, clinical and health system characterization of people with virological failure on first-line HIV treatment in Uganda and South Africa. HIV Med 2021; 23:474-484. [PMID: 34755438 PMCID: PMC9010349 DOI: 10.1111/hiv.13203] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 10/18/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES HIV virological failure remains a major threat to programme success in sub-Saharan Africa. While HIV drug resistance (HIVDR) and inadequate adherence are the main drivers of virological failure, the individual, clinical and health system characteristics that lead to poor outcomes are not well understood. The objective of this paper is to identify those characteristics among people failing first-line antiretroviral therapy (ART). METHODS We enrolled a cohort of adults in HIV care experiencing virological failure on first-line ART at five sites and used standard statistical methods to characterize them with a focus on three domains: individual/demographic, clinical, and health system, and compared each by country of enrolment. RESULTS Of 840 participants, 51% were women, the median duration on ART was 3.2 years [interquartile range (IQR) 1.1, 6.4 years] and the median CD4 cell count prior to failure was 281 cells/µL (IQR 121, 457 cells/µL). More than half of participants [53%; 95% confidence interval (CI) 49-56%] stated that they had > 90% adherence and 75% (95% CI 72-77%) took their ART on time all or most of the time. Conversely, the vast majority (90%; 95% CI 86-92%) with a completed genotypic drug resistance test had any HIV drug resistance. This population had high health system use, reporting a median of 3 (IQR 2.6) health care visits and a median of 1 (IQR 1.1) hospitalization in the preceding 6 months. CONCLUSIONS Patients failing first-line ART in sub-Saharan Africa generally report high rates of adherence to ART, have extremely high rates of HIV drug resistance and utilize significant health care resources. Health systems interventions to promptly detect and manage treatment failure will be a prerequisite to establishing control of the HIV epidemic.
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Affiliation(s)
| | - Suzanne M McCluskey
- Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | | | | | | | - Isaac Aturinda
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Kevin L Ard
- Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | | | | | - Godfrey Masette
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Pravi Moodley
- University of KwaZulu-Natal, Durban, South Africa.,National Health Laboratory Service, KwaZulu-Natal, Durban, South Africa
| | | | | | - Gavin George
- University of KwaZulu-Natal, Durban, South Africa
| | - Brent A Johnson
- Department of Biostatistics and Computation Biology, University of Rochester, Rochester, NY, USA
| | - Rajesh T Gandhi
- Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | | | - Vincent C Marconi
- Emory University School of Medicine, Atlanta, GA, USA.,Department of Global Health, Emory University, Atlanta, GA, USA.,Emory Vaccine Center, Atlanta, GA, USA
| | | | - Mark J Siedner
- Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,University of KwaZulu-Natal, Durban, South Africa.,Mbarara University of Science and Technology, Mbarara, Uganda.,Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa
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13
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Bengtson AM, Espinosa Dice AL, Kirwa K, Cornell M, Colvin CJ, Lurie MN. Patient Transfers and Their Impact on Gaps in Clinical Care: Differences by Gender in a Large Cohort of Adults Living with HIV on Antiretroviral Therapy in South Africa. AIDS Behav 2021; 25:3337-3346. [PMID: 33609203 DOI: 10.1007/s10461-021-03191-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2021] [Indexed: 01/14/2023]
Abstract
For people living with HIV (PLWH), patient transfers may affect engagement in care. We followed a cohort of PLWH in Cape Town, South Africa who tested positive for HIV in 2012-2013 from ART initiation in 2012-2016 through December 2016. Patient transfers were defined as moving from one healthcare facility to another on a different day, considering all healthcare visits and recorded HIV-visits only. We estimated incidence rates (IR) for transfers by time since ART initiation, overall and by gender, and associations between transfers and gaps of > 180 days in clinical care. Overall, 4,176 PLWH were followed for a median of 32 months, and 8% (HIV visits)-17% (all healthcare visits) of visits were patient transfers. Including all healthcare visits, transfers were highest through 3 months on ART (IR 20.2 transfers per 100 visits, 95% CI 19.2-21.2), but increased through 36 months on ART when only HIV visits were included (IR 9.7, 95% CI 8.8-10.8). Overall, women were more likely to transfer than men, and transfers were associated with gaps in care (IR ratio [IRR] 3.06 95% CI 2.83-3.32; HIV visits only). In this cohort, patient transfers were frequent, more common among women, and associated with gaps in care.
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14
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Fast-track treatment initiation counselling in South Africa: A cost-outcomes analysis. PLoS One 2021; 16:e0248551. [PMID: 33735206 PMCID: PMC7971492 DOI: 10.1371/journal.pone.0248551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 03/01/2021] [Indexed: 11/19/2022] Open
Abstract
Introduction In 2016, under its new National Adherence Guidelines (AGL), South Africa formalized an existing model of fast-track HIV treatment initiation counselling (FTIC). Rollout of the AGL included an evaluation study at 24 clinics, with staggered AGL implementation. Using routinely collected data extracted as part of the evaluation study, we estimated and compared the costs of HIV care and treatment from the provider’s perspective at the 12 clinics implementing the new, formalized model (AGL-FTIC) to costs at the 12 clinics continuing to implement some earlier, less formalized, model that likely varied across clinics (denoted here as early-FTIC). Methods This was a cost-outcome analysis using standard methods and a composite outcome defined as initiated antiretroviral therapy (ART) within 30 days of treatment eligibility and retained in care at 9 months. Using patient-level, bottom-up resource-utilization data and local unit costs, we estimated patient-level costs of care and treatment in 2017 U.S. dollars over the 9-month evaluation follow-up period for the two models of care. Resource use and costs, disaggregated by antiretroviral medications, laboratory tests, and clinic visits, are reported by model of care and stratified by the composite outcome. Results A total of 350/343 patients in the early-FTIC/AGL-FTIC models of care are included in this analysis. Mean/median costs were similar for both models of care ($135/$153 for early-FTIC, $130/$151 for AGL-FTIC). For the subset achieving the composite outcome, resource use and therefore mean/median costs were similar but slightly higher, reflecting care consistent with treatment guidelines ($163/$166 for early-FTIC, $168/$170 for AGL-FTIC). Not surprisingly, costs for patients not achieving the composite outcome were substantially less, mainly because they only had two or fewer follow-up visits and, therefore, received substantially less ART than patients who achieved the composite outcome. Conclusion The 2016 adherence guidelines clarified expectations for the content and timing of adherence counseling sessions in relation to ART initiation. Because clinics were already initiating patients on ART quickly by 2016, little room existed for the new model of fast-track initiation counseling to reduce the number of pre-ART clinic visits at the study sites and therefore to reduce costs of care and treatment. Trial registration Clinical Trial Number: NCT02536768.
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15
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Van Ginderdeuren E, Bassett J, Hanrahan CF, Mutunga L, Van Rie A. Novel health system strategies for tuberculin skin testing at primary care clinics: Performance assessment and health economic evaluation. PLoS One 2021; 16:e0246523. [PMID: 33596215 PMCID: PMC7888676 DOI: 10.1371/journal.pone.0246523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 01/20/2021] [Indexed: 11/18/2022] Open
Abstract
Background Tuberculin skin test (TST) for guiding initiation of tuberculosis preventive therapy poses major challenges in high tuberculosis burden settings. Methods At a primary care clinic in Johannesburg, South Africa, 278 HIV-positive adults self-read their TST by reporting if they felt a bump (any induration) at the TST placement site. TST reading (in mm) was fast-tracked to reduce patient wait time and task-shifted to delegate tasks to lower cadre healthcare workers, and result was compared to TST reading by high cadre research staff. TST reading and placement cost to the health system and patients were estimated. Simulations of health system costs were performed for 5 countries (USA, Germany, Brazil, India, Russia) to evaluate generalizability. Results Almost all participants (269 of 278, 97%) correctly self-identified the presence or absence of any induration [sensitivity 89% (95% CI 80,95) and specificity 99.5% (95% CI 97,100)]. For detection of a positive TST (induration ≥ 5mm), sensitivity was 90% (95% CI 81,96) and specificity 99% (95% CI 97,100). TST reading agreement between low and high cadre staff was high (kappa 0.97, 95% CI 0.94, 1.00). Total TST cost was 2066 I$ (95% UI 594, 5243) per 100 patients, 87% (95% UI 53, 95) of which were patient costs. Combining fast-track and task-shifting, reduced total costs to 1736 I$ (95% UI 497, 4300) per 100 patients, with 31% (95% UI 15, 42) saving in health system costs. Combining fast-tracking, task-shifting and self-reading, lowered the TST health system costs from 16% (95% UI 8, 26) in Russia to 40% (95% UI 18, 54) in the USA. Conclusion A TST strategy where only patients with any self-read induration are asked to return for fast-tracked TST reading by lower cadre healthcare workers is a promising strategy that could be effective and cost-saving, but real-life cost-effectiveness should be further examined.
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Affiliation(s)
- Eva Van Ginderdeuren
- Witkoppen Clinic, Johannesburg, South Africa
- Family Medicine and Population Health, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
- * E-mail:
| | | | - Colleen F. Hanrahan
- Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | | | - Annelies Van Rie
- Family Medicine and Population Health, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
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16
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Jopling R, Nyamayaro P, Andersen LS, Kagee A, Haberer JE, Abas MA. A Cascade of Interventions to Promote Adherence to Antiretroviral Therapy in African Countries. Curr HIV/AIDS Rep 2021; 17:529-546. [PMID: 32776179 PMCID: PMC7497365 DOI: 10.1007/s11904-020-00511-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Purpose of Review We reviewed interventions to improve uptake and adherence to antiretroviral therapy (ART) in African countries in the Treat All era. Recent Findings ART initiation can be improved by facilitated rapid receipt of first prescription, including community-based linkage and point-of-care strategies, integration of HIV care into antenatal care and peer support for adolescents. For people living with HIV (PLHIV) on ART, scheduled SMS reminders, ongoing intensive counselling for those with viral non-suppression and economic incentives for the most deprived show promise. Adherence clubs should be promoted, being no less effective than facility-based care for stable patients. Tracing those lost to follow-up should be targeted to those who can be seen face-to-face by a peer worker. Summary Investment is needed to promote linkage to initiating ART and for differentiated approaches to counselling for youth and for those with identified suboptimal adherence. More evidence from within Africa is needed on cost-effective strategies to identify and support PLHIV at an increased risk of non-adherence across the treatment cascade. Electronic supplementary material The online version of this article (10.1007/s11904-020-00511-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rebecca Jopling
- Health Service & Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Primrose Nyamayaro
- Department of Psychiatry, University of Zimbabwe College of Health Sciences, Mazowe Street, Avondale, Harare, Zimbabwe
| | - Lena S Andersen
- HIV Mental Health Research Unit, Division of Neuropsychiatry, Department of Psychiatry and Mental Health, University of Cape Town, Groote Schuur Hospital Anzio Road, Observatory, Cape Town, South Africa
| | - Ashraf Kagee
- Department of Psychology, Stellenbosch University, Stellenbosch, 7602, South Africa
| | - Jessica E Haberer
- Center for Global Health, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Melanie Amna Abas
- Health Service & Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.
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17
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Grimsrud A, Wilkinson L, Eshun-Wilson I, Holmes C, Sikazwe I, Katz IT. Understanding Engagement in HIV Programmes: How Health Services Can Adapt to Ensure No One Is Left Behind. Curr HIV/AIDS Rep 2020; 17:458-466. [PMID: 32844274 PMCID: PMC7497373 DOI: 10.1007/s11904-020-00522-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW Despite the significant progress in the HIV response, gaps remain in ensuring engagement in care to support life-long medication adherence and viral suppression. This review sought to describe the different points in the HIV care cascade where people living with HIV were not engaging and highlight promising interventions. RECENT FINDINGS There are opportunities to improve engagement both between testing and treatment and to support re-engagement in care for those in a treatment interruption. The gap between testing and treatment includes people who know their HIV status and people who do not know their status. People in a treatment interruption include those who interrupt immediately following initiation, early on in their treatment (first 6 months) and late (after 6 months or more on ART). For each of these groups, specific interventions are required to support improved engagement. There are diverse needs and specific populations of people living with HIV who are not engaged in care, and differentiated service delivery interventions are required to meet their needs and expectations. For the HIV response to realise the 2030 targets, engagement will need to be supported by quality care and patient choice combined with empowered patients who are treatment literate and have been supported to improve self-management.
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Affiliation(s)
- Anna Grimsrud
- International AIDS Society, 3 Doris Road, Claremont, Cape Town, 7708 South Africa
- Desmond Tutu HIV Centre, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925 South Africa
| | - Lynne Wilkinson
- International AIDS Society, 3 Doris Road, Claremont, Cape Town, 7708 South Africa
- Department of Public Health Medicine, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Charles Holmes
- Center for Innovation in Global Health, Georgetown University, Washington, DC USA
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Ingrid T. Katz
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA USA
- Harvard Medical School, Boston, MA USA
- Massachusetts General Hospital Center for Global Health, Boston, MA USA
- Harvard Global Health Institute, Cambridge, MA USA
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18
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Pascoe SJS, Scott NA, Fong RM, Murphy J, Huber AN, Moolla A, Phokojoe M, Gorgens M, Rosen S, Wilson D, Pillay Y, Fox MP, Fraser‐Hurt N. "Patients are not the same, so we cannot treat them the same" - A qualitative content analysis of provider, patient and implementer perspectives on differentiated service delivery models for HIV treatment in South Africa. J Int AIDS Soc 2020; 23:e25544. [PMID: 32585077 PMCID: PMC7316408 DOI: 10.1002/jia2.25544] [Citation(s) in RCA: 11] [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: 11/06/2019] [Revised: 04/15/2020] [Accepted: 05/08/2020] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION In 2014, the South African government adopted a differentiated service delivery (DSD) model in its "National Adherence Guidelines for Chronic Diseases (HIV, TB and NCDs)" (AGL) to strengthen the HIV care cascade. We describe the barriers and facilitators of the AGL implementation as experienced by various stakeholders in eight intervention and control sites across four districts. METHODS Embedded within a cluster-randomized evaluation of the AGL, we conducted 48 in-depth interviews (IDIs) with healthcare providers, 16 IDIs with Department of Health and implementing partners and 24 focus group discussions (FGDs) with three HIV patient groups: new, stable and those not stable on treatment or not adhering to care. IDIs were conducted from August 2016 to August 2017; FGDs were conducted in January to February 2017. Content analysis was guided by the Consolidated Framework for Implementation Research. Findings were triangulated among respondent types to elicit barriers and facilitators to implementation. RESULTS New HIV patients found counselling helpful but intervention respondents reported sub-optimal counselling and privacy concerns as barriers to initiation. Providers felt insufficiently trained for this intervention and were confused by the simultaneous rollout of the Universal Test and Treat strategy. For stable patients, repeat prescription collection strategies (RPCS) were generally well received. Patients and providers concurred that RPCS reduced congestion and waiting times at clinics. There was confusion though, among providers and implementers, around implementation of RPCS interventions. For patients not stable on treatment, enhanced counselling and tracing patients lost-to-follow-up were perceived as beneficial to adherence behaviours but faced logistical challenges. All providers faced difficulties accessing data and identifying patients in need of tracing. Congestion at clinics and staff attitude were perceived as barriers preventing patients returning to care. CONCLUSIONS Implementation of DSD models at scale is complex but this evaluation identified several positive aspects of AGL implementation. The positive perception of RPCS interventions and challenges managing patients not stable on treatment aligned with results from the larger evaluation. While some implementation challenges may resolve with experience, ensuring providers and implementers have the necessary training, tools and resources to operationalize AGL effectively is critical to the overall success of South Africa's HIV control strategy.
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Affiliation(s)
- Sophie J S Pascoe
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Nancy A Scott
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
| | - Rachel M Fong
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
| | - Joshua Murphy
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Amy N Huber
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Aneesa Moolla
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | | | | | - Sydney Rosen
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
| | | | - Yogan Pillay
- National Department of HealthPretoriaSouth Africa
| | - Matthew P Fox
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
- Department of EpidemiologyBoston University School of Public HealthBostonMAUSA
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19
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Joseph Davey D, Kehoe K, Serrao C, Prins M, Mkhize N, Hlophe K, Sejake S, Malone T. Same-day antiretroviral therapy is associated with increased loss to follow-up in South African public health facilities: a prospective cohort study of patients diagnosed with HIV. J Int AIDS Soc 2020; 23:e25529. [PMID: 32510186 PMCID: PMC7277782 DOI: 10.1002/jia2.25529] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 03/09/2020] [Accepted: 04/17/2020] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION South Africa introduced Universal Test and Treat in 2016 including antiretroviral therapy (ART) initiation on the same-day as HIV diagnosis. Our study sought to evaluate the impact of same-day ART initiation on loss to follow-up (LTFU) and mortality comparing with patients who initiated ART after their HIV diagnosis. METHODS We conducted a file review of patients with a HIV diagnosis and ART start date on file between September 2016 and May 2018 in six high HIV burden districts. Our primary outcome was LTFU (>90 days from the last clinical visit or drug pick-up until database closure 31 July 2018). The secondary outcome was mortality after ART initiation. Time to outcome was assessed comparing same-day vs. one to seven, eight to twenty-one and ≥ twenty-two days to ART initiation using Kaplan-Meier estimators stratified by sex. We investigated predictors using univariate and multivariable Cox proportional hazards models, adjusting for a priori characteristics. RESULTS Overall, 92,609 ART patients contributed 43,922 person-years from ART initiation, with a median follow-up time of 246 days (IQR = 112 to 455). Of these patients, 33,399 (36%) initiated ART on the same-day as their HIV diagnosis date and had a median follow-up time of 174 days (IQR = 85 to 349). Same-day patients were predominantly non-pregnant females (56%) and aged 25 to 34 years (40%). Same-day ART initiation increased from 2.8% in September 2016 to 7.1% in April 2018. In same-day patients, 33% (n = 11,114) were classified as LTFU with a median time of 55 days (IQR = 1 to 185), compared to 371 mean days (IQR = 161 to 560) in patients who initiated ≥22 days after diagnosis. A similar proportion of LTFU was observed for patients who initiated later: 31% 1 to 21 day and 33% ≥22 day. Same-day ART patients had an increased risk of LTFU vs. ≥1 day (adjusted hazard ratio (aHR) = 1.28, 95% CI = 1.24 to 1.33) adjusting for covariates. Although all-cause mortality was slightly lower in same-day patients (0.9%) vs. >1 day (1.4%; aHR = 0.87, 95% CI = 0.72 to 1.05) adjusting for covariates. Men had highest risk of mortality and LTFU. CONCLUSIONS Same-day ART increased the risk of LTFU, but same-day patients experienced slightly lower mortality. Same-day patients may require additional counselling and interventions to improve retention. Additional research is needed on targeted interventions, including differentiated care, to reduce LTFU in patients initiating ART same-day.
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Affiliation(s)
- Dvora Joseph Davey
- Department of EpidemiologyFielding School of Public HealthUniversity of CaliforniaLos AngelesCAUSA
- Division of Epidemiology and BiostatisticsSchool of Public Health and Family MedicineUniversity of Cape TownSouth Africa
| | - Kathleen Kehoe
- Division of Epidemiology and BiostatisticsSchool of Public Health and Family MedicineUniversity of Cape TownSouth Africa
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Dorward J, Sookrajh Y, Gate K, Khubone T, Mtshaka N, Mlisana K, Ngobese H, Yende‐Zuma N, Garrett N. HIV treatment outcomes among people with initiation CD4 counts >500 cells/µL after implementation of Treat All in South African public clinics: a retrospective cohort study. J Int AIDS Soc 2020; 23:e25479. [PMID: 32319203 PMCID: PMC7174836 DOI: 10.1002/jia2.25479] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 01/30/2020] [Accepted: 03/05/2020] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION The World Health Organisation recommends to Treat All people with HIV, irrespective of CD4 count. However, people with CD4 counts >500 cells/µL may be asymptomatic and therefore less motivated to adhere to antiretroviral therapy (ART). We aimed to assess whether people initiated with CD4 counts >500 cells/µL had worse treatment outcomes compared to those initiated at lower CD4 counts. METHODS We performed a retrospective cohort study among non-pregnant adults initiating ART at eight public clinics in South Africa between September 2016, when Treat All was implemented, and August 2017. We assessed whether initiation CD4 count >500 cells/µL was associated with the outcomes of attrition (death, lost to follow-up or treatment interruption >180 days), and viraemia >1000 copies/mL, by twelve months using Cox proportional hazards and Poisson regression models. RESULTS AND DISCUSSION Among 4952 patients initiating ART, the median age was 32.4 years (interquartile range (IQR) 27.2 to 39.7), 58.9% were women and 30.3% had an initiation CD4 count >500 cells/µL. After twelve months, 3382 (68.3%) were retained in care, 303 (6.1%) had transferred to another clinic, 1010 (20.4%) were lost to follow-up, 232 (4.7%) had a treatment interruption >180 days and 25 (0.5%) were known to have died. Overall, 1267 experienced attrition at a median time of 91 days (IQR 23 to 213), with 302 of these (23.8%) experiencing attrition immediately after their ART initiation visit. Among those in care at twelve months with viral load results, 4.6% had viraemia. In multivariable analysis, the hazard of attrition was similar between patients newly eligible for ART with CD4 counts >500 cells/µL compared to those with CD4 ≤500 cells/µL (adjusted hazard ratio 1.03, 95% confidence interval (CI) 0.90 to 1.17). The risk of viraemia was lower among patients with CD4 counts >500 cells/µL compared to those with CD4 ≤500 cells/µL (adjusted risk ratio 0.58, 95% CI 0.37 to 0.92). CONCLUSIONS After implementation of Treat All in South African public clinics, we found that patients newly eligible for ART with initiation CD4 counts >500 cells/µL had comparable or better outcomes compared to those with lower CD4 counts. These finding support ongoing implementation of Treat All in our setting.
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Affiliation(s)
- Jienchi Dorward
- Centre for the AIDS Programme of Research in South Africa (CAPRISA)University of KwaZulu–NatalDurbanSouth Africa
- Nuffield Department of Primary Care Health SciencesUniversity of OxfordOxfordUnited Kingdom
| | - Yukteshwar Sookrajh
- eThekwini Municipality Health Unit, eThekwini MunicipalityDurbanSouth Africa
| | - Kelly Gate
- Bethesda HospitalUbomboSouth Africa
- Department of Family MedicineUniversity of KwaZulu‐NatalDurbanSouth Africa
| | - Thokozani Khubone
- eThekwini Municipality Health Unit, eThekwini MunicipalityDurbanSouth Africa
| | - Nomsa Mtshaka
- eThekwini Municipality Health Unit, eThekwini MunicipalityDurbanSouth Africa
| | - Koleka Mlisana
- Centre for the AIDS Programme of Research in South Africa (CAPRISA)University of KwaZulu–NatalDurbanSouth Africa
- National Health Laboratory ServiceJohannesburgSouth Africa
- School of Laboratory Medicine and Medical SciencesUniversity of KwaZulu‐NatalDurbanSouth Africa
| | - Hope Ngobese
- eThekwini Municipality Health Unit, eThekwini MunicipalityDurbanSouth Africa
| | - Nonhlanhla Yende‐Zuma
- Centre for the AIDS Programme of Research in South Africa (CAPRISA)University of KwaZulu–NatalDurbanSouth Africa
| | - Nigel Garrett
- Centre for the AIDS Programme of Research in South Africa (CAPRISA)University of KwaZulu–NatalDurbanSouth Africa
- Discipline of Public Health MedicineSchool of Nursing and Public HealthUniversity of KwaZulu‐NatalDurbanSouth Africa
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