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Cowan FM, Machingura F, Ali MS, Chabata ST, Takaruza A, Dirawo J, Makamba M, Hove T, Bansi-Matharu L, Matambanadzo P, Shahmanesh M, Busza J, Steen R, Yekeye R, Mpofu A, Mugurungi O, Phillips AN, Hargreaves JR. A risk-differentiated, community-led intervention to strengthen uptake and engagement with HIV prevention and care cascades among female sex workers in Zimbabwe (AMETHIST): a cluster randomised trial. Lancet Glob Health 2024; 12:e1424-e1435. [PMID: 39151978 PMCID: PMC11345450 DOI: 10.1016/s2214-109x(24)00235-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 04/28/2024] [Accepted: 05/31/2024] [Indexed: 08/19/2024]
Abstract
BACKGROUND Female sex workers remain disproportionately affected by HIV. The aim of this study was to determine the effect of risk-differentiated, peer-led support for female sex workers in Zimbabwe on the risk of HIV acquisition and HIV transmission from sex among female sex workers. METHODS In this cluster randomised, open-label, controlled study, 22 clinics dedicated to female sex workers co-located in government health facilities throughout Zimbabwe were allocated (1:1, through restricted randomisation) to usual care or AMETHIST intervention. Usual care comprised HIV testing, pre-exposure prophylaxis (PrEP), referral to government antiretroviral therapy (ART) services, contraception, condoms, syndromic management of sexually transmitted infections, health education, legal advice, and peer support. AMETHIST added peer-led microplanning tailored to individuals' risk and participatory self-help groups. All cisgender women (aged >18 years) who had sold sex within the past 30 days and lived or worked within trial cluster areas were eligible. Intervention status was not masked to programme implementers but was masked to survey teams and laboratory staff. After 28 months, a respondent-driven sampling (RDS) survey was done in the female sex worker population around each clinic, which measured the primary outcome, the combined proportion of female sex workers in the surveyed population at risk of transmitting HIV (ie, were HIV positive, not virally suppressed, and not consistently using condoms) or at risk of acquiring HIV (ie, were HIV negative and not consistently using condoms or PrEP). We report prespecified analyses of the disaggregated proportions of female sex workers in the surveyed population at risk of either transmission or acquisition of HIV. Analyses were prespecified, RDS-weighted, and age-adjusted. This trial is registered with the Pan African Clinical Trials Registry, PACTR202007818077777. FINDINGS The AMETHIST intervention was started on May 15, 2019, and data were collected from June 1, 2019, until Dec 13, 2021. The RDS survey was done from Oct 18 to Dec 13, 2021, with 2137 women included in the usual care group (11 clusters) and 2131 in the AMETHIST intervention group (11 clusters) after excluding survey seeds (n=132) and women with missing key data (n=44). 1973 (46·2%) of the 4268 female sex workers surveyed were living with HIV; of these, 863 (93·5%; RDS-adjusted) of 931 women in the intervention group and 927 (88·8%) of 1042 in the usual care group were virologically suppressed. 287 (22·4%) of 1200 HIV-negative women in the intervention group and 194 (15·7%) of 1096 in the usual care group reported currently taking PrEP, of whom only two (0·4%) of 569 had protective tenofovir diphosphate concentrations in dried blood spots (>700 fmol/dried blood punch). There was no effect of the intervention on the primary endpoint of risk of both HIV transmission and acquisition (intervention group n=1156/2131, RDS-adjusted proportion 55·3%; usual care group n=1104/2137, RDS-adjusted proportion 52·7%; age-adjusted risk difference -0·9%, 95% CI -5·7% to 3·9%, p=0·70). For the secondary outcomes, the proportion of women living with HIV at risk of transmission was low and significantly reduced in the intervention group (n=63/931, RDS-adjusted proportion 5·8%) compared with the usual care group (103/1041, 10·4%), with an age-adjusted risk difference of -5·5% (95% CI -8·2% to -2·9%, p=0·0003). Risk of acquisition among HIV-negative women was similar in the intervention (n=1093/1200, RDS-adjusted proportion 92·1%) and the usual care group (1001/1096, 92·2%), with an age-adjusted risk difference of -0·6% (95% CI -4·6 to 3·4, p=0·74). INTERPRETATION There was no overall benefit of the intervention on combined risk of transmission or acquisition. Viral load suppression in women living with HIV was high and appeared to be further improved by AMETHIST, suggesting potential for impressive uptake and adherence to ART in vulnerable and mobile populations. Sustaining treatment and reinvigorating prevention remain crucial. FUNDING The Wellcome Trust and the Bill & Melinda Gates Foundation. TRANSLATIONS For the Shona and Ndebele translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- Frances M Cowan
- Department of International Health, Liverpool School of Tropical Medicine, Liverpool, UK; Centre for Sexual Health and HIV AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe.
| | - Fortunate Machingura
- Centre for Sexual Health and HIV AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe
| | - M Sanni Ali
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Sungai T Chabata
- Centre for Sexual Health and HIV AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe
| | - Albert Takaruza
- Centre for Sexual Health and HIV AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe
| | - Jeffrey Dirawo
- Centre for Sexual Health and HIV AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe
| | - Memory Makamba
- Centre for Sexual Health and HIV AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe
| | - Tsitsi Hove
- Centre for Sexual Health and HIV AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe
| | | | | | - Maryam Shahmanesh
- Institute of Global Health, University College London, London, UK; Africa Health Research Institute, Durban, South Africa
| | - Joanna Busza
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Richard Steen
- Department of International Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | | | - Owen Mugurungi
- Directorate of AIDS and TB, Ministry of Health and Child Care, Harare, Zimbabwe
| | | | - James R Hargreaves
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
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Sebeza J, Muiruri C, Riedel DJ, Stafford K, Omari H, Memiah P, Lavoie MC, Tuyishime S, Rwibasira G, Deyessa N, Ntaganira J. Is the Differentiated Service Delivery Model Suited to the Needs of People Living with HIV in Rwanda? AIDS Behav 2024; 28:2941-2949. [PMID: 38780868 DOI: 10.1007/s10461-024-04376-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2024] [Indexed: 05/25/2024]
Abstract
The primary goal of antiretroviral treatment is to improve the health of individuals with HIV, and a secondary goal is to prevent further transmission. In 2016, Rwanda adopted the World Health Organization's "treat-all" approach in combination with the differentiated service delivery (DSD) model. The model's goal was to shorten the time from HIV diagnosis to treatment initiation, regardless of the CD4 T-cell count. This study sought to identify perceptions, enablers, and challenges associated with DSD model adoption among PLHIV.This study included selected health centers in Kigali city, Rwanda, between August and September 2022. The patients included were those exposed to the new HIV care model (DSD) model and those exposed to the previous model who transitioned to the current model. Interviews and focus group discussions were also held to obtain views and opinions on the DSD model. The data were collected via questionnaires and audio-recorded focus group discussions and were subsequently analyzed.The study identified several themes, including participants' initial emotions about a new HIV diagnosis, disclosure, experiences with transitioning to the DSD model, the effect of peer education, and barriers to and facilitators of the DSD model. Participants appreciated reduced clinic visits under the DSD model but faced transition and peer educator mobility challenges.The DSD model reduces waiting times, educates patients, and aligns with national goals. Identified barriers call for training and improved peer educator retention. Recommendations include enhancing the DSD model and future research to evaluate its long-term impact and cost-effectiveness.
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Affiliation(s)
- J Sebeza
- College of Medicine and Health Sciences, School of Public Health, University of Rwanda, Gasabo District, 103KG 47ST, Kigali, Rwanda.
| | - C Muiruri
- Department of Population Health Sciences, Duke University, Duke, NC, USA
| | - D J Riedel
- Institute of Human Virology, Division of Infectious Diseases, School of Medicine, University of Maryland, Baltimore, MD, USA
| | - K Stafford
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - H Omari
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - P Memiah
- Graduate School, University of Maryland Baltimore, Baltimore, MD, USA
| | - M C Lavoie
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - S Tuyishime
- Rwanda Biomedical Center, Ministry of Health, Kigali, Rwanda
| | - G Rwibasira
- Rwanda Biomedical Center, Ministry of Health, Kigali, Rwanda
| | - N Deyessa
- College of Medicine and Health Sciences, School of Public Health, University of Rwanda, Gasabo District, 103KG 47ST, Kigali, Rwanda
| | - J Ntaganira
- College of Medicine and Health Sciences, School of Public Health, University of Rwanda, Gasabo District, 103KG 47ST, Kigali, Rwanda
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Oyuga R, Amadi E, Blanco N, Ndaga A, Abuya K, Oneya D, Ng'eno C, Koech E, Lavoie MCC. Effects of Multimonth Dispensing on Viral Suppression and Continuity in Treatment Among Children Living With HIV Aged 2-9 Years: A Cohort Study in Western Kenya. J Acquir Immune Defic Syndr 2024; 96:290-298. [PMID: 38905478 DOI: 10.1097/qai.0000000000003430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 03/14/2024] [Indexed: 06/23/2024]
Abstract
BACKGROUND In Kenya, of the 82,000 children living with HIV, only 59% are receiving ART and 67% are virally suppressed. Early in the COVID-19 pandemic, the Ministry of Health recommended 3 multimonth dispensing (3MMD) of ART to all people living with HIV, including children. This study assesses the association between 3 MMD and clinical outcomes among children in Western Kenya. SETTINGS and Methods: We conducted a retrospective cohort study using routinely collected deidentified patient-level data from 43 facilities in Kisii and Migori Counties. The study included children aged 2-9 years who had been previously initiated on ART and sought HIV services between March 01, 2020, and March 30, 2021. We used generalized linear models with Poisson regression models to assess the association between MMD on retention at 6 months and viral suppression (<1000 copies/mL). RESULTS Among the 963 children, 65.2% were aged 5-9 years and 50.7% were female patients. Seventy-eight percent received 3MMD at least once during the study period. Children who received 3MMD were 12% (adjusted risk ratio [aRR] 1.12, 95% CI: 1.01 to 1.24) more likely to be retained and 22% (aRR 1.22, 1.12 to 1.34) more likely to be virally suppressed than those on <3MMD. When stratified by viral suppression at entry, the association between 3MMD and retention (aRR 1.22, 95% CI: 1.02 to 1.46) and viral suppression (aRR 1.76, 95% CI: 1.30-2.37) was significant among individuals who were unsuppressed at baseline. CONCLUSIONS 3MMD was associated with comparable or improved HIV health outcomes among children.
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Affiliation(s)
- Roseline Oyuga
- Center for International Health, Education, and Biosecurity (Ciheb), Nairobi, Kenya
| | - Emmanuel Amadi
- Center for International Health, Education, and Biosecurity (Ciheb), Nairobi, Kenya
| | - Natalia Blanco
- School of Medicine, University of Maryland, College Park, MD
- Center for International Health, Education, and Biosecurity (Ciheb), University of Maryland School of Medicine, Institute of Human Virology, Baltimore, MD
| | - Angela Ndaga
- Center for International Health, Education, and Biosecurity (Ciheb), Nairobi, Kenya
| | - Kepha Abuya
- Department of Health, Kisii County, Kisii, Kenya
| | - Daniel Oneya
- Department of Health, Migori County, Migori, Kenya; and
| | - Caroline Ng'eno
- Center for International Health, Education, and Biosecurity (Ciheb), Maryland Global Initiative Corporation, Nairobi, Kenya
| | - Emily Koech
- Center for International Health, Education, and Biosecurity (Ciheb), Nairobi, Kenya
| | - Marie-Claude C Lavoie
- School of Medicine, University of Maryland, College Park, MD
- Center for International Health, Education, and Biosecurity (Ciheb), University of Maryland School of Medicine, Institute of Human Virology, Baltimore, MD
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Meque I, Herrera N, Gill MM, Guilaze R, Nhangave A, Mussá J, Bhatt N, Bonou M, Greenberg L. Consistency of Multi-Month Antiretroviral Therapy Dispensing and Association with Viral Load Coverage among Pediatric Clients Living with HIV in Mozambique. Trop Med Infect Dis 2024; 9:141. [PMID: 39058183 PMCID: PMC11281662 DOI: 10.3390/tropicalmed9070141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 06/18/2024] [Accepted: 06/19/2024] [Indexed: 07/28/2024] Open
Abstract
With the increase in uptake of multi-month antiretroviral therapy dispensing (MMD) for children, little is known about consistency of MMD receipt over time and its association with virological outcomes. This analysis aims to assess the uptake of 3-month MMD among children, consistent receipt of MMD after uptake, and clinical outcomes following transition to MMD in 16 health facilities in Gaza and Inhambane Provinces. This is a secondary analysis involving children <15 years living with HIV with clinical visits during the period from September 2019 to August 2020. Of 4383 children, 82% ever received MMD (at least one pickup of a 3-month MMD supply) during the study period but only 40% received it consistently (defined as MMD at every visit during the study period). Consistent MMD was most common among older children and children without indications of clinical instability. Overall viral load (VL) coverage was 40% (733/1851). Consistent MMD was significantly associated with lower odds of having a VL (0.78, 95% CI: 0.64-0.95). In conclusion, while receipt of a multi-month supply was common particularly during the early days of the COVID-19 pandemic, only a minority of children received consistent MMD; however, there is a need to ensure children with fewer visits still receive timely VL monitoring.
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Affiliation(s)
- Ivete Meque
- Elizabeth Glaser Pediatric AIDS Foundation, Maputo, Mozambique; (I.M.)
| | - Nicole Herrera
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC 20005, USA
| | - Michelle M. Gill
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC 20005, USA
| | - Rui Guilaze
- Elizabeth Glaser Pediatric AIDS Foundation, Maputo, Mozambique; (I.M.)
| | - Amancio Nhangave
- Núcleo de Pesquisa Provincial de Gaza, Provincial Health Directorate, Gaza, Mozambique
| | - Jaciara Mussá
- Núcleo de Investigação Operacional de Inhambane, Provincial Health Directorate, Inhambane, Mozambique
| | - Nilesh Bhatt
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC 20005, USA
| | - Mahoudo Bonou
- Elizabeth Glaser Pediatric AIDS Foundation, Maputo, Mozambique; (I.M.)
| | - Lauren Greenberg
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC 20005, USA
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5
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Mauleti IY, Wibisana KA, Syamsuridzal DP, Mulyati S, Lisdawati V, Saptarini I, Nurhayati, Hasugian AR, Hendarwan H. Factors Associated With Long-term Retention in Antiretroviral Therapy Among People Living With HIV: Evidence From a Tertiary Hospital in Jakarta, Indonesia. J Prev Med Public Health 2024; 57:252-259. [PMID: 38726581 PMCID: PMC11164604 DOI: 10.3961/jpmph.23.512] [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: 11/12/2023] [Revised: 03/09/2024] [Accepted: 04/01/2024] [Indexed: 06/12/2024] Open
Abstract
OBJECTIVES This study investigated factors associated with the retention of people living with human immunodeficiency virus (HIV) on antiretroviral therapy (ART) during the first 3 years of treatment. METHODS A retrospective study using electronic health records was conducted at a tertiary hospital in Jakarta, Indonesia. Adult HIV-positive patients who started ART from 2010 until 2020 were included. A binary logistic regression model was used to identify factors associated with ART retention in the first 3 years. RESULTS In total, 535 respondents were included in the analysis. The ART retention rates for the first, second, and third years were 83.7%, 79.1%, and 77.2%, respectively. The multivariate analysis revealed a negative association between CD4 count when starting ART and retention. Patients with CD4 counts >200 cells/mL were 0.65 times less likely to have good retention than those with CD4 counts ≤200 cells/mL. The year of starting ART was also significantly associated with retention. Patients who started ART in 2010-2013 or 2014-2016 were less likely to have good retention than those who started ART in 2017-2020, with adjusted odds ratios of 0.52 and 0.40, respectively. Patients who received efavirenz-based therapy were 1.69 times more likely to have good retention than those who received nevirapine (95% confidence interval, 1.05 to 2.72). CONCLUSIONS Our study revealed a decline in ART retention in the third year. The CD4 count, year of enrollment, and an efavirenz-based regimen were significantly associated with retention. Patient engagement has long been a priority in HIV programs, with interventions being implemented to address this issue.
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Affiliation(s)
| | | | | | - Sri Mulyati
- General Practitioner Staff, Fatmawati General Hospital, Jakarta, Indonesia
| | - Vivi Lisdawati
- Directorate of Human Resources, Education and Research, Fatmawati General Hospital, Jakarta, Indonesia
| | - Ika Saptarini
- Research Center for Preclinical and Clinical Medicine, National Research and Innovation Agency, Bogor, Indonesia
- Doctoral Program in Medical Sciences, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - Nurhayati
- Research Center for Preclinical and Clinical Medicine, National Research and Innovation Agency, Bogor, Indonesia
| | - Armedy Ronny Hasugian
- Research Center for Preclinical and Clinical Medicine, National Research and Innovation Agency, Bogor, Indonesia
| | - Harimat Hendarwan
- Research Center for Preclinical and Clinical Medicine, National Research and Innovation Agency, Bogor, Indonesia
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Ross J, Anastos K, Hill S, Remera E, Rwibasira GN, Ingabire C, Umwiza F, Munyaneza A, Muhoza B, Zhang C, Nash D, Yotebieng M, Murenzi G. Reducing time to differentiated service delivery for newly-diagnosed people living with HIV in Kigali, Rwanda: a pilot, unblinded, randomized controlled trial. BMC Health Serv Res 2024; 24:555. [PMID: 38693537 PMCID: PMC11062003 DOI: 10.1186/s12913-024-10950-z] [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: 08/08/2023] [Accepted: 04/04/2024] [Indexed: 05/03/2024] Open
Abstract
BACKGROUND Differentiated service delivery (DSD) programs for people living with HIV (PWH) limit eligibility to patients established on antiretroviral therapy (ART), yet uncertainty exists regarding the duration on ART necessary for newly-diagnosed PWH to be considered established. We aimed to determine the feasibility, acceptability, and preliminary impact of entry into DSD at six months after ART initiation for newly-diagnosed PWH. METHODS We conducted a pilot randomized controlled trial in three health facilities in Rwanda. Participants were randomized to: (1) entry into DSD at six months after ART initiation after one suppressed viral load (DSD-1VL); (2) entry into DSD at six months after ART initiation after two consecutive suppressed viral loads (DSD-2VL); (3) treatment as usual (TAU). We examined feasibility by examining the proportion of participants assigned to intervention arms who entered DSD, assessed acceptability through patient surveys and by examining instances when clinical staff overrode the study assignment, and evaluated preliminary effectiveness by comparing study arms with respect to 12-month viral suppression. RESULTS Among 90 participants, 31 were randomized to DSD-1VL, 31 to DSD-2VL, and 28 to TAU. Among 62 participants randomized to DSD-1VL or DSD-2VL, 37 (60%) entered DSD at 6 months while 21 (34%) did not enter DSD because they were not virally suppressed. Patient-level acceptability was high for both clinical (mean score: 3.8 out of 5) and non-clinical (mean score: 4.1) elements of care and did not differ significantly across study arms. Viral suppression at 12 months was 81%, 81% and 68% in DSD-1VL, DSD-2VL, and TAU, respectively (p = 0.41). CONCLUSIONS The majority of participants randomized to intervention arms entered DSD and had similar rates of viral suppression compared to TAU. Results suggest that early DSD at six months after ART initiation is feasible for newly-diagnosed PWH, and support current WHO guidelines on DSD. TRIAL REGISTRATION Clinicaltrials.gov NCT04567693; first registered on September 28, 2020.
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Affiliation(s)
- Jonathan Ross
- Albert Einstein College of Medicine, 3300 Kossuth Avenue, Bronx, NY, 10467, USA.
| | - Kathryn Anastos
- Albert Einstein College of Medicine, 3300 Kossuth Avenue, Bronx, NY, 10467, USA
| | - Sarah Hill
- Albert Einstein College of Medicine, 3300 Kossuth Avenue, Bronx, NY, 10467, USA
| | - Eric Remera
- Division of HIV, STIs and Viral Hepatitis, Rwanda Biomedical Center, Kigali, Rwanda
| | - Gallican N Rwibasira
- Division of HIV, STIs and Viral Hepatitis, Rwanda Biomedical Center, Kigali, Rwanda
| | | | | | | | | | - Chenshu Zhang
- Albert Einstein College of Medicine, 3300 Kossuth Avenue, Bronx, NY, 10467, USA
| | - Denis Nash
- Institute for Implementation Science in Population Health, City University of New York, New York, 10027, USA
| | - Marcel Yotebieng
- Albert Einstein College of Medicine, 3300 Kossuth Avenue, Bronx, NY, 10467, USA
| | - Gad Murenzi
- Research for Development (RD Rwanda), Kigali, Rwanda
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7
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Abdul R, Rinke de Wit TF, Martelli G, Costigan K, Katambi P, Pozniak A, Maokola W, Mfinanga S, Hermans S. Stability in care and risk of loss to follow-up among clients receiving community health worker-led differentiated HIV care: Results from a prospective cohort study in northern Tanzania. Trop Med Int Health 2024; 29:309-318. [PMID: 38279832 DOI: 10.1111/tmi.13975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024]
Abstract
BACKGROUND HIV services in Tanzania are facility-based but facilities are often overcrowded. Differentiated care models (DCM) have been introduced into the National Guidelines. We piloted a Community Health Worker (CHW)-led HIV treatment club model (CHW-DCM) in an urban region, and assessed its effectiveness in comparison to the standard of care (SoC, facility-based model), in terms of stability in care, loss to follow-up (LTFU) and treatment adherence. METHODS In two clinics in the Shinyanga region, clients established on ART (defined as stable clients by national guidelines as on first-line ART >6 months, undetectable viral load, no opportunistic infections or pregnancy, and good adherence) were offered CHW-DCM. This prospective cohort study included all stable clients who enrolled in CHW-DCM between July 2018 and March 2020 (CHW-DCM) and compared them to stable clients who remained in SoC during that period. Multivariable Cox regression models were used to analyse factors associated with continued stability in care and the risk of LTFU during 18 months of follow-up; treatment adherence was assessed by pill count and compared using Chi-square tests. RESULTS Of 2472 stable clients, 24.5% received CHW-DCM and 75.5% SoC. CHW-DCM clients were slightly older (mean 42.8 vs. 37.9 years) and more likely to be female (36.2% vs. 32.2%). Treatment adherence was better among CHW-DCM than SoC: 96.6% versus 91.9% and 98.5% versus 92.2%, respectively (both p = 0.001). SoC clients were more likely to not remain stable over time than CHW-DCM (adjusted Hazard ratio [AHR] = 2.68; 95% CI: 1.86-3.90). There was no difference in LTFU (adjusted hazard ratio [AHR] = 1.54; 95%CI: 0.82-2.93). CONCLUSION Clients attending CHW-DCM demonstrated better stability in care and treatment adherence than SoC, and the risk of LTFU was not increased. These findings demonstrate the potential of CHW in delivering community-based HIV services in the local Tanzanian context. These results could be used to extend this CHW-DCM model to similar settings.
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Affiliation(s)
- Ramadhani Abdul
- Department of Global Health, Amsterdam UMC, location University of Amsterdam, Amsterdam Institute for Global Health and Development, Amsterdam, the Netherlands
| | - Tobias F Rinke de Wit
- Department of Global Health, Amsterdam UMC, location University of Amsterdam, Amsterdam Institute for Global Health and Development, Amsterdam, the Netherlands
| | - Giulia Martelli
- Infectious Diseases Unit, AUSL Romagna, Morgagni Pierantoni Hospital, Doctors with Africa CUAMM IT, Forlí, Italy
| | | | | | - Anton Pozniak
- Department of HIV, London, UK
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Werner Maokola
- Strategic Information Unit, National AIDS, STIs and Hepatitis Control Program, Ministry of Health, Dodoma, Tanzania
| | - Sayoki Mfinanga
- Research Department, National Institute for Medical Research (NIMR)-Muhimbili Centre, Dar es Salaam, Tanzania
- Department of Epidemiology, Alliance for Africa Health Research, Dar es Salaam, Tanzania
- School of Public Health, Department of Epidemiology and Statistics, Muhimbili University of Health, and Allied Science, Dar es Salaam, Tanzania
| | - Sabine Hermans
- Department of Global Health, Amsterdam UMC, location University of Amsterdam, Amsterdam Institute for Global Health and Development, Amsterdam, the Netherlands
- Centre for Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
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8
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Hill SE, Zhang C, Remera E, Ingabire C, Umwiza F, Munyaneza A, Muhoza B, Rwibasira G, Yotebieng M, Anastos K, Murenzi G, Ross J. Association Between Clinical Encounter Frequency and HIV-Related Stigma Among Newly-Diagnosed People Living with HIV in Rwanda. AIDS Behav 2024; 28:1390-1400. [PMID: 38112826 PMCID: PMC10947825 DOI: 10.1007/s10461-023-04226-6] [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: 11/15/2023] [Indexed: 12/21/2023]
Abstract
HIV-related stigma in healthcare settings remains a key barrier to engaging people living with HIV (PLHIV) in care. This study investigated the association between clinical encounter frequency and HIV-related anticipated, enacted, and internalized stigma among newly-diagnosed PLHIV in Rwanda. From October 2020 to May 2022, we collected data from adult PLHIV on antiretroviral therapy (ART) in Kigali, Rwanda who were participating in a randomized, controlled trial testing early entry into differentiated care at 6 months after ART initiation. We measured anticipated HIV stigma with five-point Likert HIV Stigma Framework measures, enacted stigma with the four-point Likert HIV/AIDS Stigma Instrument, and internalized stigma with the four-point Likert HIV/AIDS Stigma Instrument. We used multivariable linear regression to test the associations between clinical encounter frequency (average inter-visit interval ≥ 50 days vs. < 50 days) and change in mean anticipated, enacted and internalized HIV stigma over the first 12 months in care. Among 93 individuals enrolled, 76 had complete data on encounter frequency and stigma measurements and were included in the present analysis. Mean internalized stigma scores of all participants decreased over the first 12 months in care. Anticipated and enacted stigma scores were low and did not change significantly over time. There was no association between encounter frequency and change in internalized stigma. In this pilot study of newly-diagnosed Rwandan PLHIV with relatively low levels of HIV-related stigma, clinical encounter frequency was not associated with change in stigma. Additional research in diverse settings and with larger samples is necessary to further explore this relationship.
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Affiliation(s)
- Sarah E Hill
- Division of General Internal Medicine, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY, 10461, USA.
| | - Chenshu Zhang
- Division of General Internal Medicine, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY, 10461, USA
| | - Eric Remera
- HIV/AIDS and STIs Diseases Division, Rwanda Biomedical Center, Institute of HIV Disease Prevention and Control, Kigali, Rwanda
| | - Charles Ingabire
- Rwanda Military Hospital, Kigali, Rwanda
- Research for Development, Kigali, Rwanda
| | - Francine Umwiza
- Rwanda Military Hospital, Kigali, Rwanda
- Research for Development, Kigali, Rwanda
| | - Athanase Munyaneza
- Rwanda Military Hospital, Kigali, Rwanda
- Research for Development, Kigali, Rwanda
| | - Benjamin Muhoza
- Rwanda Military Hospital, Kigali, Rwanda
- Research for Development, Kigali, Rwanda
| | - Gallican Rwibasira
- HIV/AIDS and STIs Diseases Division, Rwanda Biomedical Center, Institute of HIV Disease Prevention and Control, Kigali, Rwanda
| | - Marcel Yotebieng
- Division of General Internal Medicine, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY, 10461, USA
| | - Kathryn Anastos
- Division of General Internal Medicine, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY, 10461, USA
| | - Gad Murenzi
- Rwanda Military Hospital, Kigali, Rwanda
- Research for Development, Kigali, Rwanda
| | - Jonathan Ross
- Division of General Internal Medicine, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY, 10461, USA
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Mokhele I, Huber A, Rosen S, Kaiser JL, Lekodeba N, Ntjikelane V, Hendrickson C, Scott N, Pascoe S. Satisfaction with service delivery among HIV treatment clients enrolled in differentiated and conventional models of care in South Africa: a baseline survey. J Int AIDS Soc 2024; 27:e26233. [PMID: 38528370 DOI: 10.1002/jia2.26233] [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: 08/28/2023] [Accepted: 03/01/2024] [Indexed: 03/27/2024] Open
Abstract
INTRODUCTION Differentiated service delivery (DSD) models aim to increase the responsiveness of HIV treatment programmes to the individual needs of antiretroviral therapy (ART) clients to improve treatment outcomes and quality of life. Little is known about how DSD client experiences differ from conventional care. METHODS From May to November 2021, we interviewed adult (≥18) ART clients at 21 primary clinics in four districts of South Africa. Participants were enrolled consecutively at routine visits and stratified into four groups: conventional care-not eligible for DSD (conventional-not-eligible); conventional care eligible for but not enrolled in DSD (conventional-not-enrolled); facility pickup point DSD model; and external pickup point DSD model. Satisfaction was assessed using questions with 5-point Likert-scale responses. Mean scores were categorized as not satisfied (score ≤3) or satisfied (>3). We used logistic regression to assess differences and report crude and adjusted odds ratios (aORs). Qualitative themes were identified through content analysis. RESULTS Eight hundred and sixty-seven participants (70% female, median age 39) were surveyed: 24% facility pick-up points; 27% external pick-up points; 25% conventional-not-eligible; and 24% conventional-not-enrolled. Seventy-four percent of all study participants expressed satisfaction with their HIV care. Those enrolled in DSD models were more likely to be satisfied, with an aOR of 6.24 (95% CI [3.18-12.24]) for external pick-up point versus conventional-not-eligible and an aOR of 3.30 (1.95-5.58) for facility pick-up point versus conventional-not-eligible. Conventional-not-enrolled clients were slightly but not significantly more satisfied than conventional-not-eligible clients (1.29, 0.85-1.96). Those seeking outside healthcare (crude OR 0.57, 0.41-0.81) or reporting more annual clinic visits (0.52, 0.29-0.93) were less likely to be satisfied. Conventional care participants reporting satisfaction with their current model of care perceived providers as helpful, respectful, and friendly and were satisfied with care despite long queues. DSD model participants emphasized ease and convenience, particularly not having to queue. CONCLUSIONS Most adult ART clients in South Africa were satisfied with their care, but those enrolled in DSD models expressed slightly greater satisfaction than those remaining in conventional care. Efforts should focus on enrolling more eligible patients into DSD models, expanding eligibility criteria to cover a wider client base, and further improving the models' desirable characteristics.
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Affiliation(s)
- Idah Mokhele
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Amy Huber
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sydney Rosen
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Jeanette L Kaiser
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Nkgomeleng Lekodeba
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Vinolia Ntjikelane
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Cheryl Hendrickson
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Nancy Scott
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Sophie Pascoe
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Jiang W, Ronen K, Osborn L, Drake AL, Unger JA, Matemo D, Richardson BA, Kinuthia J, John-Stewart G. HIV Viral Load Patterns and Risk Factors Among Women in Prevention of Mother-To-Child Transmission Programs to Inform Differentiated Service Delivery. J Acquir Immune Defic Syndr 2024; 95:246-254. [PMID: 37977207 PMCID: PMC10922247 DOI: 10.1097/qai.0000000000003352] [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: 06/24/2023] [Accepted: 11/06/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Differentiated service delivery (DSD) approaches decrease frequency of clinic visits for individuals who are stable on antiretroviral therapy. It is unclear how to optimize DSD models for postpartum women living with HIV (PWLH). We evaluated longitudinal HIV viral load (VL) and cofactors, and modelled DSD eligibility with virologic failure (VF) among PWLH in prevention of mother-to-child transmission programs. METHODS This analysis used programmatic data from participants in the Mobile WAChX trial (NCT02400671). Women were assessed for DSD eligibility using the World Health Organization criteria among general people living with HIV (receiving antiretroviral therapy for ≥6 months and having at least 1 suppressed VL [<1000 copies/mL] within the past 6 months). Longitudinal VL patterns were summarized using group-based trajectory modelling. VF was defined as having a subsequent VL ≥1000 copies/mL after being assessed as DSD-eligible. Predictors of VF were determined using log-binomial models among DSD-eligible PWLH. RESULTS Among 761 women with 3359 VL results (median 5 VL per woman), a 3-trajectory model optimally summarized longitudinal VL, with most (80.8%) women having sustained low probability of unsuppressed VL. Among women who met DSD criteria at 6 months postpartum, most (83.8%) maintained viral suppression until 24 months. Residence in Western Kenya, depression, reported interpersonal abuse, unintended pregnancy, nevirapine-based antiretroviral therapy, low-level viremia (VL 200-1000 copies/mL), and drug resistance were associated with VF among DSD-eligible PWLH. CONCLUSIONS Most postpartum women maintained viral suppression from early postpartum to 24 months and may be suitable for DSD referral. Women with depression, drug resistance, and detectable VL need enhanced services.
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Affiliation(s)
- Wenwen Jiang
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Keshet Ronen
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Lusi Osborn
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Alison L. Drake
- Global Health, University of Washington, Seattle, Washington, USA
| | - Jennifer A. Unger
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA, Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Daniel Matemo
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Barbra A. Richardson
- Departments of Biostatistics and Global Health, University of Washington, Division of Vaccine and Infectious Disease, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - John Kinuthia
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Grace John-Stewart
- Departments of Global Health, Medicine, Pediatrics, and Epidemiology, University of Washington, Seattle, Washington, USA
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11
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Ye J, Sanuade OA, Hirschhorn LR, Walunas TL, Smith JD, Birkett MA, Baldridge AS, Ojji DB, Huffman MD. Interventions and contextual factors to improve retention in care for patients with hypertension in primary care: Hermeneutic systematic review. Prev Med 2024; 180:107880. [PMID: 38301908 PMCID: PMC10919242 DOI: 10.1016/j.ypmed.2024.107880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 01/23/2024] [Accepted: 01/24/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND Regular engagement over time in hypertension care, or retention, is a crucial but understudied step in optimizing patient outcomes. This systematic review leverages a hermeneutic methodology to identify, evaluate, and quantify the effects of interventions and contextual factors for improving retention for patients with hypertension. METHODS We searched for articles that were published between 2000 and 2022 from multiple electronic databases, including MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, clinicaltrials.gov, and WHO International Trials Registry. We followed the latest version of the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guideline to report the findings for this review. We also synthesized the findings using a hermeneutic methodology for systematic reviews, which used an iterative process to review, integrate, analyze, and interpret evidence. RESULTS From 4686 screened titles and abstracts, 18 unique studies from 9 countries were identified, including 10 (56%) randomized controlled trials (RCTs), 3 (17%) cluster RCTs, and 5 (28%) non-RCT studies. The number of participants ranged from 76 to 1562. The overall mean age range was 41-67 years, and the proportion of female participants ranged from 0% to 100%. Most (n = 17, 94%) studies used non-physician personnel to implement the proposed interventions. Fourteen studies (78%) implemented multilevel combinations of interventions. Education and training, team-based care, consultation, and Short Message Service reminders were the most common interventions tested. CONCLUSIONS This review presents the most comprehensive findings on retention in hypertension care to date and fills the gaps in the literature, including the effectiveness of interventions, their components, and contextual factors. Adaptation of and implementing HIV care models, such differentiated service delivery, may be more effective and merit further study. REGISTRATION CRD42021291368. PROTOCOL REGISTRATION PROSPERO 2021 CRD42021291368. Available at: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=291368.
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Affiliation(s)
- Jiancheng Ye
- Weill Cornell Medicine, NY, New York, USA; Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Olutobi A Sanuade
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Department of Population Health Sciences, Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, UT, USA
| | - Lisa R Hirschhorn
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Northwestern University Robert J Havey Institute for Global Health, Chicago, IL, USA
| | - Theresa L Walunas
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Justin D Smith
- Department of Population Health Sciences, Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, UT, USA
| | | | - Abigail S Baldridge
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Northwestern University Robert J Havey Institute for Global Health, Chicago, IL, USA
| | - Dike B Ojji
- Cardiovascular Research Unit, University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria; University of Abuja, Abuja, Nigeria
| | - Mark D Huffman
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Washington University in St. Louis, St. Louis, MO, USA; The George Institute for Global Health, Sydney, Australia
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12
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Reis K, Wolf A, Perumal R, Seepamore B, Guzman K, Ross J, Cheung K, Amico KR, Brust JC, Padayatchi N, Friedland G, Naidoo K, Daftary A, Zelnick J, O’Donnell M. Differentiated service delivery framework for people with multidrug-resistant tuberculosis and HIV co-infection. J Acquir Immune Defic Syndr 2024; 96:00126334-990000000-00374. [PMID: 38323838 PMCID: PMC11300702 DOI: 10.1097/qai.0000000000003394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
INTRODUCTION For people living with HIV/AIDS, care is commonly delivered through Differentiated Service Delivery (DSD). Although people with multidrug-resistant tuberculosis (MDR-TB) and HIV/AIDS experience severe treatment associated challenges, there is no DSD model to support their treatment. In this study, we defined patterns of medication adherence and characterized longitudinal barriers to inform development of an MDR-TB/HIV DSD framework. METHODS Adults with MDR-TB and HIV initiating bedaquiline (BDQ) and receiving antiretroviral therapy (ART) in KwaZulu-Natal, South Africa, were enrolled and followed through the end of MDR-TB treatment. Electronic dose monitoring devices (EDM) measured BDQ and ART adherence. Longitudinal focus groups were conducted and transcripts analyzed thematically to describe discrete treatment stage-specific and cross-cutting treatment challenges. RESULTS 283 participants were enrolled and followed through treatment completion (median 17.8 months [IQR 16.5-20.2]). Thirteen focus groups were conducted. Most participants (82.7%, 234/283) maintained high adherence (mean BDQ adherence 95.3%; mean ART adherence 85.5%), but an adherence-challenged subpopulation with <85% cumulative adherence (17.3%, 49/283) had significant declines in mean weekly BDQ adherence from 94.9% to 39.9% (p<0.0001) and mean weekly ART adherence from 83.9% to 26.6% (p<0.0001) over 6 months. Psychosocial, behavioral, and structural obstacles identified in qualitative data were associated with adherence deficits in discrete treatment stages, and identified potential stage specific interventions. CONCLUSION A DSD framework for MDR-TB/HIV should intensify support for adherence-challenged subpopulations, provide multi-modal support for adherence across the treatment course and account for psychosocial, behavioral, and structural challenges linked to discrete treatment stages.
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Affiliation(s)
- Karl Reis
- Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY
| | - Allison Wolf
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York City, NY
| | - Rubeshan Perumal
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Boitumelo Seepamore
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
- School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Kevin Guzman
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York City, NY
| | - Jesse Ross
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York City, NY
| | - Ken Cheung
- Department of Biostatistics, Columbia University Irving Medical Center, New York City, NY
| | - K. Rivet Amico
- University of Michigan School of Public Health, Ann Arbor, MI
| | - James C.M. Brust
- Divisions of General Internal Medicine and Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Nesri Padayatchi
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Gerald Friedland
- Department of Medicine (Infections Diseases), Yale University School of Medicine, New Haven, CT
| | - Kogieleum Naidoo
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Amrita Daftary
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
- Dahdaleh Institute of Global Health Research, School of Global Health, York University, Toronto, Canada
| | - Jennifer Zelnick
- Graduate School of Social Work, Touro University, New York City, NY
| | - Max O’Donnell
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York City, NY
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
- Department of Epidemiology, Columbia University Irving Medical Center, New York City, NY
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13
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Giovenco D, Pettifor A, Qayiya Y, Jones J, Bekker LG. The Acceptability, Feasibility, and Preliminary Effectiveness of a Courier HIV-Treatment Delivery and SMS Support Intervention for Young People Living With HIV in South Africa. J Acquir Immune Defic Syndr 2024; 95:161-169. [PMID: 37856424 PMCID: PMC10841708 DOI: 10.1097/qai.0000000000003332] [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: 02/21/2023] [Accepted: 10/05/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Young people living with HIV (YPLWH) experience poorer rates of virological suppression compared with adults. Differentiated service delivery models for YPLWH are urgently needed to address this disparity. SETTING Participants were recruited from an HIV treatment clinic near Cape Town, South Africa. METHODS We conducted a longitudinal pilot study to examine the acceptability, feasibility, and preliminary effectiveness of a courier ART delivery and SMS support intervention to retain YPLWH (13-24 years) in care during COVID-19. YPLWH had the option to enroll in the courier service and were randomized 1:1 to receive adherence support via a weekly SMS. Modified Poisson regression was used to estimate the preliminary effectiveness of the courier intervention on viral suppression (HIV-1 RNA <200 copies/mL) at months 3 and 6. RESULTS Among 215 participants, 82% elected to enroll in the courier ART service at baseline, 41% reported receiving a delivery in the past 3 months at month 3, and 49% reported receiving a delivery in the past 3 months at month 6. Among those who received a delivery, most (91%-100%) rated the intervention as acceptable. Participants who reported receiving a delivery in the past 3 months at month 3 were 1.26 (95% CI: 1.05, 1.54) times as likely to have a suppressed viral load at month 3 and 1.21 (0.99, 1.48) times as likely at month 6, controlling for potential confounders. CONCLUSIONS Findings reveal high uptake and acceptability of a courier ART delivery intervention among YPLWH and promising evidence for its effectiveness in increasing the probability of viral suppression. A fully powered trial is warranted.
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Affiliation(s)
- Danielle Giovenco
- Emory University, Department of Epidemiology, Atlanta, GA, USA
- University of North Carolina at Chapel Hill, Department of Epidemiology, Chapel Hill, NC, USA
- Desmond Tutu HIV Centre, Cape Town, South Africa
| | - Audrey Pettifor
- University of North Carolina at Chapel Hill, Department of Epidemiology, Chapel Hill, NC, USA
| | | | - Jeb Jones
- Emory University, Department of Epidemiology, Atlanta, GA, USA
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14
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Gill MM, Bakebua W, Ditekemena J, Gbomosa CN, Tshishi D, Loando A, Giri A, Ngantsui RB, Hoffman HJ. Virological and care outcomes of community ART distribution: Experience with the PODI+ model in Kinshasa, Democratic Republic of the Congo. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002343. [PMID: 38295044 PMCID: PMC10830041 DOI: 10.1371/journal.pgph.0002343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 12/12/2023] [Indexed: 02/02/2024]
Abstract
INTRODUCTION Differentiated service delivery models for HIV treatment can minimize unnecessary burdens on health systems and promote efficient delivery of antiretroviral therapy (ART). Under the PODI+ (poste de distribution communautaire) model, ART multi-month dispensation (MMD) was provided by lay workers (peers) in communities. We compared outcomes among clinically stable adults living with HIV receiving MMD via PODI+ or health facility (HF). METHODS Clients receiving MMD at nine HFs and two PODI+ sites in Kinshasa were followed prospectively for one year (2018-2020). Medication possession ratio (MPR) was measured as proportion of total days with medication during the study through record abstraction at 3-month intervals. Viral load was assessed at enrollment and 12 months. We compared MPR and viral load suppression by arm and examined associations and potential confounders using unadjusted and adjusted odds ratios (AOR). Likert-style client satisfaction was collected during 12-month interviews and described by arm. RESULTS Odds of maintaining viral load suppression at 12 months for PODI+ participants were two times that for HF participants. In adjusted models, PODI+ participants had 1.89 times the odds of being suppressed at 12 months compared to HF participants (95% CI: 1.10, 3.27). No significant differences in MPR were found between groups (OR: 0.86, 0.38-1.99). Older participants had significantly higher odds of MPR (AOR: 1.02, 95% CI: 1.01, 1.03) and viral suppression (AOR: 1.03, 95% CI: 1.00, 1.07). Satisfaction with services was ≥87% overall, but PODI+ participants rated time spent at site, provider attributes and other care aspects more favorably. CONCLUSIONS Participants receiving MMD via peer-run community distribution points had similar MPR, but better virological outcomes and greater satisfaction with care than clinically similar participants receiving MMD through facilities. PODI+ could be a useful model for expansion to serve larger clinic populations from overburdened health facilities, particularly as policy shifts towards more inclusive MMD eligibility requirements.
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Affiliation(s)
- Michelle M. Gill
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, District of Columbia, United States of America
| | - Winnie Bakebua
- Elizabeth Glaser Pediatric AIDS Foundation, Kinshasa, Democratic Republic of the Congo
| | - John Ditekemena
- Elizabeth Glaser Pediatric AIDS Foundation, Kinshasa, Democratic Republic of the Congo
| | | | - Dieudonné Tshishi
- Elizabeth Glaser Pediatric AIDS Foundation, Kinshasa, Democratic Republic of the Congo
| | - Aimé Loando
- Elizabeth Glaser Pediatric AIDS Foundation, Kinshasa, Democratic Republic of the Congo
| | - Abhigya Giri
- Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia, United States of America
| | - Roger Beni Ngantsui
- DRC Ministry of Health, National AIDS Control Program, Kinshasa, Democratic Republic of the Congo
| | - Heather J. Hoffman
- Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia, United States of America
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15
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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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Maskew M, Ntjikelane V, Juntunen A, Scott N, Benade M, Sande L, Hasweeka P, Haimbe P, Lumano-Mulenga P, Shakewelele H, Mukumbwa-Mwenechanya M, Rosen S. Preferences for services in a patient's first six months on antiretroviral therapy for HIV in South Africa and Zambia (PREFER): research protocol for a prospective observational cohort study. Gates Open Res 2024; 7:119. [PMID: 38343769 PMCID: PMC10858017 DOI: 10.12688/gatesopenres.14682.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2024] [Indexed: 02/15/2024] Open
Abstract
Background For patients on HIV treatment in sub-Saharan Africa, the highest risk for loss from care remains the first six months after antiretroviral (ART) initiation, when patients are not yet eligible for differentiated service delivery (DSD) models that offer lower-burden, patient-centred care and thus improve treatment outcomes. To reduce early disengagement from care, the PREFER study will use a sequential mixed-methods approach to describe the characteristics, needs, concerns, and preferences of patients in South Africa and Zambia 0-6 months after ART initiation or re-initiation. Protocol PREFER is an observational, prospective cohort study of adults on ART for ≤6 months at 12 public healthcare facilities in Zambia and 18 in South Africa. Its objective is to describe and understand the needs and preferences of initiating and re-initiating ART clients to inform the design of DSD models for the early HIV treatment period, improve early treatment outcomes, and distinguish the barriers encountered by naïve patients from those facing re-initiators. It has four components: 1) survey of clients 0-6 months after ART initiation (identify characteristics and preferences of clients starting ART); 2) follow up through routinely collected medical records for <24 months after enrollment (describe resource utilization and patterns and predictors of engagement in care); 3) focus group discussions and discrete choice experiment (explore reported barriers to and facilitators of retention); and 4) in South Africa only, collection of blood samples (assess the prevalence of ARV metabolites indicating prior ART use). Conclusions PREFER aims to understand why the early treatment period is so challenging and how service delivery can be amended to address the obstacles that lead to early disengagement from care. It will generate information about client characteristics and preferences to help respond to patients' needs and design better strategies for service delivery and improve resource allocation going forward.
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Affiliation(s)
- Mhairi Maskew
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand Johannesburg, Johannesburg, Gauteng, South Africa
| | - Vinolia Ntjikelane
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand Johannesburg, Johannesburg, Gauteng, South Africa
| | | | - Nancy Scott
- Global Health, Boston University, Boston, MA, 02118, USA
| | - Mariet Benade
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand Johannesburg, Johannesburg, Gauteng, South Africa
- Global Health, Boston University, Boston, MA, 02118, USA
- Department of Medical Microbiology, Amsterdam University Medical Center, Amstersdam, The Netherlands
| | - Linda Sande
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand Johannesburg, Johannesburg, Gauteng, South Africa
| | | | - Prudence Haimbe
- CHAI-Zambia, Clinton Health Access Initiative, Lusaka, Zambia
| | | | | | | | - Sydney Rosen
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand Johannesburg, Johannesburg, Gauteng, South Africa
- Global Health, Boston University, Boston, MA, 02118, USA
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17
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Mugenyi L, Namuwenge PM, Ouma S, Bakashaba B, Nanfuka M, Zech J, Agaba C, Mijumbi Ojok A, Kaliba F, Bossa Kato J, Opito R, Miya Y, Katureebe C, Hirsch-Moverman Y. Isoniazid preventive therapy completion between July-September 2019: A comparison across HIV differentiated service delivery models in Uganda. PLoS One 2024; 19:e0296239. [PMID: 38166009 PMCID: PMC10760732 DOI: 10.1371/journal.pone.0296239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 12/08/2023] [Indexed: 01/04/2024] Open
Abstract
BACKGROUND Tuberculosis (TB) remains the leading cause of death among people living with HIV (PLHIV). To prevent TB among PLHIV, the Ugandan national guidelines recommend Isoniazid Preventive Therapy (IPT) across differentiated service delivery (DSD) models, an effective way of delivering ART. DSD models include Community Drug Distribution Point (CDDP), Community Client-led ART Delivery (CCLAD), Facility-Based Individual Management (FBIM), Facility-Based Group (FBG), and Fast Track Drug Refill (FTDR). Little is known about the impact of delivering IPT through DSD. METHODS We reviewed medical records of PLHIV who initiated IPT between June-September 2019 at TASO Soroti (TS), Katakwi Hospital (KH) and Soroti Regional Referral Hospital (SRRH). We defined IPT completion as completing a course of isoniazid within 6-9 months. We utilized a modified Poisson regression to compare IPT completion across DSD models and determine factors associated with IPT completion in each DSD model. RESULTS Data from 2968 PLHIV were reviewed (SRRH: 50.2%, TS: 25.8%, KH: 24.0%); females: 60.7%; first-line ART: 91.7%; and Integrase Strand Transfer Inhibitor (INSTI)-based regimen: 61.9%. At IPT initiation, the median age and duration on ART were 41.5 (interquartile range [IQR]; 32.3-50.2) and 6.0 (IQR: 3.7-8.6) years, respectively. IPT completion overall was 92.8% (95%CI: 91.8-93.7%); highest in CDDP (98.1%, 95%CI: 95.0-99.3%) and lowest in FBG (85.8%, 95%CI: 79.0-90.7%). Compared to FBIM, IPT completion was significantly higher in CDDP (adjusted rate ratio [aRR] = 1.15, 95%CI: 1.09-1.22) and CCLAD (aRR = 1.09, 95% CI 1.02-1.16). In facility-based models, IPT completion differed between sites (p<0.001). IPT completion increased with age for FBIM and CCLAD and was lower among female participants in the CCLAD (aRR = 0.82, 95%CI 0.67-0.97). CONCLUSION IPT completion was high overall but highest in community-based models. Our findings provide evidence that supports integration of IPT within DSD models for ART delivery in Uganda and similar settings.
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Affiliation(s)
- Levicatus Mugenyi
- The AIDS Support Organization, Kampala, Uganda
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | | | - Simple Ouma
- The AIDS Support Organization, Kampala, Uganda
- Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
| | | | | | - Jennifer Zech
- ICAP at Columbia University, New York, NY, United States of America
| | | | | | | | | | - Ronald Opito
- The AIDS Support Organization, Kampala, Uganda
- Department of Pubic Health, School of Health Sciences, Soroti University, Soroti, Uganda
| | - Yunus Miya
- The AIDS Support Organization, Kampala, Uganda
| | | | - Yael Hirsch-Moverman
- ICAP at Columbia University, New York, NY, United States of America
- Epidemiology Department, Mailman School of Public Health, Columbia University, New York, NY, United States of America
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18
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Aurpibul L, Kaewpoowat Q, Detsakunathiwatchara C, Chairat S, Chaiwarith R, Tangmunkongvorakul A. Health Behaviors and Attitudes Toward HIV Clinic Among Young Men who Have Sex with Men Living with HIV in Chiang Mai, Thailand: A Mixed Methods Study. AIDS Behav 2024; 28:332-342. [PMID: 37542628 DOI: 10.1007/s10461-023-04132-x] [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: 07/09/2023] [Indexed: 08/07/2023]
Abstract
Today, many young men who have sex with men (YMSM) with a new HIV infection were diagnosed and successfully linked to HIV services. Studies on their health behaviors while living with HIV and their attitude toward the HIV clinic are scarce. We characterized common health behaviors of YMSM and assessed their perspective towards the existing HIV services. We collected data from a self-administered questionnaire and in-depth interviews (IDI) using a mixed-method cross-sectional study design. A hundred YMSM, aged 18-24, who attended the HIV clinic were enrolled. Their median age was 23 years (interquartile range, IQR 21-24). Eighty-four (84%) were gay men. Their common health behaviors included 15 (15%) being current smokers and 30 (30%) using alcohol regularly. Sixty-four (64%) reported > 95% antiretroviral treatment adherence, while 32 (32%) self-reported adherence at 80-95%. Fifty-three (53%) reported 100% condom use, while 30 (30%) reported using a condom in > 80% of their sexual activities. From the questionnaire respondents, individual characteristics of providers were the most critical factor affecting participants' willingness to attend HIV services. From the IDI, social disclosure of HIV status was their primary concern, with the presence of self- and anticipating HIV-related stigma issues. In summary, YMSM living with HIV who regularly attended the HIV clinic had a low frequency of health risk behaviors. Most did not socially disclose their serostatus but could manage their health. They were generally satisfied with patient-friendly services while calling to protect their confidentiality and privacy.
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Affiliation(s)
- Linda Aurpibul
- Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Quanhathai Kaewpoowat
- Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Department of Internal Medicine, University of Iowa, Iowa, USA
| | | | - Suchada Chairat
- Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Romanee Chaiwarith
- Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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19
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Casalini C, D’Almeida Y, Nassam MA, Kokoloko E, Wade S, Tchupo JP, Damarly M, Mandala J, Lanham M, Mack N, Akolo C, Pitche VP, Guidigbi H, Dagnra CA. Targeted solutions to increase dolutegravir coverage, viral load testing coverage, and viral suppression among children living with HIV in Togo: An analysis of routine facility data. PLoS One 2023; 18:e0296293. [PMID: 38128036 PMCID: PMC10735014 DOI: 10.1371/journal.pone.0296293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 12/08/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND According to UNAIDS, Togo halved AIDS-related deaths among children ages 0-14 from 2010 to 2020. However, available data show low dolutegravir (DTG)-containing antiretroviral therapy (ART) coverage and low viral load suppression (VLS) among children living with HIV (CLHIV). We analyzed routine facility data before and after implementation of root-cause-based solutions for improving DTG coverage, viral load (VL) testing coverage, and VLS among CLHIV. DESCRIPTION We analyzed routine data for CLHIV ≤14 years from October 2019 through September 2022. We assessed proportion of CLHIV on ART receiving DTG, VL testing coverage (CLHIV on ART with documented VL test result), and VLS (CLHIV with documented VL test result of <1,000 copies among those with test result). From October 2019 to September 2020, 52% were on a DTG-containing regimen, 48% had documented VL test results, and 64% had VLS. Site-level teams conducted a root-cause analysis and designed corresponding solutions implemented beginning October 2020: line listing and contacting eligible CLHIV to start/transition to DTG-containing regimen and collect VL samples; ART adherence support; monthly DTG stock monitoring; tracking pending VL test results through laboratory focal persons; documenting VL test results; and informing caregivers within one week if CLHIV not virally suppressed. Granular data were used to prioritize technical assistance to sites with lowest DTG coverage, VL testing coverage, and VLS. RESULTS From baseline (October 2019-September 2020) to endline (October 2021-September 2022), increases were observed for DTG coverage (52% to 71%), VL testing coverage (48% to 90%), and VLS (64% to 82%). Age-disaggregated data showed positive trends. CONCLUSIONS Root-cause-based solutions and granular data use increased DTG coverage, resulting in increased VL testing and VLS among CLHIV. These interventions should be scaled and become the national standard of care.
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Affiliation(s)
| | | | | | | | | | | | | | - Justin Mandala
- HIV Programs, FHI 360, Durham, NC, United States of America
| | - Michele Lanham
- HIV Programs, FHI 360, Durham, NC, United States of America
| | - Natasha Mack
- HIV Programs, FHI 360, Durham, NC, United States of America
| | - Chris Akolo
- HIV Programs, FHI 360, Durham, NC, United States of America
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20
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Hariprasad S, Phiri K, Thorp M, Holland K, Nyirenda R, Gupta S, Phiri S, Sabin L, Dovel K. Stakeholder Priorities for ART Initiation and Early Retention Interventions in Malawi: A Qualitative Study Comparing International and National Perspectives. RESEARCH SQUARE 2023:rs.3.rs-3725505. [PMID: 38196656 PMCID: PMC10775367 DOI: 10.21203/rs.3.rs-3725505/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: 01/11/2024]
Abstract
Background New or returning ART clients are often ineligible for differentiated service delivery (DSD) models, though they are at increased risk of treatment interruption and may benefit greatly from flexible care models. Stakeholder support may limit progress on development and scale-up of interventions for this population. We qualitatively explored stakeholder perceptions of and decision-making criteria regarding DSD models for new or returning ART clients in Malawi. Methods We conducted in-depth interviews with internationally based stakeholders (from foundations, multilateral organizations, and NGOs) and Malawi-based stakeholders (from the Malawi Ministry of Health and PEPFAR implementing partners). The interviews included two think-aloud scenarios in which participants rated and described their perceptions of 1) the relative importance of five criteria (cost, effectiveness, acceptability, feasibility, and equity) in determining which interventions to implement for new or returning ART clients and 2) their relative interest in seven potential interventions (monetary incentives, nonmonetary incentives, community-based care, ongoing peer/mentor support and counseling, eHealth, facility-based interventions, and multimonth dispensing) for the same population. The interviews were completed in English via video conference and were audio-recorded. Transcriptions were coded using ATLAS.ti version 9. We examined the data using thematic content analysis and explored differences between international and national stakeholders. Results We interviewed twenty-two stakeholders between October 2021 and March 2022. Thirteen were based internationally, and nine were based in Malawi. Both groups prioritized client acceptability but diverged on other criteria: international stakeholders prioritized effectiveness, and Malawi-based stakeholders prioritized cost, feasibility, and sustainability. Both stakeholder groups were most interested in facility-based DSD models, such as multimonth dispensing and extended facility hours. Nearly all the stakeholders described person-centered care as a critical focus for any DSD model implemented. Conclusions National and international stakeholders support DSD models for new or returning ART clients. Client acceptability and long-term sustainability should be prioritized to address the concerns of nationally based stakeholders. Future studies should explore the reasons for differences in national and international stakeholders' priorities and how to ensure that local perspectives are incorporated into funding and programmatic decisions.
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21
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Humphrey J, Wanjama E, Carlucci JG, Naanyu V, Were E, Muli L, Alera M, McGuire A, Nyandiko W, Songok J, Wools-Kaloustian K, Zimet G. Preferences of Pregnant and Postpartum Women for Differentiated Service Delivery in Kenya. J Acquir Immune Defic Syndr 2023; 94:429-436. [PMID: 37949446 PMCID: PMC10642693 DOI: 10.1097/qai.0000000000003303] [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: 04/25/2023] [Accepted: 08/15/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Differentiated service delivery models are implemented by HIV care programs globally, but models for pregnant and postpartum women living with HIV (PPWH) are lacking. We conducted a discrete choice experiment to determine women's preferences for differentiated service delivery. SETTING Five public health facilities in western Kenya. METHODS PPWH were enrolled from April to December 2022 and asked to choose between pairs of hypothetical clinics that differed across 5 attributes: clinic visit frequency during pregnancy (monthly vs. every 2 months), postpartum visit frequency (monthly vs. only with routine infant immunizations), seeing a mentor mother (each visit vs. as needed), seeing a clinician (each visit vs. as needed), and basic consultation cost (0, 50, or 100 Kenya Shillings [KSh]). We used multinomial logit modeling to determine the relative effects (β) of each attribute on clinic choice. RESULTS Among 250 PPWH (median age 31 years, 42% pregnant, 58% postpartum, 20% with a gap in care), preferences were for pregnancy visits every 2 months (β = 0.15), postpartum visits with infant immunizations (β = 0.36), seeing a mentor mother and clinician each visit (β = 0.05 and 0.08, respectively), and 0 KSh cost (β = 0.39). Preferences were similar when stratified by age, pregnancy, and retention status. At the same cost, predicted market choice for a clinic model with fewer pregnant/postpartum visits was 75% versus 25% for the standard of care (ie, monthly visits during pregnancy/postpartum). CONCLUSION PPWH prefer fewer clinic visits than currently provided within the standard of care in Kenya, supporting the need for implementation of differentiated service delivery for this population.
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Affiliation(s)
- John Humphrey
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Esther Wanjama
- Department of Pediatrics, Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - James G. Carlucci
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Violet Naanyu
- Department of Sociology Psychology and Anthropology, Moi University School of Arts and Social Science, Eldoret, Kenya
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Edwin Were
- Department of Reproductive Health, Moi University College of Health Sciences, Eldoret, Kenya
| | - Lindah Muli
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Marsha Alera
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Alan McGuire
- Department of Psychology, Indiana University-Purdue University, Indianapolis, IN
- Health Services Research and Development, Richard L. Roudebush VAMC, Indianapolis, IN; and
| | - Winstone Nyandiko
- Department of Child Health and Pediatrics, Moi University College of Health Sciences, Eldoret, Kenya
| | - Julia Songok
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Department of Child Health and Pediatrics, Moi University College of Health Sciences, Eldoret, Kenya
| | | | - Gregory Zimet
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
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22
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Lavoie MCC, Koech E, Blanco N, Wangusi R, Jumbe M, Kimonye F, Ndaga A, Ndichu G, Makokha V, Awuor P, Momanyi E, Oyuga R, Nzyoka S, Mutisya I, Joseph R, Miruka F, Musingila P, Stafford KA, Lascko T, Ngunu C, Owino E, Kiplangat A, Kepha A, Ng’eno C. Factors associated with enrollment into differentiated service delivery model among adults with HIV in Kenya. AIDS 2023; 37:2409-2417. [PMID: 37707787 PMCID: PMC11317986 DOI: 10.1097/qad.0000000000003725] [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] [Indexed: 09/15/2023]
Abstract
INTRODUCTION Differentiated service delivery (DSD) such as multimonth dispensing (MMD) aims to provide client-centered HIV services, while reducing the workload within health facilities. We assessed individual and facility factors associated with receiving more than three MMD and switching from ≥3MMD back to <3MMD in Kenya. METHODS We conducted a retrospective cohort study of clients eligible for DSD between July 2017 and December 2019. A random sample of clients eligible for DSD was selected from 32 randomly selected facilities located in Nairobi, Kisii, and Migori counties. We used a multilevel Poisson regression model to assess the factors associated with receiving ≥3MMD, and with switching from ≥3MMD back to <3MMD. RESULTS A total of 3501 clients eligible for ≥3MMD were included in our analysis: 1808 (51.6%) were receiving care in Nairobi County and the remaining 1693 (48.4%) in Kisii and Migori counties. Overall, 65% of clients were enrolled in ≥3MMD at the time of entry into the cohort. In the multivariable model, younger age (20-24; 25-29; 30-34 vs. 50 or more years) and switching ART regimen was significantly associated with a lower likelihood of ≥3MMD uptake. Factors associated with a higher likelihood of enrollment in ≥3MMD included receiving DTG vs. EFV-based ART regimen (aRR: 1.10; 95% confidence interval: 1.05-1.15). CONCLUSION Client-level characteristics are associated with being on ≥3MMD and the likelihood of switching from ≥3MMD to <3MMD. Monitoring DSD enrollment across different populations is critical to successfully implementing these models continually.
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Affiliation(s)
- Marie-Claude C. Lavoie
- Division of Global Health Sciences, Department of Epidemiology and Public Health
- Institute of Human Virology
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Emily Koech
- Center for International Health, Education, and Biosecurity, MGIC-an affiliate of the University of Maryland Baltimore, Nairobi
| | - Natalia Blanco
- Institute of Human Virology
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Rebecca Wangusi
- Center for International Health, Education, and Biosecurity, MGIC-an affiliate of the University of Maryland Baltimore, Nairobi
| | - Marline Jumbe
- Center for International Health, Education, and Biosecurity, MGIC-an affiliate of the University of Maryland Baltimore, Nairobi
| | - Francis Kimonye
- Center for International Health, Education, and Biosecurity, MGIC-an affiliate of the University of Maryland Baltimore, Nairobi
| | - Angela Ndaga
- Center for International Health, Education, and Biosecurity, MGIC-an affiliate of the University of Maryland Baltimore, Nairobi
| | - Geofrey Ndichu
- Center for International Health, Education, and Biosecurity, MGIC-an affiliate of the University of Maryland Baltimore, Nairobi
| | - Violet Makokha
- Center for International Health, Education, and Biosecurity, MGIC-an affiliate of the University of Maryland Baltimore, Nairobi
| | - Patrick Awuor
- Center for International Health, Education, and Biosecurity, MGIC-an affiliate of the University of Maryland Baltimore, Nairobi
| | - Emmah Momanyi
- Center for International Health, Education, and Biosecurity, MGIC-an affiliate of the University of Maryland Baltimore, Nairobi
| | - Roseline Oyuga
- Center for International Health, Education, and Biosecurity, MGIC-an affiliate of the University of Maryland Baltimore, Nairobi
| | - Sarah Nzyoka
- Center for International Health, Education, and Biosecurity, MGIC-an affiliate of the University of Maryland Baltimore, Nairobi
| | - Immaculate Mutisya
- Division of Global HIV & TB (DGHT), U.S. Centers for Disease Control and Prevention (CDC), Kisumu
| | - Rachel Joseph
- Division of Global HIV & TB (DGHT), U.S. Centers for Disease Control and Prevention (CDC), Kisumu
| | - Fredrick Miruka
- Division of Global HIV & TB (DGHT), U.S. Centers for Disease Control and Prevention (CDC), Kisumu
| | - Paul Musingila
- Division of Global HIV & TB (DGHT), U.S. Centers for Disease Control and Prevention (CDC), Kisumu
| | - Kristen A. Stafford
- Division of Global Health Sciences, Department of Epidemiology and Public Health
- Institute of Human Virology
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Taylor Lascko
- Institute of Human Virology
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Carol Ngunu
- Nairobi Metropolitan Services Health Management Team, Nairobi
| | | | | | - Abuya Kepha
- Kisii County Health Management Team, Western, Kenya
| | - Caroline Ng’eno
- Center for International Health, Education, and Biosecurity, MGIC-an affiliate of the University of Maryland Baltimore, Nairobi
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23
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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: 1.0] [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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24
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Claassen CW, Kafunda I, Mwango L, Shiyanda S, Stoebenau K, Gekanju-Toeque M, Lindsay B, Adebayo O, Sinjani M, Kaayunga C, Wa Banza PK, Mweebo K, Kancheya N, Musokotwane K, Mwila A, Monze N, Nichols BE, Blanco N, Lavoie MCC, Watson DC, Hachaambwa L, Sheneberger R. Achieving HIV Epidemic Control and Improving Maternal Healthcare Services with Community-Based HIV Service Delivery in Zambia: Mixed-Methods Assessment of the SMACHT Project. AIDS Behav 2023; 27:3571-3583. [PMID: 37204561 PMCID: PMC11252556 DOI: 10.1007/s10461-023-04071-7] [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: 04/26/2023] [Indexed: 05/20/2023]
Abstract
Novel community-based approaches are needed to achieve and sustain HIV epidemic control in Zambia. Under the Stop Mother and Child HIV Transmission (SMACHT) project, the Community HIV Epidemic Control (CHEC) differentiated service delivery model used community health workers to support HIV testing, ART linkage, viral suppression, and prevention of mother-to-child transmission (MTCT). A multi-methods assessment included programmatic data analysis from April 2015 to September 2020, and qualitative interviews from February to March 2020. CHEC provided HIV testing services to 1,379,387 clients; 46,138 were newly identified as HIV-positive (3.3% yield), with 41,366 (90%) linked to ART. By 2020, 91% (60,694/66,841) of clients on ART were virally suppressed. Qualitatively, healthcare workers and clients benefitted from CHEC, with provision of confidential services, health facility decongestion, and increased HIV care uptake and retention. Community-based models can increase uptake of HIV testing and linkage to care, and help achieve epidemic control and elimination of MTCT.
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Affiliation(s)
- Cassidy W Claassen
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA.
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia.
- MGIC-Zambia, Plot 31C. Bishops Road. Kabulonga, P/B E017, Post-Net Box 319 Crossroads, Lusaka, Zambia.
| | - Ina Kafunda
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia
| | | | - Steven Shiyanda
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia
| | | | - Mona Gekanju-Toeque
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Brianna Lindsay
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia
| | | | - Msangwa Sinjani
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia
| | | | | | - Keith Mweebo
- U.S. Centers for Disease Control and Prevention, Lusaka, Zambia
| | - Nzali Kancheya
- U.S. Centers for Disease Control and Prevention, Lusaka, Zambia
| | | | - Annie Mwila
- U.S. Centers for Disease Control and Prevention, Lusaka, Zambia
| | - Newman Monze
- Southern Provincial Health Office, Ministry of Health, Choma, Zambia
| | | | - Natalia Blanco
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Marie-Claude C Lavoie
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | | | - Robb Sheneberger
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia
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Mekuria AD, Meseret WA, Assefa HK, Sisay AL, Bilchut AH, Derseh BT, Abebe AM, Tesfahun E, Minda A, Equbay M. Time to Virological Failure and Its Predictor Among HIV-Positive Clients with the Differentiated Service Delivery Model of HIV at Debre Berhan Comprehensive Specialized Hospital, Amhara Regional State, Ethiopia, 2021: A Retrospective Cohort Study. AIDS Res Hum Retroviruses 2023; 39:547-557. [PMID: 37183404 DOI: 10.1089/aid.2022.0153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023] Open
Abstract
Diversified antiretroviral therapy (ART) approach is needed in methods that were acceptable to communities and maintain good viral suppression outcomes to reach the UNAIDS targets to end the HIV/AIDS epidemic by 2030. Ethiopia is fully implementing differentiated service delivery (DSD) approaches, appointment spacing, and standard care. This study aimed to determine the time to HIV virological failure and its predictors among patients with a DSD model. An institution-based retrospective cohort study was conducted with data collection dates ranging from May 1, 2021, to May 30, 2021. All adult HIV-positive patients (n = 2,148) between January 2018 and January 2021 were a source population. Data were extracted using a standard checklist by trained data collectors and entered into EpiData, exported to SPSS version 20 for data management, and then exported to R Studio version 1.4 for analysis. Kaplan-Meier survival curves, the log-rank test, and Cox proportional hazard regression models were employed. The incidence of virological failure was 86 per 10,000 person-months. The independent predictors for the hazard of virological failure were being on standard care [adjusted hazard ratios (AHR) = 1.91; 95% confidence interval (CI) 1.07-3.40], primarily educated (AHR = 3.46; 95% CI 1.02-11.72), having no education (AHR = 3.45; 95% CI 1.01-11.85), and ambulatory status at baseline (AHR = 1.81; 95% CI 1.06-3.09). Patients who had a viral load with a detectable range from 50 to 999 at engagement (AHR = 2.65; 95% CI 1.33-5.27) and a 1-month increase in ART for HIV patients (AHR = 1.045; 95% CI 1.01-1.09). The incidence of virological failure was 86 per 10,000 person-months, whereas the incidences were 52 per 10,000 person-months and 71 per 10,000 person-months on appointment spacing model and standard care, respectively, with independent predictors: patient category, educational status, baseline functional status, viral load at engagement, and duration of ART.
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Affiliation(s)
- Abinet Dagnaw Mekuria
- Department of Public Health, Asrate Woldeyes Health Science Campus, Debre Berhan University, Debre Berhan, Ethiopia
| | - Wondesen Asegidew Meseret
- Department of Public Health, Asrate Woldeyes Health Science Campus, Debre Berhan University, Debre Berhan, Ethiopia
| | - Hilina Ketema Assefa
- Department of Nursing, Asrate Woldeyes Health Science Campus, Debre Berhan University, Debre Berhan, Ethiopia
| | - Assefa Legesse Sisay
- Department of Epidemiology and Bio-Statistics, Public Health Faculty Institute of Health Science, Jimma University, Jimma, Ethiopia
| | - Awraris Hailu Bilchut
- Department of Public Health, Asrate Woldeyes Health Science Campus, Debre Berhan University, Debre Berhan, Ethiopia
| | - Behailu Tariku Derseh
- Department of Public Health, Asrate Woldeyes Health Science Campus, Debre Berhan University, Debre Berhan, Ethiopia
| | - Ayele Mamo Abebe
- Department of Nursing, Asrate Woldeyes Health Science Campus, Debre Berhan University, Debre Berhan, Ethiopia
| | - Esubalew Tesfahun
- Department of Public Health, Asrate Woldeyes Health Science Campus, Debre Berhan University, Debre Berhan, Ethiopia
| | - Abebe Minda
- Department of Public Health, Asrate Woldeyes Health Science Campus, Debre Berhan University, Debre Berhan, Ethiopia
| | - Meseret Equbay
- Department of Public Health, Asrate Woldeyes Health Science Campus, Debre Berhan University, Debre Berhan, Ethiopia
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Uetela DAM, Augusto O, Hughes JP, Uetela OA, Gudo ES, Chicumbe SA, Couto AM, Gaspar IA, Chavana DL, Gaveta SE, Zimmermann MR, Gimbel S, Sherr K. Impact of differentiated service delivery models on 12-month retention in HIV treatment in Mozambique: an interrupted time-series analysis. Lancet HIV 2023; 10:e674-e683. [PMID: 37802568 DOI: 10.1016/s2352-3018(23)00184-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 07/13/2023] [Accepted: 07/21/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND HIV treatment has been available in Mozambique since 2004, but coverage of, and retention in, antiretroviral therapy (ART) remain suboptimal. Therefore, to increase health system efficiency and reduce HIV-associated mortality, in November, 2018, the Ministry of Health launched national guidelines on implementing eight differentiated service delivery models (DSDMs) for HIV treatment. We assessed the effect of this implementation on retention in ART 12 months after initiation, and explored the associated effects of COVID-19. METHODS In this uncontrolled interrupted time-series analysis, data were extracted from the Mozambique ART database, which contains data on individuals in ART care from 1455 health facilities providing ART in Mozambique. We included individual-level data from facilities that were providing ART at the beginning of the study period (Jan 1, 2016) and at the start of DSDM implementation (Dec 1, 2018). We compared the proportion of individuals retained in ART 12 months after initiation between the periods before (Jan 1, 2017, to Nov 30, 2018) and after (Dec 1, 2019, to June 30, 2021) implementation of the DSDMs, overall and stratified by sex and age. We applied a generalised estimating equation model with a working independence correlation and cluster-robust standard errors to account for clustering at the facility level. In a secondary analysis, we assessed the effect of COVID-19 response measures during the post-intervention period on ART retention. FINDINGS The study included 613 facilities and 1 131 118 individuals who started ART during the inclusion period up to June 30, 2020, of whom 79 178 (7·0%) were children (age ≤14 years), 226 224 (20·0%) were adolescents and young adults (age 15-24 years), and 825 716 (73·0%) were adults (age ≥25 years). 731 623 (64·7%) were female and 399 495 (35·3%) were male. Introduction of the DSDMs was associated with an estimated increase of 24·5 percentage points (95% CI 21·1 to 28·0) in 12-month ART retention by the end of the study period, compared with the counterfactual scenario without DSDM implementation. By age, the smallest effect was estimated in children (6·1 percentage points, 1·3 to 10·9) and the largest effect in adolescents and young adults (28·8 percentage points, 24·2 to 33·4); by sex, a larger effect was estimated in males (29·7 percentage points, 25·6 to 33·7). Our analysis showed that COVID-19 had an overall negative effect on 12-month retention in ART compared with a counterfactual scenario based on the post-intervention period without COVID-19 (-10·0 percentage points, -18·2 to -1·8). INTERPRETATION The implementation of eight DSDMs for HIV treatment had a positive impact on 12-month retention in ART. COVID-19 negatively influenced this outcome. FUNDING None. TRANSLATION For the Portuguese translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Dorlim A Moiana Uetela
- Instituto Nacional de Saúde, Marracuene, Mozambique; Department of Global Health, University of Washington, Seattle, WA, USA.
| | - Orvalho Augusto
- Department of Global Health, University of Washington, Seattle, WA, USA; Universidade Eduardo Mondlane, Maputo, Mozambique
| | - James P Hughes
- School of Public Health-Biostatistics, University of Washington, Seattle, WA, USA
| | - Onei A Uetela
- Department of Global Health, University of Washington, Seattle, WA, USA
| | | | | | - Aleny M Couto
- National STI and HIV/AIDS Control Program, Ministry of Health, Maputo, Mozambique
| | - Irénio A Gaspar
- National STI and HIV/AIDS Control Program, Ministry of Health, Maputo, Mozambique
| | | | | | - Marita R Zimmermann
- The Comparative Health Outcomes, Policy, and Economics Institute, University of Washington, Seattle, WA, USA
| | - Sarah Gimbel
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Child, Family and Population Health Nursing, University of Washington, Seattle, WA, USA
| | - Kenneth Sherr
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA; Department of Industrial and Systems Engineering, University of Washington, Seattle, WA, USA
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Lewis L, Sookrajh Y, van der Molen J, Khubone T, Sosibo P, Maraj M, van Heerden R, Little F, Kassanjee R, Garrett N, Dorward J. Clinical outcomes after extended 12-month antiretroviral therapy prescriptions in a community-based differentiated HIV service delivery programme in South Africa: a retrospective cohort study. J Int AIDS Soc 2023; 26:e26164. [PMID: 37767825 PMCID: PMC10535055 DOI: 10.1002/jia2.26164] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 08/22/2023] [Indexed: 09/29/2023] Open
Abstract
INTRODUCTION There is an urgent need for more efficient models of differentiated antiretroviral therapy (ART) delivery for people living with HIV (PLHIV), with the World Health Organization calling for evidence to guide whether annual ART prescriptions and consultations (12M scripts) should be recommended in global guidelines. We assessed the association between 12M scripts (allowed temporarily during the COVID-19 pandemic) versus standard 6-month prescriptions and consultations (6M scripts) and clinical outcomes. METHODS We performed a retrospective cohort study using routine, de-identified data from 59 public clinics in KwaZulu-Natal, South Africa. We included PLHIV aged ≥18 years with a recent suppressed viral load (VL) who had been referred for community ART delivery with 6M or 12M scripts. We used modified Poisson regression to compare 12-month retention-in-care (≤90 days late for all visits) and viral suppression (<50 copies/ml) between prescription groups. RESULTS Among 27,148 PLHIV referred for community ART during Jun-Dec 2020, 57.4% received 12M scripts. The median age was 39 years and 69.4% were women. Age, sex, prior community ART use and time on ART were similar across groups. However, more of the 12M script group had dolutegravir-based regimens (60.0% vs. 46.3%). The median (interquartile range) number of clinic visits in the year of follow-up was 1(1-1) in the 12M group and 2(2-3) in the 6M group. Retention was 94.6% (95% confidence interval [CI]: 94.2%-94.9%) among those receiving 12M scripts and 91.8% (95% CI: 91.3%-92.3%) among those with 6M scripts. 17.1% and 16.9% of clients in the 12M and 6M groups were missing follow-up VL data, respectively. Among those with VLs, 92.4% (95% CI: 92.0%-92.9%) in the 12M group and 91.4% (95% CI: 90.8%-92.0%) in the 6M group were suppressed. After adjusting for age, sex, ART regimen, time on ART, prior community ART use and calendar month, retention (adjusted risk ratio [aRR]: 1.03, 95% CI: 1.01-1.05) and suppression (aRR: 1.00, 95% CI: 0.99-1.01) were similar across groups. CONCLUSIONS Among PLHIV referred for community ART with a recent suppressed VL, the use of 12M scripts reduced clinic visits without impacting short-term clinical outcomes. 12M scripts should be considered for differentiated service delivery programmes.
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Affiliation(s)
- Lara Lewis
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
- Department of Statistical Sciences, University of Cape Town, Cape Town, South Africa
| | - Yukteshwar Sookrajh
- eThekwini Municipality Health Unit, eThekwini Municipality, Durban, South Africa
| | - Johan van der Molen
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Thokozani Khubone
- eThekwini Municipality Health Unit, eThekwini Municipality, Durban, South Africa
| | - Phelelani Sosibo
- eThekwini Municipality Health Unit, eThekwini Municipality, Durban, South Africa
| | - Munthra Maraj
- eThekwini Municipality Health Unit, eThekwini Municipality, Durban, South Africa
| | - Rose van Heerden
- eThekwini Municipality Health Unit, eThekwini Municipality, Durban, South Africa
| | - Francesca Little
- Department of Statistical Sciences, University of Cape Town, Cape Town, South Africa
| | - Reshma Kassanjee
- Centre for Infectious Disease Epidemiology and Research, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Nigel Garrett
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Jienchi Dorward
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Pascoe S, Huber A, Mokhele I, Lekodeba N, Ntjikelane V, Sande L, Tchereni T, Haimbe P, Rosen S. The SENTINEL study of differentiated service delivery models for HIV treatment in Malawi, South Africa, and Zambia: research protocol for a prospective cohort study. BMC Health Serv Res 2023; 23:891. [PMID: 37612720 PMCID: PMC10463463 DOI: 10.1186/s12913-023-09813-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 07/13/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND Many countries in sub-Saharan Africa are rapidly scaling up "differentiated service delivery" (DSD) models for HIV treatment to improve the quality of care, increase access, reduce costs, and support the continued expansion and sustainability of antiretroviral therapy (ART) programs. Although there is some published evidence about the health outcomes of patients in DSD models, little is known about their impacts on healthcare providers' job satisfaction, patients' quality of life, costs to providers or patients, or how DSD models affect resource allocation at the facility level. METHODS SENTINEL is a multi-year observational study that will collect detailed data about DSD models for ART delivery and related services from 12 healthcare facilities in Malawi, 24 in South Africa, and 12 in Zambia. The first round of SENTINEL included a patient survey, provider survey, provider time-and-motion observations, and facility resource use inventory. A survey of clients testing for HIV and a supplement to the facility resource use component to describe service delivery integration will be added for the second round. The patient survey will ask up to 10 patients enrolled in each DSD model at each study site about their experiences in HIV care and in DSD models, costs incurred seeking treatment, and preferences for HIV service delivery. The provider survey will ask up to 10 providers per site about the impact of DSD models on their positions and clinics. The time-and-motion component will directly observe the time use of a sample of providers implementing DSD models. Finally, the resource utilization component will collect facility-level data about DSD model availability and enrollment and the human and other resources needed to implement them. SENTINEL is planned to include four or more approximately annual rounds of data collection between 2021 and 2026. DISCUSSION As national DSD programs for HIV treatment mature, it is important to understand how individual healthcare facilities are interpreting and implementing national guidelines and how healthcare workers and clients are adapting to new models of service delivery. SENTINEL will help policy makers and program managers understand the benefits and costs of differentiated service delivery and improve resource allocation going forward.
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Affiliation(s)
- Sophie Pascoe
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Sunnyside Office Park, Building C, First Floor, 32 Princess of Wales Terrace, Parktown, Johannesburg, 2193, South Africa
| | - Amy Huber
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Sunnyside Office Park, Building C, First Floor, 32 Princess of Wales Terrace, Parktown, Johannesburg, 2193, South Africa
| | - Idah Mokhele
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Sunnyside Office Park, Building C, First Floor, 32 Princess of Wales Terrace, Parktown, Johannesburg, 2193, South Africa
| | - Nkgomeleng Lekodeba
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Sunnyside Office Park, Building C, First Floor, 32 Princess of Wales Terrace, Parktown, Johannesburg, 2193, South Africa
| | - Vinolia Ntjikelane
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Sunnyside Office Park, Building C, First Floor, 32 Princess of Wales Terrace, Parktown, Johannesburg, 2193, South Africa
| | - Linda Sande
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Sunnyside Office Park, Building C, First Floor, 32 Princess of Wales Terrace, Parktown, Johannesburg, 2193, South Africa
| | - Timothy Tchereni
- Clinton Health Access Initiative-Malawi, Private Bag 68, Lilongwe, Malawi
| | - Prudence Haimbe
- Clinton Health Access Initiative-Zambia, P.O. Box 51071, Ridgeway, Lusaka, Zambia
| | - Sydney Rosen
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Sunnyside Office Park, Building C, First Floor, 32 Princess of Wales Terrace, Parktown, Johannesburg, 2193, South Africa.
- Department of Global Health, School of Public Health, Boston University, 801 Massachusetts Ave, 3rd Fl, Boston, MA, 02118, USA.
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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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Esra RT, Carstens J, Estill J, Stoch R, Le Roux S, Mabuto T, Eisenstein M, Keiser O, Maskew M, Fox MP, De Voux L, Sharpey-Schafer K. Historical visit attendance as predictor of treatment interruption in South African HIV patients: Extension of a validated machine learning model. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002105. [PMID: 37467217 DOI: 10.1371/journal.pgph.0002105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 06/05/2023] [Indexed: 07/21/2023]
Abstract
Retention of antiretroviral (ART) patients is a priority for achieving HIV epidemic control in South Africa. While machine-learning methods are being increasingly utilised to identify high risk populations for suboptimal HIV service utilisation, they are limited in terms of explaining relationships between predictors. To further understand these relationships, we implemented machine learning methods optimised for predictive power and traditional statistical methods. We used routinely collected electronic medical record (EMR) data to evaluate longitudinal predictors of lost-to-follow up (LTFU) and temporal interruptions in treatment (IIT) in the first two years of treatment for ART patients in the Gauteng and North West provinces of South Africa. Of the 191,162 ART patients and 1,833,248 visits analysed, 49% experienced at least one IIT and 85% of those returned for a subsequent clinical visit. Patients iteratively transition in and out of treatment indicating that ART retention in South Africa is likely underestimated. Historical visit attendance is shown to be predictive of IIT using machine learning, log binomial regression and survival analyses. Using a previously developed categorical boosting (CatBoost) algorithm, we demonstrate that historical visit attendance alone is able to predict almost half of next missed visits. With the addition of baseline demographic and clinical features, this model is able to predict up to 60% of next missed ART visits with a sensitivity of 61.9% (95% CI: 61.5-62.3%), specificity of 66.5% (95% CI: 66.4-66.7%), and positive predictive value of 19.7% (95% CI: 19.5-19.9%). While the full usage of this model is relevant for settings where infrastructure exists to extract EMR data and run computations in real-time, historical visits attendance alone can be used to identify those at risk of disengaging from HIV care in the absence of other behavioural or observable risk factors.
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Affiliation(s)
- Rachel T Esra
- Institute of Global Health, University of Geneva, Geneva, Switzerland
- Imperial College of London, London, United Kingdom
| | | | - Janne Estill
- Institute of Global Health, University of Geneva, Geneva, Switzerland
| | | | - Sue Le Roux
- The Aurum Institute, Johannesburg, South Africa
| | | | | | - Olivia Keiser
- Institute of Global Health, University of Geneva, Geneva, Switzerland
| | - Mhari Maskew
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Matthew P Fox
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Departments of Epidemiology and Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
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Miyingo C, Mpayenda T, Nyole R, Ayinembabazi J, Ssepuuya M, Ssebuwufu EM, Puleh SS, Udho S, Kabunga A. HIV Treatment and Care of Adolescents: Perspectives of Adolescents on Community-Based Models in Northern Uganda. HIV AIDS (Auckl) 2023; 15:105-114. [PMID: 36938317 PMCID: PMC10015975 DOI: 10.2147/hiv.s405393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 03/09/2023] [Indexed: 03/12/2023] Open
Abstract
Background Differentiated service delivery models for people living with HIV continue to be scaled up to expand access to HIV services and treatment continuity. However, there is a gap in information on adolescents' perspectives on community-based models. We aimed to explore the perspectives of adolescents living with HIV on community-based models in northern Uganda. Materials and Methods Between February and March 2022, we conducted a descriptive qualitative study at two health centres IV in Northern Uganda. Data was collected using an interview guide. The study had 25 purposively selected adolescents enrolled in community-based models for HIV care and treatment. The interviews were audio-recorded, transcribed verbatim, and translated. We analyzed data using a thematic approach. Results A total of 25 in-depth interviews with HIV-positive adolescents were conducted. More than half (52.0%) of the participants were females, 84.0% were not married, and 44.0% had no formal education. The mean age of the respondents was 15.6 (±1.9) years. The major themes were: community-based models currently accessed by adolescents, benefits, and challenges of the models. Although there are other community-based models (community pharmacies, home ART deliveries) our exploration only discovered two models used by these adolescents to access care, namely, Community Drug Distribution Point (CDDP) and Community Client-Led ART Delivery Groups (CCLADs). The benefits included reduced transportation costs, convenient service access, ART adherence, peer support, a comfortable environment and less stress. However, our results indicate that these models had some challenges, including lack of confidentiality and privacy, perceived stigma, and a lack of face-to-face interaction. Conclusion Our findings show that CDDP and CCLADs are the two CBMs used by adolescents in Lira District to access treatment and care. Adolescents benefited from these models through reduced transport costs, the convenience of accessing HIV care and treatment, and social support. The challenges associated with these models are lack of confidentiality and privacy, perceived stigma, and a lack of face-to-face interaction. The Ministry of Health should work with other implementing partners to strengthen the implementation of these models to improve HIV/AIDS service delivery for adolescents.
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Affiliation(s)
| | - Teddy Mpayenda
- Department of Midwifery, Lira University, Lira City, Uganda
| | - Ruth Nyole
- Department of Midwifery, Lira University, Lira City, Uganda
| | | | - Mujib Ssepuuya
- Department of Public Health, Lira University, Lira City, Uganda
| | | | | | - Samson Udho
- Department of Midwifery, Lira University, Lira City, Uganda
| | - Amir Kabunga
- Department of Psychiatry, Lira University, Lira City, Uganda
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Moiana Uetela D, Gimbel S, Inguane C, Uetela O, Dinis A, Couto A, Gaspar I, Gudo ES, Chicumbe S, Gaveta S, Augusto O, Sherr K. Managers' and providers' perspectives on barriers and facilitators for the implementation of differentiated service delivery models for HIV treatment in Mozambique: a qualitative study. J Int AIDS Soc 2023; 26:e26076. [PMID: 36916122 PMCID: PMC10011810 DOI: 10.1002/jia2.26076] [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: 08/24/2022] [Accepted: 02/21/2023] [Indexed: 03/15/2023] Open
Abstract
INTRODUCTION In 2018, Mozambique's Ministry of Health launched a guideline for a nationwide implementation of eight differentiated service delivery models to optimize HIV service delivery and achieve universal coverage of HIV care and treatment. The models were (1) Fast-track, (2) Three-month Antiretrovirals Dispensing, (3) Community Antiretroviral Therapy Groups, (4) Adherence Clubs, (5) Family-approach, and three one-stop shop models for (6) Tuberculosis, (7) Maternal and Child Health, and (8) Adolescent-friendly Health Services. This study identified drivers of implementation success and failure across these differentiated service delivery models. METHODS Twenty in-depth individual interviews were conducted with managers and providers from the Ministry of Health and implementing partners from all levels of the health system between July and September 2021. National-level participants were based in the capital city of Maputo, and participants at provincial, district and health facility levels were from Sofala province, a purposively selected setting. The Consolidated Framework for Implementation Research (CFIR) guided data collection and thematic analysis. Deductively selected constructs were assessed while allowing for additional themes to emerge inductively. RESULTS The CFIR constructs of Relative Advantage, Complexity, Patient Needs and Resources, and Reflecting and Evaluating were identified as drivers of implementation, whereas Available Resources and Access to Knowledge and Information were identified as barriers. Fast-track and Three-month Antiretrovirals Dispensing models were deemed easier to implement and more effective in reducing workload. Adherence Clubs and Community Antiretroviral Therapy Groups were believed to be less preferred by clients in urban settings. COVID-19 (an inductive theme) improved acceptance and uptake of individual differentiated service delivery models that reduced client visits, but it temporarily interrupted the implementation of group models. CONCLUSIONS This study described important determinants to be addressed or leveraged for the successful implementation of differentiated service delivery models in Mozambique. The models were considered advantageous overall for the health system and clients when compared with the standard of care. However, successful implementation requires resources and ongoing training for frontline providers. COVID-19 expedited individual models by loosening the inclusion criteria; this experience can be leveraged to optimize the design and implementation of differentiated service delivery models in Mozambique and other countries.
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Affiliation(s)
- Dorlim Moiana Uetela
- Instituto Nacional de Saúde, Maputo, Mozambique.,Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Sarah Gimbel
- Department of Child, Family and Population Health Nursing, University of Washington, Seattle, Washington, USA
| | - Celso Inguane
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Onei Uetela
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Aneth Dinis
- Department of Global Health, University of Washington, Seattle, Washington, USA.,National Directorate of Public Health, Ministry of Health, Maputo, Mozambique
| | - Aleny Couto
- National STI-HIV/AIDS Program, Ministry of Health, Maputo, Mozambique
| | - Irénio Gaspar
- National STI-HIV/AIDS Program, Ministry of Health, Maputo, Mozambique
| | | | | | | | - Orvalho Augusto
- Department of Global Health, University of Washington, Seattle, Washington, USA.,Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Kenneth Sherr
- Department of Global Health, University of Washington, Seattle, Washington, USA.,Department of Epidemiology, University of Washington, Seattle, Washington, USA.,Department of Industrial & Systems Engineering, University of Washington, Seattle, Washington, USA
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Lujintanon S, Amatavete S, Leenasirimakul P, Meechure J, Noopetch P, Sangtong S, Sittikarn S, Phoopisutthisak P, Seekaew P, Mills S, Phanuphak P, Ramautarsing RA, Phanuphak N. Acceptability and retention of the key population-led HIV treatment service for men who have sex with men and transgender women living with HIV in Thailand. J Int AIDS Soc 2023; 26:e26062. [PMID: 36757793 PMCID: PMC9910427 DOI: 10.1002/jia2.26062] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 01/30/2023] [Indexed: 02/10/2023] Open
Abstract
INTRODUCTION In Thailand, where the HIV epidemic is concentrated among key populations (KPs), particularly men who have sex with men (MSM) and transgender women (TGW), an HIV service delivery model tailored to KPs was piloted. This study evaluated the acceptability and retention of clients who accepted and declined the KP-led HIV treatment service. METHODS A retrospective cohort study was conducted using secondary data from three community-based organizations (CBOs) and three hospitals in Thailand. KP lay providers were trained to lead HIV treatment service in which MSM and TGW living with HIV received counselling and a 3-month antiretroviral therapy (ART) supply at CBOs. Thai MSM and TGW who were at least 18 years, on ART for at least 6-12 months, without co-morbidities/co-infections, and virally suppressed were eligible and offered the service. Those who declined received ART via other service models offered by the hospitals and served as a comparison group. RESULTS Of 220 clients screened between February 2019 and February 2020, 72% (159/220) were eligible of which 146 were MSM and 13 were TGW. Overall, 45% (72/159) accepted the KP-led service. Of those who declined, 98% (85/87) preferred to see the physician at the hospital. After 12 months of follow-up, among those accepted, 57% were in care at the CBO, 32% were referred back to and in care in other service models offered by the hospital, 10% were successfully transferred out to other hospital and 1% were lost to follow-up (LTFU); among those declined, 92% were in care in any service models offered by the hospital, 5% were successfully transferred out to other hospital, 2% were LTFU and 1% died (p-value<0.001). CONCLUSIONS Despite moderate acceptability and retention in care at the CBO among the clients accepting the KP-led service, almost all clients were engaged in care overall. Multiple service models that meet the preferences and needs of KPs living with HIV should be available to optimize engagement in care.
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Affiliation(s)
- Sita Lujintanon
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA,Institute of HIV Research and InnovationBangkokThailand
| | | | | | | | | | | | | | | | - Pich Seekaew
- Institute of HIV Research and InnovationBangkokThailand,Department of EpidemiologyColumbia University Mailman School of Public HealthNew YorkNew YorkUSA
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Wan Mohamad Darani WNS, Chen XW, Samsudin EZ, Mohd Nor F, Ismail I. Determinants of Successful Human Immunodeficiency Virus Treatment Outcomes: A Linkage of National Data Sources in Malaysia. Malays J Med Sci 2023; 30:172-184. [PMID: 36875201 PMCID: PMC9984112 DOI: 10.21315/mjms2023.30.1.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 06/18/2022] [Indexed: 03/05/2023] Open
Abstract
Background Concerted efforts have been undertaken to reduce the human immunodeficiency virus (HIV) infection by the year 2030 in Malaysia. A situational analysis of the performance of successful HIV treatment and its determinants is vital; however, this information remains scarce. This study aimed to identify the determinants of undetectable viral load among people living with HIV (PLHIV). Methods Newly diagnosed HIV cases (n = 493) registered under the Malaysia HIV/AIDS-related national databases from June 2018 to December 2019 were studied. The deterministic matching method was applied to link the records in two national databases (at Kuala Lumpur and Putrajaya Federal Territories Health Department, JKWPKLP HIV line-listing database and National AIDS Registry). Successful HIV treatment, an outcome variable, was measured by the undetectable viral load < 200 copies/mL after 1 year of antiretroviral therapy initiation. Logistic regression analysis was applied in the current study. Results Results showed that 454/493 (92.2%; 95% confidence interval [CI]: 89.8%, 94.6%) PLHIV had successful HIV treatment. Study participants had a mean (SD) age of 30 (8.10) years old, predominantly male (96.1%) and sexually transmission (99.9%). The multiple logistic regression analysis revealed two significant determinants including the timing of ART initiation (AOR = 3.94; 95% CI: 1.32, 11.70; P = 0.014) and establishment of Sexually Transmitted Infection Friendly Clinic (STIFC) (AOR = 3.40; 95% CI: 1.47, 7.85; P = 0.004). Non-significant variables included gender, education level, HIV risk exposure, and co-infections of tuberculosis and Hepatitis C. Conclusion JKWPKLP is on the right track to achieving universal treatment as a prevention strategy. Reinforcement of early ART initiation and establishment of STIFC are recommended.
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Affiliation(s)
- Wan Nur Syamimi Wan Mohamad Darani
- Department of Public Health Medicine, Faculty of Medicine, Universiti Teknologi MARA, Selangor, Malaysia
- HIV Unit, Kuala Lumpur and Putrajaya Federal Territories Health Department (JKWPKLP), Ministry of Health, Kuala Lumpur, Malaysia
| | - Xin Wee Chen
- Department of Public Health Medicine, Faculty of Medicine, Universiti Teknologi MARA, Selangor, Malaysia
- Institute of Medical Molecular Biotechnology (IMMB), Faculty of Medicine, Universiti Teknologi MARA, Selangor, Malaysia
| | - Ely Zarina Samsudin
- Department of Public Health Medicine, Faculty of Medicine, Universiti Teknologi MARA, Selangor, Malaysia
| | - Fadzilah Mohd Nor
- Institute of Medical Molecular Biotechnology (IMMB), Faculty of Medicine, Universiti Teknologi MARA, Selangor, Malaysia
- Department of Medical Microbiology and Parasitology, Faculty of Medicine, Universiti Teknologi MARA, Selangor, Malaysia
- Integrative Pharmacogenomics Institute (iPROMISE), Universiti Teknologi MARA, Puncak Alam Campus, Selangor, Malaysia
| | - Ismawati Ismail
- HIV Unit, Kuala Lumpur and Putrajaya Federal Territories Health Department (JKWPKLP), Ministry of Health, Kuala Lumpur, Malaysia
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Benade M, Nichols BE, Fatti G, Kuchukhidze S, Takarinda K, Mabhena-Ngorima N, Grimwood A, Rosen S. Economic evaluation of a cluster randomized, non-inferiority trial of differentiated service delivery models of HIV treatment in Zimbabwe. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0000493. [PMID: 36962960 PMCID: PMC10021451 DOI: 10.1371/journal.pgph.0000493] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 01/30/2023] [Indexed: 03/15/2023]
Abstract
About 85% of Zimbabwe's >1.4 million people living with HIV are on antiretroviral treatment (ART). Further expansion of its treatment program will require more efficient use of existing resources. Two promising strategies for reducing resource utilization per patient are multi-month medication dispensing and community-based service delivery. We evaluated the costs to providers and patients of community-based, multi-month ART delivery models in Zimbabwe. We used resource and outcome data from a cluster-randomized non-inferiority trial of three differentiated service delivery (DSD) models targeted to patients stable on ART: 3-month facility-based care (3MF), community ART refill groups (CAGs) with 3-month dispensing (3MC), and CAGs with 6-month dispensing (6MC). Using local unit costs, we estimated the annual cost in 2020 USD of providing HIV treatment per patient from the provider and patient perspectives. In the trial, retention at 12 months was 93.0% in the 3MF, 94.8% in the 3MC, and 95.5% in the 6MC arms. The total average annual cost of HIV treatment per patient was $187 (standard deviation $39), $178 ($30), and $167 ($39) in each of the three arms, respectively. The annual cost/patient was dominated by ART medications (79% in 3MF, 87% in 3MC; 92% in 6MC), followed by facility visits (12%, 5%, 5%, respectively) and viral load (8%, 8%, 2%, respectively). When costs were stratified by district, DSD models cost slightly less, with 6MC the least expensive in all districts. Savings were driven by differences in the number of facility visits made/year, as expected, and low uptake of annual viral load tests in the 6-month arm. The total annual cost to patients to obtain HIV care was $10.03 ($2) in the 3MF arm, $5.12 ($0.41) in the 3MC arm, and $4.40 ($0.39) in the 6MF arm. For stable ART patients in Zimbabwe, 3- and 6-month community-based multi-month dispensing models cost less for both providers and patients than 3-month facility-based care and had non-inferior outcomes.
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Affiliation(s)
- Mariet Benade
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts, United States of America
| | - Brooke E Nichols
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts, United States of America
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Medical Microbiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Geoffrey Fatti
- Kheth'Impilo AIDS Free Living, Cape Town, South Africa
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Salome Kuchukhidze
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts, United States of America
| | | | | | | | - Sydney Rosen
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts, United States of America
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Jo Y, Jamieson L, Phiri B, Grimsrud A, Mwansa M, Shakwelele H, Haimbe P, Mukumbwa-Mwenechanya M, Mulenga PL, Nichols BE, Rosen S. Attrition from HIV treatment after enrollment in a differentiated service delivery model: A cohort analysis of routine care in Zambia. PLoS One 2023; 18:e0280748. [PMID: 36917568 PMCID: PMC10013882 DOI: 10.1371/journal.pone.0280748] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 01/07/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Many sub-Saharan Africa countries are scaling up differentiated service delivery (DSD) models for HIV treatment to increase access and remove barriers to care. We assessed factors associated with attrition after DSD model enrollment in Zambia, focusing on patient-level characteristics. METHODS We conducted a retrospective record review using electronic medical records (EMR) of adults (≥15 years) initiated on antiretroviral (ART) between 01 January 2018 and 30 November 2021. Attrition was defined as lost to follow-up (LTFU) or died by November 30, 2021. We categorized DSD models into eight groups: fast-track, adherence groups, community pick-up points, home ART delivery, extended facility hours, facility multi-month dispensing (MMD, 4-6-month ART dispensing), frequent refill care (facility 1-2 month dispensing), and conventional care (facility 3 month dispensing, reference group). We used Fine and Gray competing risk regression to assess patient-level factors associated with attrition, stratified by sex and rural/urban setting. RESULTS Of 547,281 eligible patients, 68% (n = 372,409) enrolled in DSD models, most commonly facility MMD (n = 306,430, 82%), frequent refill care (n = 47,142, 13%), and fast track (n = 14,433, 4%), with <2% enrolled in the other DSD groups. Retention was higher in nearly all DSD models for all dispensing intervals, compared to the reference group, except fast track for the ≤2 month dispensing group. Retention benefits were greatest for patients in the extended clinic hours group and least for fast track dispensing. CONCLUSION Although retention in HIV treatment differed by DSD type, dispensing interval, and patient characteristics, nearly all DSD models out-performed conventional care. Understanding the factors that influence the retention of patients in DSD models could provide an important step towards improving DSD implementation.
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Affiliation(s)
- Youngji Jo
- Department of Medicine, Section of Infectious Diseases, Boston Medical Center, Boston, MA, United States of America
| | - Lise Jamieson
- Department of Internal Medicine, Health Economics and Epidemiology Research Office, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Medical Microbiology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Bevis Phiri
- Clinton Health Access Initiative, Lusaka, Zambia
| | - Anna Grimsrud
- HIV Programmes and Advocacy, International AIDS Society, Cape Town, South Africa
| | | | | | | | | | | | - Brooke E. Nichols
- Department of Internal Medicine, Health Economics and Epidemiology Research Office, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Medical Microbiology, Amsterdam University Medical Center, Amsterdam, Netherlands
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
| | - Sydney Rosen
- Department of Internal Medicine, Health Economics and Epidemiology Research Office, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
- * E-mail:
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Jamieson L, Rosen S, Phiri B, Grimsrud A, Mwansa M, Shakwelele H, Haimbe P, Mukumbwa-Mwenechanya M, Lumano-Mulenga P, Chiboma I, Nichols BE. How soon should patients be eligible for differentiated service delivery models for antiretroviral treatment? Evidence from a retrospective cohort study in Zambia. BMJ Open 2022; 12:e064070. [PMID: 36549722 PMCID: PMC9772670 DOI: 10.1136/bmjopen-2022-064070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES Patient attrition is high the first 6 months after antiretroviral therapy (ART) initiation. Patients with <6 months of ART are systematically excluded from most differentiated service delivery (DSD) models, which are intended to support retention. Despite DSD eligibility criteria requiring ≥6 months on ART, some patients enrol earlier. We compared loss to follow-up (LTFU) between patients enrolling in DSD models early with those enrolled according to guidelines, assessing whether the ART experience eligibility criterion is necessary. DESIGN Retrospective cohort study using routinely collected electronic medical record data. SETTING PARTICIPANTS: Adults (≥15 years) who initiated ART between 1 January 2019 and 31 December 2020. OUTCOMES LTFU (>30 days late for scheduled visit) at 18 months for 'early enrollers' (DSD enrolment after <6 months on ART) and 'established enrollers' (DSD enrolment after ≥6 months on ART). We used a log-binomial model to compare LTFU risk, adjusting for age, sex, location, ART refill interval and DSD model. RESULTS For 6340 early enrollers and 25 857 established enrollers, there were no differences in sex (61% female), age (median 37 years) or location (65% urban). ART refill intervals were longer for established versus early enrollers (72% vs 55% were given 4-6 months refills). LTFU at 18 months was 3% (192 of 6340) for early enrollers and 5% (24 646 of 25 857) for established enrollers. Early enrollers were 41% less likely to be LTFU than established patients (adjusted risk ratio 0.59, 95% CI 0.50 to 0.68). CONCLUSIONS Patients enrolled in DSD after <6 months of ART were more likely to be retained than patients established on ART prior to DSD enrolment. A limitation is that early enrollers may have been selected for DSD due to providers' and patients' expectations about future retention. Offering DSD models to ART patients soon after ART initiation may help address high attrition during the early treatment period. TRIAL REGISTERATION NUMBER NCT04158882.
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Affiliation(s)
- Lise Jamieson
- Health Economics and Epidemiology Research Office, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, South Africa
- Department of Medical Microbiology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - Sydney Rosen
- Health Economics and Epidemiology Research Office, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Bevis Phiri
- Clinton Health Access Initiative, Lusaka, Zambia
| | | | | | | | | | | | | | | | - Brooke E Nichols
- Health Economics and Epidemiology Research Office, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, South Africa
- Department of Medical Microbiology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
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Shigayeva A, Gcwensa N, Ndlovu CD, Ntumase N, Sabela S, Ohler L, Trivino-Duran L, Kamara EF, Hlophe K, Isaakidis P, Van Cutsem G. Retention on ART and viral suppression among patients in alternative models of differentiated HIV service delivery in KwaZulu-Natal, South Africa. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000336. [PMID: 36962695 PMCID: PMC10021436 DOI: 10.1371/journal.pgph.0000336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 11/10/2022] [Indexed: 06/18/2023]
Abstract
Differentiated models of HIV care (DMOC) aim to improve health care efficiency. We describe outcomes of five DMOC in KwaZulu-Natal, South Africa: facility adherence clubs (facility AC) and community adherence clubs (community AC), community antiretroviral treatment (ART) groups (CAG), spaced fast lane appointments (SFLA), and community pick up points (PuP). This retrospective cohort study included 8241 eligible patients enrolled into DMOC between 1/1/2012 and 31/12/2018. We assessed retention in DMOC and on ART, and viral load suppression (<1000 copies/mL). Kaplan-Meier techniques were applied to describe crude retention. Mixed effects parametric survival models with Weibull distribution and clustering on health center and individual levels were used to assess predictors for ART and DMOC attrition, and VL rebound (≥1000 copies/mL). Overall DMOC retention was 85%, 80%, and 76% at 12, 24 and 36 months. ART retention at 12, 24 and 36 months was 96%, 93%, 90%. Overall incidence rate of VL rebound was 1.9 episodes per 100 person-years. VL rebound rate was 4.9 episodes per 100 person-years among those enrolled in 2012-2015, and 0.8 episodes per 100 person-years among those enrolled in 2016-2018 (RR 0.12; 95% CI, 0.09-0.15, p<0.001). Prevalence of confirmed virological failure was 0.6% (38/6113). Predictors of attrition from DMOC and from ART were male gender, younger age, shorter duration on ART before enrollment. Low level viremia (>200-399 copies/mL) was associated with higher hazards of VL rebound and attrition from ART. Concurrent implementation of several DMOC in a large ART program is feasible and can achieve sustained retention on ART and VL suppression.
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Affiliation(s)
| | - Ntombi Gcwensa
- Médecins Sans Frontières—South Africa, Eshowe, South Africa
| | | | | | | | - Liesbet Ohler
- Médecins Sans Frontières—South Africa, Eshowe, South Africa
| | | | | | | | - Petros Isaakidis
- Southern African Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
- Clinical and Molecular Epidemiology Unit, Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece
| | - Gilles Van Cutsem
- Southern African Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa
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Pascoe SJS, Huber AN. Home delivery of ART: could this be a reality in South Africa? Lancet HIV 2022; 9:e812-e814. [PMID: 36335977 DOI: 10.1016/s2352-3018(22)00294-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 09/28/2022] [Indexed: 06/16/2023]
Affiliation(s)
- Sophie J S Pascoe
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Johannesburg, South Africa; Health Science Research Office, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.
| | - Amy N Huber
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Johannesburg, South Africa; Health Science Research Office, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
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Bachanas PJ, Chun HM, Mehta N, Aberle‐Grasse J, Parris K, Sherlock MW, Lloyd S, Zeh C, Makwepa DK, Kapanda ML, Dokubo EK, Bonono L, Balachandra S, Ehui E, Fonjungo P, Nkoso AM, Mazibuko S, Okello VN, Tefera F, Getachew M, Katiku EM, Mulwa A, Asiimwe FM, Tarumbiswa TF, Auld AF, Nyirenda R, Dos Santos De Louvado AP, Gaspar I, Hong SY, Ashipala L, Obanubi C, Ikpeazu A, Musoni C, Yoboka E, Mthethwa S, Pinini Z, Bunga S, Rumunu J, Magesa DJ, Mutayoba B, Nelson LJ, Katureebe C, Agolory S, Mulenga LB, Nyika P, Mugurungi O, Ellerbrock T, Mitruka K. Protecting the gains: analysis of HIV treatment and service delivery programme data and interventions implemented in 19 African countries during COVID-19. J Int AIDS Soc 2022; 25:e26033. [PMID: 36419346 PMCID: PMC9684677 DOI: 10.1002/jia2.26033] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 10/20/2022] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION The potential disruption in antiretroviral therapy (ART) services in Africa at the start of the COVID-19 pandemic raised concern for increased morbidity and mortality among people living with HIV (PLHIV). We describe HIV treatment trends before and during the pandemic and interventions implemented to mitigate COVID-19 impact among countries supported by the US Centers for Disease Control and Prevention (CDC) through the President's Emergency Plan for AIDS Relief (PEPFAR). METHODS We analysed quantitative and qualitative data reported by 10,387 PEPFAR-CDC-supported ART sites in 19 African countries between October 2019 and March 2021. Trends in PLHIV on ART, new ART initiations and treatment interruptions were assessed. Viral load coverage (testing of eligible PLHIV) and viral suppression were calculated at select time points. Qualitative data were analysed to summarize facility- and community-based interventions implemented to mitigate COVID-19. RESULTS The total number of PLHIV on ART increased quarterly from October 2019 (n = 7,540,592) to March 2021 (n = 8,513,572). The adult population (≥15 years) on ART increased by 14.0% (7,005,959-7,983,793), while the paediatric population (<15 years) on ART declined by 2.6% (333,178-324,441). However, the number of new ART initiations dropped between March 2020 and June 2020 by 23.4% for adults and 26.1% for children, with more rapid recovery in adults than children from September 2020 onwards. Viral load coverage increased slightly from April 2020 to March 2021 (75-78%) and viral load suppression increased from October 2019 to March 2021 (91-94%) among adults and children combined. The most reported interventions included multi-month dispensing (MMD) of ART, community service delivery expansion, and technology and virtual platforms use for client engagement and site-level monitoring. MMD of ≥3 months increased from 52% in October 2019 to 78% of PLHIV ≥ age 15 on ART in March 2021. CONCLUSIONS With an overall increase in the number of people on ART, HIV programmes proved to be resilient, mitigating the impact of COVID-19. However, the decline in the number of children on ART warrants urgent investigation and interventions to prevent further losses experienced during the COVID-19 pandemic and future public health emergencies.
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Guthrie T, Muheki C, Rosen S, Kanoowe S, Lagony S, Greener R, Miot J, Balidawa H, Kiggundu J, Calnan J, Dejene S, Xulu T, Sigwebela N, Long LC. Similar costs and outcomes for differentiated service delivery models for HIV treatment in Uganda. BMC Health Serv Res 2022; 22:1315. [PMID: 36329450 PMCID: PMC9635081 DOI: 10.1186/s12913-022-08629-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 09/15/2022] [Indexed: 11/06/2022] Open
Abstract
This cost-outcome study estimated, from the perspective of the service provider, the total annual cost per client on antiretroviral therapy (ART) and total annual cost per client virally suppressed (defined as < 1000 copies/ml at the time of the study) in Uganda in five ART differentiated service delivery models (DSDMs). These included both facility- and community-based models and the standard of care (SOC), known as the facility-based individual management (FBIM) model. The Ministry of Health (MOH) adopted guidelines for DSDMs in 2017 and sought to measure their costs and outcomes, in order to effectively plan for their resourcing, implementation, and scale-up. In Uganda, the standard of care (FBIM) is considered as a DSDM option for clients requiring specialized treatment and support, or for those who select not to join an alternative DSDM. Note that clients on second-line regimes and considered as “established on treatment” can join a suitable DSDM. Using retrospective client record review of a cohort of clients over a two-year period, with bottom-up collection of clients’ resource utilization data, top-down collection of above-delivery level and delivery-level providers’ fixed operational costs, and local unit costs. Forty-seven DSDMs located at facilities or community-based points in the four regions of Uganda were included in the study, with 653 adults on ART (> 18 years old) enrolled in a DSDM. The study found that retention in care was 98% for the sample as a whole [96–100%], and viral suppression, 91% [86-93%]. The mean cost to the provider (MOH or NGO implementers) was $152 per annum per client treated, ranging from $141 to $166. Differences among the models’ costs were largely due to clients’ ARV regimens and the proportions of clients on second line regimens. Service delivery costs, excluding ARVs, other medicines and laboratory tests, were modest, ranging from $9.66–16.43 per client per year. We conclude that differentiated ART service delivery in Uganda achieved excellent treatment outcomes at a cost similar to the standard of care. While large budgetary savings might not be immediately realized, the reallocation of “saved” staff time could improve health system efficiency and with their equivalent or better outcomes and large benefits to clients, client-centred differentiated models would nevertheless add great societal value.
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Shah GH, Etheredge GD, Smallwood SW, Maluantesa L, Waterfield KC, Ikhile O, Ditekemena J, Engetele E, Ayangunna E, Mulenga A, Bossiky B. HIV viral load suppression before and after COVID-19 in Kinshasa and Haut Katanga, Democratic Republic of the Congo. South Afr J HIV Med 2022; 23:1421. [PMCID: PMC9634654 DOI: 10.4102/sajhivmed.v23i1.1421] [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: 06/28/2022] [Accepted: 08/23/2022] [Indexed: 11/07/2022] Open
Abstract
Background The coronavirus disease 2019 (COVID-19) pandemic resulted in unique programmatic opportunities to test hypotheses related to the initiation of antiretroviral treatment (ART) and viral load (VL) suppression during a global health crisis, which would not otherwise have been possible. Objectives To generate practice-relevant evidence on the impact of initiating ART pre-COVID-19 versus during the COVID-19 pandemic on HIV VL. Method Logistic regression was performed on data covering 6596 persons with HIV whose VL data were available, out of 36 585 persons who were initiated on ART between 01 April 2019 and 30 March 2021. Results After controlling for covariates such as age, gender, duration on ART, tuberculosis status at the time of the last visit, and rural vs urban status, the odds of having a VL < 1000 copies/mL were significantly higher for clients who started ART during the COVID-19 pandemic than the year before COVID-19 (adjusted odds ratio [AOR]: 2.50; confidence interval [CI]: 1.55–4.01; P < 0.001). Odds of having a VL < 1000 copies/mL were also significantly higher among female participants than male (AOR: 1.23; CI: 1.02–1.48), among patients attending rural clinics compared to those attending urban clinics (AOR: 1.83; CI: 1.47–2.28), and in clients who were 15 years or older at the time of their last visit (AOR: 1.50; CI: 1.07–2.11). Conclusion Viral loads did not deteriorate despite pandemic-induced changes in HIV services such as the expansion of multi-month dispensing (MMD), which may have played a protective role regardless of the general negative impacts of response to the COVID-19 crises on communities and individuals. What this study adds This research capitalises on the natural experiment of COVID-19-related changes in HIV services and provides new practice-relevant research evidence.
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Affiliation(s)
- Gulzar H. Shah
- Department of Health Policy and Community Health, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, United States of America
| | | | - Stacy W. Smallwood
- Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, United States of America
| | | | - Kristie C. Waterfield
- Department of Health Policy and Community Health, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, United States of America
| | - Osaremhen Ikhile
- Department of Health Policy and Community Health, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, United States of America
| | | | | | - Elizabeth Ayangunna
- Department of Health Policy and Community Health, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, United States of America
| | | | - Bernard Bossiky
- National Multisectoral HIV/AIDS program (PNMLS), HIV Program, Presidency of DRC, Democratic Republic of the Congo
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Maskew M, Technau K, Davies MA, Vreeman R, Fox MP. Adolescent retention in HIV care within differentiated service-delivery models in sub-Saharan Africa. Lancet HIV 2022; 9:e726-e734. [PMID: 36088915 PMCID: PMC9927242 DOI: 10.1016/s2352-3018(22)00137-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 04/11/2022] [Accepted: 05/06/2022] [Indexed: 02/05/2023]
Abstract
Adolescents and young people living with HIV are at risk of disengaging from HIV care at all stages of the care cascade. Differentiated models of care offer simplified HIV-service delivery options in the hope of improving treatment outcomes, including retention on antiretroviral therapy. However, it remains unclear how successful and widespread these models are for adolescents in sub-Saharan Africa, where the burden of HIV is the greatest. Very few differentiated models of care specifically targeted to adolescents can be found and this priority group are currently ineligible from several models that exist. Where differentiated care has been made available to adolescents, data on the implementation and effectiveness of these interventions remain scarce. Despite this scarcity of evidence on the effectiveness of differentiated care among adolescent populations, several interventions, particularly community-based groups with peer navigators or supporters, might have potential to increase the reach, effectiveness, and adoption of differentiated care in adolescent HIV-care programmes.
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Affiliation(s)
- Mhairi Maskew
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa.
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Christ B, van Dijk JH, Nyandoro TY, Reichmuth ML, Kunzekwenyika C, Chammartin F, Egger M, Wringe A, Ballif M. Availability and experiences of differentiated antiretroviral therapy delivery at HIV care facilities in rural Zimbabwe: a mixed-method study. J Int AIDS Soc 2022; 25:e25944. [PMID: 36008925 PMCID: PMC9411726 DOI: 10.1002/jia2.25944] [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: 06/28/2021] [Accepted: 05/20/2022] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Zimbabwe adopted differentiated HIV care policies in 2015 to promote client-centred care and relieve strain on health facilities. We examined the availability, experiences and perceptions of differentiated antiretroviral therapy (ART) delivery in rural Zimbabwe following the policy adoption. METHODS We undertook a cross-sectional mixed methods study in all the 26 facilities providing HIV care in a rural district in Zimbabwe. We collected quantitative data about ART delivery and visit durations from 31 healthcare providers and a purposive stratified sample of 378 clients obtaining ART either through routine care or differentiated ART delivery models. We performed 26 semi-structured interviews among healthcare providers and seven focus group discussions (FGDs) among clients to elicit their perceptions and experiences of ART delivery. Data were collected in 2019, with one follow-up FGD in 2021. We analysed the transcripts thematically, with inductive coding, to identify emerging themes. RESULTS Twenty facilities (77%) offered at least one differentiated ART delivery models, including community ART refill groups (CARGs; 13 facilities, 50%), fast-track refill (8, 31%), family refill (6, 23%) or club refill (1, 4%). Thirteen facilities (50%) offered only one model. The median visit duration was 28 minutes (interquartile range [IQR]: 16-62). Participants in fast-track had the shortest visit durations (18 minutes, IQR: 11-24). Confidentiality and disclosure of HIV status, travelling long distances, travel costs and waiting times were the main issues influencing clients' views on differentiated ART delivery. Fast-track refill was perceived as the preferred model of clients for its limited involuntary disclosure and efficiency. In contrast, group- and community-based refill models reduced travel costs but were felt to be associated with involuntary disclosure of HIV status, which could discourage clients. Healthcare providers also experienced an additional workload when offering facility-based group models, such as CARGs. CONCLUSIONS Differentiated ART delivery models were widely available in this rural setting, but most facilities did not offer a choice of models to address clients' diverse preferences. A minority offered fast-track refills, although this model was often mentioned as desirable. Confidentiality, travel expenses and client waiting times are key elements to consider when planning and rolling out differentiated HIV care.
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Affiliation(s)
- Benedikt Christ
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | | | | | - Martina L Reichmuth
- 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 Research and Epidemiology, University of Cape Town, Cape Town, South Africa.,Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Alison Wringe
- London School of Hygiene and Tropical Medicine, London, UK
| | - Marie Ballif
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
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Applying machine learning and predictive modeling to retention and viral suppression in South African HIV treatment cohorts. Sci Rep 2022; 12:12715. [PMID: 35882962 PMCID: PMC9325703 DOI: 10.1038/s41598-022-16062-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 07/04/2022] [Indexed: 11/09/2022] Open
Abstract
HIV treatment programs face challenges in identifying patients at risk for loss-to-follow-up and uncontrolled viremia. We applied predictive machine learning algorithms to anonymised, patient-level HIV programmatic data from two districts in South Africa, 2016-2018. We developed patient risk scores for two outcomes: (1) visit attendance ≤ 28 days of the next scheduled clinic visit and (2) suppression of the next HIV viral load (VL). Demographic, clinical, behavioral and laboratory data were investigated in multiple models as predictor variables of attending the next scheduled visit and VL results at the next test. Three classification algorithms (logistical regression, random forest and AdaBoost) were evaluated for building predictive models. Data were randomly sampled on a 70/30 split into a training and test set. The training set included a balanced set of positive and negative examples from which the classification algorithm could learn. The predictor variable data from the unseen test set were given to the model, and each predicted outcome was scored against known outcomes. Finally, we estimated performance metrics for each model in terms of sensitivity, specificity, positive and negative predictive value and area under the curve (AUC). In total, 445,636 patients were included in the retention model and 363,977 in the VL model. The predictive metric (AUC) ranged from 0.69 for attendance at the next scheduled visit to 0.76 for VL suppression, suggesting that the model correctly classified whether a scheduled visit would be attended in 2 of 3 patients and whether the VL result at the next test would be suppressed in approximately 3 of 4 patients. Variables that were important predictors of both outcomes included prior late visits, number of prior VL tests, time since their last visit, number of visits on their current regimen, age, and treatment duration. For retention, the number of visits at the current facility and the details of the next appointment date were also predictors, while for VL suppression, other predictors included the range of the previous VL value. Machine learning can identify HIV patients at risk for disengagement and unsuppressed VL. Predictive modeling can improve the targeting of interventions through differentiated models of care before patients disengage from treatment programmes, increasing cost-effectiveness and improving patient outcomes.
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Chimbindi N, Shahmanesh M. PrEP dispensing with HIV self-testing. Lancet HIV 2022; 9:e450-e451. [PMID: 35777404 DOI: 10.1016/s2352-3018(22)00171-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 06/01/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Natsayi Chimbindi
- Africa Health Research Institute, Mtubatuba, KwaZulu-Natal, South Africa; Institute for Global Health, University College London, London, UK; University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa.
| | - Maryam Shahmanesh
- Africa Health Research Institute, Mtubatuba, KwaZulu-Natal, South Africa; Institute for Global Health, University College London, London, UK; University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
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Belay YA, Yitayal M, Atnafu A, Taye FA. Patient experiences and preferences for antiretroviral therapy service provision: implications for differentiated service delivery in Northwest Ethiopia. AIDS Res Ther 2022; 19:30. [PMID: 35761352 PMCID: PMC9237972 DOI: 10.1186/s12981-022-00452-5] [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: 02/23/2022] [Accepted: 06/01/2022] [Indexed: 11/18/2022] Open
Abstract
Background Understanding the experiences, needs, preferences, and behaviors of people living with HIV (PLHIV) are critical to tailor HIV treatment. However, there is limited empirical evidence in Ethiopia on the views of PLHIV regarding their experiences with current antiretroviral therapy (ART) services and preferred models of HIV treatment. Hence, this study aimed to explore the patients’ experiences of taking medications and preferences for ART service provision in Northwest Ethiopia. Methods A phenomenological study design was employed. In this study, stable and 18 years old and above PLHIVs, who had been using ART service at four public hospitals and two health centers in East Gojjam, West Gojjam and Awi zones, and Bahir Dar city administration of Amhara National Regional State, Northwest Ethiopia, were purposively selected. Fifteen in-depth interviews were conducted from July 2021 to September 2021 to collect data. ATLAS.ti version 9 software was used for coding translated transcripts. A thematic analysis approach was employed. Findings Participants in this study had reported positive and negative experiences in receiving ART services and also varied preferences toward ART service features. The study identified five themes on experiences for ART service and 15 attributes of ART service characteristics. The identified themes were stigma, time, availability of drugs and providers, costs for clinic visits, and provider-patient interaction. The fifteen attributes were buddy system, ART refill (individualized or group), ART packaging and labeling, drug formulation and administration, ART room labeling, distance, location of service, preferences on involvement in treatment decision-making, the person providing ART refills, provider’s attitude, spatial arrangement of ART room, time of health facility operation, time spent at clinics, and total cost of the visit. Conclusions The results raise awareness for the positive and negative experiences of patients informing us about barriers and supporting factors in ART service provision. They open up the potential for HIV treatment service improvement. The preferences of PLHIVs toward ART service delivery features were heterogeneous. Policy and program efforts should tailor ART services that suit patients’ needs and priorities in Ethiopia. Future research should further assess the reasons for patients’ distrust of the community ART delivery models. Supplementary Information The online version contains supplementary material available at 10.1186/s12981-022-00452-5.
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Affiliation(s)
- Yihalem Abebe Belay
- Department of Public Health, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia. .,Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
| | - Mezgebu Yitayal
- Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Asmamaw Atnafu
- Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Fitalew Agimass Taye
- Department of Accounting, Finance, and Economics, Griffith University, Brisbane, Australia
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Wekesa P, McLigeyo A, Owuor K, Mwangi J, Ngugi E. Survival probability and factors associated with time to loss to follow-up and mortality among patients on antiretroviral treatment in central Kenya. BMC Infect Dis 2022; 22:522. [PMID: 35668350 PMCID: PMC9171980 DOI: 10.1186/s12879-022-07505-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 05/24/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Retention of patients who are receiving antiretroviral therapy (ART) remains a challenge especially in the setting of rapid expansion of HIV services. Retention in care remains vital to the HIV care continuum, and has been associated with viral suppression and improved survival. This study aimed to ascertain survival rates, time to loss to follow-up (LTFU) or mortality events and factors associated with time to LTFU or mortality among patients enrolled on antiretroviral therapy at health facilities in central Kenya. METHODS This was a retrospective cohort study among patients initiated on ART between 2004 and 2012 in central Kenya. Demographic characteristics, clinical characteristics and outcomes data were analyzed using Stata version 15.1. Competing risks regression analysis and cummulative incidence functions were used to estimate survival. RESULTS A total of 31,346 patients were included, of whom 65.6% were female, 76.0% were aged between 20 and 50 years old, and 38.9% were diagnosed at WHO stage III. At 36 months, overall retention was 68.8%, LTFU was 27.1%, and mortality was 4.1%. The total person-years of follow up was 74,986. The incidence rate of LTFU was 9.99 per 100 person years for a total of 9383.25 person-years of follow up. The mortality rate was 1.25 per 100 person years for a total of 875.5 person-years among those who died. The median time to LTFU was 11 months (IQR 3-22) while median time to death was 3 months (IQR 0-13). Men, unmarried patients, patients presenting with advanced HIV, not on TB treatment, and enrolled into the HIV program in later cohorts, had a shorter time to mortality and LTFU. CONCLUSION Our study demonstrated evidence of scale-up of HIV treatment programs in central Kenya. While most patients were enrolled at an advanced WHO clinical stage, overall 36-month mortality remained low, but occurred earlier during follow-up. Cohort LTFU at 36-months reduced in later years with the losses occurring within the 1st year of follow-up. Predictors of early mortality and LTFU included being male, single, separated or divorced, advanced WHO clinical stage, and among patients not on TB treatment.
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Affiliation(s)
- P Wekesa
- Centre for Health Solutions - Kenya, Nairobi, Kenya.
| | - A McLigeyo
- Centre for Health Solutions - Kenya, Nairobi, Kenya
| | - K Owuor
- Centre for Health Solutions - Kenya, Nairobi, Kenya
| | - J Mwangi
- Division of Global HIV & TB, Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
| | - E Ngugi
- Division of Global HIV & TB, Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
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Fernández LG, Firima E, Robinson E, Ursprung F, Huber J, Amstutz A, Gupta R, Gerber F, Mokhohlane J, Lejone T, Ayakaka I, Xu H, Labhardt ND. Community-based care models for arterial hypertension management in non-pregnant adults in sub-Saharan Africa: a literature scoping review and framework for designing chronic services. BMC Public Health 2022; 22:1126. [PMID: 35658850 PMCID: PMC9167524 DOI: 10.1186/s12889-022-13467-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 05/13/2022] [Indexed: 12/12/2022] Open
Abstract
Background Arterial hypertension (aHT) is the leading cardiovascular disease (CVD) risk factor in sub-Saharan Africa; it remains, however, underdiagnosed, and undertreated. Community-based care services could potentially expand access to aHT diagnosis and treatment in underserved communities. In this scoping review, we catalogued, described, and appraised community-based care models for aHT in sub-Saharan Africa, considering their acceptability, engagement in care and clinical outcomes. Additionally, we developed a framework to design and describe service delivery models for long-term aHT care. Methods We searched relevant references in Embase Elsevier, MEDLINE Ovid, CINAHL EBSCOhost and Scopus. Included studies described models where substantial care occurred outside a formal health facility and reported on acceptability, blood pressure (BP) control, engagement in care, or end-organ damage. We summarized the interventions’ characteristics, effectiveness, and evaluated the quality of included studies. Considering the common integrating elements of aHT care services, we conceptualized a general framework to guide the design of service models for aHT. Results We identified 18,695 records, screened 4,954 and included twelve studies. Four types of aHT care models were identified: services provided at community pharmacies, out-of-facility, household services, and aHT treatment groups. Two studies reported on acceptability, eleven on BP control, ten on engagement in care and one on end-organ damage. Most studies reported significant reductions in BP values and improved access to comprehensive CVDs services through task-sharing. Major reported shortcomings included high attrition rates and their nature as parallel, non-integrated models of care. The overall quality of the studies was low, with high risk of bias, and most of the studies did not include comparisons with routine facility-based care. Conclusions The overall quality of available evidence on community-based aHT care is low. Published models of care are very heterogeneous and available evidence is insufficient to recommend or refute further scale up in sub-Sahara Africa. We propose that future projects and studies implementing and assessing community-based models for aHT care are designed and described according to six building blocks: providers, target groups, components, location, time of service delivery, and their use of information systems. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-13467-4.
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Bai R, Du J, Lv S, Hua W, Dai L, Wu H. Benefits and Risks of Rapid Initiation of Antiretroviral Therapy: A Systematic Review and Meta-Analysis. Front Pharmacol 2022; 13:898449. [PMID: 35721164 PMCID: PMC9205577 DOI: 10.3389/fphar.2022.898449] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 05/09/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives: To compare the benefits and risks between Rapid ART and standard/delayed treatment for HIV.Methods: Databases of PubMed, Cochrane Library, Embase and Web of science were searched from the inception to 28 October 2021. Two investigators independently screened studies related to Rapid ART, extracted data, and evaluated the literature quality. The risk of bias was assessed by Cochrane Collaboration Risk of Bias Tool and the statistical software Stata15.0 was used for meta-analysis.Results: Ten eligible studies were included in this meta-analysis, the results showed Rapid ART was superior to standard/delayed treatment in continuing care for at least 8 months (RR = 1.13, 95%CI: 1.03∼1.25, Z = 2.44, p = 0.015), and severe bacterial infection (RR = 0.42, 95%CI: 0.25∼0.70, Z = 3.33, p = 0.001). At 12 months following treatment, there was no statistically significant difference in viral load <100 copies/mL (RR = 1.05, 95%CI: 0.80∼1.39, Z = 0.35, p = 0.726), mortality (RR = 0.77, 95%CI: 0.47∼1.24, Z = 1.09, p = 0.277), or the incidence of adverse events (RR = 0.52, 95%CI: 0.16∼1.76, Z = 1.05, p = 0.294) compared with standard/delayed treatment.Conclusion: In comparison to standard/delayed treatment, rapid ART can reduce the incidence of TB and severe bacterial infections in HIV patients. Our findings suggest that rapid ART should be utilized when clinical conditions and the patient’s physical state allow.Systematic Review Registration: [https://inplasy.com/?s=202210004], identifier [INPLASY202210004].
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Affiliation(s)
- Ruojing Bai
- Beijing Key Laboratory for HIV/AIDS Research, Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Juan Du
- Beijing Key Laboratory for HIV/AIDS Research, Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Shiyun Lv
- Beijing Key Laboratory for HIV/AIDS Research, Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Wei Hua
- Travel Clinic, Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Lili Dai
- Travel Clinic, Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
- *Correspondence: Lili Dai, ; Hao Wu,
| | - Hao Wu
- Beijing Key Laboratory for HIV/AIDS Research, Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
- *Correspondence: Lili Dai, ; Hao Wu,
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