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Hoffman R, Phiri K, Kalande P, Whitehead H, Moses A, Rockers PC, Tseng CH, Talama G, Banda JC, van Oosterhout JJ, Phiri S, Moucheraud C. Preferences for Hypertension Care in Malawi: A Discrete Choice Experiment Among People Living with Hypertension, With and Without HIV. AIDS Behav 2024:10.1007/s10461-024-04492-y. [PMID: 39269593 DOI: 10.1007/s10461-024-04492-y] [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] [Accepted: 08/29/2024] [Indexed: 09/15/2024]
Abstract
Hypertension is the most common non-communicable disease diagnosed among people in sub-Saharan Africa. However, little is known about client preferences for hypertension care. We performed a discrete choice experiment in Malawi among people with hypertension, with and without HIV. Participants were asked to select between two care scenarios, each with six attributes: distance, waiting time, provider friendliness, individual or group care, antihypertensive medication supply, and antihypertensive medication dispensing frequency (three versus one month). Eight choice sets (each with two scenarios) were presented to each individual. Mixed effects logit models quantified preferences for each attribute. Estimated model coefficients were used to predict uptake of hypothetical models of care. Between July 2021 and April 2022 we enrolled 1003 adults from 14 facilities in Malawi; half were living with HIV and on ART for a median of 11 years. Median age of respondents was 57 years (IQR 49-63), 58.2% were female, and median duration on antihypertensive medications was 4 years (IQR 2-7). Participants strongly preferred seeing a provider alone versus in a group (OR 11.3, 95% CI 10.4-12.3), with stronger preference for individual care among those with HIV (OR 15.4 versus 8.6, p < 0.001). Three-month versus monthly dispensing was also strongly preferred (OR 4.2; 95% CI 3.9-4.5). 72% of respondents would choose group care if all other facility attributes were favorable, although PLHIV were less likely to make this trade-off (66% versus 77%). These findings have implications for the scale-up of hypertension care in Malawi and similar settings.
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Affiliation(s)
- Risa Hoffman
- David Geffen School of Medicine, Department of Medicine, Division of Infectious Diseases, University of California, Risa Hoffman, 911 Broxton Avenue Suite 301D, Los Angeles, CA, 90024, USA.
| | - Khumbo Phiri
- Partners in Hope Medical Center, Lilongwe, Malawi
| | | | - Hannah Whitehead
- David Geffen School of Medicine, Department of Medicine, Division of Infectious Diseases, University of California, Risa Hoffman, 911 Broxton Avenue Suite 301D, Los Angeles, CA, 90024, USA
| | - Agnes Moses
- Partners in Hope Medical Center, Lilongwe, Malawi
| | - Peter C Rockers
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Chi-Hong Tseng
- David Geffen School of Medicine, Department of Medicine, Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, CA, USA
| | | | | | - Joep J van Oosterhout
- David Geffen School of Medicine, Department of Medicine, Division of Infectious Diseases, University of California, Risa Hoffman, 911 Broxton Avenue Suite 301D, Los Angeles, CA, 90024, USA
- Partners in Hope Medical Center, Lilongwe, Malawi
| | - Sam Phiri
- Partners in Hope Medical Center, Lilongwe, Malawi
- School of Global and Public Health, Kamuzu University of Health Sciences, Lilongwe, Malawi
| | - Corrina Moucheraud
- Department of Public Health Policy and Management, New York University Global School of Public Health, New York, NY, USA
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Whitehead HS, Phiri K, Kalande P, van Oosterhout JJ, Talama G, Phiri S, Moucheraud C, Moses A, Hoffman RM. High rate of uncontrolled hypertension among adults receiving integrated HIV and hypertension care with aligned multi-month dispensing in Malawi: results from a cross-sectional survey and retrospective chart review. J Int AIDS Soc 2024; 27:e26354. [PMID: 39295131 PMCID: PMC11410859 DOI: 10.1002/jia2.26354] [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: 01/26/2024] [Accepted: 08/30/2024] [Indexed: 09/21/2024] Open
Abstract
INTRODUCTION People living with HIV have high rates of hypertension. Integrated HIV and hypertension care with aligned multi-month dispensing of medications (MMD) could decrease the burden of care for individuals and health systems. We sought to describe hypertension control and evaluate its association with different durations of MMD among Malawian adults receiving integrated care with aligned dispensing of antiretroviral therapy (ART) and antihypertensive medication. METHODS We conducted a cross-sectional survey and retrospective chart review of adults (≥18 years) receiving integrated HIV and hypertension care on medications for both conditions for at least 1 year, with aligned MMD at seven clinics in Malawi. Data were collected from July 2021 to April 2022 and included socio-demographics, clinical characteristics, antihypertensive medications and up to the three most recent blood pressure measurements. Bivariate analyses were used to characterize associations with hypertension control. Uncontrolled hypertension was defined as ≥2 measurements ≥140 and/or ≥90 mmHg. Chart reviews were conducted for a random subset of participants with uncontrolled hypertension to describe antihypertensive medication adjustments in the prior year. RESULTS We surveyed 459 adults receiving integrated care with aligned dispensing (58% female; median age 54 years). Individuals most commonly received a 3-month aligned dispensing of ART and antihypertensive medications (63%), followed by every 6 months (16%) and every 4 months (15%). Hypertension control was assessed in 359 respondents, of whom only 23% had controlled hypertension; 90% of individuals in this group reported high adherence to blood pressure medications (0-1 missed days/week). Control was more common among those with longer aligned medication dispensing intervals (20% among those with 1- to 3-month dispensing vs. 28% with 4-month dispensing vs. 40% with 6-month dispensing, p = 0.011). Chart reviews were conducted for 147 individuals with uncontrolled hypertension. Most had high self-reported adherence to blood pressure medications (89% missing 0-1 days/week); however, only 10% had their antihypertensive medication regimen changed in the prior year. CONCLUSIONS Uncontrolled hypertension was common among Malawian adults receiving integrated care with aligned MMD and was associated with shorter refill intervals and few antihypertensive medication escalations. Integrated care with aligned MMD is promising, but further work is needed to understand how to optimize hypertension outcomes.
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Affiliation(s)
- Hannah S. Whitehead
- Department of MedicineDavid Geffen School of Medicine at UCLALos AngelesCaliforniaUSA
| | | | | | - Joep J. van Oosterhout
- Department of MedicineDavid Geffen School of Medicine at UCLALos AngelesCaliforniaUSA
- Partners in HopeLilongweMalawi
| | | | - Sam Phiri
- Partners in HopeLilongweMalawi
- School of Global and Public HealthKamuzu University of Health SciencesLilongweMalawi
| | - Corrina Moucheraud
- Department of Public Health Policy and ManagementSchool of Global Public Health at NYUNew York CityNew YorkUSA
| | | | - Risa M. Hoffman
- Department of MedicineDavid Geffen School of Medicine at UCLALos AngelesCaliforniaUSA
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Katongole SP, Mukama SC, Nakawesi J, Bindeeba D, Simons E, Mugisa A, Senyimba C, Namitala E, Onzima RADDM, Mukasa B. Enhancing HIV treatment and support: a qualitative inquiry into client and healthcare provider perspectives on differential service delivery models in Uganda. AIDS Res Ther 2024; 21:47. [PMID: 39068451 PMCID: PMC11282821 DOI: 10.1186/s12981-024-00637-0] [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: 06/12/2024] [Accepted: 07/16/2024] [Indexed: 07/30/2024] Open
Abstract
BACKGROUND HIV/AIDS continues to be a significant contributor to illness and death, particularly in sub-Saharan Africa. In this study, we conducted a qualitative assessment to understand Client and Healthcare Provider Perspectives on Differential Service Delivery Models in Uganda. The purpose was to establish strengths and weaknesses within the services delivery models, inform policy and decision-making, and to facilitate context specific solutions. METHODS Between February and April 2023, a qualitative cross-sectional study was utilised to gather insights from a targeted selection of individuals, including People Living with HIV (PLHIV), healthcare workers, HIV focal persons, community retail pharmacists, and various stakeholders. The data collection process included eleven in-depth interviews, nine key informant interviews, and eight focus group discussions carried out across eight districts in Central Uganda. The collected data was analyzed through inductive thematic analysis with the aid of Excel. RESULTS The various Differentiated Service Delivery Models (DSDMs), notably Community-Client-Led Drug Distribution (CCLAD), Community Drug Distribution Point (CDDP), Community Retail Pharmacy Drug Distribution Point (CRPDDP), and the facility-based Facility Based Individual Model (FBIM), were reported to have several positive impacts. These included improved treatment adherence, efficient management of antiretroviral (ARV) supplies, reduced exposure to infectious diseases, enhanced healthcare worker hospitality, minimized travel time for ART refills, stigma reduction, and decreased waiting times. Concern was raised about the lack of improvement in HIV status disclosure, opportunistic infection treatment, adherence to seasonal appointments, and sustainability due to the overreliance of the DSDMs on donor funding, suggesting potential discontinuation without funding. Doubts about health workers' commitment surfaced. Notably, the CCLAD model displayed self-sustainability, with clients financially supporting group members to collect medicines. CONCLUSION Community-based DSDMs, such as CCLAD and CDDP, improve ART refill convenience, social support, and client experiences. These models reduce travel and waiting times, lowering infection risks. Addressing challenges and enhancing facility-based models is vital. In order to maintain funding after donor funding ends, sustainability measures like cross-subsidization can be used. If well implemented, the DSDMs have the potential to produce better or comparable ART outcomes compared to the FBIM model.
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Posner J, Ndhlovu AP, Musangulule JM, Duffy M, Casella A, Madevu-Matson C, Davis N, Sharer M. Evaluating the Preliminary Effectiveness of the Person-Centered Care Assessment Tool (PCC-AT) in Zambian Health Facilities: Protocol for a Mixed Methods Cross-Sectional Study. JMIR Res Protoc 2024; 13:e54129. [PMID: 39042423 PMCID: PMC11303880 DOI: 10.2196/54129] [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] [Received: 10/30/2023] [Revised: 05/16/2024] [Accepted: 06/10/2024] [Indexed: 07/24/2024] Open
Abstract
BACKGROUND Person-centered care (PCC) within HIV treatment services has demonstrated potential to overcome inequities in HIV service access while improving treatment outcomes. Despite PCC being widely considered a best practice, no consensus exists on its assessment and measurement. This study in Zambia builds upon previous research that informed development of a framework for PCC and a PCC assessment tool (PCC-AT). OBJECTIVE This mixed methods study aims to examine the preliminary effectiveness of the PCC-AT through assessing the association between client HIV service delivery indicators and facility PCC-AT scores. We hypothesize that facilities with higher PCC-AT scores will demonstrate more favorable HIV treatment continuity, viral load (VL) coverage, and viral suppression in comparison to those of facilities with lower PCC-AT scores. METHODS We will implement the PCC-AT at 30 randomly selected health facilities in the Copperbelt and Central provinces of Zambia. For each study facility, data will be gathered from 3 sources: (1) PCC-AT scores, (2) PCC-AT action plans, and (3) facility characteristics, along with service delivery data. Quantitative analysis, using STATA, will include descriptive statistics on the PCC-AT results stratified by facility characteristics. Cross-tabulations and/or regression analysis will be used to determine associations between scores and treatment continuity, VL coverage, and/or viral suppression. Qualitative data will be collected via action planning, with detailed notes collected and recorded into an action plan template. Descriptive coding and emerging themes will be analyzed with NVivo software. RESULTS As of May 2024, we enrolled 29 facilities in the study and data analysis from the key informant interviews is currently underway. Results are expected to be published by September 2024. CONCLUSIONS Assessment and measurement of PCC within HIV treatment settings is a novel approach that offers HIV treatment practitioners the opportunity to examine their services and identify actions to improve PCC performance. Study results and the PCC-AT will be broadly disseminated for use among all project sites in Zambia as well as other HIV treatment programs, in addition to making the PCC-AT publicly available to global HIV practitioners. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/54129.
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Affiliation(s)
- Jessica Posner
- International Division, JSI, Arlington, VA, United States
| | | | | | - Malia Duffy
- Health Across Humanity, LLC, Boston, MA, United States
- Department of Public Health, St. Ambrose University, Davenport, IA, United States
| | - Amy Casella
- International Division, JSI, Arlington, VA, United States
| | | | - Nicole Davis
- International Division, JSI, Arlington, VA, United States
| | - Melissa Sharer
- International Division, JSI, Arlington, VA, United States
- Department of Public Health, St. Ambrose University, Davenport, IA, United States
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Gumede SB, de Wit JBF, Venter WDF, Wensing AMJ, Lalla‐Edward ST. Intervention strategies to improve adherence to treatment for selected chronic conditions in sub-Saharan Africa: a systematic review. J Int AIDS Soc 2024; 27:e26266. [PMID: 38924296 PMCID: PMC11197966 DOI: 10.1002/jia2.26266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 04/23/2024] [Indexed: 06/28/2024] Open
Abstract
INTRODUCTION Evidence-based intervention strategies to improve adherence among individuals living with chronic conditions are critical in ensuring better outcomes. In this systematic review, we assessed the impact of interventions that aimed to promote adherence to treatment for chronic conditions. METHODS We systematically searched PubMed, Web of Science, Scopus, Google Scholar and CINAHL databases to identify relevant studies published between the years 2000 and 2023 and used the QUIPS assessment tool to assess the quality and risk of bias of each study. We extracted data from eligible studies for study characteristics and description of interventions for the study populations of interest. RESULTS Of the 32,698 total studies/records screened, 2814 were eligible for abstract screening and of those, 497 were eligible for full-text screening. A total of 82 studies were subsequently included, describing a total of 58,043 patients. Of the total included studies, 58 (70.7%) were related to antiretroviral therapy for HIV, 6 (7.3%) were anti-hypertensive medication-related, 12 (14.6%) were anti-diabetic medication-related and 6 (7.3%) focused on medication for more than one condition. A total of 54/82 (65.9%) reported improved adherence based on the described study outcomes, 13/82 (15.9%) did not have clear results or defined outcomes, while 15/82 (18.3%) reported no significant difference between studied groups. The 82 publications described 98 unique interventions (some studies described more than one intervention). Among these intervention strategies, 13 (13.3%) were multifaceted (4/13 [30.8%] multi-component health services- and community-based programmes, 6/13 [46.2%] included individual plus group counselling and 3/13 [23.1%] included SMS or alarm reminders plus individual counselling). DISCUSSION The interventions described in this review ranged from adherence counselling to more complex interventions such as mobile health (mhealth) interventions. Combined interventions comprised of different components may be more effective than using a single component in isolation. However, the complexity involved in designing and implementing combined interventions often complicates the practicalities of such interventions. CONCLUSIONS There is substantial evidence that community- and home-based interventions, digital health interventions and adherence counselling interventions can improve adherence to medication for chronic conditions. Future research should answer if existing interventions can be used to develop less complicated multifaceted adherence intervention strategies.
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Affiliation(s)
- Siphamandla Bonga Gumede
- Ezintsha, Faculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Interdisciplinary Social ScienceUtrecht UniversityUtrechtthe Netherlands
| | - John B. F. de Wit
- Department of Interdisciplinary Social ScienceUtrecht UniversityUtrechtthe Netherlands
- Centre for Social Research in HealthUNSWSydneyNew South WalesAustralia
| | - Willem D. F. Venter
- Ezintsha, Faculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Annemarie M. J. Wensing
- Department of Medical MicrobiologyUniversity Medical Center UtrechtUtrechtthe Netherlands
- Ndlovu Research ConsortiumElandsdoornSouth Africa
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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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Núñez I, Amuchastegui A, Vásquez-Salinas A, Díaz S, Caro-Vega Y. Challenges to the HIV Care Continuum During the COVID-19 Pandemic in Mexico: A Mixed Methods Study. AIDS Behav 2024; 28:886-897. [PMID: 37789236 DOI: 10.1007/s10461-023-04195-w] [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: 09/21/2023] [Indexed: 10/05/2023]
Abstract
The COVID-19 pandemic has been reported to disrupt the access to care of people who live with HIV (PWH). The impact of the pandemic on the longitudinal HIV care continuum, however, has not been properly evaluated. We performed a mixed-methods study using data from the Mexican System of Distribution, Logistics, and ART Surveillance on PWH that are cared for in the state of Oaxaca. We evaluated the number of HIV diagnoses performed in the state before and during the pandemic with an interrupted time series. We used the longitudinal HIV care continuum framework to describe the stages of HIV care before and during the pandemic. Finally, we performed a qualitative analysis to determine which were the challenges faced by staff and users regarding HIV care during the pandemic. New HIV diagnoses were lower during the first year of the pandemic compared with the year immediately before. Among 2682 PWH with enough information to determine their status of care, 728 started receiving care during the COVID-19 pandemic and 1954 before the pandemic. PWH engaged before the pandemic spent 42825 months (58.2% of follow-up) in optimal HIV control compared with 3061 months (56.1% of follow-up) for those engaged in care during the pandemic. Staff and users reported decreases in the frequency of appointments, prioritisation of unhealthy users, larger disbursements of ART medication, and novel communication strategies with PWH. Despite challenges due to government cutbacks, changes implemented by staff helped maintain HIV care due to higher flexibility in ART delivery and individualised attention.
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Affiliation(s)
- Isaac Núñez
- Departamento de Educación Médica, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
- División de Estudios de Postgrado, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Ana Amuchastegui
- Departamento de Educación y Comunicación, Universidad Autónoma Metropolitana-Xochimilco, Mexico City, Mexico
| | - Alejandra Vásquez-Salinas
- Centro Ambulatorio Para la Prevención y Atención del Sida E Infecciones de Transmisión Sexual (CAPASITS Oaxaca), Oaxaca, Mexico
| | | | - Yanink Caro-Vega
- Departamento de Infectología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga # 15, Belisario Domínguez Sección XVI, Tlalpan, 14080, Mexico City, Mexico.
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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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Semo BW, Ezeokafor NA, Oyawola B, Mugo C. Effect of Multi-Month Dispensing on Viral Suppression for Newly Enrolled Adolescents and Adults in Northern Nigeria. HIV AIDS (Auckl) 2023; 15:697-704. [PMID: 38028192 PMCID: PMC10658956 DOI: 10.2147/hiv.s432976] [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: 07/29/2023] [Accepted: 10/15/2023] [Indexed: 12/01/2023] Open
Abstract
Purpose We evaluated the effect of multi-month dispensing (MMD) on viral suppression among newly enrolled adolescents and adults with HIV in 11 northern Nigerian states. Patients and Methods We conducted a retrospective analysis of longitudinal data from 75 health facilities. We abstracted electronic medical records for patients ≥10 years, initiated on ART April 1, 2019 - June 30, 2021, and with a 6- or 12-month viral load (VL) result. We categorized participants in the MMD group to see if they received antiretroviral treatment (ART) for ≥84 days at any visit within 6 months of ART initiation. We consider cut-offs for viral suppression at 50 copies/mL. The period when the VL was performed was classified as pre-COVID-19 (before April 1, 2020) or during the COVID-19 pandemic. We estimated relative risks (RR) by comparing the unsuppressed proportion of those on MMD to those not on MMD, adjusted for age, gender, and COVID-19 period. Results Overall, 19,859 participant records were abstracted. Median age was 33 years, 64% were female, 91% were started on a dolutegravir (DTG)-based regimen, and 65% were on MMD. Overall, 15,259 (77%) participants were followed for ≥6 months, 4136 (27%) had a VL at 6 months and 3640 (24%) had a VL at 12 months after ART initiation. A slightly higher proportion of patients on MMD had undetectable VL levels at 6 months (65% vs 58%) and 12 months (66% vs 62%). In the adjusted analysis, we found no significant differences in undetectable VL at 6 months and 12 months between newly enrolled patients on MMD and those not on MMD. Those on Protease inhibitor-based regimen had 54% lower likelihood of undetectable VL compared to those on DTG-based regimen. Conclusion MMD does not result in poorer viral suppression among newly enrolled patients.
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Affiliation(s)
| | - Nnenna A Ezeokafor
- Maryland Global Initiative Cooperation, University of Maryland, Abuja, Nigeria
- Global Health Division, Chemonics International, Abuja, Nigeria
| | | | - Cyrus Mugo
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
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Heunis C, Chikobvu P, Muteba M, Kigozi-Male G, Engelbrecht M, Mushori P. Impact of COVID-19 on selected essential public health services - lessons learned from a retrospective record review in the Free State, South Africa. BMC Health Serv Res 2023; 23:1244. [PMID: 37951875 PMCID: PMC10640739 DOI: 10.1186/s12913-023-10166-7] [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] [Received: 04/03/2023] [Accepted: 10/17/2023] [Indexed: 11/14/2023] Open
Abstract
BACKGROUND In an attempt to discern lessons to improve future pandemic responses, this study measured the effects of the COVID-19 pandemic on essential public health services (EPHSs) related to primary health care (PHC) and outpatient department (OPD) utilisation, antiretroviral treatment (ART) commencement, drug-susceptible tuberculosis (DS-TB) confirmation and treatment commencement, and Bacillus Calmette-Guérin (BCG) coverage, in the Free State province of South Africa during January 2019 to March 2021. METHODS A pre-post study design comparing EPHS performance between 2019 and 2020/21 was employed. Routinely collected data were analysed. An interrupted time series analysis was used to measure changes in service use and outcomes from January 2019 to March 2021. Median changes were compared using Wilcoxon rank-sum tests. A 5% statistical significance level was considered. RESULTS Over the study period, the median values for the annual number of PHC visits was 1.80, 55.30% for non-referred OPD visits, 69.40% for ART commencement, 95.10% and 18.70% for DS-TB confirmation and treatment commencement respectively, and 93.70% for BCG coverage. While BCG coverage increased by 5.85% (p = 0.010), significant declines were observed in PHC utilisation (10.53%; p = 0.001), non-referred OPD visits (12.05%; p < 0.001), and ART commencement (9.53%; p = 0.017) rates. Given the importance of PHC in addressing a new pandemic, along with the existing HIV and TB epidemics - as well as the entire quadruple burden of disease - in South Africa, the finding that the PHC utilisation rate statistically significantly decreased in the Free State post-COVID-19 commencement is particularly concerning. CONCLUSIONS The lessons learned from this retrospective review attest to a measure of resilience in EPHS delivery in the Free State in as far as a significant hike in BCG vaccination over the study period, 2019-2020/21 was observed. As evidenced by a decline in PHC service utilisation and the decreased numbers of new patients commencing ART, we also learned that EPHS delivery in the province was fragile.
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Affiliation(s)
- Christo Heunis
- Centre for Health Systems Research & Development, University of the Free State, Bloemfontein, South Africa.
| | - Perpetual Chikobvu
- Free State Department of Health, Bloemfontein, South Africa
- Department of Community Health, University of the Free State, Bloemfontein, South Africa
| | - Michel Muteba
- World Health Organization, Bloemfontein, South Africa
| | - Gladys Kigozi-Male
- Centre for Health Systems Research & Development, University of the Free State, Bloemfontein, South Africa
| | - Michelle Engelbrecht
- Centre for Health Systems Research & Development, University of the Free State, Bloemfontein, South Africa
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Semo BW, Ezeokafor N, Adeyemi S, Kpamor Z, Mugo C. Differentiated service delivery models for antiretroviral treatment refills in Northern Nigeria: Experiences of people living with HIV and health care providers-A qualitative study. PLoS One 2023; 18:e0287862. [PMID: 37428746 DOI: 10.1371/journal.pone.0287862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 06/14/2023] [Indexed: 07/12/2023] Open
Abstract
Differentiated service delivery (DSD) and multi-month dispensing (MMD) of antiretroviral therapy (ART) have improved treatment adherence and viral suppression among people living with HIV (PLHIV), and service delivery efficiency. We assessed the experiences of PLHIV and providers with DSD and MMD in Northern Nigeria. We conducted in-depth interviews (IDI) with 40 PLHIV and 6 focus group discussions (FGD) with 39 health care providers across 5 states, exploring their experiences with 6 DSD models. Qualitative data were analyzed using NVivo®1.6.1. Most PLHIV and providers found the models acceptable and expressed satisfaction with service delivery. The DSD model preference of PLHIV was influenced by convenience, stigma, trust, and cost of care. Both PLHIV and providers indicated improvements in adherence and viral suppression; they also raised concerns about quality of care within community-based models. PLHIV and provider experiences suggest that DSD and MMD have the potential to improve patient retention rates and service delivery efficiency.
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Affiliation(s)
- Bazghina-Werq Semo
- Global Health Division, Chemonics International, Washington DC, United States of America
| | - Nnenna Ezeokafor
- Maryland Global Initiative Cooperation, University of Maryland, Abuja, Nigeria
- Global Health Division, Chemonics International, Abuja, Nigeria
| | | | - Zipporah Kpamor
- Global Health Division, Chemonics International, Abuja, Nigeria
| | - Cyrus Mugo
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
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Nwaokoro P, Sanwo O, Toyo O, Akpan U, Nwanja E, Elechi I, Ukpong KA, Idiong H, Gana B, Badru T, Idemudia A, Ogbechie MD, Imohi P, Achanya A, Oqua D, Kakanfo K, Olatunbosun K, Umoh A, Essiet P, Usanga I, Ezeanolue E, Obiora-Okafo C, James E, Iyortim I, Chiegil R, Khamofu H, Pandey SR, Bateganya M. Achieving HIV epidemic control through integrated community and facility-based strategies: Lessons learnt from ART-surge implementation in Akwa Ibom, Nigeria. PLoS One 2022; 17:e0278946. [PMID: 36542606 PMCID: PMC9770335 DOI: 10.1371/journal.pone.0278946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 11/25/2022] [Indexed: 12/24/2022] Open
Abstract
This study examines the lessons learnt from the implementation of a surge program in Akwa Ibom State, Nigeria as part of the Strengthening Integrated Delivery of HIV/AIDS Services (SIDHAS) Project. In this analysis, we included all clients who received HIV counseling and testing services, tested HIV positive, and initiated ART in SIDHAS-supported local government areas (LGAs) from April 2017 to March 2021. We employed descriptive and inferential statistics to analyze our results. A total of 2,018,082 persons were tested for HIV. Out of those tested, 102,165 (5.1%) tested HIV-positive. Comparing the pre-surge and post-surge periods, we observed an increase in HIV testing from 490,450 to 2,018,082 (p≤0.031) and in HIV-positive individuals identified from 21,234 to 102,165 (p≤0.001) respectively. Of those newly identified positives during the surge, 98.26% (100,393/102,165) were linked to antiretroviral therapy compared to 99.24% (21,073/21,234) pre-surge. Retention improved from 83.3% to 92.3% (p<0.001), and viral suppression improved from 73.5% to 96.2% (p<0.001). A combination of community and facility-based interventions implemented during the surge was associated with the rapid increase in case finding, retention, and viral suppression; propelling the State towards HIV epidemic control. HIV programs should consider a combination of community and facility-based interventions in their programming.
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Affiliation(s)
- Pius Nwaokoro
- Family Health International, Abuja, Nigeria
- * E-mail:
| | | | - Otoyo Toyo
- Achieving Health Nigeria Initiative (AHNi), Abuja, Nigeria
| | - Uduak Akpan
- Achieving Health Nigeria Initiative (AHNi), Abuja, Nigeria
| | - Esther Nwanja
- Achieving Health Nigeria Initiative (AHNi), Abuja, Nigeria
| | | | | | - Helen Idiong
- Achieving Health Nigeria Initiative (AHNi), Abuja, Nigeria
| | - Bala Gana
- Achieving Health Nigeria Initiative (AHNi), Abuja, Nigeria
| | | | | | | | | | | | - Dorothy Oqua
- Howard University Global Initiative, Abuja, Nigeria
| | | | | | | | | | | | - Echezona Ezeanolue
- Center for Translation & Implementation Research College of Medicine, University of Nigeria, Nsukka, Nigeria
| | | | | | | | - Robert Chiegil
- Family Health International, Durham, NC, United States of America
| | | | | | - Moses Bateganya
- Family Health International, Durham, NC, United States of America
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Ntinga X, Musiello F, Keter AK, Barnabas R, van Heerden A. The Feasibility and Acceptability of an mHealth Conversational Agent Designed to Support HIV Self-testing in South Africa: Cross-sectional Study. J Med Internet Res 2022; 24:e39816. [PMID: 36508248 PMCID: PMC9793294 DOI: 10.2196/39816] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 09/28/2022] [Accepted: 10/28/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND HIV testing rates in sub-Saharan Africa remain below the targeted threshold, and primary care facilities struggle to provide adequate services. Innovative approaches that leverage digital technologies could improve HIV testing and access to treatment. OBJECTIVE This study aimed to examine the feasibility and acceptability of Nolwazi_bot. It is an isiZulu-speaking conversational agent designed to support HIV self-testing (HIVST) in KwaZulu-Natal, South Africa. METHODS Nolwazi_bot was designed with 4 different personalities that users could choose when selecting a counselor for their HIVST session. We recruited a convenience sample of 120 consenting adults and invited them to undertake an HIV self-test facilitated by the Nolwazi_bot. After testing, participants completed an interviewer-led posttest structured survey to assess their experience with the chatbot-supported HIVST. RESULTS Participants (N=120) ranged in age from 18 to 47 years, with half of them being men (61/120, 50.8%). Of the 120 participants, 111 (92.5%) had tested with a human counselor more than once. Of the 120 participants, 45 (37.5%) chose to be counseled by the female Nolwazi_bot personality aged between 18 and 25 years. Approximately one-fifth (21/120, 17.5%) of the participants who underwent an HIV self-test guided by the chatbot tested positive. Most participants (95/120, 79.2%) indicated that their HIV testing experience with a chatbot was much better than that with a human counselor. Many participants (93/120, 77.5%) reported that they felt as if they were talking to a real person, stating that the response tone and word choice of Nolwazi_bot reminded them of how they speak in daily conversations. CONCLUSIONS The study provides insights into the potential of digital technology interventions to support HIVST in low-income and middle-income countries. Although we wait to see the full benefits of mobile health, technological interventions including conversational agents or chatbots provide us with an excellent opportunity to improve HIVST by addressing the barriers associated with clinic-based HIV testing.
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Affiliation(s)
- Xolani Ntinga
- Centre for Community Based Research, Human Sciences Research Council, Pietermaritzburg, South Africa
| | - Franco Musiello
- Centre for Community Based Research, Human Sciences Research Council, Pietermaritzburg, South Africa
| | - Alfred Kipyegon Keter
- Centre for Community Based Research, Human Sciences Research Council, Pietermaritzburg, South Africa
- Department of Clinical Sciences, Institute of Tropical Medicine Antwerp, Antwerp, Belgium
- Department of Applied Mathematics, Computer Science and Statistics, Ghent University, Ghent, Belgium
| | - Ruanne Barnabas
- Department of Medicine, Harvard Medical School, Boston, MA, United States
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, United States
| | - Alastair van Heerden
- Centre for Community Based Research, Human Sciences Research Council, Pietermaritzburg, South Africa
- South African Medical Research Council/WITS Developmental Pathways for Health Research Unit, Department of Paediatrics, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Factors Associated with Retention of HIV Patients on Antiretroviral Therapy in Care: Evidence from Outpatient Clinics in Two Provinces of the Democratic Republic of the Congo (DRC). Trop Med Infect Dis 2022; 7:tropicalmed7090229. [PMID: 36136640 PMCID: PMC9504336 DOI: 10.3390/tropicalmed7090229] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/25/2022] [Accepted: 08/26/2022] [Indexed: 12/02/2022] Open
Abstract
Interruptions in the continuum of care for HIV can inadvertently increase a patient’s risk of poor health outcomes such as uncontrolled viral load and a greater likelihood of developing drug resistance. Retention of people living with HIV (PLHIV) in care and determinants of attrition, such as adherence to treatment, are among the most critical links strengthening the continuum of care, reducing the risk of treatment failure, and assuring viral load suppression. Objective: To analyze the variation in, and factors associated with, retention of patients enrolled in HIV services at outpatient clinics in the provinces of Kinshasa and Haut-Katanga, Democratic Republic of the Congo (DRC). Methods: Data for the last visit of 51,286 patients enrolled in Centers for Disease Control (CDC)-supported outpatient HIV clinics in 18 health zones in Haut-Katanga and Kinshasa, DRC were extracted in June 2020. Chi-square tests and multivariable logistic regressions were performed. Results: The results showed a retention rate of 78.2%. Most patients were classified to be at WHO clinical stage 1 (42.1%), the asymptomatic stage, and only 3.2% were at stage 4, the severest stage of AIDS. Odds of retention were significantly higher for patients at WHO clinical stage 1 compared to stage 4 (adjusted odds ratio (AOR), 1.325; confidence interval (CI), 1.13−1.55), women as opposed to men (AOR, 2.00; CI, 1.63−2.44), and women who were not pregnant (vs. pregnant women) at the start of antiretroviral therapy (ART) (AOR, 2.80; CI, 2.04−3.85). Odds of retention were significantly lower for patients who received a one-month supply rather than multiple months (AOR, 0.22; CI, 0.20−0.23), and for patients in urban health zones (AOR, 0.75; CI, 0.59−0.94) rather than rural. Compared to patients 55 years of age or older, the odds of retention were significantly lower for patients younger than 15 (AOR, 0.35; CI, 0.30−0.42), and those aged 15 and <55 (AOR, 0.75; CI, 0.68−0.82). Conclusions: Significant variations exist in the retention of patients in HIV care by patient characteristics. There is evidence of strong associations of many patient characteristics with retention in care, including clinical, demographic, and other contextual variables that may be beneficial for improvements in HIV services in DRC.
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Flanagan CF, McCann N, Stover J, Freedberg KA, Ciaranello AL. Do not forget the children: a model‐based analysis on the potential impact of COVID‐19‐associated interruptions in paediatric HIV prevention and care. J Int AIDS Soc 2022; 25:e25864. [PMID: 35048515 PMCID: PMC8771146 DOI: 10.1002/jia2.25864] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 12/14/2021] [Indexed: 11/14/2022] Open
Abstract
Introduction The COVID‐19 pandemic has affected women and children globally, disrupting antiretroviral therapy (ART) services and exacerbating pre‐existing barriers to care for both pregnant women and paediatric populations. Methods We used the Spectrum modelling package and the CEPAC‐Pediatric model to project the impact of COVID‐19‐associated care disruptions on three key populations in the 21 Global Plan priority countries in sub‐Saharan Africa: (1) pregnant and breastfeeding women living with HIV and their children, (2) all children (aged 0–14 years) living with HIV (CLWH), regardless of their engagement in care and (3) CLWH who were engaged in care and on ART prior to the start of the pandemic. We projected clinical outcomes over the 12‐month period of 1 March 2020 to 1 March 2021. Results Compared to a scenario with no care disruption, in a 3‐month lockdown with complete service disruption, followed by 3 additional months of partial (50%) service disruption, a projected 755,400 women would have received PMTCT care (a 21% decrease), 187,800 new paediatric HIV infections would have occurred (a 77% increase) and 516,800 children would have received ART (a 35% decrease). For children on ART as of March 2020, we projected 507,200 would have experienced ART failure (an 80% increase). Additionally, a projected 88,400 AIDS‐related deaths would have occurred (a 27% increase) between March 2020 and March 2021, with 51,700 of those deaths occurring among children engaged in care as of March 2020 (a 54% increase). Conclusions While efforts will continue to curb morbidity and mortality stemming directly from COVID‐19 itself, it is critical that providers also consider the immediate and indirect harms of this pandemic, particularly among vulnerable populations. Well‐informed, timely action is critical to meet the health needs of pregnant women and children if the global community is to maintain momentum towards an AIDS‐free generation.
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Affiliation(s)
- Clare F. Flanagan
- Medical Practice Evaluation Center Massachusetts General Hospital Boston Massachusetts USA
| | - Nicole McCann
- Medical Practice Evaluation Center Massachusetts General Hospital Boston Massachusetts USA
| | | | - Kenneth A. Freedberg
- Medical Practice Evaluation Center Massachusetts General Hospital Boston Massachusetts USA
- Harvard Medical School Boston Massachusetts USA
- Division of Infectious Diseases Massachusetts General Hospital Boston Massachusetts USA
- Division of General Internal Medicine Massachusetts General Hospital Boston Massachusetts USA
- Department of Health Policy and Management Harvard T.H. Chan School of Public Health Boston Massachusetts USA
| | - Andrea L. Ciaranello
- Medical Practice Evaluation Center Massachusetts General Hospital Boston Massachusetts USA
- Harvard Medical School Boston Massachusetts USA
- Division of Infectious Diseases Massachusetts General Hospital Boston Massachusetts USA
- Harvard University Center for AIDS Research Cambridge Massachusetts USA
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