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Garfein RS, Liu L, Cepeda J, Graves S, San Miguel S, Antonio A, Cuevas-Mota J, Mercer V, Miller M, Catanzaro DG, Rios P, Raab F, Benson CA. Asynchronous Video Directly Observed Therapy to Monitor Short-Course Latent Tuberculosis Infection Treatment: Results of a Randomized Controlled Trial. Open Forum Infect Dis 2024; 11:ofae180. [PMID: 38665171 PMCID: PMC11045025 DOI: 10.1093/ofid/ofae180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 03/25/2024] [Indexed: 04/28/2024] Open
Abstract
Background Observing medication ingestion through self-recorded videos (video directly observed therapy [VDOT]) has been shown to be a cost-effective alternative to in-person directly observed therapy (DOT) for monitoring adherence to treatment for tuberculosis disease. VDOT could be a useful tool to monitor short-course latent tuberculosis infection (LTBI) treatment. Methods We conducted a prospective randomized controlled trial comparing VDOT (intervention) and clinic-based DOT (control) among patients newly diagnosed with LTBI who agreed to a once-weekly 3-month treatment regimen of isoniazid and rifapentine. Study outcomes were treatment completion and patient satisfaction. We also assessed costs. Pre- and posttreatment interviews were conducted. Results Between March 2016 and December 2019, 130 participants were assigned to VDOT (n = 68) or DOT (n = 62). Treatment completion (73.5% vs 69.4%, P = .70) and satisfaction with treatment monitoring (92.1% vs 86.7%, P = .39) were slightly higher in the intervention group than the control group, but neither was statistically significant. VDOT cost less per patient (median, $230; range, $182-$393) vs DOT (median, $312; range, $246-$592) if participants used their own smartphone. Conclusions While both groups reported high treatment satisfaction, VDOT was not associated with higher LTBI treatment completion. However, VDOT cost less than DOT. Volunteer bias might have reduced the observed effect since patients opposed to any treatment monitoring could have opted for alternative unobserved regimens. Given similar outcomes and lower cost, VDOT may be useful for treatment monitoring when in-person observation is prohibited or unavailable (eg, during a respiratory disease outbreak). The trial was registered at the National Institutes of Health (ClinicalTrials.gov NTC02641106). Clinical Trials Registration ClinicalTrials.gov NTC02641106; registered 24 October 2016.
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Affiliation(s)
- Richard S Garfein
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, California, USA
- Division of Infectious Disease and Global Public Health, School of Medicine, University of California, San Diego, California, USA
| | - Lin Liu
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, California, USA
| | - Javier Cepeda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Susannah Graves
- Tuberculosis Control and Refugee Health Branch, San Diego County Health and Human Services Agency, San Diego, California, USA
| | - Stacie San Miguel
- Student Health Services, University of California, San Diego, California, USA
| | - Antonette Antonio
- Tuberculosis Control and Refugee Health Branch, San Diego County Health and Human Services Agency, San Diego, California, USA
| | - Jazmine Cuevas-Mota
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, California, USA
| | - Valerie Mercer
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, California, USA
| | - McKayla Miller
- Division of Infectious Disease and Global Public Health, School of Medicine, University of California, San Diego, California, USA
| | - Donald G Catanzaro
- Department of Biological Sciences, University of Arkansas, Fayetteville, Arkansas, USA
| | - Phillip Rios
- Qualcomm Institute, Calit2, San Diego Division, University of California, San Diego, California, USA
| | - Fredric Raab
- Qualcomm Institute, Calit2, San Diego Division, University of California, San Diego, California, USA
| | - Constance A Benson
- Division of Infectious Disease and Global Public Health, School of Medicine, University of California, San Diego, California, USA
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AHONKHAI AA, BIAN A, ROBBINS NN, MAURER LA, CLOUSE K, PIERCE LJ, PERKINS JM, WERNKE SA, SHEPHERD BE, BRANTLEY M. Characterizing residential mobility among people with HIV in Tennessee and its impact on HIV care outcomes. AIDS 2024; 38:397-405. [PMID: 37916463 PMCID: PMC10872643 DOI: 10.1097/qad.0000000000003778] [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: 11/03/2023]
Abstract
OBJECTIVE Our objective was to assess the prevalence and patterns of mobility among people with HIV (PWH) in Tennessee and its impact on HIV care outcomes. DESIGN Retrospective cohort study. METHODS We combined residential address and HIV surveillance data from PWH in Tennessee from 2016 to 2018. Using Poisson regression, we estimated associations between in-state mobility (change in address or total miles moved) in 1 year and outcomes in the subsequent year; retention: having two CD4 + /HIV RNA values (labs) in a calendar year at least 3 months apart, loss to follow-up (LTFU): having labs at baseline but not the subsequent year, and viral suppression: HIV RNA less than 200 copies/ml. We applied a kernel density estimator to origin-destination address lines to visualize mobility patterns across demographic subgroups. RESULTS Among 17 428 PWH [median age 45 years (interquartile range; IQR 34-53)], 6564 (38%) had at least one move. Median miles moved was 8.9 (IQR 2.6-143.4)). We observed in-state movement between major cities (Chattanooga, Knoxville, Memphis and Nashville) and out-of-state movement to and from Georgia and Florida. Having at least one in-state move was associated with a decreased likelihood of retention [adjusted relative risk (aRR) = 0.91; 95% confidence interval (CI) 0.88-0.95], and an increased risk of LTFU (aRR = 1.17; 95% CI 1.04-1.31, two to three moves vs. none). Greater distance moved in-state was associated with decreased retention and increased LTFU (aRR = 0.53; 95% CI 0.49-0.58, aRR = 2.52; 95% CI 2.25-2.83, respectively for 1000 vs. 0 miles). There was no association between mobility and viral suppression. CONCLUSION Mobility is common among PWH in Tennessee and is associated with initial poor engagement in HIV care.
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Affiliation(s)
- Aima A. AHONKHAI
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Aihua BIAN
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | | | | | - Kate CLOUSE
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Vanderbilt University School of Nursing, Nashville, TN
| | - Leslie J. PIERCE
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Jessica M. PERKINS
- Department of Human & Organizational Development, Peabody College, Vanderbilt University, Nashville, TN
| | - Steven A. WERNKE
- Department of Anthropology, Vanderbilt University, Nashville, TN
| | - Bryan E. SHEPHERD
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
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Nardell MF, Govathson C, Mngadi-Ncube S, Ngcobo N, Letswalo D, Lurie M, Miot J, Long L, Katz IT, Pascoe S. Migrant men and HIV care engagement in Johannesburg, South Africa. BMC Public Health 2024; 24:435. [PMID: 38347453 PMCID: PMC10860300 DOI: 10.1186/s12889-024-17833-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 01/20/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND South Africa (SA) has one of the highest rates of migration on the continent, largely comprised of men seeking labor opportunities in urban centers. Migrant men are at risk for challenges engaging in HIV care. However, rates of HIV and patterns of healthcare engagement among migrant men in urban Johannesburg are poorly understood. METHODS We analyzed data from 150 adult men (≥ 18 years) recruited in 10/2020-11/2020 at one of five sites in Johannesburg, Gauteng Province, SA where migrants typically gather for work, shelter, transit, or leisure: a factory, building materials store, homeless shelter, taxi rank, and public park. Participants were surveyed to assess migration factors (e.g., birth location, residency status), self-reported HIV status, and use and knowledge of HIV and general health services. Proportions were calculated with descriptive statistics. Associations between migration factors and health outcomes were examined with Fisher exact tests and logistic regression models. Internal migrants, who travel within the country, were defined as South African men born outside Gauteng Province. International migrants were defined as men born outside SA. RESULTS Two fifths (60/150, 40%) of participants were internal migrants and one fifth (33/150, 22%) were international migrants. More internal migrants reported living with HIV than non-migrants (20% vs 6%, p = 0.042), though in a multi-variate analysis controlling for age, being an internal migrant was not a significant predictor of self-reported HIV positive status. Over 90% all participants had undergone an HIV test in their lifetime. Less than 20% of all participants had heard of pre-exposure prophylaxis (PrEP), with only 12% international migrants having familiarity with PrEP. Over twice as many individuals without permanent residency or citizenship reported "never visiting a health facility," as compared to citizens/permanent residents (28.6% vs. 10.6%, p = 0.073). CONCLUSIONS Our study revealed a high proportion of migrants within our community-based sample of men and demonstrated a need for HIV and other healthcare services that effectively reach migrants in Johannesburg. Future research is warranted to further disaggregate this heterogenous population by different dimensions of mobility and to understand how to design HIV programs in ways that will address migrants' challenges.
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Affiliation(s)
- Maria Francesca Nardell
- Division of Global Health Equity, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Caroline Govathson
- Health Economics and Epidemiology Research Office (HE2RO), Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sithabile Mngadi-Ncube
- Health Economics and Epidemiology Research Office (HE2RO), Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nkosinathi Ngcobo
- Health Economics and Epidemiology Research Office (HE2RO), Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Daniel Letswalo
- Health Economics and Epidemiology Research Office (HE2RO), Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mark Lurie
- Brown University School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Jacqui Miot
- Health Economics and Epidemiology Research Office (HE2RO), Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lawrence Long
- Health Economics and Epidemiology Research Office (HE2RO), Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Ingrid Theresa Katz
- Harvard Medical School, Boston, MA, USA
- Division of Women's Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Sophie Pascoe
- Health Economics and Epidemiology Research Office (HE2RO), Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Nanyonjo G, Kwena Z, Nakamanya S, Okello E, Oketch B, Bahemuka UM, Ssetaala A, Okech B, Price MA, Kapiga S, Fast P, Bukusi E, Seeley J. Finding women in fishing communities around Lake Victoria: "Feasibility and acceptability of using phones and tracking devices". PLoS One 2024; 19:e0290634. [PMID: 38206982 PMCID: PMC10783786 DOI: 10.1371/journal.pone.0290634] [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: 02/18/2022] [Accepted: 08/01/2023] [Indexed: 01/13/2024] Open
Abstract
INTRODUCTION Women in fishing communities have both high HIV prevalence and incidence, hence they are a priority population for HIV prevention and treatment interventions. However, their mobility is likely to compromise the effectiveness of interventions. We assessed the acceptability, feasibility and of using phones and global positioning system (GPS) devices for tracking mobility, to inform future health research innovations. METHODS A mult-site formative qualitative study was conducted in six purposively selected Fishing Communities on the shores of Lake Victoria in Kenya, Tanzania, and Uganda. Participants were selected based on duration of stay in the community and frequency of movement. Sixty-four (64) women participated in the study (16 per fishing community). Twenty-four (24) participants were given a study phone; 24 were asked to use their own phones and 16 were provided with a portable GPS device to understand what is most preferred. Women were interviewed about their experiences and recommendations on carrying GPS devices or phones. Twenty four (24) Focus Group Discussions with 8-12 participants were conducted with community members to generate data on community perceptions regarding GPS devices and phones acceptability among women. Data were analyzed thematically and compared across sites/countries. RESULTS Women reported being willing to use tracking devices (both phones and GPS) because they are easy to carry. Their own phone was preferred compared to a study phone and GPS device because they were not required to carry an additional device, worry about losing it or be questioned about the extra device by their sexual partner. Women who carried GPS devices suggested more sensitization in communities to avoid domestic conflicts and public concern. Women suggested changing the GPS colour from white to a darker colour and, design to look like a commonly used object such as a telephone Subscriber Identity Module (SIM) card, a rosary/necklace or a ring for easy and safe storage. CONCLUSION Women in the study communities were willing to have their movements tracked, embraced the use of phones and GPS devices for mobility tracking. Devices need to be redesigned to be more discrete, but they could be valuable tools to understanding movement patterns and inform design of interventions for these mobile populations.
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Affiliation(s)
| | - Zachary Kwena
- Research Care and Training Program (RCTP), Kenya Medical Research Institute, Kisumu, Kenya
| | - Sarah Nakamanya
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Entebbe, Uganda
| | - Elialilia Okello
- National Institute for Medical Research, Mwanza Intervention Trials Unit (MITU), Mwanza, Tanzania
| | - Bertha Oketch
- Research Care and Training Program (RCTP), Kenya Medical Research Institute, Kisumu, Kenya
| | - Ubaldo M. Bahemuka
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Entebbe, Uganda
| | - Ali Ssetaala
- UVRI-IAVI HIV Vaccine Program Limited, Entebbe, Uganda
| | - Brenda Okech
- UVRI-IAVI HIV Vaccine Program Limited, Entebbe, Uganda
| | - Matt A. Price
- IAVI, New York, NY, United States of America
- Department of Epidemiology and Biostatistics, University of California at San Francisco, San Francisco, CA, United States of America
| | - Saidi Kapiga
- National Institute for Medical Research, Mwanza Intervention Trials Unit (MITU), Mwanza, Tanzania
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Pat Fast
- IAVI, New York, NY, United States of America
| | - Elizabeth Bukusi
- Research Care and Training Program (RCTP), Kenya Medical Research Institute, Kisumu, Kenya
| | - Janet Seeley
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Entebbe, Uganda
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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Ayieko J, Balzer LB, Inviolata C, Kakande E, Opel F, Wafula EM, Kabami J, Owaraganise A, Mwangwa F, Nakato H, Bukusi EA, Camlin CS, Charlebois ED, Bacon MC, Petersen ML, Kamya MR, Havlir DV, Chamie G. Randomized Trial of a "Dynamic Choice" Patient-Centered Care Intervention for Mobile Persons With HIV in East Africa. J Acquir Immune Defic Syndr 2024; 95:74-81. [PMID: 38054932 PMCID: PMC10695335 DOI: 10.1097/qai.0000000000003311] [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: 03/15/2023] [Accepted: 08/04/2023] [Indexed: 12/07/2023]
Abstract
BACKGROUND Persons with HIV (PWH) with high mobility face obstacles to HIV care engagement and viral suppression. We sought to understand whether a patient-centered intervention for mobile PWH would improve viral suppression and retention in care, and if so, which subgroups would benefit most. METHODS In a randomized trial, we evaluated the effect of an intervention designed to address barriers to care among mobile (≥2 weeks out of community in previous year) PWH with viral nonsuppression or recent missed visits in Kenya and Uganda (NCT04810650). The intervention included dynamic choice of a "travel pack" (emergency antiretroviral therapy [ART] supply, discrete ART packaging, and travel checklist), multimonth and offsite refills, facilitated transfer to out-of-community clinics, and hotline access to a mobility coordinator. The primary outcome was viral suppression (<400 copies/mL) at 48 weeks. Secondary outcomes included retention in care and ART possession. RESULTS From April 2021 to July 2022, 201 participants were enrolled and randomized (102 intervention, 99 control): 109 (54%) were female participants and 101 (50%) from Kenya; median age was 37 years (interquartile range: 29-43). At 48 weeks, there was no significant difference in viral suppression in intervention (85%) vs. control (86%). The intervention improved retention in care (risk ratio: 1.06[1.02-1.1]; P < 0.001) and ART possession (risk ratio: 1.07[1.03-1.11]; P < 0.001), with larger effect sizes among persons with baseline nonsuppression and high mobility (≥2 weeks out of community in previous 3 months). CONCLUSIONS Mobile PWH-centered care should be considered for high-risk mobile populations, including nonsuppressed and highly mobile PWH, to improve retention in care and sustain viral suppression over time. TRIAL REGISTRATION NCT04810650.
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Affiliation(s)
| | | | | | - Elijah Kakande
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Fred Opel
- Kenya Medical Research Institute, Kisumu, Kenya
| | | | - Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | | | - Hellen Nakato
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | | | | | - Melanie C. Bacon
- National Institute of Allergy and Infectious Diseases, Bethesda, MD; and
| | | | - Moses R. Kamya
- Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Gabriel Chamie
- University of California San Francisco, San Francisco, CA
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Odayar J, Phillips TK, Kabanda S, Malaba TR, Mukonda E, Hsiao NY, Lesosky M, Myer L. Mobility during the post-partum period and viraemia in women living with HIV in South Africa. Int Health 2023; 15:692-701. [PMID: 36715066 PMCID: PMC10629960 DOI: 10.1093/inthealth/ihad001] [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: 07/28/2022] [Revised: 12/15/2022] [Accepted: 01/24/2023] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND We investigated the association between travel and viraemia in post-partum women with human immunodeficiency virus on antiretroviral therapy (ART). METHODS Data are from a trial of post-partum ART delivery strategies. Women who initiated ART during pregnancy, were clinically stable with a viral load (VL) <400 copies/ml and were <10 weeks post-partum were enrolled at a primary care antenatal clinic in Cape Town, South Africa. Study visits at 3, 6, 12, 18 and 24 months post-partum included questions about travel, defined as ≥1 night spent outside of the city, and VL testing. Generalised mixed effects models assessed the association between travel and subsequent VL ≥400 copies/ml. RESULTS Among 402 women (mean age 29 y, 35% born in the Western Cape), 69% reported one or more travel events over 24 months. Being born beyond the Western Cape (adjusted odds ratio [aOR] 2.03 [95% confidence interval {CI} 1.49 to 2.77]), duration post-partum in months (aOR 1.03 [95% CI 1.02 to 1.05]) and living with the child (aOR 0.60 [95% CI 0.38 to 0.93]) were associated with travel. In multivariable analyses, a travel event was associated with a 92% increase in the odds of a VL ≥400 copies/ml (aOR 1.92 [95% CI 1.19 to 3.10]). CONCLUSIONS Interventions to support women on ART who travel are urgently required.
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Affiliation(s)
- Jasantha Odayar
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Tamsin K Phillips
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Siti Kabanda
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Thokozile R Malaba
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Elton Mukonda
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Nei-yuan Hsiao
- Division of Medical Virology, National Health Laboratory Service, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Maia Lesosky
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
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Khalifa A, Ssekubugu R, Lessler J, Wawer M, Santelli JS, Hoffman S, Nalugoda F, Lutalo T, Ndyanabo A, Ssekasanvu J, Kigozi G, Kagaayi J, Chang LW, Grabowski MK. Implications of rapid population growth on survey design and HIV estimates in the Rakai Community Cohort Study (RCCS), Uganda. BMJ Open 2023; 13:e071108. [PMID: 37495389 PMCID: PMC10373715 DOI: 10.1136/bmjopen-2022-071108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/28/2023] Open
Abstract
OBJECTIVE Since rapid population growth challenges longitudinal population-based HIV cohorts in Africa to maintain coverage of their target populations, this study evaluated whether the exclusion of some residents due to growing population size biases key HIV metrics like prevalence and population-level viremia. DESIGN, SETTING AND PARTICIPANTS Data were obtained from the Rakai Community Cohort Study (RCCS) in south central Uganda, an open population-based cohort which began excluding some residents of newly constructed household structures within its surveillance boundaries in 2008. The study includes adults aged 15-49 years who were censused from 2019 to 2020. MEASURES We fit ensemble machine learning models to RCCS census and survey data to predict HIV seroprevalence and viremia (prevalence of those with viral load >1000 copies/mL) in the excluded population and evaluated whether their inclusion would change overall estimates. RESULTS Of the 24 729 census-eligible residents, 2920 (12%) residents were excluded from the RCCS because they were living in new households. The predicted seroprevalence for these excluded residents was 10.8% (95% CI: 9.6% to 11.8%)-somewhat lower than 11.7% (95% CI: 11.2% to 12.3%) in the observed sample. Predicted seroprevalence for younger excluded residents aged 15-24 years was 4.9% (95% CI: 3.6% to 6.1%)-significantly higher than that in the observed sample for the same age group (2.6% (95% CI: 2.2% to 3.1%)), while predicted seroprevalence for older excluded residents aged 25-49 years was 15.0% (95% CI: 13.3% to 16.4%)-significantly lower than their counterparts in the observed sample (17.2% (95% CI: 16.4% to 18.1%)). Over all ages, the predicted prevalence of viremia in excluded residents (3.7% (95% CI: 3.0% to 4.5%)) was significantly higher than that in the observed sample (1.7% (95% CI: 1.5% to 1.9%)), resulting in a higher overall population-level viremia estimate of 2.1% (95% CI: 1.8% to 2.4%). CONCLUSIONS Exclusion of residents in new households may modestly bias HIV viremia estimates and some age-specific seroprevalence estimates in the RCCS. Overall, HIV seroprevalence estimates were not significantly affected.
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Affiliation(s)
- Aleya Khalifa
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
- ICAP, Columbia University, New York, New York, USA
| | - Robert Ssekubugu
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Global and Sexual Health, Karolinska Institutet, Stockholm, Sweden
| | - Justin Lessler
- Department of Epidemiology, University of North Carolina School of Public Health, Chapel Hill, North Carolina, USA
- Carolina Population Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Maria Wawer
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - John S Santelli
- Population and Family Health, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Susie Hoffman
- Department of Epidemiology, Columbia University, New York, New York, USA
- HIV Centre for Clinical and Behavioural Studies, Columbia University Irving Medical Centre, New York, New York, USA
| | | | - Tom Lutalo
- Rakai Health Sciences Program, Kalisizo, Uganda
| | | | - Joseph Ssekasanvu
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | | | - Larry W Chang
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Mary Kathryn Grabowski
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Grimsrud A, Wilkinson L, Delany‐Moretlwe S, Ehrenkranz P, Green K, Murenga M, Ngure K, Otwoma NJ, Phanuphak N, Vandevelde W, Vitoria M, Bygrave H. The importance of the "how": the case for differentiated service delivery of long-acting and extended delivery regimens for HIV prevention and treatment. J Int AIDS Soc 2023; 26 Suppl 2:e26095. [PMID: 37439076 PMCID: PMC10339003 DOI: 10.1002/jia2.26095] [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: 11/08/2022] [Accepted: 04/27/2023] [Indexed: 07/14/2023] Open
Abstract
INTRODUCTION Long-acting and extended delivery (LAED) regimens for HIV treatment and prevention offer unique benefits to expand uptake, effective use and adherence. To date, research has focused on basic and clinical science around the safety and efficacy of these products. This commentary outlines opportunities in HIV prevention and treatment programmes, both for the health system and clients, that could be addressed through the inclusion of LAED regimens and the vital role of differentiated service delivery (DSD) in ensuring efficient and equitable access. DISCUSSION The realities and challenges within HIV treatment and prevention programmes are different. Globally, more than 28 million people are accessing HIV treatment-the vast majority on a daily fixed-dose combination oral pill that is largely available, affordable and well-tolerated. Many people collect extended refills outside of health facilities with clinical consultations once or twice a year. Conversely, uptake of daily oral pre-exposure prophylaxis (PrEP) has consistently missed global targets due to limited access with high individual cost and lack of choice contributing to substantial unmet PrEP need. Recent trends in demedicalization, simplification, additional method options and DSD for PrEP have led to accelerated uptake as its availability has become more aligned with user preferences. How people currently receive HIV treatment and prevention services and their barriers to adherence must be considered for the introduction of LAED regimens to achieve the expected improvements in access and outcomes. Important considerations include the building blocks of DSD: who (provider), where (location), when (frequency) and what (package of services). Ideally, all LAED regimens will leverage DSD models that emphasize access at the community level and self-management. For treatment, LAED regimens may address challenges with adherence but their delivery should provide clear advantages over existing oral products to be scaled. For prevention, LAED regimens expand a potential PrEP user's choice of methods, but like other methods, need to be delivered in a manner that can facilitate frequent re-initiation. CONCLUSIONS To ensure that innovative LAED HIV treatment and prevention products reach those who most stand to benefit, service delivery and client considerations during development, trial and early implementation are critical.
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Affiliation(s)
- Anna Grimsrud
- HIV Programmes and AdvocacyIAS – the International AIDS SocietyCape TownSouth Africa
| | - Lynne Wilkinson
- HIV Programmes and AdvocacyIAS – the International AIDS SocietyCape TownSouth Africa
- Centre for Infectious Disease Epidemiology and ResearchUniversity of Cape TownCape TownSouth Africa
| | | | - Peter Ehrenkranz
- Global HealthBill & Melinda Gates FoundationSeattleWashingtonUSA
| | - Kimberly Green
- Primary Health CarePATHSeattleWashingtonUSA
- Primary Health CarePATHHanoiVietnam
| | | | - Kenneth Ngure
- School of Public HealthJomo Kenyatta University of Agriculture and TechnologyNairobiKenya
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
| | - Nelson J. Otwoma
- National Empowerment Network of People Living with HIV/AIDS in Kenya (NEPHAK)NairobiKenya
| | | | - Wim Vandevelde
- Global Network of People Living with HIV (GNP+)Cape TownSouth Africa
| | - Marco Vitoria
- Global HIV, Hepatitis, and Sexually Transmitted Infections ProgrammesWorld Health OrganizationGenevaSwitzerland
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9
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Thorp M, Ayieko J, Hoffman RM, Balakasi K, Camlin CS, Dovel K. Mobility and HIV care engagement: a research agenda. J Int AIDS Soc 2023; 26:e26058. [PMID: 36943731 PMCID: PMC10029995 DOI: 10.1002/jia2.26058] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 01/10/2023] [Indexed: 03/23/2023] Open
Abstract
INTRODUCTION Mobility is common and an essential livelihood strategy in sub-Saharan Africa (SSA). Mobile people suffer worse outcomes at every stage of the HIV care cascade compared to non-mobile populations. Definitions of mobility vary widely, and research on the role of temporary mobility (as opposed to permanent migration) in HIV treatment outcomes is often lacking. In this article, we review the current landscape of mobility and HIV care research to identify what is already known, gaps in the literature, and recommendations for future research. DISCUSSION Mobility in SSA is closely linked to income generation, though caregiving, climate change and violence also contribute to the need to move. Mobility is likely to increase in the coming decades, both due to permanent migration and increased temporary mobility, which is likely much more common. We outline three central questions regarding mobility and HIV treatment outcomes in SSA. First, it is unclear what aspects of mobility matter most for HIV care outcomes and if high-risk mobility can be identified or predicted, which is necessary to facilitate targeted interventions for mobile populations. Second, it is unclear what groups are most vulnerable to mobility-associated treatment interruption and other adverse outcomes. And third, it is unclear what interventions can improve HIV treatment outcomes for mobile populations. CONCLUSIONS Mobility is essential for people living with HIV in SSA. HIV treatment programmes and broader health systems must understand and adapt to human mobility, both to promote the rights and welfare of mobile people and to end the HIV pandemic.
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Affiliation(s)
- Marguerite Thorp
- Division of Infectious DiseasesDavid Geffen School of MedicineUniversity of California Los AngelesLos AngelesCaliforniaUSA
| | - James Ayieko
- Center for Microbiology ResearchKenya Medical Research InstituteKisumuKenya
| | - Risa M. Hoffman
- Division of Infectious DiseasesDavid Geffen School of MedicineUniversity of California Los AngelesLos AngelesCaliforniaUSA
| | | | - Carol S. Camlin
- Department of ObstetricsGynecology & Reproductive SciencesUniversity of California San FranciscoSan FranciscoCaliforniaUSA
- Center for AIDS Prevention StudiesDepartment of MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Kathryn Dovel
- Division of Infectious DiseasesDavid Geffen School of MedicineUniversity of California Los AngelesLos AngelesCaliforniaUSA
- Partners in HopeLilongweMalawi
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10
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Maeri I, Eyul P, Getahun M, Hatchett K, Owino L, Akatukwasa C, Itiakorit H, Gutin SA, Johnson-Peretz J, Ssali S, Cohen CR, Bukusi EA, Kamya MR, Charlebois ED, Camlin CS. Nothing about us without us: Community-based participatory research to improve HIV care for mobile patients in Kenya and Uganda. Soc Sci Med 2023; 318:115471. [PMID: 36628879 PMCID: PMC10184576 DOI: 10.1016/j.socscimed.2022.115471] [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: 01/14/2022] [Revised: 09/11/2022] [Accepted: 10/20/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Population mobility is prevalent and complex in sub-Saharan Africa, and can disrupt HIV care and fuel onward transmission. While differentiated care models show promise for meeting the needs of mobile populations by addressing care cascade gaps, the voices of mobile populations need to be included when designing care delivery models. We assessed the unmet needs of mobile populations and engaged mobile stakeholders in the design and implementation of service delivery to improve care outcomes for mobile people living with HIV (PLHIV). METHODS CBPR was conducted in 12 rural communities in Kenya and Uganda participating in a mobility study within the Sustainable East Africa Research in Community Health (SEARCH) test-and-treat trial (NCT# 01864603) from 2016 to 2019. Annual gender-balanced meetings with between 17 and 33 mobile community stakeholders per meeting were conducted in local languages to gather information on mobility and its influence on HIV-related outcomes. Discussions were audio-recorded, transcribed and translated into English. Findings were shared at subsequent meetings to engage mobile stakeholders in interpretation. At year three, intervention ideas to address mobile populations' needs were elicited. After refinement, these intervention options were presented to the same communities for prioritization the following year, using a participatory ranking approach. RESULTS Transit hubs, trading centers, and beach sites were identified as desirable service locations. Communities prioritized mobile health 'cards' with electronic medical records and peer-delivered home-based services. Mobile health clinics, longer antiretroviral refills, and 24/7 (after service) were less desirable options. Care challenges included: lack of transfer letters to other clinics; inability to adhere to scheduled appointments, medication regimens, and monitoring of treatment outcomes while mobile amongst others. CONCLUSIONS Iterative discussions with mobile community stakeholders elicited communities' health priorities and identified challenges to achieving HIV care cascade outcomes. Understanding the mobility patterns and unique needs of mobile populations through responsive community engagement is critical.
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Affiliation(s)
- Irene Maeri
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya.
| | - Patrick Eyul
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Monica Getahun
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, USA
| | - Khalela Hatchett
- Department of Community Health Sciences, University of California Los Angeles, Los Angeles, USA
| | - Lawrence Owino
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | | | - Sarah A Gutin
- Department of Medicine, Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, USA
| | - Jason Johnson-Peretz
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, USA
| | - Sarah Ssali
- School of Women and Gender Studies, Makerere University, Kampala, Uganda
| | - Craig R Cohen
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, USA
| | - Elizabeth A Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda; School of Medicine, Makerere University, Kampala, Uganda
| | - Edwin D Charlebois
- Department of Medicine, Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, USA
| | - Carol S Camlin
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, USA; Department of Medicine, Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, USA
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11
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Tsuyuki K, Stockman JK, Stadnick NA, Moore V, Zhu H, Torres V, Cano R, Penninga K, Aldous JL. Proyecto Compadre: Using Implementation Science to Tailor Peer Navigation for Latino Men in the US-Mexico Border Region. J Acquir Immune Defic Syndr 2022; 90:S98-S104. [PMID: 35703761 PMCID: PMC9220980 DOI: 10.1097/qai.0000000000002985] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Latino men who have sex with men (MSM) in San Diego have poor HIV testing and prevention outcomes compared with non-Latino White men. Peer navigation (PN) is a promising evidence-based intervention to reduce disparities but needs tailoring for Latino MSM. SETTINGS Health centers near the US-Mexico border. METHODS Using the Exploration, Preparation, Implementation, Sustainment Framework, we conducted mixed-methods implementation science study. In phase I, we conducted interviews with Latino men (n = 15), focus groups with staff (n = 7), and surveys with all to understand the Exploration, Preparation, Implementation, Sustainment factors associated with HIV testing and care linkage. In phase II, we conducted 31 web-based surveys with Latino men and staff to rank intervention and implementation strategies from phase I. Quantitative data were analyzed descriptively, integrated with qualitative data, and reviewed by our community-academic partnership to develop an implementation model. RESULTS Latino men (N = 15) were 94% Spanish speaking, 67% gay identified, 27% US born, and their suggestions were to have navigators use peer referral to address barriers such as stigma; use the Latino social network to expand reach, leverage social media for peer-led intervention, and disseminate HIV information. Staff (N = 26) were 77% Spanish speaking, 35% gay-identified, 96% trained in cultural competency, and suggested including culturally appropriate HIV educational materials in Spanish, status and identity neutral programs, administrative/supervisorial/training structure for PNs, and PN compensation and team integration. Overall, results emphasized a need for a formalized PN model centered on referrals and using existing Latino community social networks. CONCLUSIONS Findings can be packaged for future implementation of PN programs for Latino MSM.
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Affiliation(s)
- Kiyomi Tsuyuki
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California, San Diego (9500 Gilman Drive, La Jolla, CA, 92093-0507, USA)
| | - Jamila K. Stockman
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California, San Diego (9500 Gilman Drive, La Jolla, CA, 92093-0507, USA)
| | | | | | - Helen Zhu
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California, San Diego (9500 Gilman Drive, La Jolla, CA, 92093-0507, USA)
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12
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Murnane PM, Gandhi M, Bacchetti P, Getahun M, Gutin SA, Okochi H, Maeri I, Eyul P, Omoding D, Okiring J, Tallerico R, Louie A, Akullian A, Kamya MR, Bukusi EA, Charlebois ED, Camlin CS. Distinct forms of migration and mobility are differentially associated with HIV treatment adherence. AIDS 2022; 36:1021-1030. [PMID: 35652674 PMCID: PMC9178682 DOI: 10.1097/qad.0000000000003213] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We examined whether human mobility was associated with antiretroviral treatment adherence, measured via antiretroviral hair concentrations. DESIGN This is a cross-sectional analysis of adults on antiretroviral treatment in East Africa at baseline in an observational cohort study. METHODS Participants reported recent mobility (overnight travel) and histories of migration (changes of residence), including reasons, frequency/duration, and locations. Hair antiretroviral concentrations were analyzed using validated methods. We estimated associations between mobility and antiretroviral concentrations via linear regression adjusted for age, sex, region, years on treatment. RESULTS Among 383 participants, half were women and the median age was 40. Among men, 25% reported recent work-related mobility, 30% nonwork mobility, and 11% migrated in the past year (mostly across district boundaries); among women, 6 and 57% reported work-related and nonwork mobility, respectively, and 8% recently migrated (mostly within district). Those reporting work-related trips 2 nights or less had 72% higher hair antiretroviral levels (P = 0.02) than those who did not travel for work; in contrast, nonwork mobility (any duration, vs. none) was associated with 24% lower levels (P = 0.06). Intra-district migrations were associated with 59% lower antiretroviral levels than nonmigrants (P = 0.003) while inter-district migrations were not (27% higher, P = 0.40). CONCLUSION We found that localized/intra-district migration and nonwork travel-more common among women-were associated with lower adherence, potentially reflecting care interruptions or staying with family/friends unaware of the participants' status. In contrast, short work-related trips-more common among men-were associated with higher adherence, perhaps reflecting higher income. Adherence interventions may require tailoring by sex and forms of mobility.
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Affiliation(s)
- Pamela M Murnane
- Department of Epidemiology and Biostatistics
- Institute for Global Health Sciences
| | - Monica Gandhi
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine
- UCSF-Hair Analytical Laboratory
| | | | - Monica Getahun
- Department of Obstetrics, Gynecology & Reproductive Sciences
| | - Sarah A Gutin
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, California, USA
| | - Hideaki Okochi
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine
- UCSF-Hair Analytical Laboratory
| | - Irene Maeri
- Centre For Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Patrick Eyul
- Infectious Diseases Research Collaboration, Makerere University
| | - Daniel Omoding
- Infectious Diseases Research Collaboration, Makerere University
| | - Jaffer Okiring
- Clinical Epidemiology Unit, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Regina Tallerico
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine
- UCSF-Hair Analytical Laboratory
| | - Alexander Louie
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine
- UCSF-Hair Analytical Laboratory
| | - Adam Akullian
- Institute for Disease Modeling, Bellevue, Washington, USA
| | - Moses R Kamya
- Infectious Diseases Research Collaboration, Makerere University
- School of Medicine, Makerere University, Kampala, Uganda
| | - Elizabeth A Bukusi
- Department of Obstetrics, Gynecology & Reproductive Sciences
- Centre For Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Edwin D Charlebois
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, California, USA
| | - Carol S Camlin
- Department of Obstetrics, Gynecology & Reproductive Sciences
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, California, USA
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13
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Genberg BL, Wilson-Barthes MG, Omodi V, Hogan JW, Steingrimsson J, Wachira J, Pastakia S, Tran DN, Kiragu ZW, Ruhl LJ, Rosenberg M, Kimaiyo S, Galárraga O. Microfinance, retention in care, and mortality among patients enrolled in HIV care in East Africa. AIDS 2021; 35:1997-2005. [PMID: 34115646 PMCID: PMC8963387 DOI: 10.1097/qad.0000000000002987] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To measure associations between participation in community-based microfinance groups, retention in HIV care, and death among people with HIV (PWH) in low-resource settings. DESIGN AND METHODS We prospectively analyzed data from 3609 patients enrolled in an HIV care program in western Kenya. HIV patients who were eligible and chose to participate in a Group Integrated Savings for Health Empowerment (GISHE) microfinance group were matched 1 : 2 on age, sex, year of enrollment in HIV care, and location of initial HIV clinic visit to patients not participating in GISHE. Follow-up data were abstracted from medical records from January 2018 through February 2020. Logistic regression analysis examined associations between GISHE participation and two outcomes: retention in HIV care (i.e. >1 HIV care visit attended within 6 months prior to the end of follow-up) and death. Socioeconomic factors associated with HIV outcomes were included in adjusted models. RESULTS The study population was majority women (78.3%) with a median age of 37.4 years. Microfinance group participants were more likely to be retained in care relative to HIV patients not participating in a microfinance group [adjusted odds ratio (aOR) = 1.31, 95% confidence interval (CI) 1.01-1.71; P = 0.046]. Participation in group microfinance was associated with a reduced odds of death during the follow-up period (aOR = 0.57, 95% CI 0.28-1.09; P = 0.105). CONCLUSION Participation in group-based microfinance appears to be associated with better HIV treatment outcomes. A randomized trial is needed to assess whether microfinance groups can improve clinical and socioeconomic outcomes among PWH in similar settings.
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Affiliation(s)
- Becky L. Genberg
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Marta G. Wilson-Barthes
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Victor Omodi
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Joseph W. Hogan
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Department of Biostatistics, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Jon Steingrimsson
- Department of Biostatistics, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Juddy Wachira
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Department of Behavioral Science, Moi University College of Health Sciences, School of Medicine, Eldoret, Kenya
| | - Sonak Pastakia
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Purdue University College of Pharmacy, Center for Health Equity and Innovation, Indianapolis, Indiana
| | - Dan N. Tran
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Department of Pharmacy Practice, Temple University School of Pharmacy, Philadelphia, Pennsylvania
| | - Zana W. Kiragu
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts
| | - Laura J. Ruhl
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Molly Rosenberg
- Department of Epidemiology and Biostatistics, Indiana University School of Public Health, Bloomington, Indiana
| | | | - Omar Galárraga
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
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14
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Wang KH, McAvay G, Warren A, Miller ML, Pho A, Blosnich JR, Brandt CA, Goulet JL. Examining Health Care Mobility of Transgender Veterans Across the Veterans Health Administration. LGBT Health 2021; 8:143-151. [PMID: 33512276 DOI: 10.1089/lgbt.2020.0152] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Purpose: Transgender veterans are overrepresented in the Veterans Health Administration (VHA) compared with in the general population. Utilization of multiple different health care systems, or health care mobility, can affect care coordination and potentially affect outcomes, either positively or negatively. This study examines whether transgender veterans are more or less health care mobile than nontransgender veterans and compares the patterns of geographic mobility in these groups. Methods: Using an established cohort (n = 5,414,109), we identified 2890 transgender veterans from VHA electronic health records from 2000 to 2012. We compared transgender and nontransgender veterans on sociodemographic, clinical, and health care system-level measures and conducted conditional logistic regression models of mobility. Results: Transgender veterans were more likely to be younger, White, homeless, have depressive disorders, post-traumatic stress disorder (PTSD), and hepatitis C. Transgender veterans were more likely to have been health care mobile (9.9%) than nontransgender veterans (5.2%) (unadjusted odds ratio = 2.02, 95% confidence interval = 1.73-2.36). In a multivariable model, transgender status, being separated/divorced, receiving care in less-complex facilities, and diagnoses of depression, PTSD, or hepatitis C were associated with more mobility, whereas older age was associated with less mobility. For the top three health care systems utilized, a larger proportion of transgender veterans visited a second health care system in a different state (56.2%) than nontransgender veterans (37.5%). Conclusions: Transgender veterans were more likely to be health care mobile and more likely to travel out of state for health care services. They were also more likely to have complex chronic health conditions that require multidisciplinary care.
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Affiliation(s)
- Karen H Wang
- Department of Internal Medicine, Equity Research and Innovation Center, Yale School of Medicine, New Haven, Connecticut, USA
| | - Gail McAvay
- Department of Internal Medicine, Equity Research and Innovation Center, Yale School of Medicine, New Haven, Connecticut, USA.,Pain Research, Informatics, Multi-morbidities, and Education Center, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Allison Warren
- Department of Internal Medicine, Equity Research and Innovation Center, Yale School of Medicine, New Haven, Connecticut, USA.,Pain Research, Informatics, Multi-morbidities, and Education Center, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Mary L Miller
- Department of Internal Medicine, Equity Research and Innovation Center, Yale School of Medicine, New Haven, Connecticut, USA
| | - Anthony Pho
- Columbia University School of Nursing, New York, New York, USA
| | - John R Blosnich
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California, USA.,Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Cynthia A Brandt
- Department of Internal Medicine, Equity Research and Innovation Center, Yale School of Medicine, New Haven, Connecticut, USA.,Pain Research, Informatics, Multi-morbidities, and Education Center, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Joseph L Goulet
- Department of Internal Medicine, Equity Research and Innovation Center, Yale School of Medicine, New Haven, Connecticut, USA.,Pain Research, Informatics, Multi-morbidities, and Education Center, VA Connecticut Healthcare System, West Haven, Connecticut, USA
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15
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Makurumidze R, Decroo T, Lynen L, Chinwadzimba ZK, Van Damme W, Hakim J, Rusakaniko S. District-level strategies to control the HIV epidemic in Zimbabwe: a practical example of precision public health. BMC Res Notes 2020; 13:393. [PMID: 32847619 PMCID: PMC7449062 DOI: 10.1186/s13104-020-05234-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 08/14/2020] [Indexed: 12/03/2022] Open
Abstract
Objective We conducted a descriptive cross-sectional study using survey and programme data to assess district-level performance along the HIV care cascade (HIV testing target achievement, linkage to ART and ART coverage) in order to formulate district-specific recommendations, taking into consideration prevalence and yield of testing. Results Data from 60 districts were analysed. Forty-eight districts (80.0%) surpassed 90% of their 2018 HIV testing targets. Linkage to ART was less than 90% in 40 districts (83.3%). Thirty districts (50.0%) had ART coverage above 90%. Of the 30 districts with suboptimal (< 90%) ART coverage, 18 districts had achieved high HIV testing target but with suboptimal linkage to ART, 6 had achieved high HIV testing targets and high linkage to ART, 4 had both suboptimal HIV testing target achievement and linkage to ART and 2 had suboptimal HIV testing target achievement and high linkage to ART. Priority should be given to districts with suboptimal ART coverage. Remediation strategies should be tailored to address the poorly performing stage of the cascade in each of the districts.
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Affiliation(s)
- Richard Makurumidze
- College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe. .,Institute of Tropical Medicine, Antwerp, Belgium. .,Gerontology, Faculty of Medicine & Pharmacy, Free University of Brussels (VUB), Brussels, Belgium.
| | - Tom Decroo
- Institute of Tropical Medicine, Antwerp, Belgium.,Research Foundation of Flanders, Brussels, Belgium
| | | | | | - Wim Van Damme
- Institute of Tropical Medicine, Antwerp, Belgium.,Gerontology, Faculty of Medicine & Pharmacy, Free University of Brussels (VUB), Brussels, Belgium
| | - James Hakim
- College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
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16
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Mobility and its Effects on HIV Acquisition and Treatment Engagement: Recent Theoretical and Empirical Advances. Curr HIV/AIDS Rep 2020; 16:314-323. [PMID: 31256348 DOI: 10.1007/s11904-019-00457-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE OF REVIEW We reviewed literature across multiple disciplines to describe issues with the measurement of population mobility in HIV research and to summarize evidence of causal pathways linking mobility to HIV acquisition risks and treatment engagement, with a focus on sub-Saharan Africa. RECENT FINDINGS While the literature on mobility and HIV remains hampered by problems and inconsistency in measures of mobility, the recent research reveals a turn towards a greater attentiveness to measurement and gender. Theoretical and heuristic models for the study of mobility and HIV acquisition and treatment outcomes have been published, but few studies have used longitudinal designs with clear ascertainment of exposures and outcomes for measurement of causal pathways. Notwithstanding these limitations, evidence continues to accumulate that mobility is linked to higher HIV incidence, and that it challenges optimal treatment engagement. Gender continues to be important: while men are more mobile than women, women's mobility particularly heightens their HIV acquisition risks. Recent large-scale efforts to find, test, and treat the individuals in communities who are most at risk of sustaining local HIV transmission have been severely challenged by mobility. Novel interventions, policies, and health systems improvements are urgently needed to fully engage mobile individuals in HIV care and prevention. Interventions targeting the HIV prevention and care needs of mobile populations remain few in number and urgently needed.
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17
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Davey C, Dirawo J, Hargreaves JR, Cowan FM. Exploring the Association Between Mobility and Access to HIV Services Among Female Sex Workers in Zimbabwe. AIDS Behav 2020; 24:746-761. [PMID: 31256270 DOI: 10.1007/s10461-019-02559-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Female sex workers (FSW) face structural barriers to HIV-service access, however the effect of their mobility is uncertain. Using cross-sectional data from 2839 FSW in 14 sites in Zimbabwe, we explored the association between mobility (number of trips, distance, duration) in the past 12 months and five HIV-service-access outcomes: exposure to community mobilisation, clinic attendance, HIV testing, antiretroviral treatment initiation, and viral suppression (< 1000 copies per mL). We used modified-Poisson regression, and natural-effects models to estimate how the effect of trip frequency was mediated by distance and duration away. Each additional trip in 12 months was associated with increased community-mobilisation-event attendance (adjusted RR 1.08, 95% CI 1.04-1.12) and attending clinic two-or-more times (adjusted RR 1.02, 95% CI 1.00-1.05). There was little evidence of any other associations, or of mediation. Our findings are consistent with literature that found the effects of mobility to vary by context and outcome. This is the first study to consider many FSW-mobility and HIV-service-access measures together. Future research on mobility and health-related behaviour should use a spectrum of measures.
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Affiliation(s)
- Calum Davey
- London School of Hygiene and Tropical Medicine, 15 Tavistock Place, London, WC1H 9SH, UK.
| | - Jeffrey Dirawo
- Centre for Sexual Health and HIV/AIDS Research, 9 Monmouth Rd, 5 Avondale West, Harare, Zimbabwe
| | - James R Hargreaves
- London School of Hygiene and Tropical Medicine, 15 Tavistock Place, London, WC1H 9SH, UK
| | - Frances M Cowan
- Centre for Sexual Health and HIV/AIDS Research, 9 Monmouth Rd, 5 Avondale West, Harare, Zimbabwe
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
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18
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Camlin CS, Akullian A, Neilands TB, Getahun M, Bershteyn A, Ssali S, Geng E, Gandhi M, Cohen CR, Maeri I, Eyul P, Petersen ML, Havlir DV, Kamya MR, Bukusi EA, Charlebois ED. Gendered dimensions of population mobility associated with HIV across three epidemics in rural Eastern Africa. Health Place 2019; 57:339-351. [PMID: 31152972 DOI: 10.1016/j.healthplace.2019.05.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 04/25/2019] [Accepted: 05/03/2019] [Indexed: 11/18/2022]
Abstract
Mobility in sub-Saharan Africa links geographically-separate HIV epidemics, intensifies transmission by enabling higher-risk sexual behavior, and disrupts care. This population-based observational cohort study measured complex dimensions of mobility in rural Uganda and Kenya. Survey data were collected every 6 months beginning in 2016 from a random sample of 2308 adults in 12 communities across three regions, stratified by intervention arm, baseline residential stability and HIV status. Analyses were survey-weighted and stratified by sex, region, and HIV status. In this study, there were large differences in the forms and magnitude of mobility across regions, between men and women, and by HIV status. We found that adult migration varied widely by region, higher proportions of men than women migrated within the past one and five years, and men predominated across all but the most localized scales of migration: a higher proportion of women than men migrated within county of origin. Labor-related mobility was more common among men than women, while women were more likely to travel for non-labor reasons. Labor-related mobility was associated with HIV positive status for both men and women, adjusting for age and region, but the association was especially pronounced in women. The forms, drivers, and correlates of mobility in eastern Africa are complex and highly gendered. An in-depth understanding of mobility may help improve implementation and address gaps in the HIV prevention and care continua.
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Affiliation(s)
- Carol S Camlin
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, USA; Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th Street, 3rd Floor, UCSF Mail Code 0886, San Francisco, CA 94158, USA.
| | - Adam Akullian
- Institute for Disease Modeling, 3150 139th Ave SE, Bellevue, WA 98005, USA; Department of Global Health, University of Washington, Seattle, USA.
| | - Torsten B Neilands
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th Street, 3rd Floor, UCSF Mail Code 0886, San Francisco, CA 94158, USA.
| | - Monica Getahun
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, USA.
| | - Anna Bershteyn
- Institute for Disease Modeling, 3150 139th Ave SE, Bellevue, WA 98005, USA; Department of Global Health, University of Washington, Seattle, USA.
| | - Sarah Ssali
- School of Medicine, Makerere University College of Health Sciences, Upper Mulago Hill Road, New Mulago Hospital Complex, P.O Box 7072, Kampala, Uganda.
| | - Elvin Geng
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California, San Francisco, 1001 Potrero Ave., San Francisco, CA 94110, USA.
| | - Monica Gandhi
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California, San Francisco, 1001 Potrero Ave., San Francisco, CA 94110, USA.
| | - Craig R Cohen
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, USA.
| | - Irene Maeri
- Kenya Medical Research Institute, Centre for Microbiology Research, Box 19464, Post Code 00202, Nairobi, Kenya.
| | - Patrick Eyul
- The Infectious Diseases Research Collaboration (IDRC), Plot 2C Nakasero Hill Road, P.O Box 7475, Kampala, Uganda.
| | - Maya L Petersen
- University of California, Berkeley, 101 Haviland Hall, Suite 102; School of Public Health, UC Berkeley, Berkeley, CA 94720-7358, USA.
| | - Diane V Havlir
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California, San Francisco, 1001 Potrero Ave., San Francisco, CA 94110, USA.
| | - Moses R Kamya
- School of Medicine, Makerere University College of Health Sciences, Upper Mulago Hill Road, New Mulago Hospital Complex, P.O Box 7072, Kampala, Uganda.
| | - Elizabeth A Bukusi
- Kenya Medical Research Institute, Centre for Microbiology Research, Box 19464, Post Code 00202, Nairobi, Kenya.
| | - Edwin D Charlebois
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th Street, 3rd Floor, UCSF Mail Code 0886, San Francisco, CA 94158, USA.
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Wang KH, Hendrickson ZM, Brandt CA, Nunez-Smith M. The relationship between non-permanent migration and non-communicable chronic disease outcomes for cancer, heart disease and diabetes - a systematic review. BMC Public Health 2019; 19:405. [PMID: 30987618 PMCID: PMC6466700 DOI: 10.1186/s12889-019-6646-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 03/11/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The relationship between migration and health has primarily focused on permanent migrants, although non-permanent migrants comprise a large proportion of global migrants. Non-permanent migrants may have distinct needs that affect their health outcomes. This systematic review 1) examined the evidence concerning whether non-permanent migrants have different health outcomes than other population groups for non-communicable chronic diseases (NCDs) and 2) sought to describe how non-permanent migration is defined and measured. METHODS For this systematic review, we developed a comprehensive search string for terms about non-permanent migration and disease and screening rates for three NCDs (cancer, heart disease, and diabetes) and searched thirteen electronic databases using the search string. Authors reviewed and evaluated articles for full-text review; hand-searched specific journals and grey literature; and scanned reference lists of relevant studies. Authors extracted and assessed data based on standard reporting for epidemiologic studies. RESULTS We identified twelve peer-reviewed articles that examined NCD outcomes for non-permanent migrants as compared to other populations. Some studies showed worse or no significant differences in the NCD outcomes for non-permanent migrants compared to other groups. The articles reflected substantial diversity that exists among non-permanent migrants, which ranged from economic migrants to nomadic populations. CONCLUSION Non-permanent migrants varied in their NCD outcomes as compared to other groups. Our included studies were heterogenous in their study designs and their definitions and measurement of non-permanent migration, which limited the ability to make conclusive statements about the health of the populations as compared to other populations. More standardization is needed in research to better understand the diversity in these populations and quantify differences in risk factors and disease rates between non-permanent migrants and other groups.
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Affiliation(s)
- Karen H Wang
- Section of General Internal Medicine, Yale School of Medicine, PO Box 208093, New Haven, CT, 06520, USA.
- Equity Research and Innovation Center, Yale School of Medicine, PO Box 208093, New Haven, CT, 06520, USA.
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA.
- Center for Medical Informatics, Yale School of Medicine, New Haven, CT, USA.
| | - Zoé M Hendrickson
- Health, Behavior and Society Department, John Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Cynthia A Brandt
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Center for Medical Informatics, Yale School of Medicine, New Haven, CT, USA
| | - Marcella Nunez-Smith
- Section of General Internal Medicine, Yale School of Medicine, PO Box 208093, New Haven, CT, 06520, USA
- Equity Research and Innovation Center, Yale School of Medicine, PO Box 208093, New Haven, CT, 06520, USA
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Davey C, Dirawo J, Mushati P, Magutshwa S, Hargreaves JR, Cowan FM. Mobility and sex work: why, where, when? A typology of female-sex-worker mobility in Zimbabwe. Soc Sci Med 2018; 220:322-330. [PMID: 30500610 DOI: 10.1016/j.socscimed.2018.11.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 11/15/2018] [Indexed: 11/17/2022]
Abstract
Sex-worker mobility may have implications for health and access to care but has not been described in sub-Saharan Africa. We described sex-worker mobility in Zimbabwe and a mobility typology using data from 2591 and 2839 female sex workers in 14 sites from 2013 and 2016. We used latent class analysis to identify a typology of mobile sex workers. More women travelled for work in 2016 (59%) than in 2013 (27%), usually to find clients with more money (57% of the journeys), spending a median of 21 (2013) and 24 (2016) days away. A five-class mixture model best fitted the data, with 39% women in an infrequent work-mobility class, 21% in a domestic-high-mobility class, 16% in an international-high-mobility class, 16% in an infrequent opportunistic-non-work-mobility class, and 7% who travel with clients. More-mobile classes were better educated; risk behaviours differed by class. Mobility is increasing among sex worker in Zimbabwe, multi-faceted, and not explained by other vulnerabilities.
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Affiliation(s)
- Calum Davey
- London School of Hygiene and Tropical Medicine, 15 Tavistock Place, London, WC1H 9SH, UK.
| | - Jeffrey Dirawo
- Centre for Sexual Health and HIV/AIDS Research, 9 Monmouth Rd, Avondale West, Harare, Zimbabwe
| | - Phillis Mushati
- Centre for Sexual Health and HIV/AIDS Research, 9 Monmouth Rd, Avondale West, Harare, Zimbabwe
| | - Sitholubuhle Magutshwa
- Centre for Sexual Health and HIV/AIDS Research, 9 Monmouth Rd, Avondale West, Harare, Zimbabwe
| | - James R Hargreaves
- London School of Hygiene and Tropical Medicine, 15 Tavistock Place, London, WC1H 9SH, UK
| | - Frances M Cowan
- Centre for Sexual Health and HIV/AIDS Research, 9 Monmouth Rd, Avondale West, Harare, Zimbabwe; Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
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Wolf HT, Chelliah SS, Ong'wen P, Tepper V, Kwena ZA, Cohen CR. Forming a Kanyakla: A qualitative study to develop a novel social support intervention for adolescents living with HIV. J Adolesc 2018; 69:203-211. [PMID: 30391687 DOI: 10.1016/j.adolescence.2018.10.006] [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: 01/11/2018] [Revised: 09/03/2018] [Accepted: 10/13/2018] [Indexed: 11/28/2022]
Abstract
INTRODUCTION HIV is a leading cause of morbidity and mortality among youth in sub Saharan Africa. This study explores the adaptation of an adult social network intervention for adolescents, entitled Kanyakla. METHODS The study was conducted in Kisumu, Kenya from July to November 2016. Data was collected from: (1) semi-structured interviews (n = 32) with adolescents living with HIV aged 15-19; and (2) two focus group discussions (n = 21). Transcripts were coded using thematic analysis through the lens of an Adolescent Development Model. RESULTS Participants were interested in joining a Kanyakla to build social support, learn new skills, and partake in recreational activities. Many participants feared inadvertent disclosure related to stigma. Certain dichotomous themes emerged including the need for privacy versus the need for social support; and the desire for inclusion of elders versus preference for same-aged peers in the Kanyaklas. CONCLUSIONS With this study, we have key information that can be applied to developing the Kanyakla intervention for adolescents. Further study is needed to reconcile the dichotomies that emerged.
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Affiliation(s)
- Hilary T Wolf
- Department of Pediatrics, Georgetown University School of Medicine, Washington, DC, USA.
| | - Shantha S Chelliah
- Department of Pediatrics, Division of Pediatric Hospitalist Medicine, Mattel Children's Hospital UCLA, Los Angeles, CA, USA
| | - Patricia Ong'wen
- KEMRI⌐RCTP, Kenya Medical Research Institute, Nairobi, Nairobi County, Kenya
| | - Vicki Tepper
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Zachary A Kwena
- KEMRI⌐RCTP, Kenya Medical Research Institute, Nairobi, Nairobi County, Kenya
| | - Craig R Cohen
- Department of Obstetrics, Gynecology & Reproductive Sciences, UCSF, San Francisco, CA, USA
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Masebo W. Accessing ART in Malawi while living in South Africa - a thematic analysis of qualitative data from undocumented Malawian migrants. Glob Public Health 2018; 14:621-635. [PMID: 30235977 DOI: 10.1080/17441692.2018.1524920] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The majority of international migrants from Malawi to South Africa are undocumented, and some of them are on ART. This study explored how these migrants manage to access ART. Qualitative data were collected using open-ended questions in semi-structured interviews. 23 returned undocumented Malawian migrants from South Africa participated in the study. Also, key informant discussions were held with three health workers. Data collection took place in April and May 2015 at a rural village of Namwera in Mangochi district in southern Malawi. Interviews were audio-recorded, transcribed and translated into English for thematic analysis. The guardians collected ART from health facilities in Malawi on behalf of the migrants. The guardians sent ART through truck and bus drivers to the migrants in South Africa. The migrants shared their ART. Others bought ART from the 'street pharmacies'. Others accessed ART from South African health facilities through the help of their South African friends. There are risks to dispensing ART to the migrants who do not themselves present at health facilities. There is value to more regular contacts between clients and health service system that is compromised by alternative strategies. It is better to deliver ART services in South Africa to the undocumented migrants.
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Affiliation(s)
- Wilfred Masebo
- a Health Economics and HIV and AIDS Research Division , University of KwaZulu-Natal , Durban , South Africa
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Phillips TK, Clouse K, Zerbe A, Orrell C, Abrams EJ, Myer L. Linkage to care, mobility and retention of HIV-positive postpartum women in antiretroviral therapy services in South Africa. J Int AIDS Soc 2018; 21 Suppl 4:e25114. [PMID: 30027583 PMCID: PMC6053482 DOI: 10.1002/jia2.25114] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 05/08/2018] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Linkage to care and mobility postpartum present challenges to long-term retention after initiating antiretroviral therapy (ART) in pregnancy, but there are few insights from sub-Saharan Africa. We aimed to describe postpartum linkage to care, mobility, retention and viral suppression after ART initiation in pregnancy. METHODS Using routine electronic data we assessed HIV-specific health contacts and clinic movements among women initiating ART in an integrated antenatal care (ANC) and ART clinic in Cape Town, South Africa. The local care model includes mandatory transfer to general ART clinics postpartum. We investigated linkage to care after leaving the integrated clinic and mobility to new clinics until 30 months on ART. We used Poisson regression to explore predictors of linkage, retention (accessing care at least once at both 12 [6 to <18] and 24 [18 to <30] months on ART), and viral suppression (HIV viral load [VL] ≤50 and ≤1000 copies/mL after 12 months on ART). RESULTS Among 617 women, 23% never linked to care; 71% and 65% were retained at 12 and 24 months on ART respectively, with 59% retained in care at both times. Those who linked (n = 485) accessed HIV care at 98 different clinics and 21% attended ≥2 clinics. Women >25 years, married/cohabiting or presenting early for ANC were more likely to link. Younger and unemployed women were more likely to attend ≥2 clinics (adjusted risk ratio [aRR] 1.10 95% confidence interval [CI] 1.02 to 1.18 and aRR 1.06 95% CI 0.99 to 1.12 respectively). Age >25 years (aRR 1.17 95% CI 1.02 to 1.33) and planned pregnancy (aRR 1.20 95% CI 1.09 to 1.33) were associated with being retained. Among 338 retained women with VL available, attending ≥2 clinics reduced the likelihood of viral suppression when defined as ≤50 copies/mL (aRR 0.81 95% CI 0.69 to 0.95). Distance moved was not associated with VL. CONCLUSIONS These data show that a substantial proportion of women do not link to postpartum ART care in this setting and, among those that do, long-term retention remains a challenge. Women move to a variety of clinics and young women appear particularly vulnerable to attrition. Interventions promoting linkage and continued retention for women initiating ART during pregnancy warrant urgent consideration.
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Affiliation(s)
- Tamsin K Phillips
- Division of Epidemiology & BiostatisticsCentre for Infectious Disease Epidemiology & ResearchSchool of Public Health & Family MedicineUniversity of Cape TownCape TownSouth Africa
- The South African Department of Science and Technology/National Research Foundation (DST‐NRF)Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA)Stellenbosch UniversityStellenboschSouth Africa
| | - Kate Clouse
- Vanderbilt Institute for Global HealthVanderbilt UniversityNashvilleTNUSA
- Department of MedicineDivision of Infectious DiseasesVanderbilt UniversityNashvilleTNUSA
| | - Allison Zerbe
- ICAPColumbia UniversityMailman School of Public HealthNew YorkNYUSA
| | - Catherine Orrell
- Desmond Tutu HIV CentreInstitute of Infectious Disease and Molecular Medicine and Department of MedicineUniversity of Cape TownCape TownSouth Africa
| | - Elaine J Abrams
- ICAPColumbia UniversityMailman School of Public HealthNew YorkNYUSA
- College of Physicians & SurgeonsColumbia UniversityNew YorkNYUSA
| | - Landon Myer
- Division of Epidemiology & BiostatisticsCentre for Infectious Disease Epidemiology & ResearchSchool of Public Health & Family MedicineUniversity of Cape TownCape TownSouth Africa
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Bond V, Ngwenya F, Thomas A, Simuyaba M, Hoddinott G, Fidler S, Hayes R, Ayles H, Seeley J. Spinning plates: livelihood mobility, household responsibility and anti-retroviral treatment in an urban Zambian community during the HPTN 071 (PopART) study. J Int AIDS Soc 2018; 21 Suppl 4:e25117. [PMID: 30027643 PMCID: PMC6053474 DOI: 10.1002/jia2.25117] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 05/09/2018] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Qualitative data are lacking on the impact of mobility among people living with HIV (PLHIV) and their decision-making around anti-retroviral treatment (ART). We describe challenges of juggling household responsibility, livelihood mobility and HIV management for six PLHIV in urban Zambia. METHODS Six PLHIV (three men and three women, aged 21 to 44) were recruited from different geographic zones in one urban community drawn from a qualitative cohort in a social science component of a cluster-randomized trial (HPTN071 PopART). Participants were on ART (n = 2), not on ART (n = 2) and had started and stopped ART (n = 2). At least two in-depth interviews and participant observations, and three drop-in household visits with each were carried out between February and August 2017. Themed and comparative analysis was conducted. RESULTS The six participants relied on the informal economy to meet basic household needs. Routine livelihood mobility, either within the community and to a nearby town centre, or further afield for longer periods of time, was essential to get by. Although aware of ART benefits, only one of the six participants managed to successfully access and sustain treatment. The other five struggled to find time to access ART alongside other priorities, routine mobility and when daily routines were more chaotic. Difficulty in accessing ART was exacerbated by local health facility factors (congestion, a culture of reprimanding PLHIV who miss appointments, sporadic rationed drug supply), stigma and more limited social capital. CONCLUSIONS Using a time-space framework illustrated how household responsibility, livelihood mobility and HIV management every day were like spinning plates, each liable to topple and demanding constant attention. If universal lifelong ART is to be delivered, the current service model needs to adjust the limited time that some PLHIV have to access ART because of household responsibilities and the need to earn a living moving around, often away from home. Practical strategies that could facilitate ART access in the context of livelihood mobility include challenging the practice of reprimand, improving drug supply, having ART services more widely distributed, mapped and available at night and weekends, and an effective centralized client health information system.
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Affiliation(s)
- Virginia Bond
- Zambart, School of MedicineUniversity of ZambiaLusakaZambia
- Department of Global Health and DevelopmentFaculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
| | | | - Angelique Thomas
- Desmond Tutu TB CentreStellenbosch UniversityTygerbergSouth Africa
| | | | - Graeme Hoddinott
- Desmond Tutu TB CentreStellenbosch UniversityTygerbergSouth Africa
| | - Sarah Fidler
- Department of MedicineImperial College LondonSt Mary's CampusLondonUK
| | - Richard Hayes
- Department of Infectious Disease EpidemiologyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Helen Ayles
- Zambart, School of MedicineUniversity of ZambiaLusakaZambia
- Department of Clinical ResearchLondon School of Hygiene and Tropical MedicineLondonUK
| | - Janet Seeley
- Department of Global Health and DevelopmentFaculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
- MRC/UVRI Uganda Research Unit on AIDSEntebbeUganda
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Hoddinott G, Myburgh H, de Villiers L, Ndubani R, Mantantana J, Thomas A, Mbewe M, Ayles H, Bock P, Seeley J, Shanaube K, Hargreaves J, Bond V, Reynolds L. Households, fluidity, and HIV service delivery in Zambia and South Africa - an exploratory analysis of longitudinal qualitative data from the HPTN 071 (PopART) trial. J Int AIDS Soc 2018; 21 Suppl 4:e25135. [PMID: 30027687 PMCID: PMC6053477 DOI: 10.1002/jia2.25135] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 05/22/2018] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Population distributions, family and household compositions, and people's sense of belonging and social stability in southern Africa have been shaped by tumultuous, continuing large-scale historical disruptions. As a result, many people experience high levels of geographic and social fluidity, which intersect with individual and population-level migration patterns. We describe the complexities of household fluidity and HIV service access in South Africa and Zambia to explore implications for health systems and service delivery in contexts of high household fluidity. METHODS HPTN 071 (PopART) is a three-arm cluster randomized controlled trial implemented in 21 peri-urban study communities in Zambia and South Africa between 2013 and 2018. A qualitative cohort nested in the trial included 148 purposively sampled households. Data collection was informed by ethnographic and participatory research principles. The analysis process was reflexive and findings are descriptive narrative summaries of emergent ideas. RESULTS Households in southern Africa are extremely fluid, with people having a tenuous sense of security in their social networks. This fluidity intersects with high individual and population mobility. To characterize fluidity, we describe thematic patterns of household membership and residence. We also identify reasons people give for moving around and shifting social ties, including economic survival, fostering interpersonal relationships, participating in cultural, traditional, religious, or familial gatherings, being institutionalized, and maintaining patterns of substance use. High fluidity disrupted HIV service access for some participants. Despite these challenges, many participants were able to regularly access HIV testing services and participants living with HIV were especially resourceful in maintaining continuity of antiretroviral therapy (ART). We identify three key features of health service interactions that facilitated care continuity: disclosure to family members, understanding attitudes among health services staff including flexibility to accommodate clients' transient pressures, and participants' agency in ART-related decisions. CONCLUSIONS Choices made to manage one's experiential sense of household fluidity are intentional responses to livelihood and social support constraints. To enhance retention in care for people living with HIV, policy makers and service providers should focus on creating responsive, flexible health service delivery systems designed to accommodate many shifts in client circumstances.
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Affiliation(s)
- Graeme Hoddinott
- Department of Paediatrics and Child HealthFaculty of MedicineDesmond Tutu TB CentreStellenbosch UniversityStellenboschSouth Africa
| | - Hanlie Myburgh
- Department of Paediatrics and Child HealthFaculty of MedicineDesmond Tutu TB CentreStellenbosch UniversityStellenboschSouth Africa
| | - Laing de Villiers
- Department of Paediatrics and Child HealthFaculty of MedicineDesmond Tutu TB CentreStellenbosch UniversityStellenboschSouth Africa
| | | | - Jabulile Mantantana
- Department of Paediatrics and Child HealthFaculty of MedicineDesmond Tutu TB CentreStellenbosch UniversityStellenboschSouth Africa
| | - Angelique Thomas
- Department of Paediatrics and Child HealthFaculty of MedicineDesmond Tutu TB CentreStellenbosch UniversityStellenboschSouth Africa
| | | | - Helen Ayles
- Zambart, School of MedicineLusakaZambia
- Department of Clinical ResearchLondon School of Hygiene and Tropical MedicineLondonUK
| | - Peter Bock
- Department of Paediatrics and Child HealthFaculty of MedicineDesmond Tutu TB CentreStellenbosch UniversityStellenboschSouth Africa
| | - Janet Seeley
- Department of Global Health and DevelopmentFaculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
| | | | - James Hargreaves
- Department of Social and Environmental Health ResearchCentre for EvaluationLondon School of Hygiene and Tropical MedicineLondonUK
| | - Virginia Bond
- Zambart, School of MedicineLusakaZambia
- Department of Global Health and DevelopmentFaculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Lindsey Reynolds
- Department of Sociology and Social AnthropologyFaculty of Arts and Social SciencesStellenbosch UniversityStellenboschSouth Africa
- Population Studies and Training CenterBrown UniversityProvidenceRIUSA
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Camlin CS, Cassels S, Seeley J. Bringing population mobility into focus to achieve HIV prevention goals. J Int AIDS Soc 2018; 21 Suppl 4:e25136. [PMID: 30027588 PMCID: PMC6053544 DOI: 10.1002/jia2.25136] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 05/22/2018] [Indexed: 11/08/2022] Open
Affiliation(s)
- Carol S Camlin
- Department of Obstetrics, Gynecology and Reproductive SciencesDepartment of MedicineUniversity of CaliforniaSan FranciscoUSA
| | - Susan Cassels
- Department of GeographyUniversity of CaliforniaSanta BarbaraUSA
| | - Janet Seeley
- Department of Global Health and DevelopmentLondon School of Hygiene and Tropical MedicineLondonUK
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Davey C, Cowan F, Hargreaves J. The effect of mobility on HIV-related healthcare access and use for female sex workers: A systematic review. Soc Sci Med 2018; 211:261-273. [PMID: 29966821 DOI: 10.1016/j.socscimed.2018.06.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 05/09/2018] [Accepted: 06/19/2018] [Indexed: 11/28/2022]
Abstract
Female sex workers (FSW) experience a high HIV burden and are often mobile. FSW access to HIV-related healthcare is essential for equitable welfare and to reduce new HIV infections. We systematically reviewed the literature on mobility and HIV-related healthcare access and use among FSW. Outcome measures included: HIV/STI testing, STI treatment, PrEP (initiation or adherence), and ART (initiation or adherence). We summarised the results with a narrative synthesis. From 7417 non-duplicated citations, nine studies from Canada (3), Guatamala, Honduras (2), India, South Africa, and Vietnam were included. Only one of the studies was designed to address mobility and healthcare access, and only six reported adjusted effect estimates. Mobility was measured over four time-frames (from 'current' to 'ever'), as having lived or worked elsewhere or in another town/province/country. Three studies from Canada, Guatemala, and India found mobility associated with increased odds of poor initial access to healthcare (adjusted odds ratios (AOR) from 1.33, 95% CI 1.02, 1.75, to 2.27, 95% CI 1.09, 4.76), and one from Vietnam found no association (odds ratio (OR): 0.92, 95% CI 0.65, 1.28). The study from South Africa found no association with initiating ART (risk ratio: 0.86, 95% CI 0.65, 1.14). Two studies from Canada and Honduras found increased odds of ART interruption (AOR 2.74, 95% CI 0.89, 8.42; 5.19, 95% CI 1.38, 19.56), while two other studies from Canada and Honduras found no association with detectable viral load (OR 0.84, 95% CI 0.08, 8.33; AOR 0.79, 95% CI 0.41, 1.69). We found that mobility is associated with reduced initial healthcare access and interruption of ART, consistent with literature from the general population. Discordance between effects on adherence and viral load may be due to measurement of mobility. Future research should carefully construct measures of mobility and consider a range of HIV-related healthcare outcomes.
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Affiliation(s)
- Calum Davey
- London School of Hygiene and Tropical Medicine, London, UK.
| | - Frances Cowan
- Liverpool School of Tropical Medicine, Liverpool, UK.
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Mullens AB, Kelly J, Debattista J, Phillips TM, Gu Z, Siggins F. Exploring HIV risks, testing and prevention among sub-Saharan African community members in Australia. Int J Equity Health 2018; 17:62. [PMID: 29784050 PMCID: PMC5963033 DOI: 10.1186/s12939-018-0772-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 05/03/2018] [Indexed: 12/20/2022] Open
Abstract
Background Significant health disparities persist regarding new and late Human Immunodeficiency Virus (HIV) diagnoses among sub-Saharan African (SSA) communities in Australia. Personal/cultural beliefs and practices influence HIV (risk, prevention, testing) within Australia and during visits to home countries. Method A community forum was conducted involving 23 male and female adult African community workers, members and leaders, and health workers; facilitated by cultural workers and an experienced clinician/researcher. The forum comprised small/large group discussions regarding HIV risk/prevention (responses transcribed verbatim; utilising thematic analysis). Results Stigma, denial, social norms, tradition and culture permeated perceptions/beliefs regarding HIV testing, prevention and transmission among African Australians, particularly regarding return travel to home countries. Conclusions International travel as a risk factor for HIV acquisition requires further examination, as does the role of the doctor in HIV testing and Pre-exposure Prophylaxis (PrEP). Further assessment of PrEP as an appropriate/feasible intervention is needed, with careful attention regarding negative community perceptions and potential impacts.
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Affiliation(s)
- Amy B Mullens
- School of Psychology and Counselling, Institute for Resilient Regions, University of Southern Queensland, Ipswich Campus, 11 Salisbury Road, Ipswich, Qld 4305, Australia.
| | - Jennifer Kelly
- School of Health and Wellbeing, University of Southern Queensland, Ipswich Campus, 11 Salisbury Road, Ipswich, Qld 4305, Australia
| | - Joseph Debattista
- Queensland Health, Metro North Public Health Unit, Bryden Street, Windsor, Qld 4030, Australia
| | - Tania M Phillips
- School of Psychology and Counselling, Institute for Resilient Regions, University of Southern Queensland, Ipswich Campus, 11 Salisbury Road, Ipswich, Qld 4305, Australia
| | - Zhihong Gu
- Ethnic Communities Council of Queensland, PO Box 5916, West End, Qld 4101, Australia
| | - Fungisai Siggins
- Kalpa purru Wirranjarlki, Anyinginyi Health Aboriginal Corporation, 1 Irvine Street, PO Box 40, Tennant Creek, NT, 0861, Australia
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Norris AH, Loewenberg Weisband Y, Wiles M, Ickovics JR. Prevalence of sexually transmitted infections among Tanzanian migrants: a cross-sectional study. Int J STD AIDS 2017; 28:991-1000. [PMID: 28134004 DOI: 10.1177/0956462416685486] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
For the many millions of migrants, mobility creates vulnerabilities and elevates risk for sexually transmitted infections (STIs). We document, among Tanzanian agricultural plantation residents, migrant characteristics and test associations between migrant status and prevalent STI (HSV-2, syphilis, and HIV). From 623 plantation resident participants, we limit this analysis to participants about whom we know migration status (migrants n = 242, non-migrants n = 291). We collected behavioral data via audio-computer assisted self-interview survey, and clinical data via STI testing. We used multivariate Poisson regression models, stratified by gender and controlling for behavioral risk factors, to measure associations between migrant status and STI. In men, HIV prevalence was 9% for migrants, and 6% for non-migrants. HSV-2 prevalence was 57% for migrants, and 32% for non-migrants. Syphilis prevalence was 12% for migrants, and 3% for non-migrants. Among women, there were few differences in STI prevalence by migrant status: prevalence of HIV was 6% vs. 5% (migrants vs. non-migrants); HSV-2 prevalence was 68% vs. 65%; and syphilis prevalence was 11% vs. 8%. Being a male migrant was significantly associated with increased prevalence of any STI after controlling for sociodemographic and behavioral characteristics (APR = 1.53, 95% CI 1.23-5.25). Migrant women did not have increased prevalence of STI as compared to non-migrant women (APR = 1.03, 95% CI 0.85-1.24). Amongst Tanzanian agricultural workers, male migrants experienced elevated risk for prevalent STI as compared to male non-migrants. We suggest structural interventions to reduce risks associated with migration, especially in male migrants, including workplace-based STI prevention programs, and connecting migrants to resources and support within new communities. The key messages are: migrant men experience significantly elevated risk for prevalent STI, above and beyond sociodemographic and behavioral risk factors, as compared to their non-migrant peers; women in this Tanzanian agricultural plantation community overall had higher prevalence of some STIs than men, migrant women had similar STI risk as non-migrant women; and migration for work, an economic strategy for millions, also creates vulnerabilities, so workplace-based STI prevention programs and connecting migrants to community resources are essential.
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Affiliation(s)
- Alison H Norris
- 1 Division of Epidemiology, College of Public Health, Ohio State University, Columbus, OH, USA
| | | | - Melissa Wiles
- 1 Division of Epidemiology, College of Public Health, Ohio State University, Columbus, OH, USA
| | - Jeannette R Ickovics
- 2 Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, USA
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Inzaule SC, Hamers RL, Kityo C, Rinke de Wit TF, Roura M. Long-Term Antiretroviral Treatment Adherence in HIV-Infected Adolescents and Adults in Uganda: A Qualitative Study. PLoS One 2016; 11:e0167492. [PMID: 27898736 PMCID: PMC5127654 DOI: 10.1371/journal.pone.0167492] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 11/15/2016] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Long-term success of HIV antiretroviral therapy requires near-perfect adherence, maintained throughout one's lifetime. However, perceptions towards ART and patterns of adherence may change during the life course. We assessed challenges to long-term adherence in adolescents and adults in three regional HIV treatment centers in Uganda. METHODS We conducted 24 in-depth interviews and 2 focus group discussions with a total of 33 health-care providers and expert clients (HIV patients on long-term ART who assist with adherence support of fellow patients). Interview topics included experiences with patients on long-term treatment with either declining adherence or persistent poor adherence. Transcribed texts were coded and analyzed based on the social-ecological framework highlighting differences and commonalities between adolescents and adults. RESULTS The overarching themes in adolescents were unstructured treatment holidays, delays in disclosure of HIV status by caretakers, stigma, which was mainly experienced in boarding schools, and diminishing or lack of clinical support. In particular, there was minimal support for early and gradual disclosure for caretakers to the infected children, diminishing clinical support for young adults during transition to adult-based care and declining peer-to-peer support group activities. The predominating theme in adults was challenges with treatment access among temporary economic migrants. Common themes to adults and adolescents were challenges with disclosure in intimate relationships, treatment related factors including side effects, supply of single tablets in place of fixed-dose combined drugs, supply of drug brands with unfavorable taste and missed opportunities for counseling due to shortage of staff. CONCLUSION Adherence counseling and support should be adapted differently for adolescents and adults and to the emerging life course challenges in long-term treated patients. Programs should also address constraints experienced by temporary economic migrants to ensure continuity of treatment within the host country.
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Affiliation(s)
- Seth C. Inzaule
- Dept of Global Health, Academic Medical Center of the University of Amsterdam, and Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
| | - Raph L. Hamers
- Dept of Global Health, Academic Medical Center of the University of Amsterdam, and Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
- Dept of Internal Medicine, Div. of Infectious Diseases, Academic Medical Center of the University of Amsterdam, Amsterdam, the Netherlands
| | - Cissy Kityo
- Joint Clinical Research Centre, Kampala, Uganda
| | - Tobias F. Rinke de Wit
- Dept of Global Health, Academic Medical Center of the University of Amsterdam, and Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
| | - Maria Roura
- ISGlobal, Barcelona Centre for International Health Research (CRESIB) Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
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Wang KH, Goulet JL, Carroll CM, Skanderson M, Fodeh S, Erdos J, Womack JA, Abel EA, Bathulapalli H, Justice AC, Nunez-Smith M, Brandt CA. Estimating healthcare mobility in the Veterans Affairs Healthcare System. BMC Health Serv Res 2016; 16:609. [PMID: 27769221 PMCID: PMC5075153 DOI: 10.1186/s12913-016-1841-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 10/11/2016] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Healthcare mobility, defined as healthcare utilization in more than one distinct healthcare system, may have detrimental effects on outcomes of care. We characterized healthcare mobility and associated characteristics among a national sample of Veterans. METHODS Using the Veterans Health Administration Electronic Health Record, we conducted a retrospective cohort study to quantify healthcare mobility within a four year period. We examined the association between sociodemographic and clinical characteristics and healthcare mobility, and characterized possible temporal and geographic patterns of healthcare mobility. RESULTS Approximately nine percent of the sample were healthcare mobile. Younger Veterans, divorced or separated Veterans, and those with hepatitis C virus and psychiatric disorders were more likely to be healthcare mobile. We demonstrated two possible patterns of healthcare mobility, related to specialty care and lifestyle, in which Veterans repeatedly utilized two different healthcare systems. CONCLUSIONS Healthcare mobility is associated with young age, marital status changes, and also diseases requiring intensive management. This type of mobility may affect disease prevention and management and has implications for healthcare systems that seek to improve population health.
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Affiliation(s)
- Karen H. Wang
- Veterans Affairs Connecticut Healthcare System, West Haven, CT USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT USA
- Yale School of Medicine, Equity Research and Innovation Center, New Haven, CT USA
| | - Joseph L. Goulet
- Veterans Affairs Connecticut Healthcare System, West Haven, CT USA
- Department of Psychiatry, Yale School of Medicine, New Haven, CT USA
| | | | | | - Samah Fodeh
- Veterans Affairs Connecticut Healthcare System, West Haven, CT USA
| | - Joseph Erdos
- Veterans Affairs Connecticut Healthcare System, West Haven, CT USA
- Yale School of Medicine, Center for Medical Informatics, New Haven, CT USA
| | - Julie A. Womack
- Veterans Affairs Connecticut Healthcare System, West Haven, CT USA
- Yale School of Nursing, West Haven, CT USA
| | - Erica A. Abel
- Veterans Affairs Connecticut Healthcare System, West Haven, CT USA
- Department of Psychiatry, Yale School of Medicine, New Haven, CT USA
| | | | - Amy C. Justice
- Veterans Affairs Connecticut Healthcare System, West Haven, CT USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT USA
| | - Marcella Nunez-Smith
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT USA
- Yale School of Medicine, Equity Research and Innovation Center, New Haven, CT USA
| | - Cynthia A. Brandt
- Veterans Affairs Connecticut Healthcare System, West Haven, CT USA
- Yale School of Medicine, Center for Medical Informatics, New Haven, CT USA
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Lippman SA, Shade SB, El Ayadi AM, Gilvydis JM, Grignon JS, Liegler T, Morris J, Naidoo E, Prach LM, Puren A, Barnhart S. Attrition and Opportunities Along the HIV Care Continuum: Findings From a Population-Based Sample, North West Province, South Africa. J Acquir Immune Defic Syndr 2016; 73:91-9. [PMID: 27082505 PMCID: PMC4981507 DOI: 10.1097/qai.0000000000001026] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Attrition along the HIV care continuum slows gains in mitigating the South African HIV epidemic. Understanding population-level gaps in HIV identification, linkage, retention in care, and viral suppression is critical to target programming. METHODS We conducted a population-based household survey, HIV rapid testing, point-of-care CD4 testing, and viral load measurement from dried blood spots using multistage cluster sampling in 2 subdistricts of North West Province from January to March, 2014. We used weighting and multiple imputation of missing data to estimate HIV prevalence, undiagnosed infection, linkage and retention in care, medication adherence, and viral suppression. RESULTS We sampled 1044 respondents aged 18-49. HIV prevalence was 20.0% (95% confidence interval: 13.7 to 26.2) for men and 26.7% (95% confidence interval: 22.1 to 31.4) for women. Among those HIV positive, 48.4% of men and 75.7% of women were aware of their serostatus; 44.0% of men and 74.8% of women reported ever linking to HIV care; 33.1% of men and 58.4% of women were retained in care; and 21.6% of men and 50.0% of women had dried blood spots viral loads <5000 copies per milliliter. Among those already linked to care, 81.7% on antiretroviral treatment (ART) and 56.0% of those not on ART were retained in care, and 51.8% currently retained in care on ART had viral loads <5000 copies per milliliter. CONCLUSIONS Despite expanded treatment in South Africa, attrition along the continuum of HIV care is slowing prevention progress. Improved detection is critically needed, particularly among men. Reported linkage and retention is reasonable for those on ART; however, failure to achieve viral suppression is worrisome.
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Affiliation(s)
- Sheri A. Lippman
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, USA
| | - Starley B. Shade
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, USA
| | - Alison M. El Ayadi
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, USA
| | | | - Jessica S. Grignon
- Department of Global Health, University of Washington, Seattle, USA
- International Training and Education Center for Health (I-TECH) South Africa, Pretoria, Republic of South Africa
| | - Teri Liegler
- Department of Medicine, University of California, San Francisco, USA
| | - Jessica Morris
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, USA
| | - Evasen Naidoo
- International Training and Education Center for Health (I-TECH) South Africa, Pretoria, Republic of South Africa
| | - Lisa M. Prach
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, USA
| | - Adrian Puren
- National Institute for Communicable Diseases/NHLS, Johannesburg, South Africa
| | - Scott Barnhart
- Department of Global Health, University of Washington, Seattle, USA
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Factors Associated with Retention to Care in an HIV Clinic in Gabon, Central Africa. PLoS One 2015; 10:e0140746. [PMID: 26473965 PMCID: PMC4608719 DOI: 10.1371/journal.pone.0140746] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Accepted: 09/30/2015] [Indexed: 01/30/2023] Open
Abstract
Background Retention to HIV care is vital for patients’ survival, to prevent onward transmission and emergence of drug resistance. Travelling to receive care might influence adherence. Data on the functioning of and retention to HIV care in the Central African region are limited. Methods This retrospective study reports outcomes and factors associated with retention to HIV care at a primary HIV clinic in Lambaréné, Gabon. Adult patients who presented to this clinic between January 2010 and January 2012 were included. Outcomes were retention in care (defined as documented show-up for clinical visits, regardless of delay) or LTFU (defined as a patient not retained in care; on ART or ART naïve, not returning to care during the study period with a patient delay for scheduled visits of more than 6 months), and mortality. Cox regression analysis was used to assess factors associated with respective outcomes. Qualitative data on reasons for LTFU were obtained from focus-group discussions. Results Of 223 patients included, 67.3% were female. The mean age was 40.5 (standard deviation 11.4) years and the median CD4 count 275 (interquartile range 100.5–449.5) cells/μL. In total, 34.1% were lost to follow up and 8.1% died. Documented tuberculosis was associated with increased risk of being LTFU (adjusted hazard ratio (aHR) 1.80, 95% confidence interval (95% CI) 1.05–3.11, P = 0.03), whereas early starting anti-retroviral therapy (ART) was associated with a decreased risk of LTFU (aHR 0.43, 95%CI 0.24–0.76, P = 0.004), as was confirmed by qualitative data. Conclusions Retention to HIV care in a primary clinic in Gabon is relatively poor and interventions to address this should be prioritized in the HIV program. Early initiation of ART might improve retention in care.
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Lima VD, Goldberg N, Lourenço L, Chau W, Hogg RS, Guillemi S, Barrios R, Montaner JSG. Virologic suppression and mortality of patients who migrate for HIV care in the province of British Columbia, Canada, from 2003 to 2012: a retrospective cohort study. BMC Health Serv Res 2015; 15:376. [PMID: 26369664 PMCID: PMC4570764 DOI: 10.1186/s12913-015-1042-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 09/04/2015] [Indexed: 01/27/2023] Open
Abstract
Background Migration among persons living with HIV (PLWH) seeking HIV care is common; however its effect on health outcomes in resource-rich settings is not well understood. We conducted a retrospective cohort study to quantify the extent to which PLWH are migrating for care within British Columbia (BC) and its association with virologic suppression and mortality. Methods Eligible PLWH first initiated treatment in BC between 2003 and 2012 (N = 3653). Analyses were performed at the regional Health Authority (HA) level (N = 5). For privacy reasons, we kept the name of these HAs anonymous and we re-named these five regions as 1 to 5. PLWH were classified according to the HA where they resided and received HIV care. We calculated all-cause mortality rates, life expectancies (at age of 20 years), and in, out and net migration rates across HAs using different demographic methods. Virologic suppression (<50 copies/mL) was based on the last viral load available for each PLWH. We also calculated per-capita rates (per 100 PLWH ever on cART) for each HA by dividing the number of PLWH by the number of physicians attending this population. Results There is considerable heterogeneity in physician availability across all HAs, with per-capita rates (per 100 PLWH ever on cART) ranging from 2.2 (HA 1) to 12.7 (HA 3) based on the HA PLWH received care. We observed that in HAs 1, 4, and 5, between 4 and 10 % of PLWH migrated to HA 3 (i.e. the largest urban center) to receive care, and for HA 2 this proportion increased to 21 %. In HA 3, 77 % of its PLWH residents remained in the same HA for their care. Migrating to a larger center for HIV care was not associated with higher rates of viral load suppression; it was significantly associated with lower mortality rates and higher life expectancies. Conclusions A thorough understanding of the reason(s) for these significant migration rates across BC will be critical to inform resource allocation and optimize the impact of HIV treatment.
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Affiliation(s)
- Viviane Dias Lima
- British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6. .,Division of AIDS, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada, V6Z 1Y6.
| | - Nicola Goldberg
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada, M5S 1A8.
| | - Lillian Lourenço
- British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6.
| | - William Chau
- British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6.
| | - Robert S Hogg
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada, V5A 1S6.
| | - Silvia Guillemi
- British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6.
| | - Rolando Barrios
- British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6.
| | - Julio S G Montaner
- British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6. .,Division of AIDS, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada, V6Z 1Y6.
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Bene M, Darkoh MBK. The constraints of antiretroviral uptake in rural areas: the case of Thamaga and surrounding villages, Botswana. SAHARA J 2015; 11:167-77. [PMID: 25365702 PMCID: PMC4272138 DOI: 10.1080/17290376.2014.972057] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
This article examines the constraints of antiretroviral (ARV) uptake in the villages of Thamaga, Kumakwane, Mankgodi and Gakgatla which are in the Kweneng District of Botswana. The social interactionist approach and theories of health behaviour provided the theoretical basis of the study. Data were obtained by using interviewer-administered questionnaires which were applied to a sample of 145 respondents and 61 people living with HIV/AIDS in the four villages. The results of the study showed that people aged 30–39 years represented the highest proportion of the persons on ARV treatment in the villages. Some of the people living with HIV believed that ARV therapy could better their lives during the initial stages of introduction, but with time, they lost hope and gave up the treatment. Culturally, parents and children in the villages do not discuss sexual matters at home and it was found in the study that there was little communication between parents and children on AIDS and ARV issues. Some churches in the area discouraged the use of ARV. There were also traditional doctors who made their patients mix traditional herbs treatment with ARV treatment. Distance, travel costs, cultural beliefs, stigma and discrimination among others were found to be important socio-economic factors inhibiting ARV uptake. Even though there were constraints on ARV uptake in the villages, efforts were being made by Government and non-governmental organizations to overcome them. The Ministry of Health provided information and education to the public using its strategy known as Information, Education and Communication. Nurses, doctors and chiefs taught people at kgotlas (traditional courts) in the villages about the dangers of the epidemic. Free HIV testing, ARVs and condoms were provided to the villagers. The outlook for ARV uptake looks generally promising for the future. However, if HIV/AIDS is to be contained, sexual behaviour of people in the villages needs to change.
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Affiliation(s)
- Matlhogonolo Bene
- a BA Environmental Science, MA Geography, is affiliated to the Department of Environmental Science , University of Botswana , Private Bag 708, Gaborone , Botswana
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The impact of transfer patients on the local cascade of HIV care continuum. J Acquir Immune Defic Syndr 2015; 68:236-40. [PMID: 25394193 DOI: 10.1097/qai.0000000000000430] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Cascade of Care (COC) visualizes stages of HIV care progression within a population. It is predicated on a local population model and thus may not address the impact on the COC of HIV-experienced individuals diagnosed and cared for elsewhere who move into the area. METHODS All individuals with a confirmed HIV+ test in Calgary, Canada, between January 1, 2006, and January 1, 2013 were included. Individuals were categorized as "local" if diagnosed within the area, or "transfer" if diagnosed elsewhere. Subgroups were separately placed within the COC and then aggregated. RESULTS Of 1019 new cases, 47% were transfers. Transfer patients were more likely female (35% vs. 23%; P < 0.01), non-white (61% vs. 46%; P < 0.001), heterosexual (56% vs. 38%; P < 0.001), and have higher CD4 counts (400 vs. 282/mm) with undetectable viremia in 57% [63% on antiretroviral therapy (ART)] at baseline. Engagement was higher at every stage for transfer patients: 94% of transfer vs. 92% of local patients linked to HIV care, 90% vs. 76% (P < 0.001) were retained, 86% vs. 67% (P < 0.001) received ART, and at study's end, 75% vs. 58% (P < 0.001) had undetectable viremia. When patients were aggregated, linkage increased by 1%, retention by 6%, patient use of ART by 8%, and patients with viral suppression by 7%. CONCLUSIONS The COC of local and transfer patients differs so significantly that both need to be considered separately in measuring COC, adding a previously under-recognized level of complexity. Use of aggregate COC without considering different levels of engagement could lead to imprecise information for public health initiatives and program metrics.
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Comparison of geographic methods to assess travel patterns of persons diagnosed with HIV in Philadelphia: how close is close enough? J Biomed Inform 2014; 53:93-9. [PMID: 25239262 DOI: 10.1016/j.jbi.2014.09.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Revised: 09/09/2014] [Accepted: 09/09/2014] [Indexed: 11/23/2022]
Abstract
Travel distance to medical care has been assessed using a variety of geographic methods. Network analyses are less common, but may generate more accurate estimates of travel costs. We compared straight-line distances and driving distance, as well as average drive time and travel time on a public transit network for 1789 persons diagnosed with HIV between 2010 and 2012 to identify differences overall, and by distinct geographic areas of Philadelphia. Paired t-tests were used to assess differences across methods, and analysis of variance was used to assess between-group differences. Driving distances were significantly longer than straight-line distances (p<0.001) and transit times were significantly longer than driving times (p<0.001). Persons living in the northeast section of the city traveled greater distances, and at greater cost of time and effort, than persons in all other areas of the city (p<0.001). Persons living in the northwest section of the city traveled farther and longer than all other areas except the northeast (p<0.0001). Network analyses that include public transit will likely produce a more realistic estimate of the travel costs, and may improve models to predict medical care outcomes.
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Camlin CS, Snow RC, Hosegood V. Gendered Patterns of Migration in Rural South Africa. POPULATION, SPACE AND PLACE 2014; 20:528-551. [PMID: 25332690 PMCID: PMC4201383 DOI: 10.1002/psp.1794] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Gender is increasingly recognized as fundamental to understanding migration processes, causes and consequences. In South Africa, it is intrinsic to the social transformations fueling high levels of internal migration and complex forms of mobility. While female migration in Africa has often been characterized as less prevalent than male migration, and primarily related to marriage, in South Africa a feminization of internal migration is underway, fueled by women's increasing labor market participation. In this paper, we report sex differences in patterns, trends and determinants of internal migration based on data collected in a demographic surveillance system between 2001 and 2006 in rural KwaZulu-Natal. We show that women were somewhat more likely than men to undertake any migration, but sex differences in migration trends differed by migration flow, with women more likely to migrate into the area than men, and men more likely to out-migrate. Out-migration was suppressed by marriage particularly for women, but most women were not married; both men's and women's out-migrations were undertaken mainly for purposes of employment. Over half of female out-migrations (versus 35% of male out-migrations) were to nearby rural areas. The findings highlight the high mobility of this population and the extent to which gender is intimately related to the processes determining migration. We consider the implications of these findings for the measurement of migration and mobility, in particular for health and social policy and research among highly mobile populations in southern Africa.
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Affiliation(s)
- Carol S. Camlin
- Department of Obstetrics/Gynecology & Reproductive Sciences, and Center for AIDS Prevention Studies, University of California at San Francisco
| | - Rachel C. Snow
- Department of Health Behavior and Health Education, University of Michigan School of Public Health
| | - Victoria Hosegood
- Faculty of Human and Social Sciences, University of Southampton
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal
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Taylor BS, Reyes E, Levine EA, Khan SZ, Garduño LS, Donastorg Y, Hammer SM, Brudney K, Hirsch JS. Patterns of geographic mobility predict barriers to engagement in HIV care and antiretroviral treatment adherence. AIDS Patient Care STDS 2014; 28:284-95. [PMID: 24839872 DOI: 10.1089/apc.2014.0028] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Migration and geographic mobility increase risk for HIV infection and may influence engagement in HIV care and adherence to antiretroviral therapy. Our goal is to use the migration-linked communities of Santo Domingo, Dominican Republic, and New York City, New York, to determine the impact of geographic mobility on HIV care engagement and adherence to treatment. In-depth interviews were conducted with HIV+Dominicans receiving antiretroviral therapy, reporting travel or migration in the past 6 months and key informants (n=45). Mobility maps, visual representations of individual migration histories, including lifetime residence(s) and all trips over the past 2 years, were generated for all HIV+ Dominicans. Data from interviews and field observation were iteratively reviewed for themes. Mobility mapping revealed five distinct mobility patterns: travel for care, work-related travel, transnational travel (nuclear family at both sites), frequent long-stay travel, and vacation. Mobility patterns, including distance, duration, and complexity, varied by motivation for travel. There were two dominant barriers to care. First, a fear of HIV-related stigma at the destination led to delays seeking care and poor adherence. Second, longer trips led to treatment interruptions due to limited medication supply (30-day maximum dictated by programs or insurers). There was a notable discordance between what patients and providers perceived as mobility-induced barriers to care and the most common barriers found in the analysis. Interventions to improve HIV care for mobile populations should consider motivation for travel and address structural barriers to engagement in care and adherence.
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Affiliation(s)
- Barbara S. Taylor
- Department of Medicine/Infectious Diseases, University of Texas Health Science Center San Antonio (UTHSCSA), San Antonio, Texas
| | - Emily Reyes
- Department of Medicine/Infectious Diseases, University of Texas Health Science Center San Antonio (UTHSCSA), San Antonio, Texas
| | - Elizabeth A. Levine
- Department of Medicine/Infectious Diseases, University of Texas Health Science Center San Antonio (UTHSCSA), San Antonio, Texas
| | - Shah Z. Khan
- Department of Medicine/Infectious Diseases, University of Texas Health Science Center San Antonio (UTHSCSA), San Antonio, Texas
| | - L. Sergio Garduño
- Department of Medicine/Infectious Diseases, University of Texas Health Science Center San Antonio (UTHSCSA), San Antonio, Texas
| | - Yeycy Donastorg
- Department of Medicine/Infectious Diseases, University of Texas Health Science Center San Antonio (UTHSCSA), San Antonio, Texas
| | - Scott M. Hammer
- Department of Medicine/Infectious Diseases, University of Texas Health Science Center San Antonio (UTHSCSA), San Antonio, Texas
| | - Karen Brudney
- Department of Medicine/Infectious Diseases, University of Texas Health Science Center San Antonio (UTHSCSA), San Antonio, Texas
| | - Jennifer S. Hirsch
- Department of Medicine/Infectious Diseases, University of Texas Health Science Center San Antonio (UTHSCSA), San Antonio, Texas
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Martinez AN, Lorvick J, Kral AH. Activity spaces among injection drug users in San Francisco. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2013; 25:516-24. [PMID: 24374172 DOI: 10.1016/j.drugpo.2013.11.008] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2013] [Revised: 11/07/2013] [Accepted: 11/13/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Representations of activity spaces, defined as the local areas within which people move or travel in the course of their daily activities, are unexplored among injection drug users (IDUs). The purpose of this paper is to use an activity space framework to study place and drug user health. METHODS Data for this analysis is from an epidemiological study of street-recruited IDUs in San Francisco (N=1084). Study participants reported geographic intersections of where they most often slept at night, hung out during the day, and used drugs during a 6 month time period. We used GIS software to construct and map activity space routes of street-based network paths between these intersections. We further identified if syringe exchange program (SEP) locations intersected with, participant activity space routes. We used logistic regression to estimate associations between activity space variables and HIV serostatus, syringe sharing, and non-fatal overdose, after adjusting for individual and Census tract covariates. RESULTS Mean activity space distance for all participants was 1.5miles. 9.6% of participants had a SEP located along their activity space. An increase in activity space distance was associated with a decrease in odds of being HIV positive. An increase in residential transience, or the number of different locations slept in by participants in a 6 month time period, was associated with higher odds of syringe sharing. Activity space distance was not independently associated with overdose or syringe sharing. DISCUSSION Research that locates individuals in places of perceived importance is needed to inform placement and accessibility of HIV and overdose prevention programs. More attention needs to be given to the logistics of collecting sensitive geospatial data from vulnerable populations as well as how to maximize the use of GIS software for visualizing and understanding how IDUs interact with their environment.
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Affiliation(s)
- Alexis N Martinez
- Department of Sociology, San Francisco State University, United States.
| | - Jennifer Lorvick
- Urban Health Program, RTI International, San Francisco, CA, United States
| | - Alex H Kral
- Urban Health Program, RTI International, San Francisco, CA, United States
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