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Wamuti B, Jamil MS, Siegfried N, Ford N, Baggaley R, Johnson CC, Cherutich P. Understanding effective post-test linkage strategies for HIV prevention and care: a scoping review. J Int AIDS Soc 2024; 27:e26229. [PMID: 38604993 PMCID: PMC11009370 DOI: 10.1002/jia2.26229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 02/20/2024] [Indexed: 04/13/2024] Open
Abstract
INTRODUCTION Following HIV testing services (HTS), the World Health Organization recommends prompt linkage to prevention and treatment. Scale-up of effective linkage strategies is essential to achieving the global 95-95-95 goals for maintaining low HIV incidence by 2030 and reducing HIV-related morbidity and mortality. Whereas linkage to care including same-day antiretroviral therapy (ART) initiation for all people with HIV is now routinely implemented in testing programmes, linkage to HIV prevention interventions including behavioural or biomedical strategies, for HIV-negative individuals remains sub-optimal. This review aims to evaluate effective post-HTS linkage strategies for HIV overall, and highlight gaps specifically in linkage to prevention. METHODS Using the five-step Arksey and O'Malley framework, we conducted a scoping review searching existing published and grey literature. We searched PubMed, Cochrane Library, CINAHL, Web of Science and EMBASE databases for English-language studies published between 1 January 2010 and 30 November 2023. Linkage interventions included as streamlined interventions-involving same-day HIV testing, ART initiation and point-of-care CD4 cell count/viral load, case management-involving linkage coordinators developing personalized HIV care and risk reduction plans, incentives-financial and non-financial, partner services-including contact tracing, virtual-like social media, quality improvement-like use of score cards, and peer-based interventions. Outcomes of interest were linkage to any form of HIV prevention and/or care including ART initiation. RESULTS Of 2358 articles screened, 66 research studies met the inclusion criteria. Only nine linkage to prevention studies were identified (n = 9/66, 14%)-involving pre-exposure prophylaxis, voluntary medical male circumcision, sexually transmitted infection and cervical cancer screening. Linkage to care studies (n = 57/66, 86%) focused on streamlined interventions in the general population and on case management among key populations. DISCUSSION Despite a wide range of HIV prevention interventions available, there was a dearth of literature on HIV prevention programmes and on the use of messaging on treatment as prevention strategy. Linkage to care studies were comparatively numerous except those evaluating virtual interventions, incentives and quality improvement. CONCLUSIONS The findings give insights into linkage strategies but more understanding of how to provide these effectively for maximum prevention impact is needed.
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Affiliation(s)
- Beatrice Wamuti
- Department of Global Health and PopulationHarvard UniversityCambridgeMassachusettsUSA
| | - Muhammad S. Jamil
- Global HIV, Hepatitis and STIs Programs, World Health OrganizationGenevaSwitzerland
- Regional Office to the Eastern Mediterranean, World Health OrganizationCairoEgypt
| | | | - Nathan Ford
- Global HIV, Hepatitis and STIs Programs, World Health OrganizationGenevaSwitzerland
| | - Rachel Baggaley
- Global HIV, Hepatitis and STIs Programs, World Health OrganizationGenevaSwitzerland
| | - Cheryl Case Johnson
- Global HIV, Hepatitis and STIs Programs, World Health OrganizationGenevaSwitzerland
| | - Peter Cherutich
- Global HIV, Hepatitis and STIs Programs, World Health OrganizationGenevaSwitzerland
- Department of Preventive and Promotive HealthMinistry of HealthNairobiKenya
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Okonkwo NE, Blum A, Viswasam N, Hahn E, Ryan S, Turpin G, Lyons CE, Baral S, Hansoti B. A Systematic Review of Linkage-to-Care and Antiretroviral Initiation Implementation Strategies in Low- and Middle-Income Countries Across Sub-Saharan Africa. AIDS Behav 2022; 26:2123-2134. [PMID: 35088176 PMCID: PMC9422958 DOI: 10.1007/s10461-021-03558-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2021] [Indexed: 01/29/2023]
Abstract
Linkage to care (LTC) and initiation of antiretroviral therapy (ART) are key components in the longitudinal care cascade for people living with HIV. Many strategies to optimize these stages of HIV care have been implemented, though there is a paucity of analyses comparing the outcomes of these efforts in low- and middle-income countries. We conducted a systematic review of studies assessing interventions along all stages of the HIV care continuum published between 2008 and 2020. A comprehensive search strategy reviewed five electronic databases to capture studies assessing HIV testing, LTC, ART initiation, ART adherence, and viral suppression. Of the 388 articles that met the inclusion criteria, 78 described interventions for improving LTC/ART initiation. Efforts focused on empowering patients through integrative approaches generally yielded more substantive results compared to provider-initiated non-adaptive LTC interventions or cash incentives. Specifically, tailoring care and incorporating ART initiation into existing infrastructures, such as maternal clinics, had a high impact across settings. Moreover, strategies such as home-based HIV counseling and testing (HBHCT) appear to be most effective when implemented in tandem with other approaches including motivational counseling and point-of-care CD4 testing.
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Affiliation(s)
- Nneoma E Okonkwo
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Alexander Blum
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Nikita Viswasam
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Elizabeth Hahn
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sofia Ryan
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Gnilane Turpin
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Carrie E Lyons
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Stefan Baral
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Bhakti Hansoti
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Suite 200, 5801 Smith Avenue, Baltimore, MD, 21209, USA.
- Department of International Health, Bloomberg School of Public Health, Baltimore, MD, USA.
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Opio M, Akello F, Twongyeirwe DK, Opio D, Aceng J, Namagga JK, Kabakyenga JK. Perspectives on linkage to care for patients diagnosed with HIV: A qualitative study at a rural health center in South Western Uganda. PLoS One 2022; 17:e0263864. [PMID: 35239667 PMCID: PMC8893616 DOI: 10.1371/journal.pone.0263864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 01/29/2022] [Indexed: 11/18/2022] Open
Abstract
Linkage to care for newly diagnosed human immunodeficiency virus (HIV) patients is important to ensure that patients have good access to care. However, there is little information about factors influencing linkage to care for HIV patients. We aimed to identify existing measures in place that promote linkage to care and to explore facilitators and barriers to linkage to care for clients diagnosed with HIV/acquired immune deficiency syndrome at a rural health center in Uganda. This descriptive qualitative study enrolled 33 purposively selected participants who included expert clients, linkage facilitators, heads of families with people living with HIV, and health workers. Data were collected using in-depth interviews that were audio-recorded, transcribed, and translated. The data were manually analyzed to generate themes. The following four themes were generated: 1) availability of services that include counseling, testing, treatment, follow-up, referral, outreach activities, and support systems. 2) Barriers to linkage to care were at the individual, health facility, and community levels. Individual-level barriers were socioeconomic status, high transport costs, fear of adverse drug effects, fear of broken relationships, and denial of positive results or treatment, while health facility barriers were reported to be long waiting time, negative staff attitude, and drug stock outs. Community barriers were mostly due to stigma experienced by HIV clients, resulting in discrimination by community members. 3) Facilitators to linkage to care were positive staff attitudes, access to information, fear of death, and support from others. 4) Suggestions for improving service delivery were shortening waiting time, integrating HIV services, increasing staff numbers, and intensifying outreaches. Our findings highlight the importance of stakeholder involvement in linkage to care. Access and linkage to care are positively and negatively influenced at the individual, community, and health facility levels. However, integration of HIV services and intensifying outreaches are key to improving linkage to care.
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Affiliation(s)
- Mark Opio
- Department of Nursing, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Florence Akello
- Department of Nursing, Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - David Opio
- Department of Nursing, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Juliet Aceng
- Department of Medical Laboratory Science, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Jane Kasozi Namagga
- Department of Nursing, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Jerome Kahuma Kabakyenga
- Maternal Newborn and Child Health Institute, Mbarara University of Science and Technology, Mbarara, Uganda
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Factors Associated with Linkage to Care following Community-Level Identification of HIV-Positive Clients in Lira District. ADVANCES IN PUBLIC HEALTH 2022. [DOI: 10.1155/2022/4731006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background. Community HIV testing helps to increase access to high-risk groups who are less likely to visit a clinic for a test. A large proportion of people identified with HIV following community-based testing are not easily linked to care compared to facility-based identified cases. There is a paucity of literature on linkage to HIV care and its predictors particularly following community-based testing in a rural setting. We assessed the level of linkage to the care of HIV-positive individuals and associated factors following community-level identification in Lira district. Method. A cross-sectional survey was conducted in Lira district employing mixed methods among HIV-positive adults identified in the communities. Quantitative data were collected from 329 randomly selected study participants using interviewer-administered questionnaires. Key informant interview guide was used to collect qualitative data. The data were double entered, cleaned, and analyzed using SPSS version 23. Odds ratios and confidence intervals were used to assess the association between predictors of linkage with HIV care. Qualitative data were analyzed using thematic content analysis. Results. The respondents were aged between 18 and 85 years with a mean age of 42.9 (SD = 11.6). The level of linkage to HIV care following community-level identification of HIV testing in Lira district was 98% (95% CI 96.07–99.33). Clients who self-initiated the HIV testing were more likely to link to HIV care than their counterparts (AOR = 9.03; 95% CI 1.271–64.218,
). Key informants identified factors influencing linkage to care as health education, counseling, follow-up, and family support. Fear of stigma, disclosure, denial, and distance to facility were reported as barriers to linkage. Conclusion/Recommendation. The level of linkage to HIV care following community identification was found to be excellent (98%). Predictors to linkage to care included self-initiated testing, positive perception of distance, and waiting time at health facilities. We recommend health education, counseling, follow-up, and family support as interventions to strengthen successfully linking to care.
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Kisigo GA, Issarow B, Abel K, Hashim R, Okello ES, Ayieko P, Lee MH, Grosskurth H, Fitzgerald D, Peck RN, Kapiga S. A social worker intervention to reduce post-hospital mortality in HIV-infected adults in Tanzania (Daraja): Study protocol for a randomized controlled trial. Contemp Clin Trials 2022; 113:106680. [PMID: 35032664 PMCID: PMC8882676 DOI: 10.1016/j.cct.2022.106680] [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: 10/08/2021] [Revised: 01/06/2022] [Accepted: 01/10/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND In sub-Saharan Africa (SSA), hospitalized HIV-infected patients who are discharged home have been shown to experience extremely high mortality rate. Daraja is an individual-level, time-limited, five-session case management intervention aiming to link hospitalized HIV-infected patients to outpatient HIV care upon discharge. METHODS A randomized control trial will aim at evaluating the efficacy of Daraja intervention on reducing mortality in hospitalized HIV-infected patients upon discharge from hospital. The study will recruit 500 hospitalized HIV-infected adults who are ART naïve or defaulted for >7 days from hospitals in Mwanza region, Tanzania. Participants will be enrolled during hospitalization and a baseline assessment will be done. Participants will be randomized to receive either the standard of care HIV linkage, or the Daraja intervention a day before the expected hospital discharge date. The Daraja intervention includes five sessions delivered by a social worker over a 3-month period. All participants will complete follow-up assessment at month 12 and 24. Measures will include 1-year survival, HIV care continuum outcomes (linkage, retention, antiretroviral adherence, and viral suppression), and cost (incremental cost of the intervention and cost per life saved). Quality assurance data will be collected, and the feasibility and acceptability of the intervention will be described. Statistical analysis will assess the effectiveness of the Daraja intervention on improving survival and HIV care continuum outcomes. DISCUSSION Hospitalized HIV-infected patients who are being discharged home have higher mortality due to poor linkage to primary HIV care. The Daraja intervention has the potential to address barriers that prevent successful transition from hospital to primary HIV care. TRIAL REGISTRATION ClinicalTrials.gov, NCT03858998. Registered on 01 March 2019.
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Affiliation(s)
- Godfrey A. Kisigo
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania,Center for Global Health, Weill Cornell Medicine, 1300 York Avenue, New York, NY 10065
| | - Benson Issarow
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania
| | - Kelvin Abel
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania
| | - Ramadhan Hashim
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania
| | - Elialilia S. Okello
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania
| | - Philip Ayieko
- London School of Hygiene and Tropical Medicine, Department of Infectious Disease Epidemiology, Keppel Street, London WC1E 7HT, UK
| | - Myung Hee Lee
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania
| | - Heiner Grosskurth
- London School of Hygiene and Tropical Medicine, Department of Infectious Disease Epidemiology, Keppel Street, London WC1E 7HT, UK
| | - Daniel Fitzgerald
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania
| | - Robert N. Peck
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania,Center for Global Health, Weill Cornell Medicine, 1300 York Avenue, New York, NY 10065
| | - Saidi Kapiga
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania,London School of Hygiene and Tropical Medicine, Department of Infectious Disease Epidemiology, Keppel Street, London WC1E 7HT, UK
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Njau B, Damian DJ, Abdullahi L, Boulle A, Mathews C. The effects of HIV self-testing on the uptake of HIV testing, linkage to antiretroviral treatment and social harms among adults in Africa: A systematic review and meta-analysis. PLoS One 2021; 16:e0245498. [PMID: 33503050 PMCID: PMC7840047 DOI: 10.1371/journal.pone.0245498] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 12/31/2020] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION HIV infection is still a global public health problem. More than 75% of HIV-infected people are in Africa, and up to 54% are unaware of their HIV status, limiting access to antiretroviral treatment. CONTEXT AND PURPOSE OF THE STUDY This review aimed to determine whether HIV self-testing (HIVST) increases the uptake of testing, the yield of new HIV-positive diagnoses, and the linkage to antiretroviral treatment, and social harms among adults in Africa. METHODS PubMed, The Cochrane Central Register of Controlled Trials (CENTRAL), Pan African Clinical Trials Registry, The Cochrane Database of Systematic Reviews (CDSR), Databases of Abstracts of Reviews of Effectiveness (DARE), Social Sciences Citation Index, Web of Science and African Index Medicus databases were searched from 1998 to 2019 (updated in December 2019). Eligible trials employed randomized controlled trials (RCTs), before/after studies, and interrupted time series design comparing HIVST to standard HIV testing services or comparing different approaches to HIVST among adults living in Africa were systematically sought. RESULTS After searching 2,617 citations eleven trials were identified including 59,119 participants from four (4) African countries. Meta-analysis of seven trials showed a significant increase in the uptake of HIVST compared to standard HIV testing services: Both fixed-effects (Rate Ratio (RR) = 2.64, 95% CI: 2.51 to 2.79), and random-effects (RR) = 3.10, 95% CI: 1.80 to 5.37, and a significant increase in the uptake of couples' HIVST (RR = 2.50, 95% CI: 2.29 to 2.73 in fixed-effects models; and RR = 2.64, 95% CI: 2.01 to 3.49 in random-effects model). A decrease in linkage to care and ART was observed in HIVST compared to standard HIV testing services (RR = 0.88, 95% CI: 0.88 to 0.95 in fixed-effects models; and RR = 0.78, 95% CI: 0. 56 to 1.08 in random-effects models). Six RCTs measured social harms, with a total of ten reported cases related to HIVST. One RCT comparing two approaches to HIVST showed that offering home-based HIVST with optional home-initiation of antiretroviral treatment increased the reporting of a positive HIV test result (RR: 1.86; 95% CI: 1.16 to 2.98), and linkage to antiretroviral treatment (RR: 2.94; 95% CI: 2.10 to 4.12), compared with facility-based linkage to antiretroviral treatment. CONCLUSIONS HIVST has the potential to increase the uptake of HIV testing compared to standard HIV testing services. Offering HIVST with optional home initiation of HIV care compared to HIVST with facility-based HIV care increases HIV positivity and linkage to antiretroviral treatment. Reported incidences of intimate partner violence related to HIVST were rare. Future research should focus on the potential of HIVST to reach first-time testers, the effect of using different approaches to HIVST, and strategies for linkage to HIV services. SYSTEMATIC REVIEW REGISTRATION This systematic review was prospectively registered on the Prospero International Prospective Register of Systematic Review (CRD42015023935).
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Affiliation(s)
- Bernard Njau
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Damian J. Damian
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Leila Abdullahi
- Save the Children International SCI, Somalia/Somaliland Country Office, Nairobi, Kenya
| | - Andrew Boulle
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Catherine Mathews
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
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Njau B, Lisasi E, Damian DJ, Mushi DL, Boulle A, Mathews C. Feasibility of an HIV self-testing intervention: a formative qualitative study among individuals, community leaders, and HIV testing experts in northern Tanzania. BMC Public Health 2020; 20:490. [PMID: 32293370 PMCID: PMC7161285 DOI: 10.1186/s12889-020-08651-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 04/03/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Achieving the 95-95-95 global targets by 2030, innovative HIV testing models, such as HIV self-testing are needed for people, who are unaware of their HIV status. We aimed to explore key informants, mountain climbing porters, and female bar workers' attitudes, perceived norms, and personal agency related to HIV self-testing. METHODS This was a formative qualitative study to inform the design of an HIV self-testing intervention in Northern Tanzania. Informed by the Integrated Behaviour Model, we conducted four focus group discussions, and 18 in-depth interviews with purposively selected participants. Data were analyzed using the framework method. RESULTS We recruited 55 participants. Most participants had positive attitudes towards HIVST, in that they anticipated positive consequences related to the introduction and uptake of HIVST. These included privacy and convenience, avoidance of long queues at health facilities, reduced counselor workload, and reduced indirect costs (given that transport to health facilities might not be required). Participants expressed the belief that significant people in their social environment, such as parents and peers, would approve their uptake of HIVST, and that they would accept HIVST. Additionally, features of HIVST that might facilitate its uptake were that it could be performed in private and would obviate visits to health facilities. Most participants were confident in their capacity to use HIVST kits, while a few were less confident about self-testing while alone. Strategies to maximize beliefs about personal agency and facilitate uptake included supplying the self-test kits in a way that was easy to access, and advocacy. Perceived potential constraints to the uptake of HIVST were the cost of buying the self-test kits, poverty, illiteracy, poor eyesight, fear of knowing one's HIV status, lack of policy/ guidelines for HIVST, and the absence of strategies for linkage to HIV care, treatment, and support. CONCLUSIONS The findings suggest that HIVST may be feasible to implement in this study setting, with the majority of participants reporting positive attitudes, supportive perceived norms, and self-efficacy. Hence, future HIVST interventions should address the negative beliefs, and perceived barriers towards HIVST to increase HIV testing among the target population in Northern Tanzania.
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Affiliation(s)
- Bernard Njau
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Kilimanjaro Christian Medical University College, Kilimanjaro, Tanzania
| | - Esther Lisasi
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Damian J. Damian
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Kilimanjaro Christian Medical University College, Kilimanjaro, Tanzania
| | - Declare L. Mushi
- Kilimanjaro Christian Medical University College, Kilimanjaro, Tanzania
| | - Andrew Boulle
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Centre of Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Catherine Mathews
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
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Koduah Owusu K, Adu-Gyamfi R, Ahmed Z. Strategies To Improve Linkage To HIV Care In Urban Areas Of Sub-Saharan Africa: A Systematic Review. HIV AIDS (Auckl) 2019; 11:321-332. [PMID: 31819663 PMCID: PMC6898990 DOI: 10.2147/hiv.s216093] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Accepted: 09/05/2019] [Indexed: 12/17/2022] Open
Abstract
Of the 37 million people estimated to be living with HIV globally in 2017, about 24.7 million were in the sub-Saharan Africa region, which has been and remains worst affected by the epidemic. Enrolment of newly diagnosed individuals into care in the region, however, remains poor with up to 54% not being linked to care. Linkage to care is a very important step in the HIV cascade as it is the precursor to initiating antiretroviral therapy (ART), retention in care, and viral suppression. A systematic review was conducted to gather information regarding the strategies that have been documented to increase linkage to care of Persons living with HIV(PLHIV) in urban areas of sub-Saharan Africa. An electronic search was conducted on Scopus, Cochrane central, CINAHL Plus, PubMed and OpenGrey for linkage strategies implemented from 2006. A total of 189 potentially relevant citations were identified, of which 7 were eligible for inclusion. The identified strategies were categorized using themes from literature. The most common strategies included: health system interventions (i.e. comprehensive care, task shifting); patient convenience and accessibility (i.e. immediate CD4 count testing, immediate ART initiation, community HIV testing); behavior interventions and peer support (i.e. assisted partner services, care facilitation, mobile phone appointment reminders, health education) and incentives (i.e. non-cash financial incentives and transport reimbursement). Several strategies showed favorable outcomes: comprehensive care, immediate CD4 count testing, immediate ART initiation, and assisted partner services. Assisted partner services, same day home-based ART initiation, combination intervention strategies and point-of-care CD4 testing significantly improved linkage to care in urban settings of sub-Saharan African region. They can be delivered either in a health facility or in the community but should be facilitated by health workers. There is, however, the need to conduct more linkage-specific studies in the sub-region.
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Affiliation(s)
- Kwadwo Koduah Owusu
- School of Life and Medical Sciences, University of Hertfordshire, Hertfordshire, UK
| | - Raphael Adu-Gyamfi
- National AIDS/STI Control Programme, Ghana Health Service, Korle-Bu, Accra, Ghana
| | - Zamzam Ahmed
- School of Life and Medical Sciences, University of Hertfordshire, Hertfordshire, UK
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Nyato D, Nnko S, Komba A, Kuringe E, Plotkin M, Mbita G, Shao A, Changalucha J, Wambura M. Facilitators and barriers to linkage to HIV care and treatment among female sex workers in a community-based HIV prevention intervention in Tanzania: A qualitative study. PLoS One 2019; 14:e0219032. [PMID: 31743336 PMCID: PMC6863533 DOI: 10.1371/journal.pone.0219032] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 11/05/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND HIV-infected female sex workers (FSWs) have poor linkage to HIV care in sub-Sahara Africa. METHODS We conducted 21 participatory group discussions (PGDs) to explore factors influencing linkage to HIV care among FSWs tested for HIV through a comprehensive community-based HIV prevention project in Tanzania. RESULTS Influences on linkage to care were present at the system, societal and individual levels. System-level factors included unfriendly service delivery environment, including lengthy pre-enrolment sessions, concerns about confidentiality, stigmatising attitudes of health providers. Societal-level factors included myths and misconceptions about ART and stigma. On the individual level, most notable was fear of not being able to continue to have a livelihood if one's status were to be known. Facilitators were noted, including the availability of transport to services, friendly health care providers and peer-support referral and networks. CONCLUSION Findings of this study underscore the importance of peer-supported linkages to HIV care and the need for respectful, high-quality care.
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Affiliation(s)
- Daniel Nyato
- Department of Sexual and Reproductive Health, National Institute for Medical Research, Mwanza Centre, Mwanza, Tanzania
- * E-mail:
| | - Soori Nnko
- Department of Sexual and Reproductive Health, National Institute for Medical Research, Mwanza Centre, Mwanza, Tanzania
| | - Albert Komba
- Jhpiego Tanzania - An Affiliate of Johns Hopkins University, Dar-es-Salaam, Tanzania
| | - Evodius Kuringe
- Department of Sexual and Reproductive Health, National Institute for Medical Research, Mwanza Centre, Mwanza, Tanzania
| | - Marya Plotkin
- Jhpiego Tanzania - An Affiliate of Johns Hopkins University, Dar-es-Salaam, Tanzania
| | - Gaspar Mbita
- Jhpiego Tanzania - An Affiliate of Johns Hopkins University, Dar-es-Salaam, Tanzania
| | - Amani Shao
- Department of Sexual and Reproductive Health, National Institute for Medical Research, Mwanza Centre, Mwanza, Tanzania
| | - John Changalucha
- Department of Sexual and Reproductive Health, National Institute for Medical Research, Mwanza Centre, Mwanza, Tanzania
| | - Mwita Wambura
- Department of Sexual and Reproductive Health, National Institute for Medical Research, Mwanza Centre, Mwanza, Tanzania
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Haachambwa L, Kandiwo N, Zulu PM, Rutagwera D, Geng E, Holmes CB, Sinkala E, Claassen CW, Mugavero MJ, Wa Mwanza M, Turan JM, Vinikoor MJ. Care Continuum and Postdischarge Outcomes Among HIV-Infected Adults Admitted to the Hospital in Zambia. Open Forum Infect Dis 2019; 6:ofz336. [PMID: 31660330 PMCID: PMC6778319 DOI: 10.1093/ofid/ofz336] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 07/15/2019] [Indexed: 12/30/2022] Open
Abstract
Background We characterized the extent of antiretroviral therapy (ART) experience and postdischarge mortality among hospitalized HIV-infected adults in Zambia. Methods At a central hospital with an opt-out HIV testing program, we enrolled HIV-infected adults (18+ years) admitted to internal medicine using a population-based sampling frame. Critically ill patients were excluded. Participants underwent a questionnaire regarding their HIV care history and CD4 count and viral load (VL) testing. We followed participants to 3 months after discharge. We analyzed prior awareness of HIV-positive status, antiretroviral therapy (ART) use, and VL suppression (VS; <1000 copies/mL). Using Cox proportional hazards regression, we assessed risk factors for mortality. Results Among 1283 adults, HIV status was available for 1132 (88.2%), and 762 (67.3%) were HIV-positive. In the 239 who enrolled, the median age was 36 years, 59.7% were women, and the median CD4 count was 183 cells/mm3. Active tuberculosis or Cryptococcus coinfection was diagnosed in 82 (34.3%); 93.3% reported prior awareness of HIV status, and 86.2% had ever started ART. In the 64.0% with >6 months on ART, 74.4% had VS. The majority (92.5%) were discharged, and by 3 months, 48 (21.7%) had died. Risk of postdischarge mortality increased with decreasing CD4, and there was a trend toward reduced risk in those treated for active tuberculosis. Conclusions Most HIV-related hospitalizations and deaths may now occur among ART-experienced vs -naïve individuals in Zambia. Development and evaluation of inpatient interventions are needed to mitigate the high risk of death in the postdischarge period.
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Affiliation(s)
- Lottie Haachambwa
- Department of Medicine, University Teaching Hospital, Lusaka, Zambia.,School of Medicine, University of Zambia, Lusaka, Zambia.,School of Medicine, University of Maryland at Baltimore, Baltimore, Maryland
| | - Nyakulira Kandiwo
- Department of Medicine, University Teaching Hospital, Lusaka, Zambia
| | - Paul M Zulu
- Zambia National Public Health Institute, Lusaka, Zambia
| | - David Rutagwera
- University Teaching Hospital HIV AIDS Programme, Lusaka, Zambia
| | - Elvin Geng
- Department of Medicine, University of California at San Francisco, San Francisco, California
| | - Charles B Holmes
- Johns Hopkins University, Baltimore, Maryland.,Center for Global Health and Quality, Georgetown University School of Medicine, Washington, District of Columbia
| | - Edford Sinkala
- Department of Medicine, University Teaching Hospital, Lusaka, Zambia.,School of Medicine, University of Zambia, Lusaka, Zambia
| | - Cassidy W Claassen
- Department of Medicine, University Teaching Hospital, Lusaka, Zambia.,School of Medicine, University of Zambia, Lusaka, Zambia.,School of Medicine, University of Maryland at Baltimore, Baltimore, Maryland
| | - Michael J Mugavero
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Mwanza Wa Mwanza
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Janet M Turan
- School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - Michael J Vinikoor
- School of Medicine, University of Zambia, Lusaka, Zambia.,Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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11
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Factors Influencing the Risk of Becoming Sexually Active Among HIV Infected Adolescents in Kampala and Kisumu, East Africa. AIDS Behav 2019; 23:1375-1386. [PMID: 30406334 DOI: 10.1007/s10461-018-2323-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
About 2.1 million adolescents aged 10-19 years are living with HIV, 80% of them in sub-Saharan Africa. Early sexual activity remains an important risk factor for HIV transmission and potentially result in negative health consequences including onward transmission of sexually transmitted infections. Cross-sectional data of 580 adolescents living with HIV (ALHIV) aged 13-17 years (317 girls and 263 boys) from Kenya and Uganda were analyzed to assess factors associated with risk to become sexually active. Factors associated with risk of sexual intercourse were identified using Kaplan-Meier survival curves and Cox regression with gender-stratified bi-and multivariable models. Slightly more females (22%) than males (20%) reported they have had sex. Multivariable models showed that being aware of one's own HIV infection, and receiving antiretroviral treatment were negatively associated with risk of becoming sexually active, while subjective norms conducive to sexuality, and girls' poor health experience increased the risk. In the final multi-variable models, schooling was protective for girls, but not for boys. Being more popular with the opposite sex was negatively associated with the outcome variable only for girls, but not for boys. This study expands the knowledge base on factors associated with onset of sexual activity among ALHIV, potentially informing positive prevention interventions.
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12
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Ayieko J, Petersen ML, Charlebois ED, Brown LB, Clark TD, Kwarisiima D, Kamya MR, Cohen CR, Bukusi EA, Havlir DV, Van Rie A. A Patient-Centered Multicomponent Strategy for Accelerated Linkage to Care Following Community-Wide HIV Testing in Rural Uganda and Kenya. J Acquir Immune Defic Syndr 2019; 80:414-422. [PMID: 30807481 PMCID: PMC6410970 DOI: 10.1097/qai.0000000000001939] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 11/26/2018] [Indexed: 01/01/2023]
Abstract
INTRODUCTION As countries move toward universal HIV treatment, many individuals fail to link to care after diagnosis of HIV. Efficient and effective linkage strategies are needed. METHODS We implemented a patient-centered, multicomponent linkage strategy in the SEARCH "test-and-treat" trial (NCT 01864603) in Kenya and Uganda. After population-based, community-wide HIV testing, eligible participants were (1) introduced to clinic staff after testing, (2) provided a telephone "hot-line" for enquiries, (3) provided an appointment reminder phone call, (4) given transport reimbursement on linkage, and (5) tracked if linkage appointment was missed. We estimated the proportion linked to care within 1 year and evaluated factors associated with linkage at 7, 30, and 365 days after diagnosis. RESULTS Among 71,308 adults tested, 6811 (9.6%) were HIV-infected; of these, 4760 (69.9%) were already in HIV care, and 30.1% were not. Among 2051 not in care, 58% were female, median age was 32 (interquartile range 26-40) years, and median CD4 count was 493 (interquartile range 331-683) cells/µL. Half (49.7%) linked within 1 week, and 73.4% linked within 1 year. Individuals who were younger [15-34 vs. >35 years, adjusted Risk Ratio (aRR) 0.83, 95% confidence interval (CI): 0.74 to 0.94], tested at home vs. community campaign (aRR = 0.87, 95% CI: 0.81 to 0.94), had a high HIV-risk vs. low-risk occupation (aRR = 0.81, 95% CI: 0.75 to 0.88), and were wealthier (aRR 0.90, 95% CI: 0.83 to 0.97) were less likely to link. Linkage did not differ by marital status, stable residence, level of education, or having a phone contact. CONCLUSIONS Using a multicomponent linkage strategy, high proportions of people living with HIV but not in care linked rapidly after HIV testing.
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Affiliation(s)
- James Ayieko
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Maya L. Petersen
- Department of Biostatistics, School of Public Health, University of California, Berkeley, CA
| | | | | | - Tamara D. Clark
- School of Medicine, University of California, San Francisco, CA
| | - Dalsone Kwarisiima
- Department of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Moses R. Kamya
- Department of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Craig R. Cohen
- School of Medicine, University of California, San Francisco, CA
| | - Elizabeth A. Bukusi
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Diane V. Havlir
- School of Medicine, University of California, San Francisco, CA
| | - Annelies Van Rie
- Faculty of Medicine and Public Health, University of Antwerp, Antwerp, Belgium
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13
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Ingabire PM, Semitala F, Kamya MR, Nakanjako D. Delayed Antiretroviral Therapy (ART) Initiation among Hospitalized Adults in a Resource-Limited Settings: A Challenge to the Global Target of ART for 90% of HIV-Infected Individuals. AIDS Res Treat 2019; 2019:1832152. [PMID: 31057959 PMCID: PMC6463639 DOI: 10.1155/2019/1832152] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 01/02/2019] [Accepted: 02/26/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Combination antiretroviral therapy (cART) initiation in hospital settings, where individuals often present with undiagnosed, untreated, advanced HIV disease, is not well understood. METHODS A cross-sectional study was conducted to determine a period prevalence of cART initiation within two weeks of eligibility, as determined at hospitalization. Using a pretested and precoded data extraction tool, data on cART initiation status and reason for not initiating cART was collected. Phone calls were made to patients that had left the hospital by the end of the two-week period. Delayed cART initiation was defined as failure to initiate cART within two weeks. Sociodemographic characteristics, WHO clinical stage, CD4 count, cART initiation status, and reasons for delayed cART initiation were extracted and analyzed. RESULTS Overall, 386 HIV-infected adults were enrolled, of whom 289/386 (74.9%) had delayed cART initiation, 77/386 (19.9%) initiated cART, and 20/386 (5.2%) were lost-to-follow-up, within two weeks of cART eligibility. Of 289 with delayed ART initiation, 94 (32.5%) died within two weeks of cART eligibility. Patients with a CD4 cell count≥ 50 cells/μl and who resided in ≥8 kilometers from the hospital were more likely to have delayed cART initiation [adjusted odds ratio (AOR) 2.34, 95% CI: 1.33-4.10, p value 0.003; and AOR 1.92, 95% CI: 1.09-3.40, p value 0.025; respectively]. CONCLUSION Up to 75% of hospitalized HIV-infected, cART-naïve, cART-eligible patients did not initiate cART and had a 33% pre-ART mortality rate within two weeks of eligibility for cART. Hospital based strategies to hasten cART initiation during hospitalization and electronic patient tracking systems could promote active linkage to HIV treatment programs, to prevent HIV/AIDS-associated mortality in resource-limited settings.
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Affiliation(s)
- Prossie Merab Ingabire
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
- St. Francis Hospital, Nsambya, Kampala, Uganda
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Fred Semitala
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Moses R. Kamya
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Damalie Nakanjako
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
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14
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Macken M, Chan J, O'Hare B, Thornton HV, Dube Q, Kennedy N. Bedside paediatric HIV testing in Malawi: Impact on testing rates. Malawi Med J 2018; 29:237-239. [PMID: 29872513 PMCID: PMC5811995 DOI: 10.4314/mmj.v29i3.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Provider initiated testing and counselling (PITC) is recommended for all inpatients in Malawi if they have not been tested in the previous 3 months. However testing rates remain low among children. We audited the effect of implementing a bedside diagnostic HIV testing service to determine if it would improve testing rates amongst paediatric inpatients. Methods We audited the existing HIV testing service to determine the numbers of children being tested for HIV. This was followed by the introduction of a bedside diagnostic service followed by re-audit. Bedside testing was facilitated by health systems strengthening measures including identification of suitable counsellors, appropriate supervision and remuneration. Results In the initial audit in March-April 2014, 85 (63%) of 135 children had documented HIV tests.. Following implementation of the bedside HIV testing service, there was a significant increase in the proportion of children whose HIV status was known. On re-audit in July 2015, 110 (94.8%) of 116 children had documented HIV tests (p<0.001). Of those with documented tests, 94.5% had been tested within the last 3-months compared to 61% in 2014. Following the introduction of the service, the proportion of children tested for HIV during admission increased from 31.9% to 68.1% (p<0.001). Conclusions Implementation of a bedside testing service at Queen Elizabeth Central Hospital significantly increased HIV testing among paediatric inpatients. This has important implications in establishing earlier treatment, reducing HIV-associated morbidity and mortality.
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Affiliation(s)
- Marita Macken
- Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi.,Birmingham Children's Hospital, Birmingham, United Kingdom
| | - James Chan
- Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Bernadette O'Hare
- Department of Paediatrics and Child Health, College of Medicine, Blantyre, Malawi.,University of St Andrews, Fife, United Kingdom
| | - Hannah V Thornton
- School of Social and Community Medicine, University of Bristol, Bristol United Kingdom
| | - Queen Dube
- Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Neil Kennedy
- Department of Paediatrics and Child Health, College of Medicine, Blantyre, Malawi.,Centre for Medical Education, Queens University Belfast, Belfast, United Kingdom
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15
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Beres LK, Narasimhan M, Robinson J, Welbourn A, Kennedy CE. Non-specialist psychosocial support interventions for women living with HIV: A systematic review. AIDS Care 2017; 29:1079-1087. [PMID: 28438030 PMCID: PMC6957075 DOI: 10.1080/09540121.2017.1317324] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Many women living with HIV experience a range of physical, social, and psychological challenges linked to their HIV status. Psychosocial support interventions may help women cope with these challenges and may allow women to make better decisions around their sexual and reproductive health (SRH), yet no reviews have summarized the evidence for the impact of such interventions on well-being and SRH decision-making among women living with HIV. We systematically reviewed the evidence for non-specialist delivered psychosocial support interventions for women living with HIV, which are particularly relevant in low-resource settings. Outcomes of interest included mental, emotional, social well-being and/or quality of life, common mental health disorders, and SRH decision-making. Searching was conducted through four electronic databases and secondary reference screening. Systematic methods were used for screening and data abstraction. Nine articles met the inclusion criteria, showing positive or mixed results for well-being and depressive symptoms indicators. No studies reported on SRH decision-making outcomes. The available evidence suggests that psychosocial support interventions may improve self-esteem, coping and social support, and reduce depression, stress, and perceived stigma. However, evidence is mixed. Most studies placed greater emphasis on instrumental health outcomes to prevent HIV transmission than on the intrinsic well-being and SRH of women living with HIV. Many interventions included women living with HIV in their design and implementation. More research is required to understand the most effective interventions, and their effect on sexual and reproductive health and rights.
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Affiliation(s)
- Laura K Beres
- a Department of International Health , Johns Hopkins Bloomberg School of Public Health , Baltimore , USA
| | - Manjulaa Narasimhan
- b Department of Reproductive Health and Research , World Health Organization , Geneva , Switzerland
| | - Jennifer Robinson
- a Department of International Health , Johns Hopkins Bloomberg School of Public Health , Baltimore , USA
| | | | - Caitlin E Kennedy
- a Department of International Health , Johns Hopkins Bloomberg School of Public Health , Baltimore , USA
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16
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Testing and linkage to HIV care in China: a cluster-randomised trial. Lancet HIV 2017; 4:e555-e565. [PMID: 28867267 DOI: 10.1016/s2352-3018(17)30131-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 06/16/2017] [Accepted: 06/20/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Multistage, stepwise HIV testing and treatment procedures can result in lost opportunities to provide timely antiretroviral therapy (ART). Incomplete engagement of patients along the care cascade translates into high preventable mortality. We aimed to identify whether a structural intervention to streamline testing and linkage to HIV health care would improve testing completeness, ART initiation, and viral suppression and reduce mortality. METHODS We did a cluster-randomised, controlled trial in 12 hospitals in Guangxi, China. All hospitals were required to be level 2A county general hospitals and ART delivery sites. We selected the 12 most similar hospitals in terms of structural characteristics, past patient caseloads, and testing procedures. Hospitals were randomly assigned (1:1) to either the One4All intervention or standard of care. Hospitals were randomised in a block design and stratified by the historical rate of testing completeness of the individual hospital during the first 6 months of 2013. We enrolled patients aged 18 years or older who were identified as HIV-reactive during screening in study hospitals, who sought inpatient or outpatient care in a study hospital, and who resided in the study catchment area. The One4All strategy incorporated rapid, point-of-care HIV screening and CD4 counts, and in-parallel viral load testing, to promote fast and complete diagnosis and staging and provide immediate ART to eligible patients. Participants in control hospitals received standard care services. All enrolled patients were assessed for the primary outcome, which was testing completeness within 30 days, defined as completion of three required tests and their post-test counselling. Safety assessments were hospital admissions for the first 90 days and deaths up to 12 months after enrolment. This trial is registered with ClinicalTrials.gov, number NCT02084316. FINDINGS Between Feb 24 and Nov 25, 2014, we enrolled 478 patients (232 in One4All, 246 in standard of care). In the One4All group, 177 (76%) of 232 achieved testing completeness within 30 days versus 63 (26%) of 246 in the standard-of-care group (odds ratio 19·94, 95% CI 3·86-103·04, p=0·0004). Although no difference was observed between study groups in the number of hospital admissions at 90 days, by 12 months there were 65 deaths (28%) in the in the One4All group compared with 115 (47%) in the standard-of-care group (Cox proportional hazard ratio 0·44, 0·19-1·01, p=0·0531). INTERPRETATION Our study provides strong evidence for the benefits of a patient-centred approach to streamlined HIV testing and treatment that could help China change the trajectory of its HIV epidemic, and help to achieve the goal of an end to AIDS. FUNDING US National Institute on Drug Abuse Clinical Trials Network and China's National Health and Family Planning Commission.
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17
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Hickey MD, Odeny TA, Petersen M, Neilands TB, Padian N, Ford N, Matthay Z, Hoos D, Doherty M, Beryer C, Baral S, Geng EH. Specification of implementation interventions to address the cascade of HIV care and treatment in resource-limited settings: a systematic review. Implement Sci 2017; 12:102. [PMID: 28784155 PMCID: PMC5547499 DOI: 10.1186/s13012-017-0630-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 07/17/2017] [Indexed: 01/23/2023] Open
Abstract
Background The global response to HIV has started over 18 million persons on life-saving antiretroviral therapy (ART)—the vast majority in low- and middle-income countries (LMIC)—yet substantial gaps remain: up to 40% of persons living with HIV (PLHIV) know their status, while another 30% of those who enter care are inadequately retained after starting treatment. Identifying strategies to enhance use of treatment is urgently needed, but the conceptualization and specification of implementation interventions is not always complete. We sought to assess the completeness of intervention reporting in research to advance uptake of treatment for HIV globally. Methods We carried out a systematic review to identify interventions targeting the adult HIV care cascade in LMIC dating from 1990 to 2017. We identified components of each intervention as “intervention types” to decompose interventions into common components. We grouped “intervention types” into a smaller number of more general “implementation approaches” to aid summarization. We assessed the reporting of six intervention characteristics adapted from the implementation science literature: the actor, action, action dose, action temporality, action target, and behavioral target in each study. Findings In 157 unique studies, we identified 34 intervention “types,” which were empirically grouped into six generally understandable “approaches.” Overall, 42% of interventions defined the actor, 64% reported the action, 41% specified the intervention “dose,” 43% reported action temporality, 61% defined the action target, and 69% reported a target behavior. Average completeness of reporting varied across approaches from a low of 50% to a high of 72%. Dimensions that involved conceptualization of the practices themselves (e.g., actor, dose, temporality) were in general less well specified than consequences (e.g., action target and behavioral target). Implications The conceptualization and Reporting of implementation interventions to advance treatment for HIV in LMIC is not always complete. Dissemination of standards for reporting intervention characteristics can potentially promote transparency, reproducibility, and scientific accumulation in the area of implementation science to address HIV in low- and middle-income countries. Electronic supplementary material The online version of this article (doi:10.1186/s13012-017-0630-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Matthew D Hickey
- Division of General Internal Medicine, San Francisco General Hospital, Department of Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA
| | | | - Maya Petersen
- Department of Biostatistics and Epidemiology, School of Public Health, University of California, Berkeley, CA, USA
| | - Torsten B Neilands
- Center for AIDS Prevention Studies, Department of Medicine, UCSF, San Francisco, CA, USA
| | - Nancy Padian
- Department of Biostatistics and Epidemiology, School of Public Health, University of California, Berkeley, CA, USA
| | - Nathan Ford
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | | | - David Hoos
- Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Meg Doherty
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Chris Beryer
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Stefan Baral
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Elvin H Geng
- Division of ID HIV and Global Medicine, San Francisco General Hospital, Department of Medicine, UCSF, Building 80, 6th Floor, 1001 Potrero Avenue, San Francisco, CA, 94110, USA.
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18
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Mao Y, Wu Z, McGoogan JM, Liu D, Gu D, Erinoff L, Ling W, VanVeldhuisen P, Detels R, Hasson AL, Lindblad R, Montaner JSG, Tang Z, Zhao Y. Care cascade structural intervention versus standard of care in the diagnosis and treatment of HIV in China: a cluster-randomized controlled trial protocol. BMC Health Serv Res 2017; 17:397. [PMID: 28606085 PMCID: PMC5469156 DOI: 10.1186/s12913-017-2323-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 05/19/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The high rate of attrition along the care cascade of infection with human immunodeficiency virus (HIV) results in lost opportunities to provide timely antiretroviral therapy (ART) and to prevent unnecessarily high mortality. This study aims to assess the effectiveness of a structural intervention, the one-stop ("One4All") strategy that streamlines China's HIV care cascade with the intent to improve testing completeness, ART initiation, viral suppression, and mortality. METHOD A two-arm, cluster-randomized controlled trial was implemented in twelve county hospitals in Guangxi China to test the effectiveness of the One4All strategy (intervention arm) compared to the current standard of care (SOC; control arm). The twelve study hospitals were selected for homogeneity and allocated one-to-one to the intervention and control arms. All patients screening HIV positive in study hospitals were enrolled. Target study enrollment was 180 participants per arm, 30 participants per hospital. Basic demographic information was collected as well as HIV risk behavior and route of infection. In intervention hospitals, patients then went on to receive point-of-care CD4 testing and in-parallel viral load (VL) testing whereas patients in control hospitals progressed through the usual SOC cascade. The primary outcome measure was testing completeness within 30 days of positive initial HIV screening result. Testing completeness was defined as receipt of all tests, test results, and post-test counseling. The secondary outcome measure was ART initiation (receipt of first ART prescriptions) within 90 days of positive initial HIV screening result. Tertiary outcome measures were viral suppression (≤200 copies/mL) and all-cause mortality at 12 months. DISCUSSION We expect that this first-ever, cluster-randomized controlled trial of a bundle of interventions intended to streamline the HIV care cascade in China (the One4All strategy) will provide strong evidence for the benefit of accelerating diagnosis, thorough clinical assessment, and ART initiation via an optimized HIV care cascade. We furthermore anticipate that this evidence will be valuable to policymakers looking to elevate China's overall HIV/AIDS response to meet the UNAIDS 90-90-90 targets and the broader, global goal of eradication of the HIV/AIDS epidemic. TRIAL REGISTRATION ClinicalTrials.gov # NCT02084316 . (Registered on March 7, 2014).
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Affiliation(s)
- Yurong Mao
- The National Centre for AIDS/STD Prevention and Control, Chinese Center for Disease Control and Prevention, 155 Changbai Road, Changping District, Beijing, 102206, China
| | - Zunyou Wu
- The National Centre for AIDS/STD Prevention and Control, Chinese Center for Disease Control and Prevention, 155 Changbai Road, Changping District, Beijing, 102206, China.
| | - Jennifer M McGoogan
- The National Centre for AIDS/STD Prevention and Control, Chinese Center for Disease Control and Prevention, 155 Changbai Road, Changping District, Beijing, 102206, China
| | - David Liu
- National Institute on Drug Abuse, US National Institutes of Health, Bethesda, USA
| | - Diane Gu
- The National Centre for AIDS/STD Prevention and Control, Chinese Center for Disease Control and Prevention, 155 Changbai Road, Changping District, Beijing, 102206, China
| | - Lynda Erinoff
- National Institute on Drug Abuse, US National Institutes of Health, Bethesda, USA
| | - Walter Ling
- Integrated Substance Abuse Programs, University of California at Los Angeles (UCLA) School of Medicine, Los Angeles, USA
| | | | - Roger Detels
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, USA
| | - Albert L Hasson
- Integrated Substance Abuse Programs, University of California at Los Angeles (UCLA) School of Medicine, Los Angeles, USA
| | | | - Julio S G Montaner
- British Columbia Centre for Excellence in HIV/AIDS, University of British Columbia, Vancouver, Canada
| | - Zhenzhu Tang
- Guangxi Centre for Disease Control and Prevention, Nanning, China
| | - Yan Zhao
- The National Centre for AIDS/STD Prevention and Control, Chinese Center for Disease Control and Prevention, 155 Changbai Road, Changping District, Beijing, 102206, China
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19
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Keane J, Pharr JR, Buttner MP, Ezeanolue EE. Interventions to Reduce Loss to Follow-up During All Stages of the HIV Care Continuum in Sub-Saharan Africa: A Systematic Review. AIDS Behav 2017; 21:1745-1754. [PMID: 27578001 DOI: 10.1007/s10461-016-1532-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The continuum of care for successful HIV treatment includes HIV testing, linkage, engagement in care, and retention on antiretroviral therapy (ART). Loss to follow-up (LTFU) is a significant disruption to this pathway and a common outcome in sub-Saharan Africa. This review of literature identified interventions that have reduced LTFU in the HIV care continuum. A search was conducted utilizing terms that combined the disease state, stages of the HIV care continuum, interventions, and LTFU in sub-Saharan Africa and articles published between January 2010 and July 2015. Thirteen articles were included in the final review. Use of point of care CD4 testing and community-supported programs improved linkage, engagement, and retention in care. There are few interventions directed at LTFU and none that span across the entire continuum of HIV care. Further research could focus on devising programs that include a series of interventions that will be effective through the entire continuum.
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20
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A Comparison of Home-Based Versus Outreach Event-Based Community HIV Testing in Ugandan Fisherfolk Communities. AIDS Behav 2017; 21:547-560. [PMID: 27900501 DOI: 10.1007/s10461-016-1629-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
We compared two community-based HIV testing models among fisherfolk in Lake Victoria, Uganda. From May to July 2015, 1364 fisherfolk residents of one island were offered (and 822 received) home-based testing, and 344 fisherfolk on another island were offered testing during eight community mobilization events (outreach event-based testing). Of 207 home-based testing clients identified as HIV-positive (15% of residents), 82 were newly diagnosed, of whom 31 (38%) linked to care within 3 months. Of 41 who screened positive during event-based testing (12% of those tested), 33 were newly diagnosed, of whom 24 (75%) linked to care within 3 months. Testing costs per capita were similar for home-based ($45.09) and event-based testing ($46.99). Compared to event-based testing, home-based testing uncovered a higher number of new HIV cases but was associated with lower linkage to care. Novel community-based test-and-treat programs are needed to ensure timely linkage to care for newly diagnosed fisherfolk.
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Peck RN, Wang RJ, Mtui G, Smart L, Yango M, Elchaki R, Wajanga B, Downs JA, Mteta K, Fitzgerald DW. Linkage to Primary Care and Survival After Hospital Discharge for HIV-Infected Adults in Tanzania: A Prospective Cohort Study. J Acquir Immune Defic Syndr 2016; 73:522-530. [PMID: 27846069 PMCID: PMC5129656 DOI: 10.1097/qai.000000000001107] [Citation(s) in RCA: 8] [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
INTRODUCTION Little is known about outcomes after hospitalization for HIV-infected adults in sub-Saharan Africa. We determined 12-month, posthospital mortality rates in HIV-infected vs. uninfected adults and predictors of mortality. METHODS In this prospective cohort study, we enrolled adults admitted to the medical wards of a public hospital in northwestern Tanzania. We conducted standardized questionnaires, physical examinations, and basic laboratory analyses including HIV testing. Participants or proxies were called at 1, 3, 6, and 12 months to determine outcomes. Predictors of in-hospital and posthospital mortality were determined using logistic regression. Cox regression models were used to analyze mortality incidence and associated factors. To confirm our findings, we studied adults admitted to another government hospital. RESULTS We enrolled 637 consecutive adult medical inpatients: 38/143 (26.6%) of the HIV-infected adults died in hospital vs. 104/494 (21.1%) of the HIV-uninfected adults. Twelve-month outcomes were determined for 98/105 (93.3%) vs. 352/390 (90.3%) discharged adults, respectively. Posthospital mortality was 53/105 (50.5%) for HIV-infected adults vs. 126/390 (32.3%) for HIV-uninfected adults (adjusted P = 0.006). The 66/105 (62.9%) HIV-infected adults who attended clinic within 1 month after discharge had significantly lower mortality than the other HIV-infected adults [adjusted hazards ratio = 0.17 (0.07-0.39), P < 0.001]. Adults admitted to a nearby government hospital had similar high rates of posthospital mortality. CONCLUSIONS Posthospital mortality is disturbingly high among HIV-infected adult inpatients in Tanzania. The posthospital period may offer a window of opportunity to improve survival in this population. Interventions are urgently needed and should focus on increasing posthospital linkage to primary HIV care.
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Affiliation(s)
- Robert N. Peck
- Weill Bugando School of Medicine
- Bugando Medical Centre
- Weill Cornell Medical College
| | - Richard J. Wang
- Weill Cornell Medical College
- University of California, San Francisco
| | - Graham Mtui
- Weill Bugando School of Medicine
- Bugando Medical Centre
| | - Luke Smart
- Weill Bugando School of Medicine
- Bugando Medical Centre
- Weill Cornell Medical College
| | - Missana Yango
- Weill Bugando School of Medicine
- University of Dodoma School of Medicine
| | | | | | - Jennifer A. Downs
- Weill Bugando School of Medicine
- Bugando Medical Centre
- Weill Cornell Medical College
| | - Kien Mteta
- Weill Bugando School of Medicine
- Bugando Medical Centre
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MacCarthy S, Hoffmann M, Nunn A, da Silva LAV, Dourado I. Barriers to HIV testing, linkage to care, and treatment adherence: a cross-sectional study from a large urban center of Brazil. Rev Panam Salud Publica 2016; 40:418-426. [PMID: 28718490 PMCID: PMC9897025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 09/29/2016] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVE Early, continued engagement with the HIV treatment continuum can help achieve viral suppression, though few studies have explored how risk factors for delays differ across the continuum. The objective of this study was to identify predictors of delayed diagnosis, delayed linkage to care, and nonadherence to treatment in the city of Salvador, Bahia, Brazil. METHODS Data were collected during 2010 in a cross-sectional study with a sample (n = 1 970) of HIV-infected individuals enrolled in care. Multiple logistic regression analyses identified sociodemographic variables, behaviors, and measures of health service quality that were associated with delayed diagnosis, delayed linkage to care, and treatment nonadherence. RESULTS For delayed diagnosis, male gender (adjusted odds ratio (AOR), 3.02; 95% confidence interval (CI), 2.0-4.6); age 45 years and older (AOR, 1.67; 95% CI, 1.1-2.5); and provider-initiated testing (AOR, 3.00; 95% CI, 2.1-4.4) increased odds, while drug use (AOR, 0.29; 95% CI, 0.2-0.5) and receiving results in a private space (AOR, 0.37; 95% CI, 0.2-0.8) decreased odds. For delayed linkage to care, unemployment (AOR, 1.42; 95% CI, 1.07-1.9) and difficulty understanding or speaking with a health care worker (AOR, 1.61; 95% CI, 1.2-2.1) increased odds, while posttest counseling (AOR, 0.49; 95% CI, 0.3-0.7) decreased odds. For nonadherence, experiencing verbal or physical discrimination related to HIV (AOR, 1.94; 95% CI, 1.3-3.0) and feeling mistreated or not properly attended to at HIV care (AOR, 1.60; 95% CI, 1.0-2.5) increased odds, while posttest counseling (AOR, 0.34; 95% CI, 0.2-0.6) decreased odds. CONCLUSIONS More attention is needed on how policies, programs, and research can provide tailored support across the treatment continuum.
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Affiliation(s)
- Sarah MacCarthy
- RAND Corporation, Santa Monica, California, United States of America
| | - Michael Hoffmann
- Brown University, Providence, Rhode Island, United States of America
| | - Amy Nunn
- Brown University, Providence, Rhode Island, United States of America
| | | | - Ines Dourado
- Instituto de Saúde Coletiva/Universidade Federal da Bahia, Salvador, Bahia, Brazil
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Lubogo D, Ddamulira JB, Tweheyo R, Wamani H. Factors associated with access to HIV care services in eastern Uganda: the Kumi home based HIV counseling and testing program experience. BMC FAMILY PRACTICE 2015; 16:162. [PMID: 26530286 PMCID: PMC4630893 DOI: 10.1186/s12875-015-0379-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Accepted: 10/26/2015] [Indexed: 11/10/2022]
Abstract
Background The HIV/AIDS health challenge continues to ravage many resource-constrained countries of the world. Approximately 75 % of all the global HIV/AIDS related deaths totaling 1.6 (1.4–1.9) million in 2012 occurred in sub-Saharan Africa, Uganda contributed 63,000 (52,000–81,000) to these deaths. Most of the morbidity and mortality associated with HIV/AIDS can be averted if individuals with HIV/AIDS have improved access to HIV care and treatment. The aim of this study therefore, was to explore the factors associated with access to HIV care services among HIV seropositive clients identified by a home based HIV counseling and testing program in Kumi district, eastern Uganda. Methods In a cross sectional study conducted in February 2009, we explored predictor variables: socio-demographics, health facility and community factors related to access to HIV care and treatment. The main outcome measure was reported receipt of cotrimoxazole for prophylaxis. Results The majority [81.1 % (284/350)] of respondents received cotrimoxazole prophylaxis (indicating access to HIV care). The main factors associated with access to HIV care include; age 25–34 years (AOR = 5.1, 95 % CI: 1.5–17.1), male sex (AOR = 2.3, 95 % CI: 1.2–4.4), urban residence (AOR = 2.5, CI: 1.1–5.9) and lack of family support (AOR = 0.5, CI: 0.2–0.9). Conclusions There was relatively high access to HIV care and treatment services at health facilities for HIV positive clients referred from the Kumi home based HIV counseling and testing program. The factors associated with access to HIV care services include; age group, sex, residence and having a supportive family. Stakeholders involved in providing HIV care and treatment services in similar settings should therefore consider these socio-demographic variables as they formulate interventions to improve access to HIV care services. Electronic supplementary material The online version of this article (doi:10.1186/s12875-015-0379-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- David Lubogo
- Department of Community Health and Behavioural Sciences, Makerere University, College of Health Sciences, School of Public Health, P.O.Box 7072, Kampala, Uganda.
| | - John Bosco Ddamulira
- Department of Disease Control and Environmental Health, Makerere University, College of Health Sciences, School of Public Health, Kampala, Uganda.
| | - Raymond Tweheyo
- Department of Health Policy Planning and Management, Makerere University, College of Health Sciences, School of Public Health, Kampala, Uganda.
| | - Henry Wamani
- Department of Community Health and Behavioural Sciences, Makerere University, College of Health Sciences, School of Public Health, P.O.Box 7072, Kampala, Uganda.
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IAPAC Guidelines for Optimizing the HIV Care Continuum for Adults and Adolescents. J Int Assoc Provid AIDS Care 2015; 14 Suppl 1:S3-S34. [PMID: 26527218 DOI: 10.1177/2325957415613442] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND An estimated 50% of people living with HIV (PLHIV) globally are unaware of their status. Among those who know their HIV status, many do not receive antiretroviral therapy (ART) in a timely manner, fail to remain engaged in care, or do not achieve sustained viral suppression. Barriers across the HIV care continuum prevent PLHIV from achieving the therapeutic and preventive effects of ART. METHODS A systematic literature search was conducted, and 6132 articles, including randomized controlled trials, observational studies with or without comparators, cross-sectional studies, and descriptive documents, met the inclusion criteria. Of these, 1047 articles were used to generate 36 recommendations to optimize the HIV care continuum for adults and adolescents. RECOMMENDATIONS Recommendations are provided for interventions to optimize the HIV care environment; increase HIV testing and linkage to care, treatment coverage, retention in care, and viral suppression; and monitor the HIV care continuum.
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Mwisongo A, Mehlomakhulu V, Mohlabane N, Peltzer K, Mthembu J, Van Rooyen H. Evaluation of the HIV lay counselling and testing profession in South Africa. BMC Health Serv Res 2015. [PMID: 26197722 PMCID: PMC4509846 DOI: 10.1186/s12913-015-0940-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND With the launch of the national HIV Counselling and Testing (HCT) campaign in South Africa (SA), lay HIV counsellors, who had been trained in blood withdrawal, have taken up the role of HIV testing. This study evaluated the experiences, training, motivation, support, supervision, and workload of HIV lay counsellors and testers in South Africa. The aim was to identify gaps in their resources, training, supervision, motivation, and workload related to HCT services. In addition it explored their experiences with providing HIV testing under the task shifting context. METHODS The study was conducted in eight of South Africa's nine provinces. 32 lay counsellors were recruited from 67 HCT sites, and were interviewed using two questionnaires that included structured and semi-structured questions. One questionnaire focused on their role as HIV counsellors and the other on their role as HIV testers. RESULTS Ninety-seven percent of counsellors reported that they have received training in counselling and testing. Many rated their training as more than adequate or adequate, with 15.6% rating it as not adequate. Respondents reported a lack of standardised counselling and testing training, and revealed gaps in counselling skills for specific groups such as discordant couples, homosexuals, older clients and children. They indicated health system barriers, including inadequate designated space for counselling, which compromises privacy and confidentiality. Lay counsellors carry the burden of counselling and testing nationally, and have other tasks such as administration and auxiliary duties due to staff shortages. CONCLUSIONS This study demonstrates that HCT counselling and testing services in South Africa are mainly performed by lay counsellors and testers. They are challenged by inadequate work space, limited counselling skills for specific groups, a lack of standardised training policies and considerable administrative and auxiliary duties. To improve HCT services, there needs to be training needs with a standardised curriculum and refresher courses, for HIV counselling and testing, specifically for specific elderly clients, discordant couples, homosexuals and children. The Department of Health should formally integrate lay counsellors into the health care system with proper allocation of tasks under the task shifting policy.
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Affiliation(s)
- Aziza Mwisongo
- School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa. .,Wits Health Consortium-Clinical HIV Research Unit (CHRU), Department of Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.
| | - Vuyelwa Mehlomakhulu
- HIV/AIDS, STIs, and TB (HAST) Research Programme, Human Sciences Research Council (HSRC), Pretoria, Cape Town, Durban, Port Elizabeth, South Africa.
| | - Neo Mohlabane
- HIV/AIDS, STIs, and TB (HAST) Research Programme, Human Sciences Research Council (HSRC), Pretoria, Cape Town, Durban, Port Elizabeth, South Africa.
| | - Karl Peltzer
- HIV/AIDS, STIs, and TB (HAST) Research Programme, Human Sciences Research Council (HSRC), Pretoria, Cape Town, Durban, Port Elizabeth, South Africa. .,Department of Research & Innovation, University of Limpopo, Turfloop, South Africa. .,ASEAN Institute for Health Development, Madidol University, Salaya, Phutthamonthon, Nakhonpathom, 73170, Thailand.
| | - Jacque Mthembu
- HIV/AIDS, STIs, and TB (HAST) Research Programme, Human Sciences Research Council (HSRC), Pretoria, Cape Town, Durban, Port Elizabeth, South Africa.
| | - Heidi Van Rooyen
- HIV/AIDS, STIs, and TB (HAST) Research Programme, Human Sciences Research Council (HSRC), Pretoria, Cape Town, Durban, Port Elizabeth, South Africa.
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Mothers who sell sex: a potential paradigm for integrated HIV, sexual, and reproductive health interventions among women at high risk of HIV in Burkina Faso. J Acquir Immune Defic Syndr 2015; 68 Suppl 2:S154-61. [PMID: 25723980 DOI: 10.1097/qai.0000000000000454] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Antenatal care is a point of entry into the health system for women across Africa and may facilitate the uptake of HIV services among female sex workers (FSWs). This study aimed to evaluate the determinants of motherhood among FSWs, their sexual risks, and their engagement in health care. METHODS A cross-sectional study was conducted from January to July 2013 among FSWs in Ouagadougou and Bobo-Dioulasso, Burkina Faso. The study used respondent-driven sampling for HIV testing and behavioral data collection. Predictors of motherhood and the association of motherhood and sex work dynamics were assessed separately using logistic regression. RESULTS Of the 696 women enrolled, the majority of participants (76.6%, n = 533) had at least 1 biological child. Mothers were more likely to have a nonpaying partner [adjusted odds ratio (aOR), 1.73; 95% confidence interval (CI): 1.20 to 2.49], and significantly less likely to currently desire to conceive (aOR, 0.21; 95% CI: 0.13 to 0.33). Motherhood was predictive of having reduced condomless vaginal or anal sex with a new client [age-adjusted odds ratio (aaOR), 0.80; 95% CI: 0.65 to 0.97] in the past 30 days, and increased condomless vaginal or anal sex with a nonpaying partner (aaOR, 1.49; 95% CI: 1.13 to 1.96). Motherhood was prognostic of a higher likelihood of ever being tested for HIV (aaOR, 1.89; 95% CI: 1.55 to 2.31). Motherhood was predictive of reporting limited difficulty when accessing health services (aaOR, 0.15; 95% CI: 0.67 to 0.34). CONCLUSIONS Motherhood is common among FSWs. The results indicate that FSWs who are mothers may have more exposure to health care because of seeking antenatal/perinatal services, presenting important opportunities for inclusion in the HIV continuum of care and to prevent vertical transmission.
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HIV and critical care delivery in resource-constrained settings: a public health perspective. Glob Heart 2014; 9:343-6. [PMID: 25667186 DOI: 10.1016/j.gheart.2014.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 08/06/2014] [Accepted: 08/08/2014] [Indexed: 11/20/2022] Open
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Hensen B, Taoka S, Lewis JJ, Weiss HA, Hargreaves J. Systematic review of strategies to increase men's HIV-testing in sub-Saharan Africa. AIDS 2014; 28:2133-45. [PMID: 25062091 PMCID: PMC4819892 DOI: 10.1097/qad.0000000000000395] [Citation(s) in RCA: 114] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Revised: 06/27/2014] [Accepted: 07/02/2014] [Indexed: 12/31/2022]
Abstract
OBJECTIVE This systematic review summarizes evidence on the effectiveness of strategies to increase men's HIV-testing in sub-Saharan Africa. METHODS Medline, EmBase, Africa-Wide Information and Global Health were searched. Cluster and individually randomized trials evaluating interventions to increase the proportion of adults (≥ 15 years) testing for HIV were eligible if they were conducted in sub-Saharan Africa, included men in the study population, and reported HIV-testing data by sex. References were independently screened. RESULTS Of the 1852 references, 15 papers including 16 trials were eligible. Trials were judged too heterogeneous to combine in meta-analysis. Three interventions invited men to attend antenatal care-based HIV-testing via pregnant partners, of which two showed a significant effect on partner-testing. One intervention invited men to HIV-test through pregnant partners and showed an increase in HIV-testing when it was offered in bars compared with health facilities. A trial of notification to partners of newly diagnosed HIV-positive patients showed an increase in testing where notification was by healthcare providers compared with notification by the patient. Three interventions reached men already at health facilities and eight reported the effects of community-based HIV testing. Mobile-testing had a significant effect on HIV-testing compared with standard voluntary counselling and testing. Home-based testing also had a significant effect, but reached smaller numbers of men than mobile-testing. DISCUSSION Interventions to encourage HIV-testing can increase men's levels of HIV testing. Community-based programmes in particular had a large effect on population levels of HIV-testing. More data on costs and potential population impact of these approaches over different time-horizons would aid policy-makers in planning resource allocation to increase male HIV-testing.
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Affiliation(s)
- Bernadette Hensen
- Department of Social and Environmental Health Research, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine
| | | | - James J. Lewis
- MRC Tropical Epidemiology Group, Faculty of Epidemiology and Population Health
- Centre for Evaluation, London School of Hygiene and Tropical Medicine, London, UK
| | - Helen A. Weiss
- MRC Tropical Epidemiology Group, Faculty of Epidemiology and Population Health
| | - James Hargreaves
- Department of Social and Environmental Health Research, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine
- Centre for Evaluation, London School of Hygiene and Tropical Medicine, London, UK
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Philbin MM, Tanner AE, DuVal A, Ellen JM, Xu J, Kapogiannis B, Bethel J, Fortenberry JD. Factors affecting linkage to care and engagement in care for newly diagnosed HIV-positive adolescents within fifteen adolescent medicine clinics in the United States. AIDS Behav 2014; 18:1501-10. [PMID: 24682848 PMCID: PMC4000283 DOI: 10.1007/s10461-013-0650-6] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Early linkage to care and engagement in care are critical for initiation of medical interventions. However, over 50 % of newly diagnosed persons do not receive HIV-related care within 6 months of diagnosis. We evaluated a linkage to care and engagement in care initiative for HIV-positive adolescents in 15 U.S.-based clinics. Structural and client-level factors (e.g. demographic and behavioral characteristics, clinic staff and location) were evaluated as predictors of successful linkage and engagement. Within 32 months, 1,172/1,679 (69.8 %) of adolescents were linked to care of which 1,043/1,172 (89 %) were engaged in care. Only 62.1 % (1,043/1,679) of adolescents were linked and engaged in care. Linkage to care failure was attributed to adolescent, provider, and clinic-specific factors. Many adolescents provided incomplete data during the linkage process or failed to attend appointments, both associated with failure to linkage to care. Additional improvements in HIV care will require creative approaches to coordinated data sharing, as well as continued outreach services to support newly diagnosed adolescents.
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Affiliation(s)
- Morgan M Philbin
- HIV Center for Clinical and Behavioral Studies, Columbia University, New York State Psychiatric Institute, New York, NY, USA,
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Interventions to improve or facilitate linkage to or retention in pre-ART (HIV) care and initiation of ART in low- and middle-income settings--a systematic review. J Int AIDS Soc 2014; 17:19032. [PMID: 25095831 PMCID: PMC4122816 DOI: 10.7448/ias.17.1.19032] [Citation(s) in RCA: 199] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Revised: 05/26/2014] [Accepted: 06/11/2014] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Several approaches have been taken to reduce pre-antiretroviral therapy (ART) losses between HIV testing and ART initiation in low- and middle-income countries, but a systematic assessment of the evidence has not yet been undertaken. The aim of this systematic review is to assess the potential for interventions to improve or facilitate linkage to or retention in pre-ART care and initiation of ART in low- and middle-income settings. METHODS An electronic search was conducted on Medline, Embase, Global Health, Web of Science and conference databases to identify studies describing interventions aimed at improving linkage to or retention in pre-ART care or initiation of ART. Additional searches were conducted to identify on-going trials on this topic, and experts in the field were contacted. An assessment of the risk of bias was conducted. Interventions were categorized according to key domains in the existing literature. RESULTS A total of 11,129 potentially relevant citations were identified, of which 24 were eligible for inclusion, with the majority (n=21) from sub-Saharan Africa. In addition, 15 on-going trials were identified. The most common interventions described under key domains included: health system interventions (i.e. integration in the setting of antenatal care); patient convenience and accessibility (i.e. point-of-care CD4 count (POC) testing with immediate results, home-based ART initiation); behaviour interventions and peer support (i.e. improved communication, patient referral and education) and incentives (i.e. food support). Several interventions showed favourable outcomes: integration of care and peer supporters increased enrolment into HIV care, medical incentives increased pre-ART retention, POC CD4 testing and food incentives increased completion of ART eligibility screening and ART initiation. Most studies focused on the general adult patient population or pregnant women. The majority of published studies were observational cohort studies, subject to an unclear risk of bias. CONCLUSIONS Findings suggest that streamlining services to minimize patient visits, providing adequate medical and peer support, and providing incentives may decrease attrition, but the quality of the current evidence base is low. Few studies have investigated combined interventions, or assessed the impact of interventions across the HIV cascade. RESULTS from on-going trials investigating POC CD4 count testing, patient navigation, rapid ART initiation and mobile phone technology may fill the quality of evidence gap. Further high-quality studies on key population groups are required, with interventions informed by previously reported barriers to care.
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Ayudhya DPN, Khawcharoenporn T. HIV care engagement within 30 days after hospital discharge among patients from a Thai tertiary-care centre. Int J STD AIDS 2014; 26:467-9. [PMID: 25015932 DOI: 10.1177/0956462414543843] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Accepted: 06/23/2014] [Indexed: 11/15/2022]
Abstract
A cohort study was conducted to assess the rate of follow-up visit within 30 days after hospital discharge and to determine factors associated with no follow-up among Thai HIV-infected adults during the period from November 2012 to October 2013. Of the 120 eligible patients, 76 (63%) were males, median age was 40 years, and 57 (48%) were newly diagnosed with HIV infection. The rate of follow-up within 30 days after hospital discharge was 69%. Independent factors associated with no follow-up were no caregiver (adjusted odds ratio [aOR] 7.82; p = 0.002), age (aOR 1.06; p = 0.007 for each year younger), being immigrant (aOR 5.10; p = 0.03) and monthly household income less than $US 300 (aOR 2.99; p = 0.04). These findings suggest the need for interventions to improve care engagement including close monitoring for follow-up, pre-discharge financial and medical coverage planning, assessment for the need for caregiver and patient education about the importance of care engagement.
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Bigogo G, Amolloh M, Laserson KF, Audi A, Aura B, Dalal W, Ackers M, Burton D, Breiman RF, Feikin DR. The impact of home-based HIV counseling and testing on care-seeking and incidence of common infectious disease syndromes in rural western Kenya. BMC Infect Dis 2014; 14:376. [PMID: 25005353 PMCID: PMC4107953 DOI: 10.1186/1471-2334-14-376] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 06/30/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In much of Africa, most individuals living with HIV do not know their status. Home-based counseling and testing (HBCT) leads to more HIV-infected people learning their HIV status. However, there is little data on whether knowing one's HIV-positive status necessarily leads to uptake of HIV care, which could in turn, lead to a reduction in the prevalence of common infectious disease syndromes. METHODS In 2008, Kenya Medical Research Institute (KEMRI) in collaboration with the Centers for Disease Control and Prevention (CDC) offered HBCT to individuals (aged ≥13 years) under active surveillance for infectious disease syndromes in Lwak in rural western Kenya. HIV test results were linked to morbidity and healthcare-seeking data collected by field workers through bi-weekly home visits. We analyzed changes in healthcare seeking behaviors using proportions, and incidence (expressed as episodes per person-year) of acute respiratory illness (ARI), severe acute respiratory illness (SARI), acute febrile illness (AFI) and diarrhea among first-time HIV testers in the year before and after HBCT, stratified by their test result and if HIV-positive, whether they sought care at HIV Patient Support Centers (PSCs). RESULTS Of 9,613 individuals offered HBCT, 6,366 (66%) were first-time testers, 698 (11%) of whom were HIV-infected. One year after HBCT, 50% of HIV-infected persons had enrolled at PSCs - 92% of whom had started cotrimoxazole and 37% of those eligible for antiretroviral treatment had initiated therapy. Among HIV-infected persons enrolled in PSCs, AFI and diarrhea incidence decreased in the year after HBCT (rate ratio [RR] 0.84; 95% confidence interval [CI] 0.77 - 0.91 and RR 0.84, 95% CI 0.73 - 0.98, respectively). Among HIV-infected persons not attending PSCs and among HIV-uninfected persons, decreases in incidence were significantly lower. While decreases also occurred in rates of respiratory illnesses among HIV-positive persons in care, there were similar decreases in the other two groups. CONCLUSIONS Large scale HBCT enabled a large number of newly diagnosed HIV-infected persons to know their HIV status, leading to a change in care seeking behavior and ultimately a decrease in incidence of common infectious disease syndromes through appropriate treatment and care.
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Affiliation(s)
- Godfrey Bigogo
- Center for Global Health Research, Kenya Medical Research Institute, P,O, Box 1578, 40100 Kisumu, Kenya.
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Lankowski AJ, Siedner MJ, Bangsberg DR, Tsai AC. Impact of geographic and transportation-related barriers on HIV outcomes in sub-Saharan Africa: a systematic review. AIDS Behav 2014; 18:1199-223. [PMID: 24563115 DOI: 10.1007/s10461-014-0729-8] [Citation(s) in RCA: 151] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Difficulty obtaining reliable transportation to clinic is frequently cited as a barrier to HIV care in sub-Saharan Africa (SSA). Numerous studies have sought to characterize the impact of geographic and transportation-related barriers on HIV outcomes in SSA, but to date there has been no systematic attempt to summarize these findings. In this systematic review, we summarized this body of literature. We searched for studies conducted in SSA examining the following outcomes in the HIV care continuum: (1) voluntary counseling and testing, (2) pre-antiretroviral therapy (ART) linkage to care, (3) loss to follow-up and mortality, and (4) ART adherence and/or viral suppression. We identified 34 studies containing 52 unique estimates of association between a geographic or transportation-related barrier and an HIV outcome. There was an inverse effect in 23 estimates (44 %), a null association in 26 (50 %), and a paradoxical beneficial impact in 3 (6 %). We conclude that geographic and transportation-related barriers are associated with poor outcomes across the continuum of HIV care.
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Brennan A, Browne JP, Horgan M. A systematic review of health service interventions to improve linkage with or retention in HIV care. AIDS Care 2013; 26:804-12. [DOI: 10.1080/09540121.2013.869536] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Govindasamy D, Kranzer K, van Schaik N, Noubary F, Wood R, Walensky RP, Freedberg KA, Bassett IV, Bekker LG. Linkage to HIV, TB and non-communicable disease care from a mobile testing unit in Cape Town, South Africa. PLoS One 2013; 8:e80017. [PMID: 24236170 PMCID: PMC3827432 DOI: 10.1371/journal.pone.0080017] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Accepted: 09/27/2013] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND HIV counseling and testing may serve as an entry point for non-communicable disease screening. OBJECTIVES To determine the yield of newly-diagnosed HIV, tuberculosis (TB) symptoms, diabetes and hypertension, and to assess CD4 count testing, linkage to care as well as correlates of linkage and barriers to care from a mobile testing unit. METHODS A mobile unit provided screening for HIV, TB symptoms, diabetes and hypertension in Cape Town, South Africa between March 2010 and September 2011. The yield of newly-diagnosed cases of these conditions was measured and clients were followed-up between January and November 2011 to assess linkage. Linkage to care was defined as accessing care within one, three or six months post-HIV diagnosis (dependent on CD4 count) and one month post-diagnosis for other conditions. Clinical and socio-demographic correlates of linkage to care were evaluated using Poisson regression and barriers to care were determined. RESULTS Of 9,806 clients screened, the yield of new diagnoses was: HIV (5.5%), TB suspects (10.1%), diabetes (0.8%) and hypertension (58.1%). Linkage to care for HIV-infected clients, TB suspects, diabetics and hypertensives was: 51.3%, 56.7%, 74.1% and 50.0%. Only disclosure of HIV-positive status to family members or partners (RR=2.6, 95% CI: 1.04-6.3, p=0.04) was independently associated with linkage to HIV care. The main barrier to care reported by all groups was lack of time to access a clinic. CONCLUSION Screening for HIV, TB symptoms and hypertension at mobile units in South Africa has a high yield but inadequate linkage. After-hours and weekend clinics may overcome a major barrier to accessing care.
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Affiliation(s)
- Darshini Govindasamy
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Katharina Kranzer
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Nienke van Schaik
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Farzad Noubary
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts, United States of America
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts, United States of America
| | - Robin Wood
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Rochelle P. Walensky
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Divisions of General Medicine and Infectious Disease, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Division of Infectious Disease, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Harvard University Center for AIDS Research (CFAR), Boston, Massachusetts, United States of America
| | - Kenneth A. Freedberg
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Divisions of General Medicine and Infectious Disease, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard University Center for AIDS Research (CFAR), Boston, Massachusetts, United States of America
- Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Ingrid V. Bassett
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Divisions of General Medicine and Infectious Disease, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard University Center for AIDS Research (CFAR), Boston, Massachusetts, United States of America
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Wanyenze RK, Kamya MR, Fatch R, Mayanja-Kizza H, Baveewo S, Szekeres G, Bangsberg DR, Coates T, Hahn JA. Abbreviated HIV counselling and testing and enhanced referral to care in Uganda: a factorial randomised controlled trial. LANCET GLOBAL HEALTH 2013; 1:e137-45. [PMID: 25104262 PMCID: PMC4129546 DOI: 10.1016/s2214-109x(13)70067-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background HIV counselling and testing and linkage to care are crucial for successful HIV prevention and treatment. Abbreviated counselling could save time; however, its effect on HIV risk is uncertain and methods to improve linkage to care have not been studied. Methods We did this factorial randomised controlled study at Mulago Hospital, Uganda. Participants were randomly assigned to abbreviated or traditional HIV counselling and testing; HIV-infected patients were randomly assigned to enhanced linkage to care or standard linkage to care. All study personnel except counsellors and the data officer were masked to study group assignment. Participants had structured interviews, given once every 3 months. We compared sexual risk behaviour by counselling strategy with a 6·5% non-inferiority margin. We used Cox proportional hazards analyses to compare HIV outcomes by linkage to care over 1 year and tested for interaction by sex. This trial is registered with ClinicalTrials.gov (NCT00648232). Findings We enrolled 3415 participants; 1707 assigned to abbreviated counselling versus 1708 assigned to traditional. Unprotected sex with an HIV discordant or status unknown partner was similar in each group (232/823 [27·9%] vs 251/890 [28·2%], difference −0·3%, one-sided 95% CI 3·2). Loss to follow-up was lower for traditional counselling than for abbreviated counselling (adjusted hazard ratio [HR] 0·61, 95% CI 0·44–0·83). 1003 HIV-positive participants were assigned to enhanced linkage (n=504) or standard linkage to care (n=499). Linkage to care did not have a significant effect on mortality or receipt of co-trimoxazole. Time to treatment in men with CD4 cell counts of 250 cells per μL or fewer was lower for enhanced linkage versus standard linkage (adjusted HR 0·60, 95% CI 0·41–0·87) and time to HIV care was decreased among women (0·80, 0·66–0·96). Interpretation Abbreviated HIV counselling and testing did not adversely affect risk behaviour. Linkage to care interventions might decrease time to enrolment in HIV care and antiretroviral treatment and thus might affect secondary HIV transmission and improve treatment outcomes. Funding US National Institute of Mental Health.
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Affiliation(s)
- Rhoda K Wanyenze
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda.
| | - Moses R Kamya
- Department of Medicine, Makerere University School of Medicine, Kampala, Uganda
| | - Robin Fatch
- Department of Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA
| | | | - Steven Baveewo
- Department of Medicine, Makerere University School of Medicine, Kampala, Uganda
| | - Gregory Szekeres
- Division of Infectious Diseases, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA
| | - David R Bangsberg
- Massachusetts General Hospital Center for Global Health and Harvard Medical School, Boston, MA, USA
| | - Thomas Coates
- Division of Infectious Diseases, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA
| | - Judith A Hahn
- Department of Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA
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Provider-initiated testing and counselling programmes in sub-Saharan Africa: a systematic review of their operational implementation. AIDS 2013; 27:617-26. [PMID: 23364442 DOI: 10.1097/qad.0b013e32835b7048] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The routine offer of an HIV test during patient-provider encounters is gaining momentum within HIV treatment and prevention programmes. This review examined the operational implementation of provider-initiated testing and counselling (PITC) programmes in sub-Saharan Africa. DESIGN AND METHODS PUBMED, EMBASE, Global Health, COCHRANE Library and JSTOR databases were searched systematically for articles published in English between January 2000 and November 2010. Grey literature was explored through the websites of international and nongovernmental organizations. Eligibility of studies was based on predetermined criteria applied during independent screening by two researchers. RESULTS We retained 44 studies out of 5088 references screened. PITC polices have been effective at identifying large numbers of previously undiagnosed individuals. However, the translation of policy guidance into practice has had mixed results, and in several studies of routine programmes the proportion of patients offered an HIV test was disappointingly low. There were wide variations in the rates of acceptance of the test and poor linkage of those testing positive to follow-up assessments and antiretroviral treatment. The challenges encountered encompass a range of areas from logistics, to data systems, human resources and management, reflecting some of the weaknesses of health systems in the region. CONCLUSIONS The widespread adoption of PITC provides an unprecedented opportunity for identifying HIV-positive individuals who are already in contact with health services and should be accompanied by measures aimed at strengthening health systems and fostering the normalization of HIV at community level. The resources and effort needed to do this successfully should not be underestimated.
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Voss De Lima Y, Evans D, Page-Shipp L, Barnard A, Sanne I, Menezes CN, Van Rie A. Linkage to care and treatment for TB and HIV among people newly diagnosed with TB or HIV-associated TB at a large, inner city South African hospital. PLoS One 2013; 8:e49140. [PMID: 23341869 PMCID: PMC3547004 DOI: 10.1371/journal.pone.0049140] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Accepted: 10/03/2012] [Indexed: 01/16/2023] Open
Abstract
Objective To assess the outcomes of linkage to TB and HIV care and identify risk factors for poor referral outcomes. Design Cohort study of TB patients diagnosed at an urban hospital. Methods Linkage to care was determined by review of clinic files, national death register, and telephone contact, and classified as linked to care, delayed linkage to care (>7 days for TB treatment, >30 days for HIV care), or failed linkage to care. We performed log-binomial regression to identify patient and referral characteristics associated with poor referral outcomes. Results Among 593 TB patients, 23% failed linkage to TB treatment and 30.3% of the 77.0% who linked to care arrived late. Among 486 (86.9%) HIV-infected TB patients, 38.3% failed linkage to HIV care, and 32% of the 61.7% who linked to care presented late. One in six HIV-infected patients failed linkage to both TB and HIV care. Only 20.2% of HIV-infected patients were referred to a single clinic for integrated care. A referral letter was present in 90.3%, but only 23.7% included HIV status and 18.8% CD4 cell count. Lack of education (RR 1.85) and low CD4 count (CD4≤50 vs. >250cells/mm3; RR 1.66) were associated with failed linkage to TB care. Risk factors for failed linkage to HIV care were antiretroviral-naïve status (RR 1.29), and absence of referral letter with HIV or CD4 cell count (RR1.23). Conclusions Linkage to TB/HIV care should be strengthened by communication of HIV and CD4 results, ART initiation during hospitalization and TB/HIV integration at primary care.
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Affiliation(s)
- Yara Voss De Lima
- Clinical HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Denise Evans
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Antonia Barnard
- Gauteng Department of Health and Social Development, Johannesburg, South Africa
| | - Ian Sanne
- Clinical HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Colin N. Menezes
- Infectious Diseases Unit, Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Annelies Van Rie
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- * E-mail:
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Scanlon ML, Vreeman RC. Current strategies for improving access and adherence to antiretroviral therapies in resource-limited settings. HIV AIDS (Auckl) 2013; 5:1-17. [PMID: 23326204 PMCID: PMC3544393 DOI: 10.2147/hiv.s28912] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The rollout of antiretroviral therapy (ART) significantly reduced human immunodeficiency virus (HIV)-related morbidity and mortality, but good clinical outcomes depend on access and adherence to treatment. In resource-limited settings, where over 90% of the world's HIV-infected population resides, data on barriers to treatment are emerging that contribute to low rates of uptake in HIV testing, linkage to and retention in HIV care systems, and suboptimal adherence rates to therapy. A review of the literature reveals limited evidence to inform strategies to improve access and adherence with the majority of studies from sub-Saharan Africa. Data from observational studies and randomized controlled trials support home-based, mobile and antenatal care HIV testing, task-shifting from doctor-based to nurse-based and lower level provider care, and adherence support through education, counseling and mobile phone messaging services. Strategies with more limited evidence include targeted HIV testing for couples and family members of ART patients, decentralization of HIV care, including through home- and community-based ART programs, and adherence promotion through peer health workers, treatment supporters, and directly observed therapy. There is little evidence for improving access and adherence among vulnerable groups such as women, children and adolescents, and other high-risk populations and for addressing major barriers. Overall, studies are few in number and suffer from methodological issues. Recommendations for further research include health information technology, social-level factors like HIV stigma, and new research directions in cost-effectiveness, operations, and implementation. Findings from this review make a compelling case for more data to guide strategies to improve access and adherence to treatment in resource-limited settings.
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Affiliation(s)
- Michael L Scanlon
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- USAID, Academic Model Providing Access to Healthcare (AMPATH) Partnership, Eldoret, Kenya
| | - Rachel C Vreeman
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- USAID, Academic Model Providing Access to Healthcare (AMPATH) Partnership, Eldoret, Kenya
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Quantifying and addressing losses along the continuum of care for people living with HIV infection in sub-Saharan Africa: a systematic review. J Int AIDS Soc 2012. [PMID: 23199799 PMCID: PMC3503237 DOI: 10.7448/ias.15.2.17383] [Citation(s) in RCA: 243] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Introduction Recent years have seen an increasing recognition of the need to improve access and retention in care for people living with HIV/AIDS. This review aims to quantify patients along the continuum of care in sub-Saharan Africa and review possible interventions. Methods We defined the different steps making up the care pathway and quantified losses at each step between acquisition of HIV infection and retention in care on antiretroviral therapy (ART). We conducted a systematic review of data from studies conducted in sub-Saharan Africa and published between 2000 and June 2011 for four of these steps and performed a meta-analysis when indicated; existing data syntheses were used for the remaining two steps. Results The World Health Organization estimates that only 39% of HIV-positive individuals are aware of their status. Among patients who know their HIV-positive status, just 57% (95% CI, 48 to 66%) completed assessment of ART eligibility. Of eight studies using an ART eligibility threshold of≤200 cells/µL, 41% of patients (95% CI, 27% to 55%) were eligible for treatment, while of six studies using an ART eligibility threshold of≤350 cells/µL, 57% of patients (95% CI, 50 to 63%) were eligible. Of those not yet eligible for ART, the median proportion remaining in pre-ART care was 45%. Of eligible individuals, just 66% (95% CI, 58 to 73%) started ART and the proportion remaining on therapy after three years has previously been estimated as 65%. However, recent studies highlight that this is not a simple linear pathway, as patients cycle in and out of care. Published studies of interventions have mainly focused on reducing losses at HIV testing and during ART care, whereas few have addressed linkage and retention during the pre-ART period. Conclusions Losses occur throughout the care pathway, especially prior to ART initiation, and for some patients this is a transient event, as they may re-engage in care at a later time. However, data regarding interventions to address this issue are scarce. Research is urgently needed to identify effective solutions so that a far greater proportion of infected individuals can benefit from long-term ART.
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MacPherson P, Corbett EL, Makombe SD, van Oosterhout JJ, Manda E, Choko AT, Thindwa D, Squire SB, Mann GH, Lalloo DG. Determinants and consequences of failure of linkage to antiretroviral therapy at primary care level in Blantyre, Malawi: a prospective cohort study. PLoS One 2012; 7:e44794. [PMID: 22984560 PMCID: PMC3439373 DOI: 10.1371/journal.pone.0044794] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Accepted: 08/14/2012] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Poor rates of linkage from HIV diagnosis to ART initiation are a major barrier to universal coverage of ART in sub-Saharan Africa, with reasons for failure poorly understood. In the first study of this kind at primary care level, we investigated the pathway to care in the Malawian National Programme, one of the strongest in Africa. METHODS AND FINDINGS A prospective cohort study was undertaken at two primary care clinics in Blantyre, Malawi. Newly diagnosed HIV-positive adults (>15 years) were followed for 6-months to assess completion of eligibility assessments, initiation of ART and death. Two hundred and eighty participants were followed for 82.6 patient-years. ART eligibility assessments were problematic: only 134 (47.9%) received same day WHO staging and 121 (53.2%) completed assessments by 6-months. Completion of CD4 measurement (stage 1/2 only) was 81/153 (52.9%). By 6-months, 87/280 (31.1%) had initiated ART with higher uptake in participants who were ART eligible (68/91, 74.7%), and among participants who received same-day staging (52/134 [38.8%] vs. 35/146 [24.0%] p = 0.007). Non-completion of ART eligibility assessments (adjusted hazard ratio: 0.11, 95% CI: 0.06-0.21) was associated with failure to initiate ART. Retention in pre-ART care for non-ART initiators was low (55/193 [28.5%]). Of the 15 (5.4%) deaths, 11 (73.3%) occurred after ART initiation. CONCLUSIONS Although uptake of ART was high and prompt for patients with known eligibility, there was frequent failure to complete eligibility assessment and poor retention in pre-ART care. HIV care programmes should urgently evaluate the way patients are linked to ART. In particular, there is a critical need for simplified, same-day ART eligibility assessments, reduced requirements for hospital visits, and active defaulter follow-up.
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Affiliation(s)
- Peter MacPherson
- Clinical Group, Liverpool School of Tropical Medicine, Liverpool, Merseyside, United Kingdom.
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Peterson K, van Griensven J, Huis in 't Veld D, Colebunders R. Interventions to reduce mortality in sub-Saharan Africa among HIV-infected adults not yet on antiretroviral therapy. Expert Rev Anti Infect Ther 2012; 10:43-50. [PMID: 22149613 DOI: 10.1586/eri.11.151] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Where antiretroviral therapy is available, the primary source of mortality among HIV-infected people is the delay in starting treatment. Many of these delays occur in the context of care and are modifiable through changes in the protocols followed by healthcare providers for HIV testing, staging and preparation of patients for antiretroviral therapy. A number of potential evidence-based interventions are discussed in the context of sub-Saharan Africa. Included are decentralizing services, initiating counseling on antiretroviral therapy without delay, tracing patients that miss appointments, protecting patient confidentiality, reducing user fees, and providing point-of-care tests for CD4 cell counts, cryptococcal antigen, and for the diagnosis of TB.
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Affiliation(s)
- Kevin Peterson
- Institute for Tropical Medicine, Nationalestraat 155, 2000 Antwerpen, Belgium.
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Hatcher AM, Turan JM, Leslie HH, Kanya LW, Kwena Z, Johnson MO, Shade SB, Bukusi EA, Doyen A, Cohen CR. Predictors of linkage to care following community-based HIV counseling and testing in rural Kenya. AIDS Behav 2012; 16:1295-307. [PMID: 22020756 DOI: 10.1007/s10461-011-0065-1] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Despite innovations in HIV counseling and testing (HCT), important gaps remain in understanding linkage to care. We followed a cohort diagnosed with HIV through a community-based HCT campaign that trained persons living with HIV/AIDS (PLHA) as navigators. Individual, interpersonal, and institutional predictors of linkage were assessed using survival analysis of self-reported time to enrollment. Of 483 persons consenting to follow-up, 305 (63.2%) enrolled in HIV care within 3 months. Proportions linking to care were similar across sexes, barring a sub-sample of men aged 18-25 years who were highly unlikely to enroll. Men were more likely to enroll if they had disclosed to their spouse, and women if they had disclosed to family. Women who anticipated violence or relationship breakup were less likely to link to care. Enrollment rates were significantly higher among participants receiving a PLHA visit, suggesting that a navigator approach may improve linkage from community-based HCT campaigns.
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Affiliation(s)
- Abigail M Hatcher
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, 50 Beale Street, Suite 1200, San Francisco, CA 94105, USA.
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Siedner MJ, Lankowski A, Haberer JE, Kembabazi A, Emenyonu N, Tsai AC, Muzoora C, Geng E, Martin JN, Bangsberg DR. Rethinking the "pre" in pre-therapy counseling: no benefit of additional visits prior to therapy on adherence or viremia in Ugandans initiating ARVs. PLoS One 2012; 7:e39894. [PMID: 22761924 PMCID: PMC3383698 DOI: 10.1371/journal.pone.0039894] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Accepted: 05/28/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Many guidelines recommend adherence counseling prior to initiating antiretrovirals (ARVs), however the additional benefit of pre-therapy counseling visits on early adherence is not known. We sought to assess for a benefit of adherence counseling visits prior to ARV initiation versus adherence counseling during the early treatment period. METHODS We performed a secondary analysis of data from a prospective cohort of HIV-infected patients in Mbarara, Uganda. Adults were enrolled upon initiation of ARVs. Our primary exposure of interest was ARV adherence counseling prior to initiating therapy (versus concurrent with initiation of therapy). Our outcomes of interest were: 1) average adherence >90% in first three months; 2) absence of treatment interruptions >72 hours in first three months; and 3) Viral load >400 copies/ml at the three month visit. We fit univariable and multivariable regression models, adjusted for predictors of ARV adherence, to estimate the association between additional pre-therapy counseling visits and our outcomes. RESULTS 300 participants had records of counseling, of whom 231 (77%) completed visits prior to initiation of ARVs and 69 (23%) on or shortly after initiation. Median age was 33, 71% were female, and median CD4 was 133 cell/ml. Median 90-day adherence was 95%. Participants who completed pre-therapy counseling visits had longer delays from ARV eligibility to initiation (median 49 vs 14 days, p<0.01). In multivariable analyses, completing adherence counseling prior to ARV initiation was not associated with average adherence >90% (AOR 0.8, 95%CI 0.4-1.5), absence of treatment gaps (AOR 0.7, 95%CI 0.2-1.9), or HIV viremia (AOR 1.1, 95%CI 0.4-3.1). CONCLUSIONS Completion of adherence counseling visits prior to ARV therapy was not associated with higher adherence in this cohort of HIV-infected patients in Uganda. Because mortality and loss-to-follow-up remain high in the pre-ARV period, policy makers should reconsider whether counseling can be delivered with ARV initiation, especially in patients with advanced disease.
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Affiliation(s)
- Mark J Siedner
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America.
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Norton WE. An exploratory study to examine intentions to adopt an evidence-based HIV linkage-to-care intervention among state health department AIDS directors in the United States. Implement Sci 2012; 7:27. [PMID: 22471965 PMCID: PMC3348078 DOI: 10.1186/1748-5908-7-27] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2011] [Accepted: 04/02/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Widespread dissemination and implementation of evidence-based human immunodeficiency virus (HIV) linkage-to-care (LTC) interventions is essential for improving HIV-positive patients' health outcomes and reducing transmission to uninfected others. To date, however, little work has focused on identifying factors associated with intentions to adopt LTC interventions among policy makers, including city, state, and territory health department AIDS directors who play a critical role in deciding whether an intervention is endorsed, distributed, and/or funded throughout their region. METHODS Between December 2010 and February 2011, we administered an online questionnaire with state, territory, and city health department AIDS directors throughout the United States to identify factors associated with intentions to adopt an LTC intervention. Guided by pertinent theoretical frameworks, including the Diffusion of Innovations and the "push-pull" capacity model, we assessed participants' attitudes towards the intervention, perceived organizational and contextual demand and support for the intervention, likelihood of adoption given endorsement from stakeholder groups (e.g., academic researchers, federal agencies, activist organizations), and likelihood of enabling future dissemination efforts by recommending the intervention to other health departments and community-based organizations. RESULTS Forty-four participants (67% of the eligible sample) completed the online questionnaire. Approximately one-third (34.9%) reported that they intended to adopt the LTC intervention for use in their city, state, or territory in the future. Consistent with prior, related work, these participants were classified as LTC intervention "adopters" and were compared to "nonadopters" for data analysis. Overall, adopters reported more positive attitudes and greater perceived demand and support for the intervention than did nonadopters. Further, participants varied with their intention to adopt the LTC intervention in the future depending on endorsement from different key stakeholder groups. Most participants indicated that they would support the dissemination of the intervention by recommending it to other health departments and community-based organizations. CONCLUSIONS Findings from this exploratory study provide initial insight into factors associated with public health policy makers' intentions to adopt an LTC intervention. Implications for future research in this area, as well as potential policy-related strategies for enhancing the adoption of LTC interventions, are discussed.
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Affiliation(s)
- Wynne E Norton
- Department of Health Behavior, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA.
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Bärnighausen T, Tanser F, Dabis F, Newell ML. Interventions to improve the performance of HIV health systems for treatment-as-prevention in sub-Saharan Africa: the experimental evidence. Curr Opin HIV AIDS 2012; 7:140-50. [PMID: 22248917 PMCID: PMC4300338 DOI: 10.1097/coh.0b013e32834fc1df] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
PURPOSE OF REVIEW To reduce HIV incidence, treatment-as-prevention (TasP) requires high rates of HIV testing, and antiretroviral treatment (ART) uptake, retention, and adherence, which are currently not achieved in general populations in sub-Saharan Africa. We review the experimental evidence on interventions to increase these rates. RECENT FINDINGS In four rapid reviews, we found nine randomized controlled trials (RCTs) on HIV-testing uptake, two on ART uptake, one on ART retention, and 15 on ART adherence in sub-Saharan Africa. Only two RCTs on HIV testing investigated an intervention in general populations; the other examined interventions in selected groups (employees, or individuals attending public-sector facilities for services). One RCT demonstrated that nurse-managed ART led to the same retention rates as physician-managed ART, but failed to show how to increase retention to the rates required for successful TasP. Although the evidence on ART adherence is strongest - several RCTs demonstrate the effectiveness of cognitive and behavioural interventions - contradictory results in different settings suggest that the precise intervention content, or the context, are crucial for effectiveness. SUMMARY Future studies need to test the effectiveness of interventions to increase testing and treatment uptake, retention, and adherence under TasP, that is, ART for all HIV-infected individuals, independent of disease stage.
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Affiliation(s)
- Till Bärnighausen
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Mtubatuba, KwaZulu-Natal, South Africa.
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Burtle D, Welfare W, Elden S, Mamvura C, Vandelanotte J, Petherick E, Walley J, Wright J. Introduction and evaluation of a 'pre-ART care' service in Swaziland: an operational research study. BMJ Open 2012; 2:e000195. [PMID: 22422913 PMCID: PMC3307034 DOI: 10.1136/bmjopen-2011-000195] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To implement and evaluate a formal pre-antiretroviral therapy (ART) care service at a district hospital in Swaziland. DESIGN Operational research. SETTING District hospital in Southern Africa. PARTICIPANTS 1171 patients with a previous diagnosis of HIV. A baseline patient group consisted of the first 200 patients using the service. Two follow-up groups were defined: group 1 was all patients recruited from April to June 2009 and group 2 was 200 patients recruited in February 2010. INTERVENTION Introduction of pre-ART care-a package of interventions, including counselling; regular review; clinical staging; timely initiation of ART; social and psychological support; and prevention and management of opportunistic infections, such as tuberculosis. PRIMARY AND SECONDARY OUTCOME MEASURES Proportion of patients assessed for ART eligibility, proportion of eligible patients who were started on ART and proportion receiving defined evidence-based interventions (including prophylactic co-trimoxazole and tuberculosis screening). RESULTS Following the implementation of the pre-ART service, the proportion of patients receiving defined interventions increased; the proportion of patient being assessed for ART eligibility significantly increased (baseline: 59%, group 1: 64%, group 2: 76%; p=0.001); the proportion of ART-eligible patients starting treatment increased (baseline: 53%, group 1: 81%, group: 2, 81%; p<0.001) and the median time between patients being declared eligible for ART and initiation of treatment significantly decreased (baseline: 61 days, group 1: 39 days, group 2: 14 days; p<0.001). CONCLUSIONS This intervention was part of a shift in the model of care from a fragmented acute care model to a more comprehensive service. The introduction of structured pre-ART was associated with significant improvements in the assessment, management and timeliness of initiation of treatment for patients with HIV.
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Affiliation(s)
- David Burtle
- Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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HIV Diagnosis, Linkage to HIV Care, and HIV Risk Behaviors Among Newly Diagnosed HIV-Positive Female Sex Workers in Kigali, Rwanda. J Acquir Immune Defic Syndr 2011; 57:e70-6. [PMID: 21407083 DOI: 10.1097/qai.0b013e3182170fd3] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Wanyenze RK, Kamya MR, Fatch R, Mayanja-Kizza H, Baveewo S, Sawires S, Bangsberg DR, Coates T, Hahn JA. Missed opportunities for HIV testing and late-stage diagnosis among HIV-infected patients in Uganda. PLoS One 2011; 6:e21794. [PMID: 21750732 PMCID: PMC3130049 DOI: 10.1371/journal.pone.0021794] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2010] [Accepted: 06/11/2011] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Late diagnosis of HIV infection is a major challenge to the scale-up of HIV prevention and treatment. In 2005 Uganda adopted provider-initiated HIV testing in the health care setting to ensure earlier HIV diagnosis and linkage to care. We provided HIV testing to patients at Mulago hospital in Uganda, and performed CD4 tests to assess disease stage at diagnosis. METHODS Patients who had never tested for HIV or tested negative over one year prior to recruitment were enrolled between May 2008 and March 2010. Participants who tested HIV positive had a blood draw for CD4. Late HIV diagnosis was defined as CD4≤250 cells/mm. Predictors of late HIV diagnosis were analyzed using multi-variable logistic regression. RESULTS Of 1966 participants, 616 (31.3%) were HIV infected; 47.6% of these (291) had CD4 counts ≤250. Overall, 66.7% (408) of the HIV infected participants had never received care in a medical clinic. Receiving care in a non-medical setting (home, traditional healer and drug stores) had a threefold increase in the odds of late diagnosis (OR = 3.2; 95%CI: 2.1-4.9) compared to receiving no health care. CONCLUSIONS Late HIV diagnosis remains prevalent five years after introducing provider-initiated HIV testing in Uganda. Many individuals diagnosed with advanced HIV did not have prior exposure to medical clinics and could not have benefitted from the expansion of provider initiated HIV testing within health facilities. In addition to provider-initiated testing, approaches that reach individuals using non-hospital based encounters should be expanded to ensure early HIV diagnosis.
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Affiliation(s)
- Rhoda K Wanyenze
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda.
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Rosen S, Fox MP. Retention in HIV care between testing and treatment in sub-Saharan Africa: a systematic review. PLoS Med 2011; 8:e1001056. [PMID: 21811403 PMCID: PMC3139665 DOI: 10.1371/journal.pmed.1001056] [Citation(s) in RCA: 602] [Impact Index Per Article: 46.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2011] [Accepted: 05/31/2011] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Improving the outcomes of HIV/AIDS treatment programs in resource-limited settings requires successful linkage of patients testing positive for HIV to pre-antiretroviral therapy (ART) care and retention in pre-ART care until ART initiation. We conducted a systematic review of pre-ART retention in care in Africa. METHODS AND FINDINGS We searched PubMed, ISI Web of Knowledge, conference abstracts, and reference lists for reports on the proportion of adult patients retained between any two points between testing positive for HIV and initiating ART in sub-Saharan African HIV/AIDS care programs. Results were categorized as Stage 1 (from HIV testing to receipt of CD4 count results or clinical staging), Stage 2 (from staging to ART eligibility), or Stage 3 (from ART eligibility to ART initiation). Medians (ranges) were reported for the proportions of patients retained in each stage. We identified 28 eligible studies. The median proportion retained in Stage 1 was 59% (35%-88%); Stage 2, 46% (31%-95%); and Stage 3, 68% (14%-84%). Most studies reported on only one stage; none followed a cohort of patients through all three stages. Enrollment criteria, terminology, end points, follow-up, and outcomes varied widely and were often poorly defined, making aggregation of results difficult. Synthesis of findings from multiple studies suggests that fewer than one-third of patients testing positive for HIV and not yet eligible for ART when diagnosed are retained continuously in care, though this estimate should be regarded with caution because of review limitations. CONCLUSIONS Studies of retention in pre-ART care report substantial loss of patients at every step, starting with patients who do not return for their initial CD4 count results and ending with those who do not initiate ART despite eligibility. Better health information systems that allow patients to be tracked between service delivery points are needed to properly evaluate pre-ART loss to care, and researchers should attempt to standardize the terminology, definitions, and time periods reported.
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Affiliation(s)
- Sydney Rosen
- Center for Global Health and Development, Boston University, Boston, Massachusetts, USA.
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