Barriers and Facilitators to Interventions Improving Retention in HIV Care: A Qualitative Evidence Meta-Synthesis

Perceptions and attitudes towards unmanned aerial vehicles (drones) use for delivery of HIV medication among fisher folk communities on the Islands of Kalangala, Uganda

The study aimed to assess the attitudes of stakeholders towards the use of unmanned aerial vehicles (medical drones) for delivering antiretroviral therapy (ART) in the Kalangala district of Uganda, which is comprised of 84 islands and has approximately 18,500 People Living with HIV (PLHIV). A qualitative baseline study was conducted to assess the acceptability and feasibility of using a medical drone for ART delivery in the island settlements of Kalangala Islands. The data revealed four emerging themes: knowledge about the drones, perceived benefits of medical drone delivery, perceived risks of medical drone use, and recommendations for future use. The study found that most participants, especially healthcare workers and key opinion leaders, were aware of the medical drones, which could reduce transport costs, deliver medication on time, and reduce healthcare workers' workload. However, there were also perceived risks related to the use of medical drones, such as stigma, reduced contact with healthcare providers, and maintenance and security issues. The study provided evidence that medical drones would be acceptable and have support from various stakeholders in the island settlements for ART delivery. However, concerns were raised about potential stigma and less health worker interaction. This qualitative work allowed the team to address these concerns during the pilot phase.

Study APV20002: Safety and Efficacy Results Through Week 684 for Pediatric Participants Living with HIV-1 Treated with Ritonavir-Boosted Fosamprenavir Oral Solution-Based Antiretroviral Therapy

APV20002 was a multicenter, international, open-label study that began in 2003 investigating the pharmacokinetics, efficacy, and safety of ritonavir-boosted fosamprenavir (FPV/r) oral solution (OS) in combination with nucleoside reverse transcriptase inhibitor-based antiretroviral therapy (ART) in participants living with HIV-1 aged 4 weeks to <2 years with a primary endpoint at Week 48 (48W). Participants in APV20002 could continue in the study post-48W until FPV OS was locally available in their countries. Children were required to discontinue after reaching >39 kg or if FPV OS had no clinical benefit. Fifty-nine participants were enrolled; 5/59 received a single FPV OS visit for pharmacokinetic determinations. Most (38/54; 70%) were antiretroviral experienced; 39/59 participants had >48 weeks on treatment, 4/39 of whom discontinued after 48 weeks due to an adverse event (AE). At 48W, 88% of participants had HIV-1 RNA <400 copies/mL by Observed analysis; the proportion with HIV-1 RNA <400 copies/mL remained high (84%-100%) through Week 684. The median CD4+ cell count was 1,235 cells/mm3 [n = 51] at baseline, 1,690 cells/mm3 (n = 41) at Week 48, and 1,280 cells/mm3 (n = 21) at Week 180. From baseline to Week 684, 54/59 (92%) participants had ≥1 treatment-emergent AE regardless of causality; 42/59 (71%) had a treatment-emergent grade 2-4 AE, predominantly maximum toxicity: grade 2; 21/59 (36%) and 21/59 (36%) had severe or grade 3/4 AEs. From baseline to Week 684, 14/54 (26%) participants met virologic failure (VF) criteria, 9/14 before 48W. HIV from 1/9 VFs through 48W developed treatment-emergent reduced susceptibility to FPV and 1/9 to lamivudine/emtricitabine. Post-48W, 4/5 participants with VF had phenotype results; all were still susceptible to all study drugs at VF. In conclusion, FPV OS-based ART was efficacious and generally well tolerated in this long-running pediatric study through 684 weeks of treatment, with a safety profile consistent with experience in adults and older children.

Disengagement from Care Among People Co-Infected with HIV and HCV: A Scoping Review

Disengagement from care among people with HIV (PWH) and hepatitis C (HCV) increases the risks of adverse health outcomes and poses significant barriers to achieving global HIV and HCV elimination goals. In accordance with the Joanna Briggs Institute framework, a scoping review was conducted to synthesize and highlight existing gaps in the literature on (dis)engagement in care among PWH and HCV. We searched for original studies on (dis)engagement in care among PWH and HCV in high-income countries using eight electronic databases from inception to May 2023. Our search yielded 4462 non-duplicated records, which were scoped to 27 studies. Definitions of (dis)engagement in care were diverse, with considerable heterogeneity in how retention was operationalized and temporally measured. Studies identified predictors of (dis)engagement to be related to drug and substance use (n = 5 articles), clinical factors (n = 5), social and welfare (n = 4), and demographic characteristics (n = 2). When engagement in care was treated as an exposure, it was associated with HCV treatment initiation (n = 3), achieving sustained virological response (n = 2), and maintaining HIV viral suppression (n = 1). Interventions to improve care engagement among PWH and HCV were limited to five studies using cash incentives (n = 1) and individual case management (n = 4). (Dis)engagement in care is a dynamic process influenced by shifting priorities that may 'tip the balance' towards or away from regularly interacting with healthcare professionals. However, inconsistent definitions render cross-study comparisons and meta-analyses virtually impossible. Further research needs to establish a standardized definition to identify patients at high risk of disengagement and develop interventions that leverage the nested HIV/HCV care cascades to retain and recover patients lost from care.

Barriers and facilitators to implementing evidence-based integrated HIV and behavioral health care: perspectives from seven federal ending the HIV epidemic jurisdictions

The federal Ending the HIV Epidemic (EHE) initiative was created to reduce new US HIV infections, largely through pre-exposure prophylaxis and HIV treatments that reduce HIV transmissibility to zero. Behavioral health disorders (mental health and substance use) remain significant barriers to achieving EHE goals. Addressing behavioral health (BH) disorders within HIV primary care settings has been promoted as a critical EHE strategy. Implementation of efficacious HIV-BH care integration and its impact on HIV-related health outcomes is not well documented. In a federally-funded, exploratory phase implementation science study, we used the Collective Impact Framework to engage partners in seven EHE jurisdictions about the feasibility, acceptability, and sustainability of implementing HIV-BH integration interventions within local HIV settings. Partners concluded that full integration will remain the exception unless health systems invest in collaborative practice, professional training, appropriate health technology, and inter-system communication. Partners supported smaller incremental improvements including transdiagnostic approaches to reinforce each team member's sense of value in the shared endeavor. This early phase implementation science study identified research and implementation gaps that are critical to fill to end the HIV epidemic. Both the Collective Impact Framework and implementation science show promise for guiding future implementation of evidence-based HIV-BH intervention integration.

St. Louis Enhancing Engagement and Retention in HIV/AIDS Care (STEER): a participatory intersectional needs assessment for intervention and implementation planning

Background Missouri is one of seven priority states identified by the Ending the HIV Epidemic Initiative, and St. Louis contains almost half of the people living with HIV (PLWH) in Missouri. As St. Louis has a marked history of structural racism and economic inequities, we utilized the Intersectionality Based Policy Analysis (IBPA) framework to guide a participatory needs assessment for planning and program development. Methods The planning team included researchers, the lead implementer from our community partner, and two community representatives, and had biweekly 60-90 minute meetings for 18 months. The planning team discussed and approved all research materials, reviewed and interpreted results, and made decisions about outreach, recruitment, conduct of the needs assessment and development of the planned intervention. The needs assessment integrated information from existing data, (1) interviews with (a) PLWH (n=12), (b) community leaders (n=5), (c) clinical leaders (n=4), and (d) community health workers (CHWs) (n=3) and (e) CHW supervisors (n=3) who participated in a Boston University-led demonstration project on CHWs in the context of HIV and (2) focus groups (2 FG, 12 participants) with front line health workers such as peer specialists, health coaches and outreach workers. A rapid qualitative analysis approach was used for all interviews and focus groups. Results The IBPA was used to guide team discussions of team values, definition and framing of the problem, questions and topics in the key informant interviews, and implementation strategies. Applying the IBPA framework contributed to a focus on intersectional drivers of inequities in HIV services. The effective management of HIV faces significant challenges from high provider turnover, insufficient integration of CHWs into care teams, and organizational limitations in tailoring treatment plans. Increasing use of CHWs for HIV treatment and prevention also faces challenges. People living with HIV (PLWH) encounter multiple barriers such as stigma, lack of social support, co-morbidities, medication side effects and difficulties in meeting basic needs. Conclusions Addressing intersectional drivers of health inequities may require multi-level, structural approaches. We see the IBPA as a valuable tool for participatory planning while integrating community engagement principles in program and implementation design for improving HIV outcomes.

Cost-effectiveness analysis of two-way texting (2wT) intervention to improve ART retention among newly-initiated antiretroviral therapy clients in Malawi

Background

Retention in HIV care is crucial for improved health outcomes. Malawi has a high HIV prevalence and struggles with retention despite significant progress in controlling the epidemic. Mobile health (mHealth) interventions, such as two-way texting (2wT), have shown promise in improving anti-retroviral therapy (ART) retention. We explore the cost-effectiveness of a 2wT intervention in Lighthouse Trust's Martin Preuss Center (MPC) in Lilongwe, Malawi, that sends automated SMS visit reminders, weekly motivational messages, and supports direct communication between clients and healthcare workers.

Methods

Costs and retention rates were compared between 2wT and standard of care (SOC) for 468 clients enrolled in each. Incremental cost-effectiveness ratios (ICERs) were calculated. Scenario analyses were conducted to estimate costs if 2wT expanded.

Results

The 2wT group had higher retention (80%) than SOC (67%) at 12 months post-ART initiation. For 468 clients, the total annual costs for 2wT were $36,670.38 as compared to SOC costs at $33,458.72, resulting in an ICER of $24,705. Among scenarios, the ICER was -$105,315 if 2wT expanded to all new clients (2678 at MPC and -$723,739 as 2wT expanded to other four high-burden facilities (2901 clients), suggesting high cost savings if 2wT was effectively scaled.

Conclusion

The 2wT intervention appears cost-effective to improve ART retention among new ART initiates in a high-burden ART clinic. While mHealth interventions have potential limitations, their benefits in improving patient outcomes and cost savings support their integration into HIV care programs.

Predicting Lost to Follow-Up Status Using an Adolescent HIV Psychosocial Attrition Risk Assessment Tool: Results From a Mixed Methods Prospective Cohort Study in Uganda

BACKGROUND

Low retention in care for adolescents living with HIV (ALHIV) has been a key driver of suboptimal viral load suppression rates in Uganda. The objective of this study was to develop a psychosocial risk assessment tool and evaluate its ability to predict the risk of attrition of ALHIV between the ages 15 and 19 years.

SETTING

The study was conducted in 20 facilities in Central and Western Uganda from August 2021 through July 2022.

METHODS

A mixed methods prospective cohort study was conducted in two phases. In the first phase, the Adolescent Psychosocial Attrition Risk Assessment tool was developed and revised using feedback from focus group discussions and interviews. In the second phase, the ability of the Adolescent Psychosocial Attrition Risk Assessment tool to predict attrition among ALHIV was evaluated using diagnostic accuracy tests.

RESULTS

A total of 597 adolescents between the ages 15 and 19 years were enrolled, of which 6% were lost to follow-up at the end of the study period. A 20-question tool was developed, with 12 questions being responded to affirmatively by >50% of all participants. Using a cut-off score of 6 or more affirmative answers translated to an area under the curve of 0.58 (95% CI: 0.49 to 0.66), sensitivity of 55% (95% CI: 36% to 72%), and specificity of 61% (95% CI: 56% to 65%).

CONCLUSION

Although the Adolescent Psychosocial Attrition Risk Assessment tool was not effective at predicting lost to follow-up status among ALHIV, the tool was useful for identifying psychosocial issues experienced by ALHIV and may be appropriate to administer during routine care visits to guide action.

Exploring experiences of HIV care to optimize patient-centred care in Conakry, Guinea: a qualitative study

Introduction

Studies on the organisation of care and the power dynamic between providers and patients with HIV in sub-Saharan Africa are rare. This study aims to describe the patient-provider relationship and explore the challenges to optimal and patient-centred care for HIV patients.

Methods

This was a qualitative exploratory descriptive study using in-depth individual interviews and focus group discussions. In total, 17 individual interviews and 5 focus group discussions were conducted. This was conducted in four urban health facilities in Conakry, the capital of Guinea. Three group of participants were included in this study namely patients with HIV; health providers including facilities and services managers; and psychosocial counsellors. Psychosocial counsellors provide emotional and psychosocial support to HIV patients. Their role in the organization care in Guinea is new and they contribute to strengthening adherence of patients with HIV to ARV treatment.

Results

Patients with HIV, health providers, and psychosocial counsellors have a positive perception of the patient-provider relationship. This relationship was characterized essentially by maintaining confidentiality of HIV status disclosure, caring attitudes towards patients (being available, adjusting locations for accessing ART, based on patients' preferences), and participating in HIV patient's social life. However, scolding and miscommunication about the interpretation of viral load tests were reported. The shortage of human resources, low salaries of health staff, poor infrastructure, and the financial burden borne by patients with HIV impede the implementation of optimal patient-centred care.

Conclusion

Integrating psychosocial counsellors in HIV care organization, improving access to ARV, infrastructure, increasing human resources, and removing the financial burden for HIV patients are needed to optimal patient-centred care in Guinea.

Improving access to HIV care among people who inject drugs through tele-harm reduction: a qualitative analysis of perceived discrimination and stigma

BACKGROUND

Tele-harm reduction (THR) is a telehealth-enhanced, peer-led, harm reduction intervention delivered within a trusted syringe services program (SSP) venue. The primary goal of THR is to facilitate linkage to care and rapid, enduring virologic suppression among people who inject drugs (PWID) with HIV. An SSP in Miami, Florida, developed THR to circumvent pervasive stigma within the traditional healthcare system.

METHODS

During intervention development, we conducted in-depth interviews with PWID with HIV (n = 25) to identify barriers and facilitators to care via THR. We employed a general inductive approach to transcripts guided by iterative readings of the raw data to derive the concepts, themes, and interpretations of the THR intervention.

RESULTS

Of the 25 PWID interviewed, 15 were in HIV care and adherent to medication; 4 were in HIV care but non-adherent; and 6 were not in care. Themes that emerged from the qualitative analysis included the trust and confidence PWID have with SSP clinicians as opposed to professionals within the traditional healthcare system. Several barriers to treatment were reported among PWID, including perceived and actual discrimination by friends and family, negative internalized behaviors, denial of HIV status, and fear of engaging in care. Facilitators to HIV care included empathy and respect by SSP staff, flexibility of telehealth location, and an overall destigmatizing approach.

CONCLUSION

PWID identified barriers and facilitators to receipt of HIV care through the THR intervention. Interviews helped inform THR intervention development, centered on PWID in the destigmatizing environment of an SSP.

Barriers to longitudinal follow-up for hepatitis B treatment in rural Sierra Leone: A mixed methods study of retention in care

HBV disproportionately affects resource-limited settings, and retaining patients in longitudinal care remains challenging. We conducted a mixed methods investigation to understand the causes of losses to follow-up within an HBV clinic in rural Sierra Leone. We developed a multivariable logistic regression model of baseline clinical and sociodemographic factors predicting losses to follow-up, defined as failing to present for a follow-up visit within 14 months of enrollment. We included patients enrolled between April 30, 2019 and March 1, 2020, permitting 14 months of follow-up by April 30, 2021. We then developed a survey to solicit patient perspectives on the challenges surrounding retention. We interviewed randomly selected patients absent from HBV care for at least 6 months. Among 271 patients enrolled in the Kono HBV clinic, 176 (64.9%) did not have a follow-up visit within 14 months of the study end point. Incomplete baseline workup (aOR 2.9; 95% CI: 1.6-4.8), lack of treatment at baseline (aOR 5.0; 95% CI: 1.7-14.4), and having cirrhosis at baseline (aOR 3.3; 95% CI: 0.99-10.8) were independently associated with being lost to follow-up. For the patient survey, 21 patients completed the interview (median age 34 years [IQR: 25-38]). Travel-related factors were the most frequently reported barrier to retention (57%). Almost 30% suggested improved customer care might support retention in care; 24% requested to be given medication. In our setting, factors that might reduce losses to follow-up included expanded criteria for treatment initiation, overcoming transportation barriers, reducing wait times, ensuring against stockouts, and scaling up point-of-care testing services.

Effects of economic interventions on pediatric and adolescent HIV care outcomes: a systematic review

Economic insecurity and poverty present major barriers to HIV care for young people. We conducted a systematic review of the current evidence for the effect of economic interventions on HIV care outcomes among pediatric populations encompassing young children, adolescents, and youth (ages 0-24). We conducted a search of PubMed MEDLINE, Cochrane, Embase, Scopus, CINAHL, and Global Health databases on October 12, 2022 using a search strategy curated by a medical librarian. Studies included economic interventions targeting participants <25 years in age which measured clinical HIV outcomes. Study characteristics, care outcomes, and quality were independently assessed, and findings were synthesized. Title/abstract screening was performed for 1934 unique records. Thirteen studies met inclusion criteria, reporting on nine distinct interventions. Economic interventions included incentives (n = 5), savings and lending programs (n = 3), and government cash transfers (n = 1). Study designs included three randomized controlled trials, an observational cohort study, a matched retrospective cohort study, and pilot intervention studies. While evidence is very limited, some promising findings were observed supporting retention and viral suppression, particularly for those with suboptimal care engagement or with detectable viral load. There is a need to further study and optimize economic interventions for children and adolescents living with HIV.

A community-based dynamic choice model for HIV prevention improves PrEP and PEP coverage in rural Uganda and Kenya: a cluster randomized trial

INTRODUCTION

Optimizing HIV prevention may require structured approaches for providing client-centred choices as well as community-based entry points and delivery. We evaluated the effect of a dynamic choice model for HIV prevention, delivered by community health workers (CHWs) with clinician support, on the use of biomedical prevention among persons at risk of HIV in rural East Africa.

METHODS

We conducted a cluster randomized trial among persons (≥15 years) with current or anticipated HIV risk in 16 villages in Uganda and Kenya (SEARCH; NCT04810650). The intervention was a client-centred HIV prevention model, including (1) structured client choice of product (pre-exposure prophylaxis [PrEP] or post-exposure prophylaxis [PEP]), service location (clinic or out-of-clinic) and HIV testing modality (self-test or rapid test), with the ability to switch over time; (2) a structured assessment of patient barriers and development of a personalized support plan; and (3) phone access to a clinician 24/7. The intervention was delivered by CHWs and supported by clinicians who oversaw PrEP and PEP initiation and monitoring. Participants in control villages were referred to local health facilities for HIV prevention services, delivered by Ministry of Health staff. The primary outcome was biomedical prevention coverage: a proportion of 48-week follow-up with self-reported PrEP or PEP use.

RESULTS

From May to July 2021, we enrolled 429 people (212 intervention; 217 control): 57% women and 35% aged 15-24 years. Among intervention participants, 58% chose PrEP and 58% chose PEP at least once over follow-up; self-testing increased from 52% (baseline) to 71% (week 48); ≥98% chose out-of-facility service delivery. Among 413 (96%) participants with the primary outcome ascertained, average biomedical prevention coverage was 28.0% in the intervention versus 0.5% in the control: a difference of 27.5% (95% CI: 23.0-31.9%, p<0.001). Impact was larger during periods of self-reported HIV risk: 36.6% coverage in intervention versus 0.9% in control, a difference of 35.7% (95% CI: 27.5-43.9, p<0.001). Intervention effects were seen across subgroups defined by sex, age group and alcohol use.

CONCLUSIONS

A client-centred dynamic choice HIV prevention intervention, including the option to switch between products and CHW-based delivery in the community, increased biomedical prevention coverage by 27.5%. However, substantial person-time at risk of HIV remained uncovered.

"CoviSainik Program" - A Novel Public Private Partnership Initiative in the Control of COVID-19 in Rural India

Background

"CoviSainik Program" was implemented in collaboration with the Ambuja Cement Foundation and Community Medicine Department in rural districts of eight states of India from May to December 2021 to create a cadre of volunteers. The aim of the present paper is to describe the program and evaluate it so that the findings can be the guiding tool for policymakers to replicate a similar program.

Material and Method

A cross-sectional, mixed-method - concurrent study design was adopted to evaluate the program for its short-term outcomes such as gain in the basic knowledge of COVID-19 amongst master trainers and their feedback and program output viz - the proportion of volunteers trained and their profile by census sampling. Motivational factors, experiences of volunteers, and outcomes of COVID-19 work in their villages were explored by purposive with maximum diversity sampling with 62 online in-depth interviews and 8 online focus group discussions (FGDs).

Results

There was a statistically significant difference in the pre-test (12.8 ± 5.6) and post-test (25.9 ± 9.3) scores of the Master Training Program evaluation test. Out of 6534 trained volunteers, 5901 worked as volunteers, and amongst those, 47.1%, 35.1%, and 17.8% worked for ≤3 months, 3 to 6 months, and ≥6 months, respectively, in their villages. The major themes generated for motivational factors to join the program were altruism, savior nature, generating awareness, and concern for others. The major outcomes generated by trained volunteers COVID-19 vaccination were in raising awareness on COVID-19 appropriate behavior and early identification of COVID-19 cases in their villages.

Conclusion

The "CoviSainik Program" was successful in creating cadres of trained volunteers.

Socio-demographic and clinical characteristics associated with retention in care among adults living with HIV and severe mental illness and reasons for loss to follow-up in Uganda: a mixed-methods study

OBJECTIVE

This study aimed to determine the socio-demographic and clinical characteristics associated with retention in care and reasons for loss to follow-up (LTFU) among people living with HIV (PLWH) with a known diagnosis of severe mental illness (SMI).

DESIGN

We conducted a parallel convergent mixed-methods study. The quantitative study was used to determine the proportion and factors associated with retention in care among PLWH and SMI. The qualitative study explored reasons for LTFU.

SETTING

This study was conducted at two the HIV clinics of two tertiary hospitals in Uganda.

PARTICIPANTS

We reviewed records of 608 PLWH who started antiretroviral therapy (ART) and included participants who had a documented diagnosis of SMI.

OUTCOMES

The primary outcome was retention in care. Age, gender, religion, tuberculosis (TB) status, WHO clinical stage, functional status, cluster of differentiation 4 (CD4) cell count, viral load and SMI diagnosis were among the predictor variables.

RESULTS

We collected data from 328 participants. Retention at 6 months was 43.3% compared with 35.7% at 12 months. Having an unsuppressed viral load (≥1000 copies/mL) (adjusted incidence risk ratio (IRR)=1.54, 95% CI: 1.17 to 2.03), being 36 years and below (adjusted IRR=0.94, 95% CI: 0.94 to 0.95), initial presentation at outpatient department (adjusted IRR=0.74, 95% CI: 0.57 to 0.96), having TB signs and symptoms (adjusted IRR=0.98 95% CI: 0.97 to 0.99) and being in lower WHO stages (I and II) (adjusted IRR=1.08, 95% CI: 1.02 to 1.14) at ART initiation were significantly associated with retention in care at 6 and 12 months. Inadequate social support, long waiting hours at the clinic, perceived stigma and discrimination, competing life activities, low socioeconomic status and poor adherence to psychiatric medication were barriers to retention in care.

CONCLUSION

Twelve-month retention in care remains low at 35.7% far below the 90% WHO target. There is a need to design and implement targeted interventions to address barriers to retention in care among PLWH and SMI.

The Moderating Role of Social Support and HIV Stigma on the Association Between Depression and ART Adherence Among Young Thai Men Who Have Sex with Men

In Thailand, antiretroviral therapy (ART) programs still have difficulties reaching and promoting adherence among a key population - young men who have sex with men (YMSM) living with HIV. As such, we sought to examine potential psychosocial barriers that may contribute to suboptimal levels of ART adherence for this population. Data were drawn from a study of 214 YMSM living with HIV from Bangkok, Thailand. Linear regression models tested the association between depression and ART adherence, and whether social support and HIV-related stigma moderated that relationship. Multivariable models demonstrated social support was significantly associated with higher levels of ART adherence, and that there was a three-way interaction between depression, social support, and HIV-related stigma on ART adherence. These results further our understanding of the role of depression, stigma, and social support in ART adherence among Thai YMSM living with HIV, and that additional supports for YMSM with depression and HIV-related stigma are needed.

Emergency departments as under-utilized venues to provide HIV prevention services to female sex workers in Nairobi, Kenya

BACKGROUND

Female sex workers (FSW) in sub-Saharan Africa are disproportionately affected by HIV and remain a key target population for efforts to reduce transmission. While HIV prevention tools such as PEP and PrEP are available through outpatient FSW clinics, these services are underused. Emergency medicine is a rapidly expanding field in Kenya and may provide a novel venue for initiating or optimizing HIV prevention services. This study examined the characteristics of FSW from Nairobi, Kenya, who had utilized an emergency department (ED) during the past year to broaden our understanding of the patient factors related to usage.

METHODS

An anonymous questionnaire was administered to a convenience sample of 220 Nairobi FSW attending dedicated clinics from June to July 2019. The participants were categorized into those who attended an ED over the past year (acute care users) and clinic-only users (control). A modified version of the WHO Violence Against Women Instrument assessed gender-based violence. Multivariable negative binomial logistic regressions evaluated predictors of health care use among these populations.

RESULTS

Of the total 220 women (median [IQR] age 32 [27-39]), 101 and 116 were acute care and control populations, respectively. Acute care users had 12.7 ± 8.5 healthcare visits over a 12-month period, and the control population had 9.1 ± 7.0 (p < 0.05). ED attendance did not improve the PrEP usage, with 48.5%, and 51% of acute care and clinic users indicated appropriate PrEP use. Patient factors that correlated with health care utilization among acute care users included client sexual violence (OR 2.2 [1.64-2.94], p < 0.01), PrEP use (OR 1.54 (1.25-1.91), < 0.01), and client HIV status (OR 1.35 (1.02-1.69), p < 0.01).

CONCLUSIONS

Many FSW at high risk for HIV were not accessing HIV prevention tools despite attending a dedicated FSW clinic offering such services. FSW who had attended an ED over the past year had a higher prevalence of HIV risk factors, demonstrating that emergency departments may be important acute intervention venues to prevent HIV transmission in this population. These results can guide policy design, health care provider training, and facility preparedness to support strategies aimed at improving HIV prevention strategies for FSW in Kenyan ED's.

Social and structural barriers and facilitators to HIV healthcare and harm reduction services for people experiencing syndemics in Manitoba: study protocol

INTRODUCTION

In Manitoba, Canada, there has been an increase in the number of people newly diagnosed with HIV and those not returning for regular HIV care. The COVID-19 pandemic resulted in increased sex and gender disparities in disease risk and mortalities, decreased harm reduction services and reduced access to healthcare. These health crises intersect with increased drug use and drug poisoning deaths, houselessness and other structural and social factors most acutely among historically underserved groups. We aim to explore the social and structural barriers and facilitators to HIV care and harm reduction services experienced by people living with HIV (PLHIV) in Manitoba.

METHODS AND ANALYSIS

Our study draws on participatory action research design. Guiding the methodological design are the lived experiences of PLHIV. In-depth semi-structured face-to-face interviews and quantitative questionnaires will be conducted with two groups: (1) persons aged ≥18 years living or newly diagnosed with HIV and (2) service providers who work with PLHIV. Data collection will include sex, gender, sociodemographic information, income and housing, experiences with the criminal justice system, sexual practices, substance use practices and harm reduction access, experiences with violence and support, HIV care journey (since diagnosis until present), childhood trauma and a decision-making questionnaire. Data will be analysed intersectionally, employing grounded theory for thematic analysis, sex-based and gender-based analysis and social determinants of health and syndemic framework to understand the experiences of PLHIV in Manitoba.

ETHICS AND DISSEMINATION

We received approval from the University of Manitoba Health Ethics Research Board (HS25572; H2022:218), First Nations Health and Social Secretariat of Manitoba, Nine Circles Community Health Centre, Shared Health Manitoba (SH2022:194) and 7th Street Health Access Centre. Findings will be disseminated using community-focused knowledge translation strategies identified by participants, peers, community members and organisations, and reported in conferences, peer-reviewed journals and a website (www.alltogether4ideas.org).

"Whenever you need support, you first turn to the group": motivations and functions of WhatsApp groups for youth living with HIV

Social support is a critical component of achieving positive health outcomes for youth living with HIV (YLWH). Mobile health (mHealth) has significant potential for providing social support to YLWH. However, little is known about the domains of social support most needed by YLWH which mHealth interventions might address. Drawing on the spontaneous creation of WhatsApp support groups by YLWH in Nairobi, Kenya, we characterized Kenyan YLWH's social support needs and potential roles of social media groups in meeting them. We conducted interviews and focus-groups with 68 YLWH, 24 caregivers and 20 healthcare workers, and observed two YLWH-led WhatsApp groups for 6 weeks. Youth reported that existing support systems, including family and healthcare workers, already provided informational and instrumental support. However, they emphasized unmet companionship and emotional support needs, leading to isolation, hopelessness, and medication adherence challenges. Participants identified connection with other YLWH as a unique source of emotional and companionship support that allowed them to feel more secure and less isolated. Interviews and observed WhatsApp chats demonstrated that WhatsApp groups were a desirable medium for companionship support that overcame barriers to in-person connection.

How different incentives influence reported motivation and perceptions of performance in Ghanaian community-based health planning and services zones

BACKGROUND

Maternal mortality is still a burden worldwide, and Ghana's maternal and child mortalities are still high. Incentive schemes have been effective in improving health workers' performance thereby reducing maternal and child deaths. The efficiency of public health services in most developing countries has been linked to the provision of incentives. Thus, financial packages for Community Health Volunteers (CHVs) serve as enablers for them to be focused and committed to their work. However, the poor performance of CHVs is still a challenge in health service delivery in many developing countries. Although the reasons for these persistent problems are understood, we need to find out how to implement what works in the face of political will and financial constraints. This study assesses how different incentives influence reported motivation and perceptions of performance in Community-based Health Planning and Services Program (CHPS) zones in the Upper East region.

METHODS

A quasi-experimental study design with post-intervention measurement was used. Performance-based interventions were implemented for 1 year in the Upper East region. The different interventions were rolled out in 55 of 120 CHPS zones. The 55 CHPS zones were randomly assigned to four groups: three groups of 14 CHPS zones with the last group containing 13 CHPS zones. Several alternative types of financial and non-financial incentives as well as their sustainability were explored. The financial incentive was a small monthly performance-based Stipend. The non-financial incentives were: Community recognition; paying for National Health Insurance Scheme (NHIS) premiums and fees for CHV, one spouse, and up to two children below 18 years, and; quarterly performance-based Awards for best-performing CHVs. The four groups represent the four different incentive schemes. We conducted 31 In-depth interviews (IDIs) and 31 Focus Group Discussions (FGDs) with health professionals and community members.

RESULTS

Community members and the CHVs wanted the stipend as the first incentive but requested that it be increased from the current level. The Community Health Officers (CHOs) prioritized the Awards over the Stipend because they felt it was too small to generate the required motivation in the CHVs. The second incentive was the National Health Insurance Scheme (NHIS) registration. Community recognition was also considered by health professionals as effective in motiving CHVs and work support inputs and CHVs training helped in improving output. The various incentives have helped increase health education and facilitated the work of the volunteers leading to increased outputs: Household visits and Antenatal Care and Postnatal Care coverage improved. The incentives have also influenced the initiative of volunteers. Work support inputs were also regarded as motivators by CHVs, but the challenges with the incentives included the size of the stipend and delays in disbursement.

CONCLUSION

Incentives are effective in motivating CHVs to improve their performance, thereby improving access to and use of health services by community members. The Stipend, NHIS, Community recognition and Awards, and the work support inputs all appeared to be effective in improving CHVs' performance and outcomes. Therefore, if health professionals implement these financial and non-financial incentives, it could bring a positive impact on health service delivery and use. Also, building the capacities of CHVs and providing them with the necessary inputs could improve output.

Trajectories of re-engagement: factors and mechanisms enabling patient return to HIV care in Zambia

INTRODUCTION

While disengagement from HIV care threatens the health of persons living with HIV (PLWH) and incidence-reduction targets, re-engagement is a critical step towards positive outcomes. Studies that establish a deeper understanding of successful return to clinical care among previously disengaged PLWH and the factors supporting re-engagement are essential to facilitate long-term care continuity.

METHODS

We conducted narrative, patient-centred, in-depth interviews between January and June 2019 with 20 PLWH in Lusaka, Zambia, who had disengaged and then re-engaged in HIV care, identified through electronic medical records (EMRs). We applied narrative analysis techniques, and deductive and inductive thematic analysis to identify engagement patterns and enablers of return.

RESULTS

We inductively identified five trajectories of care engagement, suggesting patterns in patient characteristics, experienced barriers and return facilitators that may aid intervention targeting including: (1) intermittent engagement;(2) mostly engaged; (3) delayed linkage after testing; (4) needs time to initiate antiretroviral therapy (ART); and (5) re-engagement with ART initiation. Patient-identified periods of disengagement from care did not always align with care gaps indicated in the EMR. Key, interactive re-engagement facilitators experienced by participants, with varied importance across trajectories, included a desire for physical wellness and social support manifested through verbal encouragement, facility outreach or personal facility connections and family instrumental support. The mechanisms through which facilitators led to return were: (1) the promising of living out one's life priorities; (2) feeling valued; (3) fostering interpersonal accountability; (4) re-entry navigation support; (5) facilitated care and treatment access; and (6) management of significant barriers, such as depression.

CONCLUSIONS

While preliminary, the identified trajectories may guide interventions to support re-engagement, such as offering flexible ART access to patients with intermittent engagement patterns instead of stable patients only. Further, for re-engagement interventions to achieve impact, they must activate mechanisms underlying re-engagement behaviours. For example, facility outreach that reminds a patient to return to care but does not affirm a patient's value or navigate re-entry is unlikely to be effective. The demonstrated importance of positive health facility connections reinforces a growing call for patient-centred care. Additionally, interventions should consider the important role communities play in fostering treatment motivation and overcoming practical barriers.

Enrollment and retention of female sex workers in HIV care in health facilities in Mbarara city

Background

Sex work is a global driver of the HIV epidemic, and the risk of acquiring HIV is 13 times higher for female sex workers (FSWs) compared to the general population. The enrollment and retention of FSWs in HIV care is a challenge and has been a major contributing factor to increased new HIV infections.

Methods

We conducted a qualitative study among 30 FSWs and 21 healthcare workers (HCWs) working in antiretroviral therapy (ART) clinics at the selected three primary health facilities in Mbarara City, Southwestern Uganda. The study participants were enrolled by both purposive and snowball sampling techniques. We obtained informed consent from all the participants, and data were collected using in-depth interviews and thematically analyzed.

Results

Three themes emerged as facilitators toward enrollment and retention of FSWs into HIV care, namely, (1) good health living, (2) receptive HCWs and availability of health services, and (3) community outreach services and peer support. The barriers are summarized into four major themes: (1) stigma, community discrimination, and beliefs; (2) social obstacles; (3) adverse effects of ART; and (4) inadequate services at the health facilities.

Conclusion

FSWs are challenged by unsupportive environments and communities where they live and work, which hinders their enrollment and retention in HIV care. Creating awareness of the utilization of HIV care services and extending such services to hotspot communities could enhance the response of HIV-positive FSWs to ART.

Understanding the Unique Barriers and Facilitators that Affect Men’s Initiation and Retention in HIV Care: A Qualitative Study to Inform Interventions for Men Across the Treatment Cascade in Malawi

Men in sub-Saharan Africa are underrepresented in antiretroviral therapy (ART) programs. Our secondary analysis of 40 in-depth interviews with Malawian men living with HIV examined barriers and facilitators for ART initiation versus retention. Interviewees included men who never initiated or initiated ART late (initiation respondents, n = 19); and men who initiated ART but were late for an appointment (retention respondents, n = 21). Transcribed interviews were coded using deductive and inductive coding techniques and analyzed using constant comparison methods. Long wait times, frequent facility visits, and insufficient in-clinic privacy were barriers for initiation and retention. Poor knowledge of ART was primarily a barrier for initiation; unexpected travel was a barrier for retention. Key facilitators for initiation and retention included previous positive experiences with health facilities. Having examples of successful men using ART primarily facilitated initiation; support from spouses and male peers facilitated retention. Results may inform interventions to increase men’s engagement in ART services.

Nurses' clinical practices reducing the impact of HIV-related stigmatisation in non-HIV-specialised healthcare settings: a protocol for a realist synthesis

INTRODUCTION

Despite tremendous progress in care, people living with HIV (PLHIV) continue to experience HIV-related stigmatisation by nurses in non-HIV-specialised healthcare settings. This has consequences for the health of PLHIV and the spread of the virus. In the province of Quebec (Canada), only four interventions aimed at reducing the impact of HIV-related stigmatisation by nurses have been implemented since the beginning of the HIV pandemic. While mentoring and persuasion could be promising strategies, expression of fears of HIV could have deleterious effects on nurses' attitudes towards PLHIV. In literature reviews on stigma reduction interventions, the contextual elements in which these interventions have been implemented is not considered. In order to develop new interventions, we need to understand how the mechanisms (M) by which interventions (I) interact with contexts (C) produce their outcomes (O).

METHODS AND ANALYSIS

Realist synthesis (RS) was selected to formulate a programme theory that will rely on CIMO configuration to describe (1) nursing practices that may influence stigmatisation experiences by PLHIV in non-HIV-specialised healthcare settings, and (2) interventions that may promote the adoption of such practices by nurses. The RS will draw on the steps recommended by Pawson: clarify the scope of the review; search for evidence; appraise primary studies and extract data; synthesise evidence and draw conclusions. To allow an acute interpretation of the disparities between HIV-related stigmatisation experiences depending on people's serological status, an initial version of the programme theory will be formulated from data gathered from scientific and grey literature, and then consolidated through realist interviews with various stakeholders (PLHIV, nurses, community workers and researchers).

ETHICS AND DISSEMINATION

Ethical approval for realist interviews will be sought following the initial programme theory design. We intend to share the final programme theory with intervention developers via scientific publications and recommendations to community organisations that counter HIV-related stigmatisation.

Barriers and facilitators on the HIV care continuum among adults living with HIV in high-income countries: a scoping review protocol

BACKGROUND

As the life expectancy of people living with HIV increases with the advancements in antiretroviral treatment, the continuity of long-term therapy and health care for people living with HIV has gained more importance. However, the estimated proportion of people living with HIV who have access to treatment or are virally suppressed is unsatisfactory. Therefore, it is necessary to build strategies to improve treatment continuity by identifying the barriers and facilitators that affect the HIV care continuum. To enable this, we will conduct a scoping review to explore the barriers and facilitators related to the care continuum in high-income countries for adults living with HIV.

METHODS

The review question will be identified based on the JBI guidelines for the development of scoping review protocols. Studies exploring the barriers to and facilitators of the HIV care continuum among adults living with HIV in high-income countries will be included in this review. A literature search will be conducted on the databases (platform) of MEDLINE (Ovid), Cumulative Index to Nursing and Allied Health Literature (EBSCO), Embase (Ovid), and the Cochrane Central Register of Controlled Trials (Cochrane Library). Four researchers will screen articles for inclusion and subsequently build a charting form and collate the data to provide results.

DISCUSSION

The results of this scoping review will provide comprehensive evidence for the barriers and facilitators to be considered in the care continuum of people living with HIV. Importantly, the results will provide insight for healthcare providers and researchers to develop interventions and research the continuity in caring for people living with HIV.

Barriers and facilitators to scaling up Healthy Choices, a motivational interviewing intervention for youth living with HIV

Background

This study included Community Health Workers and their supervisors from HIV clinical care teams who participated in the Healthy Choices intervention program. Healthy Choices is a Motivational Interviewing-based intervention aimed at improving medication adherence and reducing alcohol use for adolescents and emerging adults ages 16—24 living with HIV. In this study, the intervention was “scaled up” for delivery by local HIV care providers in real-world clinic settings.

Methods

Providers (N = 21) completed semi-structured interviews (N = 29) about their experiences with intervention scale-up. Rigorous thematic analyses were conducted within discussions of barriers and facilitators of intervention implementation.

Results

Three dominant thematic areas emerged from the data: (1) perceptions of the Healthy Choices intervention, (2) engaging high risk YLH in in-person behavior interventions, and (3) perspectives on implementation of the intervention using local staff. Results offer insights into implementation of MI-based interventions for adolescents and emerging adults in clinic settings using local clinical staff instead of dedicated research staff.

Conclusions

Overall, scaled-up intervention programs for youth are challenged to maintain scientific rigor, provide rigorous training and supports, and offer an attractive and engaging program.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08453-w.

Availability and experiences of differentiated antiretroviral therapy delivery at HIV care facilities in rural Zimbabwe: a mixed-method study

INTRODUCTION

Zimbabwe adopted differentiated HIV care policies in 2015 to promote client-centred care and relieve strain on health facilities. We examined the availability, experiences and perceptions of differentiated antiretroviral therapy (ART) delivery in rural Zimbabwe following the policy adoption.

METHODS

We undertook a cross-sectional mixed methods study in all the 26 facilities providing HIV care in a rural district in Zimbabwe. We collected quantitative data about ART delivery and visit durations from 31 healthcare providers and a purposive stratified sample of 378 clients obtaining ART either through routine care or differentiated ART delivery models. We performed 26 semi-structured interviews among healthcare providers and seven focus group discussions (FGDs) among clients to elicit their perceptions and experiences of ART delivery. Data were collected in 2019, with one follow-up FGD in 2021. We analysed the transcripts thematically, with inductive coding, to identify emerging themes.

RESULTS

Twenty facilities (77%) offered at least one differentiated ART delivery models, including community ART refill groups (CARGs; 13 facilities, 50%), fast-track refill (8, 31%), family refill (6, 23%) or club refill (1, 4%). Thirteen facilities (50%) offered only one model. The median visit duration was 28 minutes (interquartile range [IQR]: 16-62). Participants in fast-track had the shortest visit durations (18 minutes, IQR: 11-24). Confidentiality and disclosure of HIV status, travelling long distances, travel costs and waiting times were the main issues influencing clients' views on differentiated ART delivery. Fast-track refill was perceived as the preferred model of clients for its limited involuntary disclosure and efficiency. In contrast, group- and community-based refill models reduced travel costs but were felt to be associated with involuntary disclosure of HIV status, which could discourage clients. Healthcare providers also experienced an additional workload when offering facility-based group models, such as CARGs.

CONCLUSIONS

Differentiated ART delivery models were widely available in this rural setting, but most facilities did not offer a choice of models to address clients' diverse preferences. A minority offered fast-track refills, although this model was often mentioned as desirable. Confidentiality, travel expenses and client waiting times are key elements to consider when planning and rolling out differentiated HIV care.

Extended Reality (XR) and telehealth interventions for children or adolescents with autism spectrum disorder: Systematic review of qualitative and quantitative studies

World Health Organization reported that almost one in 100 children is diagnosed with autism spectrum disorder (ASD) worldwide. Extended Reality (XR) and Telehealth interventions are evident to be effective for ASD treatments. While there is no comprehensive systematic review to summarize and evaluate the evidence for promoting the accessibility of different technology-based treatment regiments. This paper aims to verify the efficacy and validity of XR and Telehealth interventions for children and adolescents with ASD. We reviewed 112 studies from databases of PubMed, Web of Science and Cochrane Library, published in English between January 2010 to April 1st, 2022. We found that after interventions, positive improvements for ASD participants were observed in social interaction, acceptance, and engagement, communication and speech, emotion recognition and control, daily living skill, problem behavior reduction, attention, cost reduction, anxiety symptom reduction, pretend play, contextual processing, match to sample skill, and insomnia control. Our findings provide a solid and positive evidence of XR and Telehealth interventions in improving the treatment outcomes for children and adolescents with ASD. In the future, more research with RCTs and standardized outcome measurements are required to establish the therapeutic efficiency of the two interventions independently or combined.

Patient experiences and preferences for antiretroviral therapy service provision: implications for differentiated service delivery in Northwest Ethiopia

Background

Understanding the experiences, needs, preferences, and behaviors of people living with HIV (PLHIV) are critical to tailor HIV treatment. However, there is limited empirical evidence in Ethiopia on the views of PLHIV regarding their experiences with current antiretroviral therapy (ART) services and preferred models of HIV treatment. Hence, this study aimed to explore the patients’ experiences of taking medications and preferences for ART service provision in Northwest Ethiopia.

Methods

A phenomenological study design was employed. In this study, stable and 18 years old and above PLHIVs, who had been using ART service at four public hospitals and two health centers in East Gojjam, West Gojjam and Awi zones, and Bahir Dar city administration of Amhara National Regional State, Northwest Ethiopia, were purposively selected. Fifteen in-depth interviews were conducted from July 2021 to September 2021 to collect data. ATLAS.ti version 9 software was used for coding translated transcripts. A thematic analysis approach was employed.

Findings

Participants in this study had reported positive and negative experiences in receiving ART services and also varied preferences toward ART service features. The study identified five themes on experiences for ART service and 15 attributes of ART service characteristics. The identified themes were stigma, time, availability of drugs and providers, costs for clinic visits, and provider-patient interaction. The fifteen attributes were buddy system, ART refill (individualized or group), ART packaging and labeling, drug formulation and administration, ART room labeling, distance, location of service, preferences on involvement in treatment decision-making, the person providing ART refills, provider’s attitude, spatial arrangement of ART room, time of health facility operation, time spent at clinics, and total cost of the visit.

Conclusions

The results raise awareness for the positive and negative experiences of patients informing us about barriers and supporting factors in ART service provision. They open up the potential for HIV treatment service improvement. The preferences of PLHIVs toward ART service delivery features were heterogeneous. Policy and program efforts should tailor ART services that suit patients’ needs and priorities in Ethiopia. Future research should further assess the reasons for patients’ distrust of the community ART delivery models.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12981-022-00452-5.

Barriers and enablers in the implementation and sustainability of toothbrushing programs in early childhood settings and primary schools: a systematic review

Background

Untreated dental caries negatively impacts a child's quality of life including overall health and wellbeing, growth and development, social interaction ability, and school attendance. School-based toothbrushing programs have been recognised as an effective intervention to reduce the burden of dental caries. However, limited information is available to understand the real-world enablers and challenges in the implementation and sustainability of toothbrushing programs. This review aims to understand the barriers and enablers in the implementation and sustainability of toothbrushing programs in early childhood settings and primary schools.

Methods

Five electronic databases [i.e., CINAHL (EBSCO), Medline (EBSCO), EMBASE (Ovid), Web of Science, and PsycINFO] and backward citation chasing were performed. The last updated databases searches were conducted in May 2022. Studies reporting on barriers and enablers in the implementation and sustainability of toothbrushing programs in early childhood settings or primary schools were included in the review. The methodological quality of included studies was assessed by using Joanna Briggs Institute [JBI] and mixed methods appraisal tool [MMAT] critical appraisal tools and results were reported in accordance with PRISMA guidelines.

Results

A total of six studies met the eligibility criteria and were included in the review. Toothbrushing programs in early childhood settings and primary schools were mostly implemented under the supervision of staff and teachers. A positive attitude of the staff, the flexibility of toothbrushing sessions, involvement of community volunteers and parents were a few of the identified enablers. However, the timing of the communication of the program, inadequate transfer of information among staff, frequent staffing turnover, lack of parental support, and staff feeling overburdened while acting as pseudo parents were frequently reported as barriers.

Conclusion

The results of this systematic review identify key enablers and barriers for toothbrushing programs in early childhood settings and primary schools which need to be considered for developing oral health promotion initiatives.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-022-02270-7.

Strategies to improve HIV care outcomes for people with HIV who are out of care

OBJECTIVE

The aim of this study was to evaluate the effectiveness of five intervention strategies: patient navigation, appointment help/alerts, psychosocial support, transportation/appointment accompaniment, and data-to-care on HIV care outcomes among persons with HIV (PWH) who are out of care (OOC).

DESIGN

A systematic review with meta-analysis.

METHODS

We searched CDC's Prevention Research Synthesis (PRS) Project's cumulative HIV database to identify intervention studies conducted in the U.S., published between 2000 and 2020 that included comparisons between groups or prepost, and reported at least one relevant outcome (i.e. re-engagement or retention in HIV care, and viral suppression). Effect sizes were meta-analyzed using random-effect models to assess intervention effectiveness.

RESULTS

Thirty-nine studies reporting on 42 unique interventions met the inclusion criteria. Overall, intervention strategies are effective in improving re-engagement in care [odds ratio (OR) = 1.79;95% confidence interval (95% CI): 1.36-2.36, k = 14], retention in care (OR = 2.01; 95% CI: 1.64-2.64, k = 22), and viral suppression (OR = 2.50;95% CI: 1.87-3.34, k = 27). Patient navigation, appointment help/alerts, psychosocial support, and transportation/appointment accompaniment improved all three HIV care outcomes. Data-to-care improved re-engagement and retention but had insufficient evidence for viral suppression.

CONCLUSION

Several strategies are effective for improving HIV care outcomes among PWH who are OOC. More work is still needed for consistent definitions of OOC and HIV care outcomes, better reporting of intervention and cost data, and identifying how best to implement and scale-up effective strategies to engage and retain OOC PWH in care and reach the ending the HIV epidemic goals.

The Meaning and Perceptions of HIV-Related Stigma in African American Women Living With HIV in Rural Florida: A Qualitative Study

ABSTRACT

African Americans are disproportionally affected by HIV/AIDS compared with other races/ethnicities, yet few studies have examined the cultural and/or attitudinal precursors that can make African American women vulnerable to HIV-related stigma in the rural South. This study qualitatively explored the meaning and perceptions of HIV-related stigma among African American women in Florida. Thirteen semi-structured interviews were conducted using an empirical phenomenological approach. Five observer perspectives and 26 participant perspectives emerged. Participants described stigma through self-conceptualizations (e.g., ignorance), experiences (e.g., judgments), psychological dysfunction (e.g., mental health), intersectionality (e.g., race, disability), and overcoming stigma (e.g., advocacy). Our findings reveal that HIV-related stigma is unpleasant for African American women. However, over time, women in this study developed strategies to combat stigma. Elements of stigma reduction described in this study may be an important starting point for designing a culturally targeted intervention for African American women living with HIV.

How HIV Clients Find Their Way Back to the ART Clinic: A Qualitative Study of Disengagement and Re-engagement with HIV Care in Malawi

Retention in antiretroviral therapy (ART) services is critical to achieving positive health outcomes for individuals living with HIV, but accumulating evidence indicates that individuals are likely to miss ART appointments over time. Thus, it is important to understand why individuals miss appointments and how they re-engage in HIV care. We used in-depth interviews with 44 ART clients in Malawi who recently missed an ART appointment (> 14 days) but eventually re-engaged in care (within 60 days) to explore reasons for missed appointments and barriers and facilitators to re-engagement. We found that most individuals missed ART appointments due to unexpected life events such as funerals, work, and illness for both clients and their treatment guardians who were also unable to attend facilities. Several reasons differed by gender-work-related travel was common for men, while caring for sick family members was common for women. Barriers to re-engagement included continued travel, illness, and restricted clinic schedules and/or staff shortages that led to repeat facility visits before being able to re-engage in care. Strong internal motivation combined with social support and reminders from community health workers facilitated re-engagement in HIV care.

HIV Prevention and Treatment Behavior Change and the Situated Information Motivation Behavioral Skills (sIMB) Model: A Qualitative Evaluation of a Community Health Worker Intervention in Rakai, Uganda

A community health worker (CHW) model can promote HIV prevention and treatment behaviors, especially in highly mobile populations. In a fishing community in Rakai, Uganda, the Rakai Health Sciences Program implemented a CHW HIV intervention called Health Scouts. The situated Information, Motivation, and Behavioral Skills (sIMB) framework informed the design and a qualitative evaluation of the intervention. We interviewed 51 intervention clients and coded transcripts informed by sIMB framework dimensions. Clients reported that Health Scouts provided information about HIV prevention and treatment behaviors and helped them manage personal and social motivations to carry out health-promoting behavior. Prominent barriers which moved clients away from behavior change included daily pill burdens, anticipated stigma, serostatus disclosure, substance use at social gatherings, and anticipated reactions of partners. Our study adds to the evidence establishing CHWs as facilitators of behavior change, positioned to offer supportive encouragement and navigate contextualized circumstances.

The effect of tracer contact on return to care among adult, "lost to follow-up" patients living with HIV in Zambia: an instrumental variable analysis

INTRODUCTION

Tracing patients lost to follow-up (LTFU) from HIV care is widely practiced, yet we have little knowledge of its causal effect on care engagement. In a prospective, Zambian cohort, we examined the effect of tracing on return to care within 2 years of LTFU.

METHODS

We traced a stratified, random sample of LTFU patients who had received HIV care between August 2013 and July 2015. LTFU was defined as a gap of >90 days from last scheduled appointment in the routine electronic medical record. Extracting 2 years of follow-up visit data through 2017, we identified patients who returned. Using random selection for tracing as an instrumental variable (IV), we used conditional two-stage least squares regression to estimate the local average treatment effect of tracer contact on return. We examined the observational association between tracer contact and return among patient sub-groups self-confirmed as disengaged from care.

RESULTS

Of the 24,164 LTFU patients enumerated, 4380 were randomly selected for tracing and 1158 were contacted by a tracer within a median of 14.8 months post-loss. IV analysis found that patients contacted by a tracer because they were randomized to tracing were no more likely to return than those not contacted (adjusted risk difference [aRD]: 3%, 95% CI: -2%, 8%, p = 0.23). Observational data showed that among contacted, disengaged patients, the rate of return was higher in the week following tracer contact (IR 5.74, 95% CI: 3.78-8.71) than in the 2 weeks to 1-month post-contact (IR 2.28, 95% CI: 1.40-3.72). There was a greater effect of tracing among patients lost for >6 months compared to those contacted within 3 months of loss.

CONCLUSIONS

Overall, tracer contact did not causally increase LTFU patient return to HIV care, demonstrating the limited impact of tracing in this program, where contact occurred months after patients were LTFU. However, observational data suggest that tracing may speed return among some LTFU patients genuinely out-of-care. Further studies may improve tracing effectiveness by examining the mechanisms underlying the impact of tracing on return to care, the effect of tracing at different times-since-loss and using more accurate identification of patients who are truly disengaged to target tracing.

Applying a machine learning modelling framework to predict delayed linkage to care in patients newly diagnosed with HIV in Mecklenburg County, North Carolina, USA

BACKGROUND

Machine learning has the potential to help researchers better understand and close the gap in HIV care delivery in large metropolitan regions such as Mecklenburg County, North Carolina, USA.

OBJECTIVES

We aim to identify important risk factors associated with delayed linkage to care for HIV patients with novel machine learning models and identify high-risk regions of the delay.

METHODS

Deidentified 2013-2017 Mecklenburg County surveillance data in eHARS format were requested. Both univariate analyses and machine learning random forest model (developed in R 3.5.0) were applied to quantify associations between delayed linkage to care (>30 days after diagnosis) and various risk factors for individual HIV patients. We also aggregated linkage to care by zip codes to identify high-risk communities within the county.

RESULTS

Types of HIV-diagnosing facility significantly influenced time to linkage; first diagnosis in hospital was associated with the shortest time to linkage. HIV patients with lower CD4+ cell counts (<200/ml) were twice as likely to link to care within 30 days than those with higher CD4+ cell count. Random forest model achieved high accuracy (>80% without CD4+ cell count data and >95% with CD4+ cell count data) to predict risk of delay in linkage to care. In addition, we also identified top high-risk zip codes of delayed linkage.

CONCLUSION

The findings helped public health teams identify high-risk communities of delayed HIV care continuum across Mecklenburg County. The methodology framework can be applied to other regions with HIV epidemic and challenge of delayed linkage to care.

Substance Use Stigma, Avoidance Coping, and Missed HIV Appointments Among MSM Who Use Substances

Men who have sex with men (MSM) living with HIV who use substances have multiple stigmatized identities. Theory suggests that internalization of stigma may elicit avoidance behaviors associated with these stigmas, potentially resulting in suboptimal engagement in HIV care. We investigated interrelationships between internalized stigmas related to HIV, sexual orientation, and substance use; avoidance coping; and missed HIV appointments among 202 MSM living with HIV who use substances. Neither HIV nor sexual orientation-related internalized stigmas were associated with missed appointments, however, internalized substance use stigma (SUS) was associated (OR 1.47, 95% CI 1.15, 1.87). The relationship between internalized SUS and missed appointments was partially accounted for by avoidance coping (b = 0.12; bootstrap 95% CI 0.02, 0.25). To better understand the role of SUS, we assessed relationships between enacted and anticipated SUS and missed appointments (OR 2.08, 95% CI 1.52, 2.84 and OR 1.44, 95% CI 1.10, 1.88, respectively). Avoidance coping fully accounted for the relationship between anticipated SUS and missed appointments (b = 0.12; 95% CI 0.02, 0.25). Results suggest that avoidance strategies to manage anticipated SUS may result in substance using MSM forgoing HIV care appointments.

Do Older Adults with HIV Have Distinctive Personal Networks? Stigma, Network Activation, and the Role of Disclosure in South Africa

This study considers whether the personal networks of older South African people living with HIV (PLHIV) differ from those without HIV. Using recent survey data (N = 5059), results suggest that PLHIV reported more core network members than their peers without HIV (IRR 1.08; 95% CI 1.03, 1.13), but were equally likely to receive emotional support from network members (1.21; 95% CI 0.93, 1.58). PLHIV who had yet to disclose their serostatus were more likely than others to have friends and other non-kin in their core network (B 0.08; 95% CI 0.02, 0.13) and to maintain networks of non-overlapping members (OR 2.11; 95% CI 1.33, 3.34). Even as HIV remains highly stigmatized in South Africa, PLHIV tend to maintain relatively large and supportive networks. Still, a sizeable proportion of PLHIV do not disclose their illness—these individuals disproportionately inhabit networks marked by non-kin and by high bridging potential.

Barriers and Facilitators to Effective Implementation of the NAMWEZA Intervention in Dar es Salaam, Tanzania

The NAMWEZA intervention was implemented, using a ten-session group format, to build skills targeting psychosocial vulnerabilities and enhancing HIV prevention among people living with HIV (PLH) and their social networks. The overall goal of this intervention is to improve psychological wellbeing and reduce HIV risk behaviours. These analyses aim to describe the barriers and facilitators of implementing the NAMWEZA intervention from the perspective of participants and trained peer group facilitators. Twenty-four in-depth interviews were conducted with NAMWEZA participants, and 50 pooled peer facilitator self-assessment reports were obtained from 16 trained peers. Participants identified personal and structural barriers, including fear of inadvertent HIV status disclosure, time constraints, level of participant reimbursements, and limited space available for group sessions. Factors facilitating effective implementation included perceived benefits of the program, such as reduction in HIV-related risk behaviours, increased self-esteem, and improvement in confidence in HIV prevention communications. Scaling up the NAMWEZA intervention to other areas of Tanzania or regionally should take into account these facilitators and barriers to implementation.

EmERGE mHealth Platform: Implementation and Technical Evaluation of a Digital Supported Pathway of Care for Medically Stable HIV

In this article, we described a new mobile-Health (mHealth) supported clinical pathway of care for people living with medically stable HIV in terms of platform acceptability, usability and technical feasibility. The EmERGE mHealth platform was codesigned with clinicians and the community, developed using Scrum agile methodology, integrated with hospital information systems and validated in a large prospective cohort study of 2251 participants. The evaluation of this new paradigm of care was conducted using a tailored Health Technology Assessment: the Model for Assessment of Telemedicine Applications. Usability and acceptability were assessed through the System Usability Score and a Patient Reported Experience Measure. The EmERGE platform was successfully deployed across diverse care settings in five European countries and used by 2251 patients and more than 20 clinicians for up to 30 months. Results from the formal evaluation demonstrated that the EmERGE platform is feasible and acceptable, with a high level of usability (median System Usability Score (SUS) 85.0%) and very positive patient-reported experiences (94.2% would recommend to a friend). The EmERGE platform is a secure and General Data Protection Regulation (GDPR)-compliant system with a complete set of functionalities that could be easily adapted to other clinical conditions, clinical sites and health systems thanks to its modular technical architecture.

Association Between Depression and HIV Care Engagement Outcomes Among Patients Newly Initiating ART in Lilongwe, Malawi

As in other sub-Saharan countries, the burden of depression is high among people living with HIV in Malawi. However, the association between depression at ART initiation and two critical outcomes-retention in HIV care and viral suppression-is not well understood. Prior to the launch of an integrated depression treatment program, adult patients were screened for depression at ART initiation at two clinics in Lilongwe, Malawi. We compared retention in HIV care and viral suppression at 6 months between patients with and without depression at ART initiation using tabular comparison and regression models. The prevalence of depression among this population of adults newly initiating ART was 27%. Those with depression had similar HIV care outcomes at 6 months to those without depression. Retention metrics were generally poor for those with and without depression. However, among those completing viral load testing, nearly all achieved viral suppression. Depression at ART initiation was not associated with either retention or viral suppression. Further investigation of the relationship between depression and HIV is needed to understand the ways depression impacts the different aspects of HIV care engagement.

Telephone-delivered behavioral health interventions for people living with HIV: patients' perspectives from a qualitative study

People living with HIV (PLWH) often experience mental health concerns as well as difficulties with medication adherence; they also report barriers to receipt of health services. Telephone-delivered interventions can overcome some of these barriers. To obtain patients' perspectives on telephone-delivered behavioral health services, we conducted a qualitative study with patients who participated in one of two telephone-delivered interventions (mindfulness training, health coaching) in a research trial. Patients (N = 42; M age = 46 years, 50% female, 26% Black) participated in semi-structured qualitative interviews after completing the study. They identified several advantages (e.g., being able to schedule sessions more flexibly compared to in-person appointments, ease of developing rapport with interventionists) as well as occasional challenges of phone delivery (e.g., network connectivity). Overall, PLWH view telephone-delivery as a convenient and flexible method to engage in behavioral health interventions.

Lost to follow up rate in the first year of ART in adults initiated in a universal test and treat programme: a retrospective cohort study in Ekurhuleni District, South Africa

Introduction

South Africa adopted and implemented the Universal Test and Treat (UTT) strategy for HIV since 2016. However, the care outcomes for patients initiated antiretroviral therapy (ART) through the UTT strategy have not been established. We determined the rate of lost to follow up (LTFU) and associated factors in patients who were initiated on ART through the UTT and the pre-ART strategy at 12 months post ART initiation.

Methods

this retrospective study analyzed the records of a cohort of patients at 12 months post the initiation of ART. We extracted data from the TIER.Net electronic database of selected facilities in a sub-district in Gauteng Province, South Africa. Factors associated with LFTU at 12 months of ART were assessed and logistic regression performed to identify predictors of LFTU.

Results

records of 367 patients were evaluated, and 54% were initiated ART through the UTT strategy. The mean age was 36.3 years, mean CD4 cell count at ART initiation was 341 cells/mm³, and 25% were initiated at CD4 cell count above 500 cells/mm³. LTFU at 12 months was 28%, 50% were LFTU within six months, and 28% within three months of ART. LFTU in the UTT cohort was higher than in the pre-ART cohort, patients initiated through UTT were twice more likely to be LTFU (AOR = 1.84, CI: 1.13-3.00) than pre-ART patients.

Conclusion

the rate of LTFU at 12 months of ART was 28%, which indicate that the retention in care rate (60%) falls far short of the triple 90 targets required for viral suppression.

Lived experiences of human immunodeficiency virus and hypertension in the Eastern Cape, South Africa

Background

Globally, the healthcare system is burdened with the rise in communicable diseases compounded by the comorbidity of non-communicable diseases. South Africa in particular experiences a quadruple burden of diseases, and human immunodeficiency virus (HIV) and hypertension are amongst the burden of diseases reported.

Aim

This article aims to explore and describe the lived experiences of people living with HIV (PLWH) and hypertension in the Eastern Cape, South Africa.

Setting

The study was conducted in the Sakhisizwe sub-district within the Chris Hani health district of the Eastern Cape.

Methods

A qualitative study design using Husserl’s descriptive phenomenology underpinned this study. Purposive sampling method was used to select participants. Information was gathered using semi-structured interviews from nine participants who met the inclusion criteria. The interviews were recorded on an audiotape and conducted in isiXhosa, and these were verified through back and forward translation to English. The transcribed interviews were coded manually, and underpinned by Giorgi’s phenomenological data analysis steps.

Results

This study yielded four themes that described the journey towards a new normal experienced by participants. These themes were (1) overcoming illness-related stigma, (2) sources of support, (3) self-love: taking ownership of the diseases and (4) creating transforming behaviours and self-care strategies.

Conclusion

This study demonstrated that the central theme that emerged from the lived experiences of participants with HIV and hypertension was a process of finding a new normal for their lives. This process had several enabling and inhibiting conditions that enabled participants to develop self-acceptance and find strategies to transform behaviours to better live with two chronic illnesses.

How Do People Living With HIV Acquire HIV Related Information: A Qualitative Evaluation of Jakarta Setting

Introduction: People living with HIV are fully aware of their risk behavior and future threats that might arise. The rapid progress of HIV serves the population with many options of healthcare services and treatments. Insufficient knowledge and information will only lower the outcomes of HIV eradication efforts. The ultimate goals to eradicate HIV are to upscale status notification and treat all with appropriate antiretroviral and viral suppression, but it needs sufficient information to administer. Programs and interventions have already been proposed, but an inquiry is needed to ensure all the information is actually there. The study aimed to explore the experience of people living with HIV acquiring HIV-related information.Methods: This study used phenomenological qualitative study and in-depth interviews were conducted to 12 people living with HIV. Semi-structured questions were delivered to all participants which explored their tangible experience in terms of nurturing sufficient HIV-related information.Results: The study found four consequential themes:  non-government organizations play a major role in HIV education, peers are a comfortable platform to discuss, it is all over the media and healthcare personnel are a source of knowledge. Conclusion: The distribution of HIV information and knowledge is now widespread. This situation marks   part of the success in fighting HIV. Remarkable attempts can be maintained by optimizing the viable option of information delivery.  Keyword: HIV knowledge; people living with HIV; qualitative study

Households in HIV Care: Designing an Intervention to Stimulate HIV Competency in Households in South Africa

Despite the Universal Test and Treat program and widespread antiretroviral treatment rollout, South Africa is still facing HIV prevention and treatment challenges, which are aggravated by human resource shortages in the healthcare sector. Individual- and community-level responses to these HIV-related challenges are increasingly being explored, for example, in community and home-based care. The role of the household as a crucial mediating social level has, however, largely been omitted. This paper outlines the design of an intervention to stimulate the involvement of the household in support for people living with HIV in South Africa. The 6SQuID model guided the intervention development process in four phases: (1) formative research, theory formulation, and a review of the existing literature, (2) integration of the results from the formative research into the "Positive Communication Process" (P2CP model) as a mechanism of change, (3) design of a community-health-worker-led intervention as the way to deliver the change mechanism, and (4) testing and revision of the developed intervention material-called Sinako-in a small-scale pilot study. The Sinako intervention anticipates that the future of chronic HIV care in resource-constrained settings will need to integrate the patient's household into the fight against HIV.

"It Was as Though My Spirit Left, Like They Killed Me": The Disruptive Impact of an HIV-Positive Diagnosis among Women in the Dominican Republic

An HIV diagnosis may be associated with severe emotional and psychological distress, which can contribute to delays in care or poor self-management. Few studies have explored the emotional, psychological, and psychosocial impacts of an HIV diagnosis on women in low-resource settings. We conducted in-depth interviews with 30 women living with HIV in the Dominican Republic. Interviews were audio-recorded, transcribed, and analyzed using the biographical disruption framework. Three disruption phases emerged (impacts of a diagnosis, postdiagnosis turning points, and integration). Nearly all respondents described the news as deeply distressful and feelings of depression and loss of self-worth were common. Several reported struggling with the decision to disclose—worrying about stigma. Postdiagnosis turning points consisted of a focus on survival and motherhood; social support (family members, friends, HIV community) promoted integration. The findings suggest a need for psychological resources and social support interventions to mitigate the negative impacts of an HIV diagnosis.

"It's Me as a Person, Not Me the Disease": Patient Perceptions of an HIV Care Model Designed to Engage Persons with Complex Needs

Ending the HIV epidemic will require dedicated efforts to engage the highest need persons living with HIV (PLWH) in treatment. We assessed patient perceptions of a clinic in Seattle, Washington, that is designed for PLWH who do not engage in conventional HIV care. The Max Clinic provides walk-in access to care, incentives for blood draws and achieving viral suppression, and intensive case management. We conducted semistructured individual interviews with 25 patients purposively recruited to obtain diverse viewpoints. Interviews were audio-recorded and transcribed. Analysis used a constant comparative approach to identify major themes related to the components of the program. For many participants, engagement in the Max Clinic was the first time they had success with HIV treatment. Relationships with clinic staff and the ability to receive care on a walk-in basis had the strongest influences on engagement. Participants felt that Max Clinic staff attended to their social circumstances in ways that were distinct from prior care experiences. Walk-in visits removed perceived stigma associated with failure to keep appointments and provided immediate attention to acute concerns. Financial incentives initially motivated participants to attend clinic and take medications, but were less important for supporting ongoing engagement in care. Food incentives motivated patients to seek care and helped them focus on health issues. In summary, patients identified walk-in access to care, monetary and food incentives, and relationships with clinic staff, particularly case managers, as the key elements of an HIV clinic model for high-need PLWH.

The impact of an integrated depression and HIV treatment program on mental health and HIV care outcomes among people newly initiating antiretroviral therapy in Malawi

BACKGROUND

Depression is highly prevalent among patients newly starting antiretroviral treatment (ART) in Malawi and many other countries. Untreated depression at ART initiation can disrupt the HIV care continuum. Effective approaches for depression screening and treatment exist for low-resource settings, but they are rarely applied. Identifying effective implementation strategies are critical.

METHODS

A pilot program integrated depression screening and treatment into routine HIV care using existing staff at two public health clinics in Malawi in two phases; a screening-only "control" phase and an active "intervention" phase. During the intervention phase, providers prescribed antidepressants or referred patients for Friendship Bench problem-solving therapy. We evaluated the program's impact on retention in HIV care, viral suppression, and depression remission at 6 months using tabular comparisons and log-binomial models to estimate adjusted risk ratios and mean differences among the intervention group relative to the control group.

RESULTS

Nearly all consenting participants were screened for depression appropriately and 25% had mild to severe depressive symptoms. During the intervention phase, 86% of participants with mild depressive symptoms started Friendship Bench therapy and 96% of participants with moderate to severe depressive symptoms started antidepressants. Few participants in the intervention group received consistent depression treatment over their first 6 months in care. In the adjusted main analysis, program exposure did not demonstrably affect most HIV or mental health outcomes, though the probability of currently being on ART at 6 months was significantly lower among the intervention group than the control group [RR 0.6(95%CI: 0.4-0.9)].

CONCLUSIONS

While it is feasible to integrate depression screening and treatment initiation into ART initiation, providing ongoing depression treatment over time is challenging. Similar implementation science studies focused on maintaining depression management will be increasingly important as we strive to understand and test the best ways to implement evidence-based depression treatment within HIV care.

Measuring engagement in HIV care: Measurement invariance in three racial/ethnic patient groups

Objective: The objective of the study was to evaluate a novel measure of HIV care engagement in a large sample of non-Latino White, Latino, and African American patients. The Index of Engagement in HIV care (the Index) measures the degree to which a patient feels engaged/disengaged from HIV care. However, its measurement invariance, or the degree to which observed scores can be meaningfully compared across racial/ethnic groups, has not been established. Methods: The 10-item Index is a self-report measure initially validated in the Center for AIDS Research Network of Integrated Systems cohort study. Using Center for AIDS Research Network of Integrated Systems survey data, Index scores were linked to patients' electronic medical records, which included viral load (VL) and appointment attendance data. We conducted measurement invariance analyses to test the Index's performance in the 3 racial/ethnic groups and its cross-sectional association with VL and retention in HIV care (2 primary outcomes). Results: A total of 3,127 patients completed the Index, which showed good reliability across the 3 groups (alphas >.84). Confirmatory factor analysis model fit statistics showed that the Index demonstrated configural, metric, and scalar invariance, supporting the conclusion that the Index is a single factor construct. Lastly, lower Index scores associated with a concurrent detectable VL and poor retention in HIV care for all 3 groups. Conclusion: Having demonstrated invariance, the Index scores can be used to compare engagement levels across non-Latino Whites, Latinos, and African Americans in HIV care settings. Improving HIV care retention requires tools that can accurately identify people struggling to stay engaged in HIV care, especially racial/ethnic minorities. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

PEBRA trial - effect of a peer-educator coordinated preference-based ART service delivery model on viral suppression among adolescents and young adults living with HIV: protocol of a cluster-randomized clinical trial in rural Lesotho

Background

Despite tremendous progress in controlling the HIV epidemic in sub-Saharan Africa, HIV-related mortality continues to increase among adolescents and young people living with HIV (AYPLHIV). Globally, sub-Saharan Africa accounts for 85% of the AYPLHIV. Overall outcomes along the HIV care cascade are worse among AYPLHIV as compared to all other age groups due to various challenges in accessing and adhering to antiretroviral therapy (ART). New, innovative multicomponent packages of differentiated service delivery (DSD) models, are required to address the specific needs of AYPLHIV. This study aims to evaluate the feasibility and effectiveness of a multicomponent DSD model (PEBRA model) designed for AYPLHIV and coordinated by a peer-educator.

Methods

PEBRA (Peer-Educator Based Refill of ART) is a cluster randomized, open-label, superiority trial conducted at 20 health facilities in three districts of Lesotho, Southern Africa. The clusters (health facilities) are randomly assigned to either the PEBRA model or standard of care in a 1:1 ratio, stratified by district. AYPLHIV aged 15–24 years old in care and on ART at one of the clusters are eligible. In the PEBRA model, a peer-educator coordinates the antiretroviral therapy (ART) services - such as medication pick-up, SMS notifications and support options - according to the preferences of the AYPLHIV. The peer-educator delivers this personalized model using a tablet-based application called PEBRApp. The control clusters continue to offer standard of care: ART services coordinated by the nurse. The primary endpoint is viral suppression at 12 months. Secondary endpoints include self-reported adherence to ART, quality of life, satisfaction with care and engagement in care. The target sample size is 300 AYPLHIV. Statistical analyses are conducted and reported in line with CONSORT guidelines for cluster randomized trials.

Discussion

The PEBRA trial will provide evidence on the feasibility and effectiveness of an inclusive, holistic and preference-based DSD model for AYPLHIV that is coordinated by a peer-educator. Many countries in SSA have an existing peer-educator program. If proven effective, the PEBRA model and PEBRApp have the potential to be scaled up to similar settings.

Trial registration

Clinicaltrials.gov, NCT03969030. Registered on 31 May 2019. More information: www.pebra.info