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Jiang W, Ronen K, Osborn L, Drake AL, Unger JA, Matemo D, Richardson BA, Kinuthia J, John-Stewart G. HIV Viral Load Patterns and Risk Factors Among Women in Prevention of Mother-To-Child Transmission Programs to Inform Differentiated Service Delivery. J Acquir Immune Defic Syndr 2024; 95:246-254. [PMID: 37977207 PMCID: PMC10922247 DOI: 10.1097/qai.0000000000003352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 11/06/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Differentiated service delivery (DSD) approaches decrease frequency of clinic visits for individuals who are stable on antiretroviral therapy. It is unclear how to optimize DSD models for postpartum women living with HIV (PWLH). We evaluated longitudinal HIV viral load (VL) and cofactors, and modelled DSD eligibility with virologic failure (VF) among PWLH in prevention of mother-to-child transmission programs. METHODS This analysis used programmatic data from participants in the Mobile WAChX trial (NCT02400671). Women were assessed for DSD eligibility using the World Health Organization criteria among general people living with HIV (receiving antiretroviral therapy for ≥6 months and having at least 1 suppressed VL [<1000 copies/mL] within the past 6 months). Longitudinal VL patterns were summarized using group-based trajectory modelling. VF was defined as having a subsequent VL ≥1000 copies/mL after being assessed as DSD-eligible. Predictors of VF were determined using log-binomial models among DSD-eligible PWLH. RESULTS Among 761 women with 3359 VL results (median 5 VL per woman), a 3-trajectory model optimally summarized longitudinal VL, with most (80.8%) women having sustained low probability of unsuppressed VL. Among women who met DSD criteria at 6 months postpartum, most (83.8%) maintained viral suppression until 24 months. Residence in Western Kenya, depression, reported interpersonal abuse, unintended pregnancy, nevirapine-based antiretroviral therapy, low-level viremia (VL 200-1000 copies/mL), and drug resistance were associated with VF among DSD-eligible PWLH. CONCLUSIONS Most postpartum women maintained viral suppression from early postpartum to 24 months and may be suitable for DSD referral. Women with depression, drug resistance, and detectable VL need enhanced services.
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Affiliation(s)
- Wenwen Jiang
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Keshet Ronen
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Lusi Osborn
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Alison L. Drake
- Global Health, University of Washington, Seattle, Washington, USA
| | - Jennifer A. Unger
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA, Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Daniel Matemo
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Barbra A. Richardson
- Departments of Biostatistics and Global Health, University of Washington, Division of Vaccine and Infectious Disease, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - John Kinuthia
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Grace John-Stewart
- Departments of Global Health, Medicine, Pediatrics, and Epidemiology, University of Washington, Seattle, Washington, USA
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Urrio RF, Lyatuu GW, Sando D, Mahande MJ, Philipo E, Naburi H, Lyaruu P, Kimonge A, Mayogu K, Simba B, Kibao AM, Msangi M, Zeebari Z, Biberfeld G, Ekström AM, Kilewo C, Kågesten AE. Long-term retention on antiretroviral treatment after enrolment in prevention of vertical HIV transmission services: a prospective cohort study in Dar es Salaam, Tanzania. J Int AIDS Soc 2024; 27:e26186. [PMID: 38332522 PMCID: PMC10853596 DOI: 10.1002/jia2.26186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 10/09/2023] [Indexed: 02/10/2024] Open
Abstract
INTRODUCTION To prevent vertical HIV transmission and ensure healthy mothers and children, pregnant women with HIV must remain on antiretroviral treatment (ART) for life. However, motivation to remain on ART may decline beyond the standard 2-year breastfeeding/postpartum period. We assessed attrition and retention in ART care among women with HIV up to 6 years since enrolment in vertical transmission prevention services in Dar es Salaam, Tanzania. METHODS A prospective cohort of 22,631 pregnant women with HIV were enrolled in vertical transmission prevention services between January 2015 and December 2017 in routine healthcare settings and followed-up to July 2021. Kaplan-Meier was used to estimate time to ART attrition (died, stopped ART or was lost to follow-up [no show ≥90 days since scheduled appointment]) and the proportion retained in care. Cox proportional hazard models were used to estimate adjusted hazard ratios (aHR) of ART attrition in relation to predictors. RESULTS Participants were followed-up to 6 years for a median of 3 years (IQR: 0.1-4). The overall ART attrition rate was 13.8 per 100 person-years (95% CI: 13.5-14.1), highest in the first year of enrolment at 27.1 (26.3-27.9), thereafter declined to 9.5 (8.9-10.1) in year 3 and 2.7 (2.1-3.5) in year 6. The proportion of women retained in care were 78%, 69%, 63%, 60%, 57% and 56% at 1, 2, 3, 4, 5 and 6 years, respectively. ART attrition was higher in young women aged <20 years (aHR 1.63, 95% CI: 1.38-1.92) as compared to 30-39 year-olds and women enrolled late in the third versus first trimester (aHR 1.29, 95% CI: 1.16-1.44). In contrast, attrition was lower in older women ≥40 years, women who initiated ART before versus during the index pregnancy and women attending higher-level health facilities. CONCLUSIONS ART attrition among women with HIV remains highest in the first year of enrolment in vertical transmission prevention services and declines markedly following a transition to chronic HIV care. Targeted interventions to improve ART continuity among women with HIV during and beyond prevention of vertical transmission are vital to ending paediatric HIV and keeping women and children alive and healthy.
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Affiliation(s)
- Roseline Faustine Urrio
- Management and Development for HealthDar es SalaamTanzania
- Department of Obstetrics and GynacologyMuhimbili University of Health and Allied SciencesDar es SalaamTanzania
| | - Goodluck Willey Lyatuu
- Management and Development for HealthDar es SalaamTanzania
- Department of Global Public HealthKarolinska InstitutetStockholmSweden
| | - David Sando
- Management and Development for HealthDar es SalaamTanzania
| | | | | | - Helga Naburi
- Department of Pediatric and Child HealthMuhimbili University of Health and Allied SciencesDar es SalaamTanzania
| | - Peter Lyaruu
- Management and Development for HealthDar es SalaamTanzania
| | - Amanda Kimonge
- Management and Development for HealthDar es SalaamTanzania
| | - Kasasi Mayogu
- Management and Development for HealthDar es SalaamTanzania
| | - Brenda Simba
- Management and Development for HealthDar es SalaamTanzania
| | | | | | - Zangin Zeebari
- Department of Global Public HealthKarolinska InstitutetStockholmSweden
| | - Gunnel Biberfeld
- Department of Global Public HealthKarolinska InstitutetStockholmSweden
| | - Anna Mia Ekström
- Department of Global Public HealthKarolinska InstitutetStockholmSweden
- Department of Infectious Disease/VenhälsanSouth General HospitalStockholmSweden
| | - Charles Kilewo
- Department of Obstetrics and GynacologyMuhimbili University of Health and Allied SciencesDar es SalaamTanzania
| | - Anna E. Kågesten
- Department of Global Public HealthKarolinska InstitutetStockholmSweden
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Mburu C, Njuguna I, Neary J, Mugo C, Moraa H, Beima-Sofie K, Onyango A, Oyiengo L, Richardson BA, John-Stewart G, Wamalwa D. Mortality and Loss to Follow-Up Among Adolescents and Young Adults Attending HIV Care Programs in Kenya. AIDS Patient Care STDS 2023; 37:323-331. [PMID: 37432311 PMCID: PMC10354300 DOI: 10.1089/apc.2023.0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2023] Open
Abstract
Mortality and loss to follow-up (LTFU) among adolescents and youth living with HIV (AYLHIV) remain high. We evaluated mortality and LTFU during the test and treat era. We abstracted medical records of AYLHIV for 10-24 years between January 2016 and December 2017 in 87 HIV clinics in Kenya. Using competing risk survival analysis, we compared incidence rates and determined correlates of mortality and LTFU among newly enrolled [<2 years since antiretroviral therapy (ART) initiation] and AYLHIV on ART for ≥2 years. Among 4201 AYLHIV, 1452 (35%) and 2749 (65%) were new enrollments and on ART for ≥2 years, respectively. AYLHIV on antiretroviral therapy (ART) for ≥2 years were younger and more likely to have perinatally acquired HIV (p < 0.001). Incidence of mortality and LTFU per 100 person-years were 2.32 [95% confidence interval (CI): 1.64-3.28] and 37.8 (95% CI: 34.7-41.3), respectively, among new enrollments and 1.22 (95% CI: 0.94-1.59) and 10.2 (95% CI: 9.3-11.1), respectively, among those on ART for ≥2 years. New enrollments had almost twice higher risk of mortality [subdistribution hazard ratio (sHR) 1.92 (1.30, 2.84), p = 0.001] and sevenfold higher risk of LTFU [sHR 7.71 (6.76, 8.79), p < 0.001] than those on ART for ≥2 years. Among new enrollments, mortality was higher in males and those with World Health Organization (WHO) stage III/IV disease at enrollment, and LTFU was associated with pregnancy, older age, and nonperinatal acquisition. Female sex and WHO stage (I/II) were associated with LTFU among those on ART for ≥2 years. During the study period from January 1, 2016, to December 31, 2017, the mortality incidence observed did not demonstrate improvement from earlier studies despite universal test and treat and better ART regimens. This trial was registered with ClinicalTrials.gov, NCT03574129.
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Affiliation(s)
- Caren Mburu
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Irene Njuguna
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Jillian Neary
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Cyrus Mugo
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Hellen Moraa
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Kristin Beima-Sofie
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Alvin Onyango
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Laura Oyiengo
- United Nations International Emergency Children's Fund, Department of Maternal and Newborn Health
| | - Barbra A. Richardson
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Dalton Wamalwa
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
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Sumari-de Boer IM, Ngowi KM, Swai IU, Masika LV, Maro RA, Mtenga AE, Mtesha BA, Nieuwkerk PT, Reis R, de Wit TFR, Aarnoutse RE. Effect of a customized digital adherence tool on retention in care and adherence to antiretroviral treatment in breastfeeding women, children and adolescents living with HIV in Tanzania: a mixed-methods study followed by clinical trials. Trials 2023; 24:285. [PMID: 37085913 PMCID: PMC10120095 DOI: 10.1186/s13063-023-07293-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 04/05/2023] [Indexed: 04/23/2023] Open
Abstract
BACKGROUND Adherence to antiretroviral (ARV) treatment for HIV infection is challenging because of many factors. The World Health Organization (WHO) has recommended using digital adherence technologies (DATs). However, there is limited evidence on how DATs improve adherence. Wisepill® is an internet-enabled medication dispenser found feasible and acceptable in several studies. However, limited evidence is available on its effectiveness in improving ART adherence, specifically among children and adolescents. Furthermore, DATs are often developed without involving the target groups. We propose a two-stage project consisting of a formative study to customize an existing Wisepill DAT intervention and a randomized clinical trial to investigate the effectiveness of DAT combined with reminder cues and tailored feedback on adherence to ARV treatment among children and adolescents living with HIV and retention in care among breastfeeding women living with HIV in Kilimanjaro and Arusha Region, Tanzania. METHODS We will conduct a formative mixed-methods study and three sub-trials in Kilimanjaro and Arusha Regions among (1) children aged 0-14 years and their caregivers, (2) adolescents aged 15-19 years and (3) breastfeeding women and their HIV-negative infants. In the formative study, we will collect and analyse data on needs and contents for DATs, including the contents of short message service (SMS) texts and tailored feedback. The results will inform the customization of the DAT to be tested in the sub-trials. In the trials, participants will be randomized in the intervention arm, where the DAT will be implemented or the control arm, where standard care will be followed. Participants in the intervention arm will take their medication from the Wisepill box and receive daily reminder texts and tailored feedback during clinic visits. DISCUSSION If the intervention improves adherence to ART and the devices are acceptable, accurate and sustainable, the intervention can be scaled up within the National Aids Control Programmes. TRIAL REGISTRATION PACTR202301844164954, date 27 January 2023.
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Affiliation(s)
- I Marion Sumari-de Boer
- Kilimanjaro Clinical Research Institute (KCRI), PO Box 2236, Moshi, Tanzania.
- Amsterdam Institute for Global Health and Development, Amsterdam, the Netherlands.
- Institute of Public Health, Kilimanjaro Christian Medical University College, Moshi, Tanzania.
- Knowledge, Technology & Innovation Group, Wageningen University & Research, Wageningen, the Netherlands.
| | - Kennedy M Ngowi
- Kilimanjaro Clinical Research Institute (KCRI), PO Box 2236, Moshi, Tanzania
- Department of Medial Psychology, Amsterdam UMC, Amsterdam, the Netherlands
| | - Iraseni U Swai
- Kilimanjaro Clinical Research Institute (KCRI), PO Box 2236, Moshi, Tanzania
- Department of Global Health, Amsterdam UMC, Amsterdam, the Netherlands
| | - Lyidia V Masika
- Institute of Public Health, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Rehema A Maro
- Kilimanjaro Clinical Research Institute (KCRI), PO Box 2236, Moshi, Tanzania
| | - Alan E Mtenga
- Kilimanjaro Clinical Research Institute (KCRI), PO Box 2236, Moshi, Tanzania
| | - Benson A Mtesha
- Kilimanjaro Clinical Research Institute (KCRI), PO Box 2236, Moshi, Tanzania
| | - Pythia T Nieuwkerk
- Department of Medial Psychology, Amsterdam UMC, Amsterdam, the Netherlands
| | - Ria Reis
- Amsterdam Institute for Global Health and Development, Amsterdam, the Netherlands
- The Children's Institute, University of Cape Town, Cape Town, South Africa
| | - Tobias F Rinke de Wit
- Amsterdam Institute for Global Health and Development, Amsterdam, the Netherlands
- Department of Global Health, Amsterdam UMC, Amsterdam, the Netherlands
| | - Rob E Aarnoutse
- Department of Pharmacy, Radboud UMC, Nijmegen, the Netherlands
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Jiang W, Ronen K, Osborn L, Drake AL, Unger JA, Matemo D, Richardson BA, Kinuthia J, John-Stewart G. Programmatic Retention in Prevention of Mother-to-Child Transmission (PMTCT) Programs: Estimated Rates and Cofactors Using Different Nonretention Measures. J Acquir Immune Defic Syndr 2023; 92:106-114. [PMID: 36215980 PMCID: PMC9839514 DOI: 10.1097/qai.0000000000003117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 09/13/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Prevention of mother-to-child transmission programs serve women continuing and initiating antiretroviral therapy (ART) in pregnancy, and follow-up schedules align to delivery rather than ART initiation, making conventional HIV retention measures (assessed from ART initiation) challenging to apply. We evaluated 3 measures of peripartum nonretention in Kenyan women living with HIV from pregnancy to 2 years postpartum. METHODS This longitudinal analysis used programmatic data from the Mobile WAChX trial (NCT02400671). Outcomes included loss to follow-up (LTFU) (no visit for ≥6 months), incomplete visit coverage (<80% of 3-month intervals with a visit), and late visits (>2 weeks after scheduled date). Predictors of nonretention were determined using Cox proportional hazards, log-binomial, and generalized estimating equation models. RESULTS Among 813 women enrolled at a median of 24 weeks gestation, incidence of LTFU was 13.6/100 person-years; cumulative incidence of LTFU by 6, 12, and 24 months postpartum was 16.7%, 20.9%, and 22.5%, respectively. Overall, 35.5% of women had incomplete visit coverage. Among 794 women with 12,437 scheduled visits, a median of 11.1% of visits per woman were late (interquartile range 4.3%-23.5%). Younger age, unsuppressed viral load, unemployment, ART initiation in pregnancy, and nondisclosure were associated with nonretention by all measures. Partner involvement was associated with better visit coverage and timely attendance. Women who became LTFU had higher frequency of previous late visits (16.7% vs. 7.7%, P < 0.0001). CONCLUSIONS Late visit attendance may be a sentinel indicator of LTFU. Identified cofactors of prevention of mother-to-child transmission programmatic retention may differ depending on retention measure assessed, highlighting the need for standardized measures.
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Affiliation(s)
- Wenwen Jiang
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Keshet Ronen
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Lusi Osborn
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Alison L. Drake
- Global Health, University of Washington, Seattle, Washington, USA
| | - Jennifer A. Unger
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA, Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Daniel Matemo
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Barbra A. Richardson
- Departments of Biostatistics and Global Health, University of Washington, Division of Vaccine and Infectious Disease, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - John Kinuthia
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Grace John-Stewart
- Departments of Global Health, Medicine, Pediatrics, and Epidemiology, University of Washington, Seattle, Washington, USA
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Morris BM, Nyamhagata M, Tarimo E, Sunguya B. Eliminating mother-to-child transmission of HIV in Tanzania calls for efforts to address factors associated with a low confirmatory test. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001218. [PMID: 36963073 PMCID: PMC10021727 DOI: 10.1371/journal.pgph.0001218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 12/28/2022] [Indexed: 03/14/2023]
Abstract
Option B+ approach for prevention of mother-to-child transmission (PMTCT) has demonstrated the potential to eliminate pediatric HIV infections. Its success depends on early infant diagnosis (EID) of HIV among the exposed infants within the first 6 weeks, and a subsequent confirmatory HIV test within 18 months. However, most mothers enrolling in option B+ in Tanzania do not come for such confirmatory tests. We examined factors associated with the turning-up of mother-baby pairs on the PMTCT program for a confirmatory HIV testing 18 months post-delivery in Tanzania. This study utilized longitudinal data collected between 2015 and 2017, from 751 mother-baby pairs enrolled in the PMTCT-option B+ approach in 79 health facilities from the 12 regions of Tanzania-mainland. Only 44.2% of 751 mother-baby records observed received the HIV confirmatory test by the 18th month. Mothers aged 25 years or above (adults' mothers) were 1.44 more likely to turn up for confirmatory HIV testing than young mothers; mothers with partners tested for HIV were 1.74 more likely to have confirmatory HIV testing compared with partners not tested for HIV. Newly diagnosed HIV-positive mothers were 28% less likely to bring their babies for a confirmatory HIV-testing compared to known HIV-positive mothers. Mothers with treatment supporters were 1.58 more likely to receive confirmatory HIV-testing compared to mothers without one. Mother-baby pairs who collected DBS-PCR-1 were 3.61 more likely to have confirmatory HIV-testing than those who didn't collect DBS-PCR-1. In conclusion, the confirmatory HIV testing within 18 months among mother-baby pairs enrolled in the Option B+ approach is still low in Tanzania. This is associated with low maternal age, having a male partner not tested for HIV, lack of experience with HIV services, lack of treatment supporters, and failure to take the DBS-PCR-1 HIV test within the first two months post-delivery.
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Affiliation(s)
- Baraka M Morris
- Muhimbili University of Health and Allied Sciences, Dar es salaam, Tanzania
| | | | - Edith Tarimo
- Muhimbili University of Health and Allied Sciences, Dar es salaam, Tanzania
| | - Bruno Sunguya
- Muhimbili University of Health and Allied Sciences, Dar es salaam, Tanzania
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Factors Associated with Retention of HIV Patients on Antiretroviral Therapy in Care: Evidence from Outpatient Clinics in Two Provinces of the Democratic Republic of the Congo (DRC). Trop Med Infect Dis 2022; 7:tropicalmed7090229. [PMID: 36136640 PMCID: PMC9504336 DOI: 10.3390/tropicalmed7090229] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/25/2022] [Accepted: 08/26/2022] [Indexed: 12/02/2022] Open
Abstract
Interruptions in the continuum of care for HIV can inadvertently increase a patient’s risk of poor health outcomes such as uncontrolled viral load and a greater likelihood of developing drug resistance. Retention of people living with HIV (PLHIV) in care and determinants of attrition, such as adherence to treatment, are among the most critical links strengthening the continuum of care, reducing the risk of treatment failure, and assuring viral load suppression. Objective: To analyze the variation in, and factors associated with, retention of patients enrolled in HIV services at outpatient clinics in the provinces of Kinshasa and Haut-Katanga, Democratic Republic of the Congo (DRC). Methods: Data for the last visit of 51,286 patients enrolled in Centers for Disease Control (CDC)-supported outpatient HIV clinics in 18 health zones in Haut-Katanga and Kinshasa, DRC were extracted in June 2020. Chi-square tests and multivariable logistic regressions were performed. Results: The results showed a retention rate of 78.2%. Most patients were classified to be at WHO clinical stage 1 (42.1%), the asymptomatic stage, and only 3.2% were at stage 4, the severest stage of AIDS. Odds of retention were significantly higher for patients at WHO clinical stage 1 compared to stage 4 (adjusted odds ratio (AOR), 1.325; confidence interval (CI), 1.13−1.55), women as opposed to men (AOR, 2.00; CI, 1.63−2.44), and women who were not pregnant (vs. pregnant women) at the start of antiretroviral therapy (ART) (AOR, 2.80; CI, 2.04−3.85). Odds of retention were significantly lower for patients who received a one-month supply rather than multiple months (AOR, 0.22; CI, 0.20−0.23), and for patients in urban health zones (AOR, 0.75; CI, 0.59−0.94) rather than rural. Compared to patients 55 years of age or older, the odds of retention were significantly lower for patients younger than 15 (AOR, 0.35; CI, 0.30−0.42), and those aged 15 and <55 (AOR, 0.75; CI, 0.68−0.82). Conclusions: Significant variations exist in the retention of patients in HIV care by patient characteristics. There is evidence of strong associations of many patient characteristics with retention in care, including clinical, demographic, and other contextual variables that may be beneficial for improvements in HIV services in DRC.
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Teasdale CA, Odondi J, Kidiga C, Choy M, Fayorsey R, Ngeno B, Ochanda B, Langat A, Ngugi C, Callahan T, Modi S, Hawken M, Odera D, Abrams EJ. Group antenatal care for improving retention of adolescent and young pregnant women living with HIV in Kenya. BMC Pregnancy Childbirth 2022; 22:208. [PMID: 35291978 PMCID: PMC8925235 DOI: 10.1186/s12884-022-04527-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 02/28/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pregnant and breastfeeding adolescents and young women living with HIV (AYWLH) have lower retention in prevention of mother-to-child transmission (PMTCT) services compared to older women. METHODS We evaluated a differentiated service model for pregnant and postnatal AYWLH at seven health facilities in western Kenya aimed at improving retention in antiretroviral treatment (ART) services. All pregnant AYWLH < 25 years presenting for antenatal care (ANC) were invited to participate in group ANC visits including self-care and peer-led support sessions conducted by health facility nurses per national guidelines. ART register data were used to assess loss to follow-up (LTFU) among newly-enrolled pregnant adolescent (< 20 years) and young women (20-24 years) living with HIV starting ART in the pre-period (January-December 2016) and post-period (during implementation; December 2017-January 2019). Poisson regression models compared LTFU incidence rate ratios (IRR) in the first six months after PMTCT enrollment and risk ratios compared uptake of six week testing for HIV-exposed infants (HEI) between the pre- and post-periods. RESULTS In the pre-period, 223 (63.2%) of 353 pregnant AYWLH newly enrolled in ANC had ART data, while 320 (71.1%) of 450 in the post-period had ART data (p = 0.02). A higher proportion of women in the post-period (62.8%) had known HIV-positive status at first ANC visit compared to 49.3% in the pre-period (p < 0.001). Among pregnant AYWLH < 20 years, the incidence rate of LTFU in the first six months after enrollment in ANC services declined from 2.36 per 100 person months (95%CI 1.06-5.25) in the pre-period to 1.41 per 100 person months (95%CI 0.53-3.77) in the post-period. In both univariable and multivariable analysis, AYWLH < 20 years in the post-period were almost 40% less likely to be LTFU compared to the pre-period, although this finding did not meet the threshold for statistical significance (adjusted incidence rate ratio 0.62, 95%CI 0.38-1.01, p = 0.057). Testing for HEI was 10% higher overall in the post-period (adjusted risk ratio 1.10, 95%CI 1.01-1.21, p = 0.04). CONCLUSIONS Interventions are urgently needed to improve outcomes among pregnant and postnatal AYWLH. We observed a trend towards increased retention among pregnant adolescents during our intervention and a statistically significant increase in uptake of six week HEI testing.
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Affiliation(s)
- Chloe A Teasdale
- Department of Epidemiology & Biostatistics, City University of New York (CUNY) Graduate School of Public Health & Health Policy, 55 W125th Street, Room 543, New York, NY, 10025, USA. .,ICAP-Columbia University, Mailman School of Public Health, New York, NY, USA. .,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.
| | - Judith Odondi
- ICAP-Columbia University, Mailman School of Public Health, New York, NY, USA
| | - Catherine Kidiga
- ICAP-Columbia University, Mailman School of Public Health, New York, NY, USA
| | - Michelle Choy
- ICAP-Columbia University, Mailman School of Public Health, New York, NY, USA
| | - Ruby Fayorsey
- ICAP-Columbia University, Mailman School of Public Health, New York, NY, USA
| | - Bernadette Ngeno
- Division of Global HIV and TB, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Agnes Langat
- US Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Catherine Ngugi
- National AIDS and STI Control Programme (NASCOP), Nairobi, Kenya
| | - Tegan Callahan
- Division of Global HIV and TB, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Surbhi Modi
- Division of Global HIV and TB, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Mark Hawken
- ICAP-Columbia University, Mailman School of Public Health, New York, NY, USA
| | - Doris Odera
- ICAP-Columbia University, Mailman School of Public Health, New York, NY, USA
| | - Elaine J Abrams
- ICAP-Columbia University, Mailman School of Public Health, New York, NY, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.,Department of Pediatrics, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY, USA
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Philemon RN, Mmbaga BT, Bartlett J, Renju J, Mtuy T, Mboya IB, Msuya SE. Do Women Enrolled in PMTCT Understand the Recommendations: A Case Study from Kilimanjaro. Patient Prefer Adherence 2021; 15:1301-1309. [PMID: 34163147 PMCID: PMC8216065 DOI: 10.2147/ppa.s307847] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 04/21/2021] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Prevention of mother-to-child transmission (PMTCT) remains a cornerstone of HIV prevention and control efforts. It is vital that the beneficiaries of PMTCT programs understand PMTCT recommendations, especially since their adherence to recommendations is key to successful PMTCT. There have been several major changes in PMTCT recommendations, and many women have encountered different recommendations. It is plausible that confusion has arisen as to what is currently recommended for successful PMTCT. This confusion can affect adherence to recommendations and hinder PMTCT efforts. However, little is known about how women enrolled in PMTCT understand the recommendations in the context of these frequent changes. AIM In this paper, we present our findings regarding how HIV-positive women enrolled in PMTCT in Kilimanjaro understand PMTCT recommendations pertinent to them. METHODS From August 2019 to April 2020, we surveyed 521 mothers enrolled in PMTCT in seven districts in the Kilimanjaro region, Northern Tanzania. A pretested questionnaire was administered to consenting mothers. The questionnaire collected information on mothers' demographic characteristics, previous encounters with PMTCT, and knowledge of various PMTCT program elements, including medication duration, breastfeeding recommendations and infant HIV testing schedule. A logistic regression model was used to determine factors associated with good PMTCT knowledge among mothers. RESULTS A total of 521 women were enrolled, the median score for the 19 items used to assess knowledge was 57.9%, and 64.9% scored above the median. Counselling on ART (OR=2.17, 95% CI 1.08-4.36) and counselling on breastfeeding during the ANC visits (OR=2.38, 95% CI 1.38-4.11) were the only factors that we found to be significantly associated with higher odds of good knowledge of PMTCT. CONCLUSION Even amongst mothers enrolled in PMTCT, poor understanding regarding key PMTCT recommendations prevails. There is a need to reassess the training modalities and look at ways to reinforce PMTCT messages to mothers.
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Affiliation(s)
- Rune N Philemon
- Department of Pediatrics and Child Health, Kilimanjaro Christian Medical University College (KCMUCo) & Kilimanjaro Christian Medical Centre (KCMC), Moshi, Tanzania
| | - Blandina T Mmbaga
- Department of Pediatrics and Child Health, Kilimanjaro Christian Medical University College (KCMUCo) & Kilimanjaro Christian Medical Centre (KCMC), Moshi, Tanzania
- Department of Research, Kilimanjaro Clinical Research Institute (KCRI), Moshi, Tanzania
| | - John Bartlett
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Jenny Renju
- Institute of Public Health, Department of Epidemiology & Biostatistics, Kilimanjaro Christian Medical University College (KCMUCo), Moshi, Tanzania
- Faculty of Population Health, London School of Hygiene and Tropical Medicine (LSHTM), London, UK
| | - Tara Mtuy
- Institute of Public Health, Department of Epidemiology & Biostatistics, Kilimanjaro Christian Medical University College (KCMUCo), Moshi, Tanzania
- Faculty of Public Health and Policy and the Department of Global Health and Development, London School of Hygiene & Tropical Medicine (LSHTM), London, UK
| | - Innocent B Mboya
- Institute of Public Health, Department of Epidemiology & Biostatistics, Kilimanjaro Christian Medical University College (KCMUCo), Moshi, Tanzania
- Institute of Public Health, Department of Community Health, Kilimanjaro Christian Medical University College (KCMUCo), Moshi, Tanzania
- School of Mathematics, Statistics & Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Sia E Msuya
- Institute of Public Health, Department of Epidemiology & Biostatistics, Kilimanjaro Christian Medical University College (KCMUCo), Moshi, Tanzania
- Institute of Public Health, Department of Community Health, Kilimanjaro Christian Medical University College (KCMUCo), Moshi, Tanzania
- Department of Community Health, Kilimanjaro Christian Medical Centre (KCMC), Moshi, Tanzania
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Watt MH, Minja L, Knettel BA, Mwamba RN, Osaki H, Ngocho JS, Kisigo GA, Renju J, Vissoci JRN, Sao SS, Mmbaga BT. Pilot Outcomes of Maisha: An HIV Stigma Reduction Intervention Developed for Antenatal Care in Tanzania. AIDS Behav 2021; 25:1171-1184. [PMID: 33180253 PMCID: PMC7979435 DOI: 10.1007/s10461-020-03093-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2020] [Indexed: 12/15/2022]
Abstract
HIV stigma is a persistent barrier to curbing the spread of HIV and improving quality of life for people living with HIV. We developed and pilot tested Maisha, an HIV stigma reduction intervention in antenatal care (ANC) with two objectives: 1) among individuals living with HIV, reduce internalized and anticipated HIV stigma, with subsequent improvements in HIV care engagement, and 2) among individuals who are HIV-seronegative, reduce HIV stigmatizing attitudes. We enrolled and baselined 1039 women and 492 male partners presenting to a first ANC appointment and randomized them to standard of care or the Maisha intervention. All women living with HIV (WLHIV) and a subset of HIV-negative participants completed a 3-month follow-up assessment. Participation in the three Maisha sessions was high (99.6%, 92.8%, 89.3%), and nearly all participants noted satisfaction with the intervention content (99.8%) and counselor (99.8%). Among 55 WLHIV, care engagement outcomes did not differ by condition. Among 293 HIV-negative participants, Maisha participants had significantly greater reductions in the moral judgment sub-scale of the stigma attitudes measure (p < .001), but not the social distancing subscale. The ANC setting, where women and their partners are routinely tested for HIV, is an ideal venue for addressing HIV stigma. The Maisha intervention was feasible and acceptable, and had an impact on HIV stigma attitudes. A full trial is needed to examine impacts on HIV outcomes; modifications to the intervention should be considered to reduce social alienation of PLWH.
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Chace Dwyer S, Jain A, Liambila W, Warren CE. The role of unintended pregnancy in internalized stigma among women living with HIV in Kenya. BMC WOMENS HEALTH 2021; 21:106. [PMID: 33731107 PMCID: PMC7968281 DOI: 10.1186/s12905-021-01224-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 02/09/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Kenya has successfully expanded HIV treatment, but HIV-related stigma and discrimination, and unintended pregnancy remain issues for many Kenyan women living with HIV. While HIV-related stigma can influence the health seeking behaviors of those living with HIV, less is known about how reproductive health outcomes influence internalized stigma among women living with HIV. METHODS Baseline data only were used in this analysis and came from an implementation science study conducted in Kenya from 2015 to 2017. The analytic sample was limited to 1116 women who are living with HIV, between 18 to 44 years old, and have ever experienced a pregnancy. The outcome variable was constructed from 7 internalized stigma statements and agreement with at least 3 statements was categorized as medium/high levels of internalized stigma. Unintended pregnancy, categorized as unintended if the last pregnancy was mistimed or unwanted, was the key independent variable. Univariate and multivariate logistic regression models were used to assess the association between unintended pregnancy and internalized stigma. Associations between internalized stigma and HIV-related discrimination and violence/abuse were also explored. RESULTS About 48% agreed with at least one internalized stigma statement and 19% agreed with at least three. Over half of women reported that their last pregnancy was unintended (59%). Within the year preceding the survey, 52% reported experiencing discrimination and 41% reported experiencing violence or abuse due to their HIV status. Women whose last pregnancy was unintended were 1.6 times (95% CI 1.2-2.3) more likely to have medium/high levels of internalized stigma compared to those whose pregnancy was wanted at the time, adjusting for respondents' characteristics, experiences of discrimination, and experiences of violence and abuse. Women who experienced HIV-related discrimination in the past 12 months were 1.8 times (95% CI 1.3-2.6) more likely to have medium/high levels of internalized stigma compared to those who experienced no discrimination. CONCLUSIONS Results suggest that unintended pregnancy is associated with internalized stigma. Integrated HIV and FP programs in Kenya should continue to address stigma and discrimination while increasing access to comprehensive voluntary family planning services for women living with HIV.
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Affiliation(s)
- Sara Chace Dwyer
- Population Council, 4301 Connecticut Ave NW # 280, Washington, DC, 20008, USA.
| | - Aparna Jain
- Population Council, 4301 Connecticut Ave NW # 280, Washington, DC, 20008, USA
| | | | - Charlotte E Warren
- Population Council, 4301 Connecticut Ave NW # 280, Washington, DC, 20008, USA
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Lyatuu GW, Mwashemele SZ, Urrio R, Naburi H, Kashmir N, Machumi L, Kibao A, Sellah Z, Ulenga N, Orsini N, Biberfeld G, Kilewo C, Ekström AM. Long-term virological outcomes in women who started option B+ care during pregnancy for prevention of mother-to-child transmission of HIV in Dar es Salaam, Tanzania: a cohort study. Lancet HIV 2021; 8:e256-e265. [PMID: 33581776 DOI: 10.1016/s2352-3018(20)30308-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 10/20/2020] [Accepted: 11/09/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND Option B+ marked a milestone in prevention of mother-to-child transmission (PMTCT) of HIV by recommending lifelong antiretroviral therapy (ART) for all pregnant women with HIV. Nevertheless, concerns remain regarding long-term outcomes in settings with a high HIV burden. We analysed long-term virological outcomes in women enrolled on option B+ in Tanzania. METHODS In this prospective cohort study, we extracted data for pregnant women with HIV starting PMTCT care between Oct 1, 2014, and Sept 30, 2016, in routine health-care settings in Dar es Salaam, Tanzania, from national HIV and district health information system databases. We then excluded women who exited study sites before 6 months of ART follow-up and women who did not have a viral load test. Women were followed up until March 8, 2019. We used Poisson generalised estimating equations to examine trends in HIV viral suppression (<400 copies per mL) and virological failure (≥400 copies per mL), reporting relative risks (RRs) and 95% CIs adjusted for maternal age, gestational age, and several clinical characteristics. FINDINGS We identified 15 586 pregnant women with HIV, of whom 10 161 were eligible for follow-up. Women were followed up for a median of 37 months (IQR 31-45) and a maximum of 53 months. The median age at PMTCT initiation was 31 years (IQR 27-35). At PMTCT enrolment, 1245 (17·0%) of 7318 women with available data were in their third trimester, 4901 (48·2%) of 10 161 women started ART at least 1 month before PMTCT enrolment, and 3380 (33·4%) of 10 131 women with available data had advanced HIV. Overall, a viral suppression rate of 88·2% (95% CI 87·8-88·7) was observed over the entire follow-up period, ranging from 85·1% (84·3-85·9) in viral load tests done at 0-11 months to 90·6% (89·7-91·4) at 36 months or longer since PMTCT enrolment. In a complete-case analysis (ie, including patients with <30% missing data; n=7306), the risk of virological failure among women who remained in HIV care decreased over time (adjusted RR 0·87 [95% CI 0·80-0·95] at 12-23 months since PMTCT enrolment; 0·65 [0·59-0·72] at 24-35 months; and 0·63 [0·55-0·71] at ≥36 months vs at 0-11 months). Younger women (aged <20 years: 1·76 [1·40-2·23] vs aged 30-39 years) and those starting PMTCT late in pregnancy (third trimester: 1·28 [1·10-1·50] vs first trimester) or with advanced HIV (1·33 [1·16-1·51] vs without advanced HIV) had increased risk of virological failure. Women who attended an antenatal care facility where more than 50% of attendees received couples HIV testing had a decreased risk of virological failure (adjusted RR 0·81 [0·65-0·99] vs <50% having couples testing). INTERPRETATION High rates of viral suppression among women starting option B+ who remain in HIV care are sustainable, and might increase, at least up to 53 months. This rate might be further improved by addressing challenges of adolescent mothers, late presenters, and couples HIV testing at antenatal care. FUNDING Swedish International Development Agency.
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Affiliation(s)
- Goodluck W Lyatuu
- Management and Development for Health, Dar es Salaam, Tanzania; Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.
| | | | - Roseline Urrio
- Management and Development for Health, Dar es Salaam, Tanzania; Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Helga Naburi
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Nassir Kashmir
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Lameck Machumi
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Ayoub Kibao
- Dar es Salaam Regional Administrative Secretary, Dar es Salaam, Tanzania
| | - Ziada Sellah
- Dar es Salaam Regional Administrative Secretary, Dar es Salaam, Tanzania
| | - Nzovu Ulenga
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Nicola Orsini
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Gunnel Biberfeld
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Charles Kilewo
- Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Anna Mia Ekström
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
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Williams SM, Renjua J, Moshabela M, Wringe A. Understanding the influence of health systems on women's experiences of Option B+: A meta-ethnography of qualitative research from sub-Saharan Africa. Glob Public Health 2021; 16:167-185. [PMID: 33284727 PMCID: PMC7612946 DOI: 10.1080/17441692.2020.1851385] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 11/05/2020] [Indexed: 11/21/2022]
Abstract
We explored women's experiences of Option B+ in sub-Saharan African health facility settings through a meta-ethnography of 32 qualitative studies published between 2010 and 2019. First and second-order constructs were identified from the data and authors' interpretations respectively. Using a health systems lens, third-order constructs explored how the health systems shaped women's experiences of Option B+ and their subsequent engagement in care. Women's experiences of Option B+ services were influenced by their interactions with health workers, which were often reported to be inadequate and rushed, reflecting insufficient staffing or training to address pregnant women's needs. Women's experiences were also undermined by various manifestations of stigma which persisted in the absence of resources for social or mental health support, and were exacerbated by space constraints in health facilities that infringed on patient confidentiality. Sub-optimal service accessibility, drug stock-outs and inadequate tracing systems also shaped women's experiences of care. Strengthening health systems by improving health worker capacity to provide respectful and high-quality clinical and support services, improving supply chains and improving the privacy of consultation spaces would improve women's experiences of Option B+ services, thereby contributing to improved care retention. These lessons should be considered as universal test and treat programmes expand.
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Affiliation(s)
- Shannon M. Williams
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Jenny Renjua
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
- Department of Epidemiology and Biostatistics, Kilimanjaro Christian Medical College, Moshi, Tanzania
| | - Mosa Moshabela
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Africa Health Research Institute, Durban, South Africa
| | - Alison Wringe
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
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Oshosen M, Knettel BA, Knippler E, Relf M, Mmbaga BT, Watt MH. "She Just Told Me Not To Cry": A Qualitative Study of Experiences of HIV Testing and Counseling (HTC) Among Pregnant Women Living with HIV in Tanzania. AIDS Behav 2021; 25:104-112. [PMID: 32572712 PMCID: PMC7752832 DOI: 10.1007/s10461-020-02946-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
HIV testing and counseling (HTC) in antenatal care is extremely effective at identifying women living with HIV and linking them to HIV care. However, retention is suboptimal in this population. We completed qualitative interviews with 24 pregnant women living with HIV in Tanzania to explore perceptions of HTC. Participants described intense shock and distress upon testing positive, including concerns about HIV stigma and disclosure; however, these concerns were rarely discussed in HTC. Nurses were generally kind, but relied on educational content and brief reassurances, leaving some participants feeling unsupported and unprepared to start HIV treatment. Several participants described gaps in HIV knowledge, including the purpose of antiretroviral therapy and the importance of medication adherence. Targeted nurse training related to HIV disclosure, stigma, and counseling skills may help nurses to more effectively communicate the importance of care engagement to prevent HIV transmission and support the long-term health of mother and child.
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Affiliation(s)
- Martha Oshosen
- Kilimanjaro Clinical Research Institute, P.O. Box 2236, Moshi, Tanzania
- The University of Cape Town, Rondebosch 7701, Cape Town, South Africa
| | - Brandon A Knettel
- Duke Global Health Institute, Duke University, 310 Trent Drive, Durham, NC, 27710, USA.
- Duke University School of Nursing, 307 Trent Drive, Durham, NC, 27710, USA.
| | - Elizabeth Knippler
- Duke Global Health Institute, Duke University, 310 Trent Drive, Durham, NC, 27710, USA
- The University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, 27599, USA
| | - Michael Relf
- Duke Global Health Institute, Duke University, 310 Trent Drive, Durham, NC, 27710, USA
- Duke University School of Nursing, 307 Trent Drive, Durham, NC, 27710, USA
| | - Blandina T Mmbaga
- Kilimanjaro Clinical Research Institute, P.O. Box 2236, Moshi, Tanzania
- Duke Global Health Institute, Duke University, 310 Trent Drive, Durham, NC, 27710, USA
- Kilimanjaro Christian Medical Centre, P.O. Box 3010, Moshi, Tanzania
| | - Melissa H Watt
- Duke Global Health Institute, Duke University, 310 Trent Drive, Durham, NC, 27710, USA
- Department of Population Health Sciences, The University of Utah School of Medicine, Salt Lake City, USA
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Watt MH, Knettel BA, Knippler ET, Kisigo G, Ngocho JS, Renju J, Rogathi J, Sao SS, Minja L, Osaki H, Mwamba RN, Mmbaga BT. The development of Maisha, a video-assisted counseling intervention to address HIV stigma at entry into antenatal care in Tanzania. EVALUATION AND PROGRAM PLANNING 2020; 83:101859. [PMID: 32795711 PMCID: PMC7686260 DOI: 10.1016/j.evalprogplan.2020.101859] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 02/10/2020] [Accepted: 07/30/2020] [Indexed: 06/11/2023]
Abstract
HIV stigma has a profound impact on clinical outcomes and undermines the quality of life of people living with HIV (PLWH). Among HIV-negative individuals, misinformation and prejudicial attitudes about HIV can fuel stigma and contribute to discrimination against PLWH. Antenatal care (ANC), with its focus on universal HIV testing, provides a unique entry point to address HIV stigma. This study describes the development of a counseling intervention to address HIV stigma among women and their partners attending a first ANC appointment in Tanzania. Formative work to inform the intervention consisted of qualitative interviews with 32 pregnant and postpartum women (both women living with HIV and HIV-negative women) and 20 healthcare workers. Data were analyzed iteratively, using a thematic analysis approach, to identify intervention targets. The resulting intervention, Maisha (Swahili for "Life"), includes three sessions informed by the HIV Stigma Framework and Cognitive-Behavioral Therapy: a video and brief counseling session prior to HIV testing and, for those who test seropositive for HIV, two additional sessions building on the video content. A pilot test of the intervention is in process. Addressing HIV stigma at the first ANC visit can help individuals living with HIV to overcome stigma-related barriers to the initiation and maintenance of HIV care, and can reduce stigmatizing attitudes among those who test negative for HIV.
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Affiliation(s)
- Melissa H Watt
- Duke Global Health Institute, Duke University, Durham, NC, USA; Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA.
| | | | - Elizabeth T Knippler
- Duke Global Health Institute, Duke University, Durham, NC, USA; Gilling School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA.
| | - Godfrey Kisigo
- Duke Global Health Institute, Duke University, Durham, NC, USA; Kilimanjaro Clinical Research Institute, Moshi, Tanzania.
| | - James S Ngocho
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania; Kilimanjaro Christian Medical Centre, Moshi, Tanzania; Kilimanjaro Christian Medical University College, Moshi, Tanzania.
| | - Jenny Renju
- Kilimanjaro Christian Medical University College, Moshi, Tanzania; London School of Hygiene and Tropical Medicine, London, UK.
| | - Jane Rogathi
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania; Kilimanjaro Christian Medical University College, Moshi, Tanzania.
| | - Saumya S Sao
- Duke Global Health Institute, Duke University, Durham, NC, USA.
| | - Linda Minja
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania.
| | - Haika Osaki
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania.
| | - Rimel N Mwamba
- Duke Global Health Institute, Duke University, Durham, NC, USA.
| | - Blandina T Mmbaga
- Duke Global Health Institute, Duke University, Durham, NC, USA; Kilimanjaro Clinical Research Institute, Moshi, Tanzania; Kilimanjaro Christian Medical Centre, Moshi, Tanzania; Kilimanjaro Christian Medical University College, Moshi, Tanzania.
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Sao SS, Knettela BA, Kisigo GA, Knippler ET, Osaki H, Mwamba RN, Rogathi J, Ngochob JS, Mmbaga BT, Watt MH. HIV Community-Level Stigmatizing Attitudes in Tanzania: Perspectives from Antenatal Care. East Afr Health Res J 2020; 4:118-127. [PMID: 34308229 PMCID: PMC8279189 DOI: 10.24248/eahrj.v4i2.635] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 11/19/2020] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Stigma significantly impacts retention in HIV care and quality of life among people living with HIV. This study explored community-level HIV stigma from the perspective of patients and healthcare workers in antenatal care (ANC) in Moshi, Tanzania. METHODS We conducted in-depth interviews with 32 women (20 living with HIV), key-informant interviews with 7 ANC clinic employees, and two focus group discussions with 13 community health workers. RESULTS Themes emerged related to drivers and manifestations of stigma, resilience to stigmatizing attitudes, and opportunities to address stigma in ANC. Drivers of stigma included a fear of infection through social contact and associations of HIV with physical weakness (e.g., death, sickness) and immoral behaviour (e.g., sexual promiscuity). Manifestations included gossip, physical and social isolation, and changes in intimate relationships. At the same time, participants identified people who were resilient to stigmatizing attitudes, most notably individuals who worked in healthcare, family members with relevant life experiences, and some supportive male partners. CONCLUSION/RECOMMENDATIONS Supportive family members, partners, and healthcare workers can serve as role models for stigma-resilient behaviour through communication platforms and peer programs in ANC. Manifestations of HIV stigma show clear links to constructs of sexuality, gender, and masculinity, which may be particularly impactful during pregnancy care. The persistence of stigma emphasizes the need for innovation in addressing stigmatizing attitudes in the community. Campaigns and policies should go beyond dispelling myths about HIV transmission and immorality to innovate peer-led and couples-based stigma reduction programming in the ANC space.
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Affiliation(s)
- Saumya S Sao
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | | | - Godfrey A Kisigo
- Duke Global Health Institute, Duke University, Durham, NC, USA
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Elizabeth T Knippler
- Duke Global Health Institute, Duke University, Durham, NC, USA
- GillingsSchool of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Haika Osaki
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Rimel N Mwamba
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Jane Rogathi
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi Tanzania
| | - James S Ngochob
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi Tanzania
| | - Blandina T Mmbaga
- Duke Global Health Institute, Duke University, Durham, NC, USA
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi Tanzania
| | - Melissa H Watt
- Duke Global Health Institute, Duke University, Durham, NC, USA
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
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Knettel BA, Mwamba RN, Minja L, Goldston DB, Boshe J, Watt MH. Exploring patterns and predictors of suicidal ideation among pregnant and postpartum women living with HIV in Kilimanjaro, Tanzania. AIDS 2020; 34:1657-1664. [PMID: 32701584 PMCID: PMC7416579 DOI: 10.1097/qad.0000000000002594] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Pregnant and postpartum women living with HIV face disproportionate risk of depression and suicide, particularly in low-income and middle-income countries. This study examined patterns and predictors of suicidal ideation among women living with HIV in antenatal care in Kilimanjaro, Tanzania. DESIGN We conducted a longitudinal cohort study of 200 pregnant women living with HIV, with surveys conducted during pregnancy and 6 months postpartum. METHODS Pregnant women were recruited during HIV and antenatal care visits at nine clinics. A structured questionnaire was verbally administered in Kiswahili by a trained study nurse. We used simple frequencies and t-tests to measure patterns of suicidal ideation and logistic regression to assess factors associated with suicidal ideation. RESULTS Suicidal ideation was endorsed by 12.8% of women during pregnancy and decreased significantly to 3.9% by 6 months postpartum. Ideation was not significantly greater among participants newly diagnosed with HIV. In univariable analyses, suicidal ideation was associated with depression, anxiety, HIV stigma, single relationship status, unknown HIV status of the father of the baby, negative attitudes about antiretroviral medication, and low social support. In the multivariable model, women experiencing anxiety and HIV stigma were significantly more likely to endorse suicidal ideation during pregnancy. CONCLUSION Suicidal ideation and associated feelings of hopelessness are a critical challenge in antenatal care among women living with HIV, with important implications for quality of life, care engagement, and survival. To better support patients, targeted approaches to address anxiety, depression, stigma, and hopelessness must be prioritized, including crisis support for suicide prevention.
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Kisigo GA, Ngocho JS, Knettel BA, Oshosen M, Mmbaga BT, Watt MH. "At home, no one knows": A qualitative study of retention challenges among women living with HIV in Tanzania. PLoS One 2020; 15:e0238232. [PMID: 32853233 PMCID: PMC7451655 DOI: 10.1371/journal.pone.0238232] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 08/12/2020] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Despite the broad success of Prevention of Mother-to-Child Transmission of HIV (PMTCT) programs, HIV care engagement during the pregnancy and postpartum periods is suboptimal. This study explored the perspectives of women who experienced challenges engaging in PMTCT care, in order to better understand factors that contribute to poor retention and to identify opportunities to improve PMTCT services. METHODS We conducted in-depth interviews with 12 postpartum women to discuss their experiences with PMTCT care. We used data from a larger longitudinal cohort study conducted in five PMTCT clinics in Moshi, Tanzania to identify women with indicators of poor care engagement (i.e., medication non-adherence, inconsistent clinic attendance, or high viral load). Women who met one of these criteria were contacted by telephone and invited to complete an interview. Data were analyzed using applied thematic analysis. RESULTS We observed a common pathway that fear of stigma contributed to a lack of HIV disclosure and reduced social support for seeking HIV care. Women commonly distrusted the results of their initial HIV test and reported medication side effects after care initiation. Women also reported barriers in the health system, including difficult-to-navigate clinic transfer policies and a lack of privacy and confidentiality in service provision. When asked how care might be improved, women felt that improved counseling and follow-up, affirming patient-provider interactions, and peer treatment supporters would have a positive effect on care engagement. CONCLUSION In order to improve the impact of PMTCT programs, there is a need to implement active tracking and follow-up of patients, targeting individuals with evidence of poor care engagement. Tailored supportive intervention approaches may help patients to cope with both the perceived and actual impacts of HIV stigma, including navigating disclosures to loved ones and accessing social support. Fostering HIV acceptance is likely to facilitate commitment to long-term treatment.
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Affiliation(s)
- Godfrey A. Kisigo
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - James S. Ngocho
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Brandon A. Knettel
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Martha Oshosen
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
- The University of Cape Town, Cape Town, South Africa
| | - Blandina T. Mmbaga
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Melissa H. Watt
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
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Dube A, Renju J, Wamoyi J, Hassan F, Seeley J, Chimukuche RS, Songo J, Kalua T, Crampin A, Moshabela M, Wringe A. Consequences of male partner engagement policies on HIV care-seeking in three African countries: Findings from the SHAPE UTT study. Glob Public Health 2020; 16:216-226. [PMID: 32780669 PMCID: PMC7612866 DOI: 10.1080/17441692.2020.1805788] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
We explored how strategies to promote male partner engagement influenced HIV care-seeking among men and women living with HIV. In-depth interviews were conducted with 25 health workers, 66 female service users and 10 male partners in Ifakara (Tanzania), Karonga (Malawi) and uMkhanyakude (South Africa) to elicit experiences of offering, providing or receiving HIV care in the context of antenatal care. Data were coded inductively and analysed thematically. Participants reported benefits of couple testing during antenatal care, including facilitated HIV status disclosure and mutual support for HIV care-seeking. However, unintended consequences included women attending without partners, being refused or delayed access to antenatal services. Some women were required to obtain letters from village leaders to justify the absence of their partners, again to delaying or disrupting care-seeking. When partners attended antenatal care, consultations were reportedly more likely to focus on HIV testing, and less on antenatal or neonatal care. Strategies to increase men's attendance at HIV clinics with their partners can promote mutual support within couples for HIV care engagement, but may risk undermining engagement in pregnancy and HIV care for some women if over-stringently applied. Efforts are needed to address the underlying pervasive stigma associated with HIV care, both alone and as a couple.
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Affiliation(s)
- Albert Dube
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
| | - Jenny Renju
- Department of population health, London School of Hygiene and Tropical Medicine, London, United Kingdom.,Department of Epidemiology and Biostatistics, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Joyce Wamoyi
- Mwanza Intervention Trials Unit, Mwanza, United Republic of Tanzania
| | - Farida Hassan
- Ifakara Health Institute, Ifakara, United Republic of Tanzania
| | - Janet Seeley
- Department of population health, London School of Hygiene and Tropical Medicine, London, United Kingdom.,Africa Health Research Institute, KwaZulu-Natal, South Africa
| | | | - John Songo
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
| | - Thokozani Kalua
- Department of HIV and AIDS, Malawi Ministry of Health, Lilongwe, Malawi
| | - Amelia Crampin
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi.,Department of population health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Mosa Moshabela
- Africa Health Research Institute, KwaZulu-Natal, South Africa.,University of Kwa-Zulu Natal, Durban, South Africa
| | - Alison Wringe
- Department of population health, London School of Hygiene and Tropical Medicine, London, United Kingdom
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20
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Sibanda EL, Webb K, Fahey CA, Kang Dufour M, McCoy SI, Watadzaushe C, Dirawo J, Deda M, Chimwaza A, Taramusi I, Mushavi A, Mukungunugwa S, Padian N, Cowan FM. Use of data from various sources to evaluate and improve the prevention of mother-to-child transmission of HIV programme in Zimbabwe: a data integration exercise. J Int AIDS Soc 2020; 23 Suppl 3:e25524. [PMID: 32602644 PMCID: PMC7325515 DOI: 10.1002/jia2.25524] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 03/13/2020] [Accepted: 04/23/2020] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Despite improvements in prevention of mother-to-child transmission (PMTCT) of HIV outcomes, there remain unacceptably high numbers of mother-to-child transmissions (MTCT) of HIV. Programmes and research collect multiple sources of PMTCT data, yet this data is rarely integrated in a systematic way. We conducted a data integration exercise to evaluate the Zimbabwe national PMTCT programme and derive lessons for strengthening implementation and documentation. METHODS We used data from four sources: research, Ministry of Health and Child Care (MOHCC) programme, Implementer - Organization for Public Health Interventions and Development, and modelling. Research data came from serial population representative cross-sectional surveys that evaluated the national PMTCT programme in 2012, 2014 and 2017/2018. MOHCC and Organization for Public Health Interventions and Development collected data with similar indicators for the period 2018 to 2019. Modelling data from 2017/18 UNAIDS Spectrum was used. We systematically integrated data from the different sources to explore PMTCT programme performance at each step of the cascade. We also conducted spatial analysis to identify hotspots of MTCT. RESULTS We developed cascades for HIV-positive and negative-mothers, and HIV exposed and infected infants to 24 months post-partum. Most data were available on HIV positive mothers. Few data were available 6-8 weeks post-delivery for HIV exposed/infected infants and none were available post-delivery for HIV-negative mothers. The different data sources largely concurred. Antenatal care (ANC) registration was high, although women often presented late. There was variable implementation of PMTCT services, MTCT hotspots were identified. Factors positively associated with MTCT included delayed ANC registration and mobility (use of more than one health facility) during pregnancy/breastfeeding. There was reduced MTCT among women whose partners accompanied them to ANC, and infants receiving antiretroviral prophylaxis. Notably, the largest contribution to MTCT was from postnatal women who had previously tested negative (12/25 in survey data, 17.6% estimated by Spectrum modelling). Data integration enabled formulation of interventions to improve programmes. CONCLUSIONS Data integration was feasible and identified gaps in programme implementation/documentation leading to corrective interventions. Incident infections among mothers are the largest contributors to MTCT: there is need to strengthen the prevention cascade among HIV-negative women.
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Affiliation(s)
- Euphemia L Sibanda
- Centre for Sexual Health and HIV AIDS ResearchHarareZimbabwe
- Liverpool School of Tropical MedicineLiverpoolUK
| | - Karen Webb
- Organization for Public Health Interventions and Development (OPHID)HarareZimbabwe
- London School of Hygiene and Tropical MedicineLondonUK
| | | | | | | | | | - Jeffrey Dirawo
- Centre for Sexual Health and HIV AIDS ResearchHarareZimbabwe
| | - Marsha Deda
- Organization for Public Health Interventions and Development (OPHID)HarareZimbabwe
| | - Anesu Chimwaza
- Ministry of Health and Child Care, ZimbabweHarareZimbabwe
| | | | - Angela Mushavi
- Ministry of Health and Child Care, ZimbabweHarareZimbabwe
| | | | | | - Frances M Cowan
- Centre for Sexual Health and HIV AIDS ResearchHarareZimbabwe
- Liverpool School of Tropical MedicineLiverpoolUK
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Tolossa T, Kassa GM, Chanie H, Abajobir A, Mulisa D. Incidence and predictors of lost to follow-up among women under Option B+ PMTCT program in western Ethiopia: a retrospective follow-up study. BMC Res Notes 2020; 13:18. [PMID: 31910888 PMCID: PMC6947837 DOI: 10.1186/s13104-019-4882-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 12/28/2019] [Indexed: 12/04/2022] Open
Abstract
Objective Although Ethiopia has been implementing Option B+ program, LTFU of women from the Option B+ program is one of the challenges that minimizes its implementation. Thus, this study assessed the incidence and predictors of LTFU among women under Option B+ PMTCT program in western Ethiopia. An institution-based retrospective follow-up study was conducted. A cox proportional hazards regression model was fitted to identify predictors of LTFU. A Hazard ratios with 95% confidence CI was computed and all predictors that were associated with the outcome variable at p-value ≤ 0.05 in the multivariable cox proportional hazards were declared as a significance predictor of the outcome. Results A total of 330 women were followed for a mean follow up time of 16.9 (± 7.6) months. An overall incidence rate of LTFU was 9/1000 person-months. Women’s educational status, residence, HIV-disclosure status, the status of women at enrollment, previous history of HIV and ART adherence were significant predictors of LTFU. The incidence of LTFU from Option B+ PMTCT is lower as compared to evidence from sub-Saharan African and strengthening linkage and referral system between clinics as well as establishing appropriates tracing mechanisms would retain pregnant women in the program.
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Affiliation(s)
- Tadesse Tolossa
- Department of Public Health, Institute of Health Science, Wollega University, P.O.BOX: 395, Nekemte, Ethiopia.
| | - Getachew Mullu Kassa
- Department of Midwifery, College of Health Science, Debre Markos University, Debre Markos, Ethiopia
| | - Habtamu Chanie
- Department of Midwifery, College of Health Science, Debre Markos University, Debre Markos, Ethiopia
| | - Amanuel Abajobir
- Maternal and Child Wellbeing Unit, African Population and Health Research Centre, Nairobi, Kenya
| | - Diriba Mulisa
- Department of Nursing, Institute of Health Science, Wollega University, Nekemte, Ethiopia
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22
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Theilgaard ZP, Chiduo MG, Flamholc L, Gerstoft J, Bygbjerg IC, Lemnge MM, Katzenstein TL. Retired Nurses Can Improve Retention in Prevention of Mother-to-Child Transmission Programmes. East Afr Health Res J 2019; 3:88-95. [PMID: 34308201 PMCID: PMC8279289 DOI: 10.24248/eahrj-d-19-00011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 09/06/2019] [Indexed: 12/03/2022] Open
Abstract
Background: The success of prevention of mother-to-child transmission (PMTCT) programmes depends on retention of mothers throughout the PMTCT cascade. Methods: In a clinical trial of short-course combination antiretroviral therapy (cART) for PMTCT in Tanzania, senior nurses were employed to reduce the substantial loss-to-follow up (LTFU) rate. Results: Following intervention, the relative risk (RR) of receiving a CD4 count result and antiretroviral therapy was 1.16 (95% confidence interval [CI], 1.05 to 1.27), the RR of delivery at clinic was 2.51 (95% CI, 2.06 to 3.06), the RR for reporting for follow-up at 6 to 8 weeks postpartum was 4.63 (95% CI, 3.41 to 6.27), and the RR for being retained until 9 months postpartum was 28.19 (95% CI, 11.81 to 67.28). No significant impact on transmission was found. Conclusion: Significantly higher retention was found after senior nurses were employed. No impact on transmission was found. Relatively low transmission was found in both study arms.
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Affiliation(s)
- Zahra Persson Theilgaard
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Mercy G Chiduo
- National Institute for Medical Research, Tanga Centre, Tanga, Tanzania
| | - Leo Flamholc
- Department of Infectious Diseases, University Hospital of Malmö, Malmö, Sweden
| | - Jan Gerstoft
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Ib C Bygbjerg
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | | | - Terese L Katzenstein
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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23
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Larson BA, Halim N, Tsikhutsu I, Bii M, Coakley P, Rockers PC. A tool for estimating antiretroviral medication coverage for HIV-infected women during pregnancy (PMTCT-ACT). Glob Health Res Policy 2019; 4:29. [PMID: 31637308 PMCID: PMC6794749 DOI: 10.1186/s41256-019-0121-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 09/23/2019] [Indexed: 12/04/2022] Open
Abstract
Background In the typical prevention of mother to child transmission (PMTCT) of HIV cascade of care discussion or analysis, the period of analysis begins at the first visit for antenatal care (ANC) for that pregnancy. This starting point is problematic for two reasons: (1) a large number of HIV-infected women are already on life-long antiretroviral therapy (ART) when presenting for ANC; and (2) women present to ANC at different gestational ages. The PMTCT ART Coverage Tool (PMTCT-ACT), which estimates the proportion of days covered (PDC) with ART, was developed to address each of these problems. Methods PDC is a preferred method to measure adherence to chronic medications, such as ART. For evaluating the PMTCT cascade of care, as indicated by PDC with ART over various time periods, a “starting point” based on a specific day before delivery must be defined that applies to all women (treatment experienced or naïve at the first ANC visit at any gestational age). Using the example of 168 days prior to delivery (24 weeks), PMTCT-ACT measures PDC with ART during that period. PMTCT-ACT is provided as a STATA do-file. Using an example dataset for two women (ID1 is treatment experienced; ID2 is treatment naïve), the details of each major portion of the tool (Parts 1–5) are presented. PMTCT-ACT along with the intermediate datasets created during the analysis are provided as supplemental files. Conclusions Evaluating the PMTCT cascade of care requires a standard definition of the follow-up period during pregnancy that applies to all HIV-infected pregnant women and a standard measure of adherence. PMTCT-ACT is a new tool that fits this purpose. PMTCT-ACT can also be easily adjusted to evaluate other ante- and post-natal periods (e.g., final 4 weeks, final 8 weeks, complete pregnancy period, initial 24 weeks postpartum, time periods consistent with infant HIV testing guidelines).
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Affiliation(s)
- Bruce A Larson
- 1Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA 02118 USA
| | - Nafisa Halim
- 1Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA 02118 USA
| | - Isaac Tsikhutsu
- Kenya Medical Research Institute, U.S. Army Medical Research Directorate, Africa, Kenya.,3U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD USA.,Henry Jackson Foundation MRI, Kericho, Kenya
| | - Margaret Bii
- Kenya Medical Research Institute, U.S. Army Medical Research Directorate, Africa, Kenya.,3U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD USA.,Henry Jackson Foundation MRI, Kericho, Kenya
| | - Peter Coakley
- 3U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD USA
| | - Peter C Rockers
- 1Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA 02118 USA
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Minja L, Cichowitz C, Knettel BA, Mahande MJ, Kisigo G, Knippler ET, Ngocho JS, Mmbaga BT, Watt MH. Attitudes Toward Long-Term Use of Antiretroviral Therapy Among HIV-Infected Pregnant Women in Moshi, Tanzania: A Longitudinal Study. AIDS Behav 2019; 23:2610-2617. [PMID: 31377894 PMCID: PMC7467083 DOI: 10.1007/s10461-019-02622-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Adherence to antiretroviral therapy (ART) during pregnancy and the postpartum period is necessary to prevent vertical HIV transmission and to secure the long-term health of an HIV-infected woman. Health behavior theory suggests that patients' attitudes towards medication can predict their medication-taking behaviour. This study sought to understand how women's attitudes towards ART changes between the pregnancy and postpartum periods, and the factors associated with these attitudes. The study enrolled 200 pregnant women living with HIV. Structured surveys were administered during pregnancy and at three and 6 months postpartum. Overall, attitudes towards ART were stable over time. More positive attitudes towards ART were associated with HIV acceptance, lower levels of depression, and lower levels of shame. Counselling interventions are needed to help HIV-infected women accept their status and reduce shameful emotions. Depression screening and treatment should be integrated into PMTCT services. This study emphasizes the importance of early attention to attitudes towards ART, in order to establish a trajectory of sustained care engagement.
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Affiliation(s)
- Linda Minja
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Cody Cichowitz
- Massachusetts General Hospital, Department of Medicine, Center for Global Health, Boston, USA
| | - Brandon A Knettel
- Duke Global Health Institute, Duke University, 310 Trent Drive, Box 90519, Durham, NC, 27708, USA
| | | | - Godfrey Kisigo
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
- Duke Global Health Institute, Duke University, 310 Trent Drive, Box 90519, Durham, NC, 27708, USA
| | - Elizabeth T Knippler
- Duke Global Health Institute, Duke University, 310 Trent Drive, Box 90519, Durham, NC, 27708, USA
| | - James S Ngocho
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Blandina T Mmbaga
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
- Duke Global Health Institute, Duke University, 310 Trent Drive, Box 90519, Durham, NC, 27708, USA
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Melissa H Watt
- Duke Global Health Institute, Duke University, 310 Trent Drive, Box 90519, Durham, NC, 27708, USA.
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Thomas DSK, Bull S, Nyanza EC, Hampanda K, Liedtke M, Ngallaba SE. An mHealth pilot designed to increase the reach of prevention of mother-to-child transmission of HIV (PMTCT) across the treatment cascade in a resource-constrained setting in Tanzania. PLoS One 2019; 14:e0212305. [PMID: 30768656 PMCID: PMC6377109 DOI: 10.1371/journal.pone.0212305] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Accepted: 01/31/2019] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Data collection and integrated reporting between the multiple health facilities for supporting more efficient care linkages is an indispensable element for prevention of mother-to-child transmission of HIV (PMTCT) by fostering continuity of patient care and improving the treatment cascade for HIV-infected pregnant women. mHealth potentially presents timely solutions to the data challenges related to efficient and effective care delivery in resource-constrained settings, particularly in low- and middle-income countries. METHODS This randomized controlled pilot study used stratified random sampling for the selection of seven intervention and seven control sites in Misungwi, Tanzania, a rural district in the northwestern region. Twenty-eight health workers at seven intervention health facilities used the Tanzania Health Information Technology (T-HIT) system during a 3-month period from February 23, 2015, through May 23, 2015, to capture antenatal, delivery, and postnatal patient visits. RESULTS T-HIT was designed for use on tablets with the goal to improve reporting, surveillance and monitoring of HIV rates and care delivery in the remote and rural settings. Health workers successfully recorded 2,453 visits. Of these, 1,594 were antenatal visits, 484 deliveries were recorded, and 375 were postnatal visits. Within the antenatal visits, 96% of women had a single visit (1474). Healthcare workers were unable to test 6.7% of women antenatally for HIV. CONCLUSION The T-HIT pilot demonstrated the feasibility for implementing an mHealth integrated solution in a rural, low-resource setting that links tablet-based surveillance, health worker capacity-building and patient reminders into a single robust and responsive system. Although the implementation phase was only three months, the pilot generated evidence that T-HIT has potential for improving patient outcomes by providing more comprehensive, linked, and timely PMTCT care data at the individual and clinic levels.
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Affiliation(s)
- Deborah S. K. Thomas
- Department of Geography & Environmental Sciences, University of Colorado Denver, Denver, Colorado, United States of America
| | - Sheana Bull
- Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Elias C. Nyanza
- School of Public Health, Catholic University of Health and Allied Sciences, Mwanza, United Republic of Tanzania
| | - Karen Hampanda
- Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Michael Liedtke
- Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Sospatro E. Ngallaba
- School of Public Health, Catholic University of Health and Allied Sciences, Mwanza, United Republic of Tanzania
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