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Chipungu J, Smith H, Mwamba C, Haambokoma M, Sharma A, Savory T, Musheke M, Pry J, Bolton C, Sikazwe I, Herce ME. An exploration of multi-level factors affecting routine linkage to HIV care in Zambia's PEPFAR-supported treatment program in the treat all era. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003094. [PMID: 38781275 PMCID: PMC11115257 DOI: 10.1371/journal.pgph.0003094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 04/24/2024] [Indexed: 05/25/2024]
Abstract
Multiple steps from HIV diagnosis to treatment initiation and confirmed engagement with the health system are required for people living with HIV to establish full linkage to care in the modern treat all era. We undertook a qualitative study to gain an in-depth understanding of the impeding and enabling factors at each step of this linkage pathway. In-depth interviews were conducted with fifty-eight people living with HIV recruited from ten routine HIV care settings supported by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) in Lusaka, Zambia. Using a semi-structured interview guide informed by an established conceptual framework for linkage to care, questions explored the reasons behind late, missed, and early linkage into HIV treatment, as well as factors influencing the decision to silently transfer to a different clinic after an HIV diagnosis. We identified previously established and intersecting barriers of internal and external HIV-related stigma, concerns about ART side effects, substance use, uncertainties for the future, and a perceived lack of partner and social support that impeded linkage to care at every step of the linkage pathway. However, we also uncovered newer themes specific to the current test and treat era related to the rapidity of ART initiation and insufficient patient-centered post-test counseling that appeared to exacerbate these well-known barriers, including callous health workers and limited time to process a new HIV diagnosis before treatment. Long travel distance to the clinic where they were diagnosed was the most common reason for silently transferring to another clinic for treatment. On the other hand, individual resilience, quality counseling, patient-centered health workers, and a supportive and empathetic social network mitigated these barriers. These findings highlight potential areas for strengthening linkage to care and addressing early treatment interruption and silent transfer in the test and treat era in Zambia.
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Affiliation(s)
- Jenala Chipungu
- Research Department, Social and Behavioral Science Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Helene Smith
- Research Department, Social and Behavioral Science Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Chanda Mwamba
- Research Department, Social and Behavioral Science Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Mwiza Haambokoma
- Research Department, Social and Behavioral Science Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Anjali Sharma
- Research Department, Social and Behavioral Science Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Theodora Savory
- Research Department, Social and Behavioral Science Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Maurice Musheke
- Research Department, Social and Behavioral Science Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Jake Pry
- Research Department, Social and Behavioral Science Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Carolyn Bolton
- Research Department, Social and Behavioral Science Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Izukanji Sikazwe
- Research Department, Social and Behavioral Science Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Michael E. Herce
- Research Department, Social and Behavioral Science Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
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DeLong SM, Kafu C, Wachira J, Knight JM, Braitstein P, Operario D, Genberg BL. Understanding motivations and resilience-associated factors to promote timely linkage to HIV care: a qualitative study among people living with HIV in western Kenya. AIDS Care 2024; 36:546-552. [PMID: 37499119 DOI: 10.1080/09540121.2023.2240066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 07/18/2023] [Indexed: 07/29/2023]
Abstract
Understanding motivations and resilience-associated factors that help people newly diagnosed with HIV link to care is critical in the context of universal test and treat. We analyzed 30 in-depth interviews (IDI) among adults aged 18 and older in western Kenya diagnosed with HIV during home-based counseling and testing and who had linked to HIV care. A directed content analysis was performed, categorizing IDI quotations into a table based on linkage stages for organization and then developing and applying codes from self-determination theory and the concept of resilience. Autonomous motivations, including internalized concerns for one's health and/or to provide care for family, were salient facilitators of accessing care. Controlled forms of motivation, such as fear or external pressure, were less salient. Social support was an important resilience-associated factor fostering linkage. HIV testing and counseling programs which incorporate motivational interviewing that emphasizes motivations related to one's health or family combined with a social support/navigator approach, may promote timely linkage to care.
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Affiliation(s)
- Stephanie M DeLong
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Catherine Kafu
- Behavioral Science Department, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
- Academic Model Providing Access to Healthcare (AMPATH) Partnership, Eldoret, Kenya
| | - Juddy Wachira
- Behavioral Science Department, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
- Mental Health Department, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Jennifer M Knight
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Paula Braitstein
- Academic Model Providing Access to Healthcare (AMPATH) Partnership, Eldoret, Kenya
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Epidemiology and Medical Statistics, School of Public Health, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Don Operario
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA
| | - Becky L Genberg
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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DeLong SM, Xu Y, Genberg BL, Nyambura M, Goodrich S, Tarus C, Ndege S, Hogan JW, Braitstein P. Population-Based Estimates and Predictors of Child and Adolescent Linkage to HIV Care or Death in Western Kenya. J Acquir Immune Defic Syndr 2023; 94:281-289. [PMID: 37643416 PMCID: PMC10609679 DOI: 10.1097/qai.0000000000003288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 07/17/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Population-level estimates of linkage to HIV care among children and adolescents (CAs) can facilitate progress toward 95-95-95 goals. SETTING This study was conducted in Bunyala, Chulaimbo, and Teso North subcounties, Western Kenya. METHODS Linkage to care was defined among CAs diagnosed with HIV through Academic Model Providing Access to Healthcare (AMPATH)'s home-based counseling and testing initiative (HBCT) by merging HBCT and AMPATH Medical Record System data. Using follow-up data from Bunyala, we examined factors associated with linkage or death, using weighted multinomial logistic regression to account for selection bias from double-sampled visits. Based on the estimated model, we imputed the trajectory for each person in 3 subcounties until a simulated linkage or death occurred or until the end of 8 years when an individual was simulated to be censored. RESULTS Of 720 CAs in the analytic sample, 68% were between 0 and 9 years and 59% were female. Probability of linkage among CAs in the combined 3 subcounties was 48%-49% at 2 years and 64%-78% at 8 years while probability of death was 13% at 2 years and 19% at 8 years. Single or double orphanhood predicted linkage (adjusted odds ratio [aOR]: 2.66, 95% confidence interval [CI]: 1.33 to 5.32) and death (aOR: 9.85 [95% CI: 2.21 to 44.01]). Having a mother known to be HIV-positive also predicted linkage (aOR = 1.94, 95% CI: 0.97 to 3.86) and death (aOR: 14.49, 95% CI: 3.32 to 63.19). CONCLUSION HIV testers/counselors should continue to ensure linkage among orphans and CAs with mothers known to be HIV-positive and also to support other CAs to link to HIV care.
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Affiliation(s)
- Stephanie M. DeLong
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Yizhen Xu
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Becky L. Genberg
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Monicah Nyambura
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Suzanne Goodrich
- Department of Biostatistics, Brown University School of Public Health, Providence, RI; and
| | - Carren Tarus
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Samson Ndege
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Moi University, School of Public Health, Eldoret, Kenya
| | - Joseph W. Hogan
- Department of Biostatistics, Brown University School of Public Health, Providence, RI; and
| | - Paula Braitstein
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Moi University, School of Public Health, Eldoret, Kenya
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Filiatreau LM, Edwards JK, Masilela N, Gómez-Olivé FX, Haberland N, Pence BW, Maselko J, Muessig KE, Kabudula CW, Dufour MSK, Lippman SA, Kahn K, Pettifor A. Understanding the effects of universal test and treat on longitudinal HIV care outcomes among South African youth: a retrospective cohort study. BMC Public Health 2023; 23:1724. [PMID: 37670262 PMCID: PMC10478421 DOI: 10.1186/s12889-023-16353-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 07/20/2023] [Indexed: 09/07/2023] Open
Abstract
INTRODUCTION Little is known about the effects of universal test and treat (UTT) policies on HIV care outcomes among youth living with HIV (YLHIV). Moreover, there is a paucity of information regarding when YLHIV are most susceptible to disengagement from care under the newest treatment guidelines. The longitudinal HIV care continuum is an underutilized tool that can provide a holistic understanding of population-level HIV care trajectories and be used to compare treatment outcomes across groups. We aimed to explore effects of the UTT policy on longitudinal outcomes among South African YLHIV and identify temporally precise opportunities for re-engaging this priority population in the UTT era. METHODS Using medical record data, we conducted a retrospective cohort study among youth aged 18-24 diagnosed with HIV from August 2015-December 2018 in nine health care facilities in South Africa. We used Fine and Gray sub-distribution proportional hazards models to characterize longitudinal care continuum outcomes in the population overall and stratified by treatment era of diagnosis. We estimated the proportion of individuals in each stage of the continuum over time and the restricted mean time spent in each stage in the first year following diagnosis. Sub-group estimates were compared using differences. RESULTS A total of 420 YLHIV were included. By day 365 following diagnosis, just 23% of individuals had no 90-or-more-day lapse in care and were virally suppressed. Those diagnosed in the UTT era spent less time as ART-naïve (mean difference=-19.3 days; 95% CI: -27.7, -10.9) and more time virally suppressed (mean difference = 17.7; 95% CI: 1.0, 34.4) compared to those diagnosed pre-UTT. Most individuals who were diagnosed in the UTT era and experienced a 90-or-more-day lapse in care disengaged between diagnosis and linkage to care or ART initiation and viral suppression. CONCLUSIONS Implementation of UTT yielded modest improvements in time spent on ART and virally suppressed among South African YLHIV- however, meeting UNAIDS' 95-95-95 targets remains a challenge. Retention in care and re-engagement interventions that can be implemented between diagnosis and linkage to care and between ART initiation and viral suppression (e.g., longitudinal counseling) may be particularly important to improving care outcomes among South African YLHIV in the UTT era.
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Affiliation(s)
- Lindsey M Filiatreau
- Division of Infectious Diseases, School of Medicine, Washington University in St. Louis, St. Louis, USA.
| | - Jessie K Edwards
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Nkosinathi Masilela
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - F Xavier Gómez-Olivé
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Brian W Pence
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Joanna Maselko
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Chodziwadziwa Whiteson Kabudula
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mi-Suk Kang Dufour
- Biostatistics Division, School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | - Sheri A Lippman
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, CA, USA
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Audrey Pettifor
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Carolina Population Center, Chapel Hill, NC, USA
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Govere SM, Kalinda C, Chimbari MJ. The impact of same-day antiretroviral therapy initiation on retention in care and clinical outcomes at four eThekwini clinics, KwaZulu-Natal, South Africa. BMC Health Serv Res 2023; 23:838. [PMID: 37553685 PMCID: PMC10408100 DOI: 10.1186/s12913-023-09801-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 07/11/2023] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND Same-day initiation (SDI) of antiretroviral therapy (ART) increases ART uptake, however retention in care after ART initiation remains a challenge. Public health behaviours, such as retention in HIV care and adherence to antiretroviral therapy (ART) pose major challenges to reducing new Human Immunodeficiency Virus (HIV) transmission and improving health outcomes among HIV patients. METHODS We evaluated 6-month retention in care, and clinical outcomes of an ART cohort comprising of SDI and delayed ART initiators. We conducted a 6 months' observational prospective cohort study of 403 patients who had been initiated on ART. A structured questionnaire was used to abstract data from patient record review which comprised the medical charts, laboratory databases, and Three Interlinked Electronic Registers.Net (TIER.Net). Treatment adherence was ascertained by patient visit constancy for the clinic scheduled visit dates. Retention in care was determined by status at 6 months after ART initiation. RESULTS Among the 403 participants enrolled in the study and followed up, 286 (70.97%) and 267 (66.25%) complied with scheduled clinics visits at 3 months and 6 months, respectively. One hundred and thirteen (28.04%) had been loss to follow-up. 17/403 (4.22%) had died and had been out of care after 6 months. 6 (1.49%) had been transferred to other health facilities and 113 (28.04%) had been loss to follow-up. Among those that had been lost to follow-up, 30 (33.63%) deferred SDI while 75 (66.37%) initiated ART under SDI. One hundred and eighty-nine (70.79%) participants who had remained in care were SDI patients while 78 (29.21%) were SDI deferred patients. In the bivariate analysis; gender (OR: 1.672; 95% CI: 1.002-2.791), number of sexual partners (OR: 2.092; 95% CI: 1.07-4.061), age (OR: 0.941; 95% CI: 0.734-2.791), ART start date (OR: 0.078; 95% CI: 0.042-0.141), partner HIV status (OR: 0.621; 95% CI: 0.387-0.995) and the number of hospitalizations after HIV diagnosis (OR: 0.173; 95% CI: 0.092-0.326). were significantly associated with viral load detection. Furthermore, SDI patients who defaulted treatment were 2.4 (95% CI: 1.165-4.928) times more likely to have increased viral load than those who had been returned in care. CONCLUSION Viral suppression under SDI proved higher but with poor retention in care. However, the results also emphasise a vital need, to not only streamline processes to increase immediate ART uptake further, but also to ensure retention in care.
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Affiliation(s)
- Sabina M Govere
- School of Nursing and Public Health, Discipline of Public Health Medicine, Howard College Campus, University of KwaZulu-Natal, Durban, South Africa.
| | - Chester Kalinda
- School of Nursing and Public Health, Discipline of Public Health Medicine, Howard College Campus, University of KwaZulu-Natal, Durban, South Africa
- Bill and Joyce Cummings Institute of Global Health and Institute of Global Health Equity Research (IGHER), University of Global Health Equity Kigali Heights, Kigali, Rwanda
| | - Moses J Chimbari
- School of Nursing and Public Health, Discipline of Public Health Medicine, Howard College Campus, University of KwaZulu-Natal, Durban, South Africa
- Department of Public Health, Great Zimbabwe University, P.O Box 1235, Masvingo, Zimbabwe
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Tollefson D, Dasgupta S, Setswe G, Reeves S, Churchyard G, Charalambous S, Duerr A. Does a youth intern programme strengthen HIV service delivery in South Africa? An interrupted time-series analysis. J Int AIDS Soc 2023; 26:e26083. [PMID: 37051619 PMCID: PMC10098286 DOI: 10.1002/jia2.26083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 03/28/2023] [Indexed: 04/14/2023] Open
Abstract
INTRODUCTION Since 2018, Youth Health Africa (YHA) has placed unemployed young adults at health facilities across South Africa in 1-year non-clinical internships to support HIV services. While YHA is primarily designed to improve employment prospects for youth, it also strives to strengthen the health system. Hundreds of YHA interns have been placed in programme (e.g. HIV testing and counselling) or administrative (e.g. data and filing) roles, but their impact on HIV service delivery has not been evaluated. METHODS Using routinely collected data from October 2017 to March 2020, we conducted an interrupted time-series analysis to explore the impact of YHA on HIV testing, treatment initiation and retention in care. We analysed data from facilities in Gauteng and North West where interns were placed between November 2018 and October 2019. We used linear regression, accounting for facility-level clustering and time correlation, to compare trends before and after interns were placed for seven HIV service indicators covering HIV testing, treatment initiation and retention in care. Outcomes were measured monthly at each facility. Time was measured as months since the first interns were placed at each facility. We conducted three secondary analyses per indicator, stratified by intern role, number of interns and region. RESULTS Based on 207 facilities hosting 604 interns, YHA interns at facilities were associated with significant improvements in monthly trends for numbers of people tested for HIV, newly initiated on treatment and retained in care (i.e. loss to follow-up, tested for viral load [VL] and virally suppressed). We found no difference in trends for the number of people newly diagnosed with HIV or the number initiating treatment within 14 days of diagnosis. Changes in HIV testing, overall treatment initiation and VL testing/suppression were most pronounced where there were programme interns and a higher number of interns; change in loss to follow-up was greatest where there were administrative interns. CONCLUSIONS Placing interns in facilities to support non-clinical tasks may improve HIV service delivery by contributing to improved HIV testing, treatment initiation and retention in care. Using youth interns as lay health workers may be an impactful strategy to strengthen the HIV response while supporting youth employment.
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Affiliation(s)
- Deanna Tollefson
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
- Fred Hutchinson Cancer Research CentreVaccine and Infectious Disease & Public Health Science DivisionsSeattleWashingtonUSA
| | - Sayan Dasgupta
- Fred Hutchinson Cancer Research CentreVaccine and Infectious Disease & Public Health Science DivisionsSeattleWashingtonUSA
| | - Geoffrey Setswe
- The Aurum InstituteJohannesburgSouth Africa
- Department of Health StudiesUniversity of South AfricaPretoriaSouth Africa
| | | | | | - Salome Charalambous
- The Aurum InstituteJohannesburgSouth Africa
- School of Public HealthUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Ann Duerr
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
- Fred Hutchinson Cancer Research CentreVaccine and Infectious Disease & Public Health Science DivisionsSeattleWashingtonUSA
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Mental Health Problems Across the HIV Care Continuum for Adolescents Living with HIV in Sub-Saharan Africa: A Scoping Review. AIDS Behav 2023:10.1007/s10461-023-03981-w. [PMID: 36650389 PMCID: PMC10350473 DOI: 10.1007/s10461-023-03981-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2023] [Indexed: 01/18/2023]
Abstract
Mental health problems (e.g., anxiety, depression) are frequently experienced by adolescents living with HIV (ALWH) and can worsen HIV-related outcomes. This scoping review synthesizes the existing research on ALWHs' mental health problems at multiple steps along the HIV care continuum in sub-Saharan Africa. Searching PubMed, CINAHL, EMBASE, and PsycINFO identified 34 peer-reviewed studies that met inclusion criteria. Most studies assessed ALWHs' mental health problems at the "Engaged or Retained in Care" continuum step, are cross-sectional, focus on depression and anxiety, and used measures developed in high-income countries. Studies identify mental health problems among ALWH as prevalent and barriers to care. Significant gaps remain in understanding how mental health problems and their relationships with HIV-related health outcomes shift across the continuum. Additional attention is needed, especially at the HIV testing and viral suppression steps, to generate a more comprehensive understanding of mental health needs and priority timepoints for intervention for ALWH.
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Mwamba C, Beres LK, Topp SM, Mukamba N, Simbeza S, Sikombe K, Mody A, Geng E, Holmes CB, Kennedy CE, Sikazwe I, Denison JA, Bolton Moore C. 'I need time to start antiretroviral therapy': understanding reasons for delayed ART initiation among people diagnosed with HIV in Lusaka, Zambia'. Ann Med 2022; 54:830-836. [PMID: 35311423 PMCID: PMC8942536 DOI: 10.1080/07853890.2022.2051069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Rapid antiretroviral therapy (ART) initiation can improve patient outcomes such as viral suppression and prevent new infections. However, not everyone who can start ART does so immediately. METHODS We conducted a qualitative study to inform interventions supporting rapid initiation in the 'Test and Start' era. We purposively sampled 20 adult patients living with HIV and a previous gap in care from ten health facilities in Lusaka, Zambia for interviews. We inductively analysed transcripts using a thematic, narrative approach. In their narratives, seven participants discussed delaying ART initiation. RESULTS Drawing on messages gleaned from facility-based counselling and community information, many cited greater fear of rapid sickness or death due to imperfect adherence or treatment side effects than negative health consequences due to delayed initiation. Participants described needing time to 'prepare' their minds for a lifetime treatment commitment. Concerns about inadvertent HIV status disclosure during drug collection discouraged immediate initiation, as did feeling healthy, and worries about the impact of ART initiation on relationship dynamics. CONCLUSION Findings suggest that counselling messages should accurately communicate treatment risks, without perpetuating fear-based narratives about HIV. Identifying and managing patient-specific concerns and reasons for the 'need for time' may be important for supporting individuals to rapidly accept lifelong treatment.Key messagesFear-based adherence messaging in health facilities about the dangers of missing a treatment dose or changing the time when ART is taken contributes to Zambian patients' refusals of immediate ART initiationResponsive health systems that balance a stated need for time to accept one's diagnosis and prepare to embark on a lifelong treatment plan with interventions to identify and manage patient-specific treatment related fears and concerns may support more rapid ART initiationPerceived social stigma around HIV continues to be a significant challenge for treatment initiation.
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Affiliation(s)
- Chanda Mwamba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Laura K Beres
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Stephanie M Topp
- College of Public Health, Medical & Veterinary Sciences, James Cook University, Townsville, Australia
| | - Njekwa Mukamba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Sandra Simbeza
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Kombatende Sikombe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.,Department of Public Health Environments and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Aaloke Mody
- Washington University School of Medicine in St. Louis, MO, USA
| | - Elvin Geng
- Washington University School of Medicine in St. Louis, MO, USA
| | | | - Caitlin E Kennedy
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Julie A Denison
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Opio M, Akello F, Twongyeirwe DK, Opio D, Aceng J, Namagga JK, Kabakyenga JK. Perspectives on linkage to care for patients diagnosed with HIV: A qualitative study at a rural health center in South Western Uganda. PLoS One 2022; 17:e0263864. [PMID: 35239667 PMCID: PMC8893616 DOI: 10.1371/journal.pone.0263864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 01/29/2022] [Indexed: 11/18/2022] Open
Abstract
Linkage to care for newly diagnosed human immunodeficiency virus (HIV) patients is important to ensure that patients have good access to care. However, there is little information about factors influencing linkage to care for HIV patients. We aimed to identify existing measures in place that promote linkage to care and to explore facilitators and barriers to linkage to care for clients diagnosed with HIV/acquired immune deficiency syndrome at a rural health center in Uganda. This descriptive qualitative study enrolled 33 purposively selected participants who included expert clients, linkage facilitators, heads of families with people living with HIV, and health workers. Data were collected using in-depth interviews that were audio-recorded, transcribed, and translated. The data were manually analyzed to generate themes. The following four themes were generated: 1) availability of services that include counseling, testing, treatment, follow-up, referral, outreach activities, and support systems. 2) Barriers to linkage to care were at the individual, health facility, and community levels. Individual-level barriers were socioeconomic status, high transport costs, fear of adverse drug effects, fear of broken relationships, and denial of positive results or treatment, while health facility barriers were reported to be long waiting time, negative staff attitude, and drug stock outs. Community barriers were mostly due to stigma experienced by HIV clients, resulting in discrimination by community members. 3) Facilitators to linkage to care were positive staff attitudes, access to information, fear of death, and support from others. 4) Suggestions for improving service delivery were shortening waiting time, integrating HIV services, increasing staff numbers, and intensifying outreaches. Our findings highlight the importance of stakeholder involvement in linkage to care. Access and linkage to care are positively and negatively influenced at the individual, community, and health facility levels. However, integration of HIV services and intensifying outreaches are key to improving linkage to care.
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Affiliation(s)
- Mark Opio
- Department of Nursing, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Florence Akello
- Department of Nursing, Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - David Opio
- Department of Nursing, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Juliet Aceng
- Department of Medical Laboratory Science, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Jane Kasozi Namagga
- Department of Nursing, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Jerome Kahuma Kabakyenga
- Maternal Newborn and Child Health Institute, Mbarara University of Science and Technology, Mbarara, Uganda
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Mwamba C, Mukamba N, Sharma A, Lumbo K, Foloko M, Nyirenda H, Simbeza S, Sikombe K, Holmes CB, Sikazwe I, Moore CB, Mody A, Geng E, Beres LK. "Provider discretionary power practices to support implementation of patient-centered HIV care in Lusaka, Zambia". FRONTIERS IN HEALTH SERVICES 2022; 2:918874. [PMID: 36925865 PMCID: PMC10012689 DOI: 10.3389/frhs.2022.918874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 08/16/2022] [Indexed: 11/13/2022]
Abstract
Introduction Traditional patient-provider relationships privilege the providers, as they possess the formal authority and clinical knowledge applied to address illness, but providers also have discretion over how they exercise their power to influence patients' services, benefits, and sanctions. In this study, we assessed providers' exercise of discretionary power in implementing patient-centered care (PCC) practices in Lusaka, Zambia. Methods HIV clinical encounters between patients on antiretroviral therapy (ART) and providers across 24 public health facilities in Lusaka Province were audio recorded and transcribed verbatim. Using qualitative content analysis, we identified practices of discretionary power (DP) employed in the implementation of PCC and instances of withholding DP. A codebook of DP practices was inductively and iteratively developed. We compared outcomes across provider cadres and within sites over time. Results We captured 194 patient-provider interactions at 24 study sites involving 11 Medical Officers, 58 Clinical Officers and 10 Nurses between August 2019 to May 2021. Median interaction length was 7.5 min. In a hierarchy where providers dominate patients and interactions are rapid, some providers invited patients to ask questions and responded at length with information that could increase patient understanding and agency. Others used inclusive language, welcomed patients, conducted introductions, and apologized for delayed services, narrowing the hierarchical distance between patient and provider, and facilitating recognition of the patient as a partner in care. Although less common, providers shared their decision-making powers, allowing patients to choose appointment dates and influence regimens. They also facilitated resource access, including access to services and providers outside of scheduled appointment times. Application of DP was not universal and missed opportunities were identified. Conclusion Supporting providers to recognize their power and intentionally share it is both inherent to the practice of PCC (e.g., making a patient a partner), and a way to implement improved patient support. More research is needed to understand the application of DP practices in improving the patient-centeredness of care in non-ART settings.
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Affiliation(s)
- Chanda Mwamba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Njekwa Mukamba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Anjali Sharma
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Kasapo Lumbo
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Marksman Foloko
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Herbert Nyirenda
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Sandra Simbeza
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Kombatende Sikombe
- Department of Public Health Environments and Society, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Charles B Holmes
- Department of Medicine, Georgetown University Medical Centre, Georgetown University, Washington, DC, United States
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | | | - Aaloke Mody
- Washington University School of Medicine, St. Louis, MO, United States
| | - Elvin Geng
- Washington University School of Medicine, St. Louis, MO, United States
| | - Laura K Beres
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
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Wekesa P, McLigeyo A, Owuor K, Mwangi J, Isavwa L, Katana A. Temporal trends in pre-ART patient characteristics and outcomes before the test and treat era in Central Kenya. BMC Infect Dis 2021; 21:1007. [PMID: 34565337 PMCID: PMC8474838 DOI: 10.1186/s12879-021-06706-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 09/16/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Retention of patients who did not initiate antiretroviral therapy (ART) has been persistently low compared to those who initiated ART. Understanding the temporal trends in clinical outcomes prior to ART initiation may inform interventions targeting patients who do not initiate ART immediately after diagnosis. METHODS A retrospective cohort analysis of known HIV-infected patients who did not initiate ART from healthcare facilities in Central Kenya was done to investigate temporal trends in characteristics, retention, and mortality outcomes. The data were sourced from the Comprehensive Care Clinic Patient Application Database (CPAD) and IQ care electronic patient-level databases for those enrolled between 2004 and 2014. RESULTS A total of 13,779 HIV-infected patients were assessed, of whom 30.7% were men.There were statisitically significant differences in temporal trends relating to marital status, WHO clinical stage, and tuberculosis (TB) status from 2004 to 2014. The proportion of widowed patients decreased from 9.1 to 6.0%. By WHO clinical stage at enrollment in program, those in WHO stage I increased over time from 8.7 to 43.1%, while those in WHO stage III and IV reduced from 28.5 to 10.8% and 4.0 to 1.1% respectively. Those on TB treatment during their last known visit reduced from 8.3 to 3.9% while those with no TB signs increased from 58.5 to 86.8%. Trends in 6 and 12 month retention in the program, loss to follow-up (LTFU) and mortality were statistically significant. At 6 months, program retention ranged between 36.0% in 2004 to a high of 54.1% in 2013. LTFU at 6 months remained around 50.0% for most of the cohorts, while mortality at 6 months was 7.5% in 2004 but reduced to 3.8% in 2014. At 12 months, LTFU was above 50.0% across all the cohorts while mortality rate reached 3.9% in 2014. CONCLUSION Trends in pre ART enrollment suggested higher enrollment among patients who were women and at earlier WHO clinical stages. Retention and mortality outcomes at 6 and 12 months generally improved over the 11 year follow-up period, though dipped as enrollment in asymptomatic disease stage increased.
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Affiliation(s)
- P Wekesa
- Centre for Health Solutions - Kenya, Nairobi, Kenya.
| | - A McLigeyo
- Centre for Health Solutions - Kenya, Nairobi, Kenya.
| | - K Owuor
- Centre for Health Solutions - Kenya, Nairobi, Kenya
| | - J Mwangi
- Division of Global HIV & TB, Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
| | - L Isavwa
- Centre for Health Solutions - Kenya, Nairobi, Kenya
| | - A Katana
- Division of Global HIV & TB, Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
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12
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Neuman M, Fielding KL, Ayles H, Cowan FM, Hensen B, Indravudh PP, Johnson C, Sibanda EL, Hatzold K, Corbett EL. ART initiations following community-based distribution of HIV self-tests: meta-analysis and meta-regression of STAR Initiative data. BMJ Glob Health 2021; 6:e004986. [PMID: 34275871 PMCID: PMC8287607 DOI: 10.1136/bmjgh-2021-004986] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 06/24/2021] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Measuring linkage after community-based testing, particularly HIV self-testing (HIVST), is challenging. Here, we use data from studies of community-based HIVST distribution, conducted within the STAR Initiative, to assess initiation of antiretroviral therapy (ART) and factors driving differences in linkage rates. METHODS Five STAR studies evaluated HIVST implementation in Malawi, Zambia and Zimbabwe. New ART initiations during the months of intervention at clinics in HIVST and comparison areas were presented graphically, and study effects combined using meta-analysis. Meta-regression was used to estimate associations between the impact of community-based HIVST distribution and indicators of implementation context, intensity and reach. Effect size estimates used (1) prespecified trial definitions of ART timing and comparator facilities and (2) exploratory definitions accounting for unexpected diffusion of HIVST into comparison areas and periods with less distribution of HIVST than was expected. RESULTS Compared with arms with standard testing only, ART initiations were higher in clinics in HIVST distribution areas in 4/5 studies. The prespecified meta-analysis found positive but variable effects of HIVST on facility ART initiations (RR: 1.14, 95% CI 0.93 to 1.40; p=0.21). The exploratory meta-analysis found a stronger impact of HIVST distribution on ART initiations (RR: 1.29, 95% CI 1.08 to 1.55, p=0.02).ART initiations were higher in studies with greater self-reported population-level intensity of HIVST use (RR: 1.12; 95% CI 1.04 to 1.21; p=0.02.), but did not differ by national-level indicators of ART use among people living with HIV, number of HIVST kits distributed per 1000 population, or self-reported knowledge of how to link to care after a reactive HIVST. CONCLUSION Community-based HIVST distribution has variable effect on ART initiations compared with standard testing service alone. Optimising both support for and approach to measurement of effective and timely linkage or relinkage to HIV care and prevention following HIVST is needed to maximise impact and guide implementation strategies.
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Affiliation(s)
- Melissa Neuman
- Department of Infectious Disease Epidemiology and MRC International Statistics and Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Katherine L Fielding
- Department of Infectious Disease Epidemiology and MRC International Statistics and Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Helen Ayles
- Zambart, Lusaka, Zambia
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Frances M Cowan
- Centre for Sexual Health HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Pitchaya P Indravudh
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine Faculty of Public Health and Policy, London, UK
- TB-HIV Group, Malawi Liverpool Wellcome Trust, Blantyre, Malawi
| | - Cheryl Johnson
- HIV, Hepatitis and STI Department, World Health Organization, Geneva, Switzerland
| | - Euphemia Lindelwe Sibanda
- Centre for Sexual Health HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Karin Hatzold
- Population Services International, Washington, District of Columbia, USA
| | - Elizabeth Lucy Corbett
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
- TB-HIV Group, Malawi Liverpool Wellcome Trust, Blantyre, Malawi
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13
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Onubogu CU, Ugochukwu EF. A 17 year experience of attrition from care among HIV infected children in Nnewi South-East Nigeria. BMC Infect Dis 2021; 21:409. [PMID: 33941101 PMCID: PMC8091640 DOI: 10.1186/s12879-021-06099-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 04/19/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A large number of HIV-infected children continue to die despite reported scale-up of paediatric HIV services. AIM The trend in attrition among children enrolled in an anti-retroviral therapy (ART) programme was evaluated. METHODS This was a retrospective review of children enrolled into NAUTH ART programme between 2003 and 2019. RESULTS 1114 children < 15 years at enrolment were studied. The male: female ratio was 1:1 while median age at enrolment was 4.3 years. About two-thirds had WHO stage 3 or 4 disease at enrolment. The rate of loss to follow-up (LTFU) and death were 41.0 and 8.4%, respectively, with overall attrition incidence of 108/1000PY. Despite the downward trend, spikes occurred among those enrolled in 2008 to 2011 and in 2017. The trend in 6-, 12-, 24- and 36-months attrition varied similarly with overall rates being 20.4, 27.7, 34.3 and 37.3%, respectively. Among those on ART, > 50% of attrition was recorded within 6 months of care. Advanced WHO stage, young age, non-initiation on ART or period of enrolment (P < 0.001), and caregiver (p = 0.026) were associated with attrition in bivariate analysis. Apart from caregiver category, these factors remained significant in multivariate analysis. Most LTFU could not be reached on phone. Among those contacted, common reasons for being lost to follow-up were financial constraints, caregiver loss, claim to divine healing, family disharmony/child custody issues and relocation of family/child. CONCLUSION/RECOMMENDATION Attrition rate was high and was mostly due to LTFU. Predictors of attrition were late presentation, young age, delay in ART initiation and financial constraints. Efforts should be intensified at early diagnosis, linkage to care and implementation of "test and treat" strategy. Innovative child centered approaches should be adopted to enable the HIV-infected children remain in care despite challenges which can truncate treatment.
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Affiliation(s)
- Chinyere Ukamaka Onubogu
- Department of Paediatrics, Faculty of Medicine, Nnamdi Azikiwe University, Awka, Nigeria. .,Paediatric Infectious Diseases Unit, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria.
| | - Ebelechuku Francesca Ugochukwu
- Department of Paediatrics, Faculty of Medicine, Nnamdi Azikiwe University, Awka, Nigeria.,Paediatric Infectious Diseases Unit, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
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14
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Mwango LK, Stafford KA, Blanco NC, Lavoie MC, Mujansi M, Nyirongo N, Tembo K, Sakala H, Chipukuma J, Phiri B, Nzangwa C, Mwandila S, Nkwemu KC, Saadani A, Mwila A, Herce ME, Claassen CW. Index and targeted community-based testing to optimize HIV case finding and ART linkage among men in Zambia. J Int AIDS Soc 2021; 23 Suppl 2:e25520. [PMID: 32589360 PMCID: PMC7319128 DOI: 10.1002/jia2.25520] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 04/23/2020] [Accepted: 04/24/2020] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION Current healthcare systems fail to provide adequate HIV services to men. In Zambia, 25% of adult men living with HIV were unaware of their HIV status in 2018, and 12% of those who were unaware of their HIV statu were not receiving antiretroviral therapy (ART) due to pervasive barriers to HIV testing services (HTS) and linkage to ART. To identify men and key and priority populations living with HIV in Zambia, and link them to care and treatment, we implemented the Community Impact to Reach Key and Underserved Individuals for Treatment and Support (CIRKUITS) project. We present HTS and ART linkage results from the first year of CIRKUITS. METHODS CIRKUITS aimed to reach beneficiaries by training, mentoring, and deploying community health workers to provide index testing services and targeted community HTS. Community leaders and workplace supervisors were engaged to enable workplace HTS for men. To evaluate the effects of these interventions, we collected age- and sex-disaggregated routinely collected programme data for the first 12 months of the project (October 2018 to September 2019) across 37 CIRKUITS-supported facilities in three provinces. We performed descriptive statistics and estimated index cascades for indicators of interest, and used Chi square tests to compare indicators by age, sex, and district strata. RESULTS Over 12 months, CIRKUITS tested 38,255 persons for HIV, identifying 10,974 (29%) new people living with HIV, of whom 10,239 (93%) were linked to ART. Among men, CIRKUITS tested 18,336 clients and identified 4458 (24%) as HIV positive, linked 4132 (93%) to ART. Men who tested HIV negative were referred to preventative services. Of the men found HIV positive, and 13.0% were aged 15 to 24 years, 60.3% were aged 25 to 39, 20.9% were aged 40 to 49 and 5.8% were ≥50 years old. Index testing services identified 2186 (49%) of HIV-positive men, with a positivity yield of 40% and linkage of 88%. Targeted community testing modalities accounted for 2272 (51%) of HIV-positive men identified, with positivity yield of 17% and linkage of 97%. CONCLUSIONS Index testing and targeted community-based HTS are effective strategies to identify men living with HIV in Zambia. Index testing results in higher yield, but lower linkage and fewer absolute men identified compared to targeted community-based HTS.
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Affiliation(s)
- Linah K Mwango
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia
| | - Kristen A Stafford
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA.,Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Natalia C Blanco
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA.,Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Marie-Claude Lavoie
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA.,Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Morley Mujansi
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia
| | - Nasho Nyirongo
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia
| | - Kalima Tembo
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia
| | - Henry Sakala
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia
| | | | - Beauty Phiri
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia
| | - Carol Nzangwa
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia
| | - Susan Mwandila
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia
| | | | - Ahmed Saadani
- U.S. Center for Disease Control and Prevention, Lusaka, Zambia
| | - Annie Mwila
- U.S. Center for Disease Control and Prevention, Lusaka, Zambia
| | - Michael E Herce
- Institute for Global Health and Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, NC, USA.,Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Cassidy W Claassen
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia.,Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA.,Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
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15
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Nyondo-Mipando AL, Kumwenda M, Suwedi- Kapesa LC, Salimu S, Kazuma T, Mwapasa V. "You Cannot Catch Fish Near the Shore nor Can You Sell Fish Where There Are No Customers": Rethinking Approaches for Reaching Men With HIV Testing Services in Blantyre Malawi. Am J Mens Health 2021; 15:15579883211011381. [PMID: 33906492 PMCID: PMC8111271 DOI: 10.1177/15579883211011381] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 03/17/2021] [Accepted: 03/24/2021] [Indexed: 11/16/2022] Open
Abstract
HIV testing is the entry point to the cascade of services within HIV care. Although Malawi has made positive strides in HIV testing, men are lagging at 65.5% while women are at 81.6%. This study explored the preferences of men on the avenues for HIV testing in Blantyre, Malawi. This was a descriptive qualitative study in the phenomenological tradition in seven public health facilities in Blantyre, Malawi, among men and health-care workers (HCWs). We conducted 20 in-depth interviews and held 14 focus group discussions among 113 men of varying HIV statuses. All our participants were purposively selected, and data were digitally recorded coded and managed through NVivo. Thematic analysis was guided by the differentiated service delivery model. Men reported a preference for formal and informal workplaces such as markets and other casual employment sites; social places like football pitches, bars, churches, and "bawo" spaces; and outreach services in the form of weekend door-to-door, mobile clinics, men-to-men group. The health facility was the least preferred avenue. The key to testing men for HIV is finding them where they are. Areas that can be leveraged in reaching men are outside the routine health system. Scaling up HIV testing among men will require targeting avenues and operations outside of the routine health system and leverage them to reach more men with services. This suggests that HIV testing and counseling (HTC) uptake among men may be increased if the services were provided at informal places.
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Affiliation(s)
- Alinane Linda Nyondo-Mipando
- Department of Health Systems and Policy, School of Public Health and Family Medicine, College of Medicine, Blantyre, Malawi
| | - Mphatso Kumwenda
- Department of Health Systems and Policy, School of Public Health and Family Medicine, College of Medicine, Blantyre, Malawi
| | | | - Sangwani Salimu
- Department of Health Systems and Policy, School of Public Health and Family Medicine, College of Medicine, Blantyre, Malawi
| | - Thokozani Kazuma
- Department of Health Systems and Policy, School of Public Health and Family Medicine, College of Medicine, Blantyre, Malawi
| | - Victor Mwapasa
- Department of Public Health, School of Public Health and Family Medicine, College of Medicine, Blantyre, Malawi
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16
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Onoya D, Hendrickson C, Sineke T, Maskew M, Long L, Bor J, Fox MP. Attrition in HIV care following HIV diagnosis: a comparison of the pre-UTT and UTT eras in South Africa. J Int AIDS Soc 2021; 24:e25652. [PMID: 33605061 PMCID: PMC7893145 DOI: 10.1002/jia2.25652] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 09/07/2020] [Accepted: 11/17/2020] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Policies for Universal Test & Treat (UTT) and same-day initiation (SDI) of antiretroviral therapy (ART) were instituted in South Africa in September 2016 and 2017 respectively. However, there is limited evidence on whether these changes have improved patient retention after HIV diagnosis. METHODS We enrolled three cohorts of newly diagnosed HIV-infected adults from two primary health clinics in Johannesburg from April to November 2015 (Pre-UTT, N = 144), May-September 2017 (UTT, N = 178) and October-December 2017 (SDI, N = 88). A baseline survey was administered immediately after HIV diagnosis after which follow-up using clinical records (paper charts, electronic health records and laboratory data) ensued for 12 months. The primary outcome was patient loss to follow-up (being >90 days late for the last scheduled appointment) at 12 months post-HIV diagnosis. We modelled attrition across HIV policy periods with Cox proportional hazard regression. RESULTS Overall, 410 of 580 screened HIV-positive patients were enrolled. Overall, attrition at 12 months was 30% lower in the UTT guideline period (38.2%) compared to pre-UTT (47.2%, aHR 0.7, 95% CI: 0.5 to 1.0). However, the total attrition was similar between the SDI (47.7%) and pre-UTT cohorts (aHR 1.0, 95% CI: 0.7 to 1.5). Older age at HIV diagnosis (aHR 0.5 for ≥40 vs. 25 to 29 years, 95% CI: 0.3 to 0.8) and being in a non-marital relationship (aHR 0.5 vs. being single, 95% CI: 0.3 to 0.8) protected against LTFU at 12 months, whereas LTFU rates increased with longer travel time to the diagnosing clinic (aHR 1.8 for ≥30 minutes vs. ≤15 minutes, 95% CI: 1.1 to 3.1). In analyses adjusted for the time-varying ART initiation status, compared to the pre-ART period of care, the hazard of on-ART LTFU was 90% higher among participants diagnosed under the SDI policy compared to pre-UTT (aHR 1.9, 95% CI: 1.1 to 2.9). CONCLUSIONS Overall, nearly two-fifths of HIV positive patients are likely to disengage from care by 12 months after HIV diagnosis under the new SDI policy. Furthermore, the increase in on-ART patient attrition after the introduction of the SDI policy is cause for concern. Further research is needed to determine the best way for rapidly initiating patients on ART and also reducing long-term attrition from care.
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Affiliation(s)
- Dorina Onoya
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Cheryl Hendrickson
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Tembeka Sineke
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Mhairi Maskew
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Lawrence Long
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
| | - Jacob Bor
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
| | - Matthew P. Fox
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
- Department of EpidemiologyBoston University School of Public HealthBostonMAUSA
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17
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Mody A, Glidden DV, Eshun-Wilson I, Sikombe K, Simbeza S, Mukamba N, Somwe P, Beres LK, Pry J, Bolton-Moore C, Padian N, Holmes CB, Sikazwe I, Geng EH. Longitudinal Care Cascade Outcomes Among People Eligible for Antiretroviral Therapy Who Are Newly Linking to Care in Zambia: A Multistate Analysis. Clin Infect Dis 2020; 71:e561-e570. [PMID: 32173743 PMCID: PMC7744998 DOI: 10.1093/cid/ciaa268] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 03/13/2020] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Retention in human immunodeficiency virus (HIV) care is dynamic, with patients frequently transitioning in and out of care. Analytical approaches (eg, survival analyses) commonly used to assess HIV care cascade outcomes fail to capture such transitions and therefore incompletely represent care outcomes over time. METHODS We analyzed antiretroviral therapy (ART)-eligible adults newly linking to care at 64 clinics in Zambia between 1 April 2014 and 31 July 2015. We used electronic medical record data and supplemented these with updated care outcomes ascertained by tracing a multistage random sample of patients lost to follow-up (LTFU, >90 days late for last appointment). We performed multistate analyses, incorporating weights from sampling, to estimate the prevalence of 9 care states over time since linkage with respect to ART initiation, retention in care, transfers, and mortality. RESULTS In sum, 23 227 patients (58% female; median age 34 years [interquartile range 28-41]) were ART-eligible at enrollment. At 1 year, 75.2% had initiated ART and were in care: 61.8% were continuously retained, 6.1% had reengaged after LTFU, and 7.3% had transferred. Also, 10.1% were LTFU within 7 days of enrollment, and 15.2% were LTFU at 1 year (6.7% prior to ART). One year after LTFU, 51.6% of those LTFU prior to ART remained out of care compared to 30.2% of those LTFU after initiating ART. Overall, 6.9% of patients had died by 1 year with 3.0% dying prior to ART. CONCLUSION Multistate analyses provide more complete assessments of longitudinal HIV cascade outcomes and reveal treatment gaps at distinct timepoints in care that will still need to be addressed even with universal treatment.
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Affiliation(s)
- Aaloke Mody
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | - David V Glidden
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | | | - Sandra Simbeza
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Njekwa Mukamba
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Paul Somwe
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Laura K Beres
- Department of International Health, Johns Hopkins University School of Public Health, Baltimore, Maryland, USA
| | - Jake Pry
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Carolyn Bolton-Moore
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
- Division of Infectious Diseases, University of Alabama, Birmingham, Alabama, USA
| | - Nancy Padian
- Division of Epidemiology, University of California, Berkeley, Berkeley, California, USA
| | - Charles B Holmes
- Department of Medicine, Georgetown University, Washington, D.C., USA
| | - Izukanji Sikazwe
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Elvin H Geng
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
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Abstract
We present recent literature describing interventions for linkage to HIV care in the era of Universal Test and Treat (UTT) policies. We also provide information for ongoing studies of linkage to care strategies registered with ClinicalTrials.gov.
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Pry J, Chipungu J, Smith HJ, Bolton Moore C, Mutale J, Duran‐Frigola M, Savory T, Herce ME. Patient-reported reasons for declining same-day antiretroviral therapy initiation in routine HIV care settings in Lusaka, Zambia: results from a mixed-effects regression analysis. J Int AIDS Soc 2020; 23:e25560. [PMID: 32618137 PMCID: PMC7333172 DOI: 10.1002/jia2.25560] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 05/14/2020] [Accepted: 06/04/2020] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION In the current "test and treat" era, HIV programmes are increasingly focusing resources on linkage to care and same-day antiretroviral therapy (ART) initiation to meet UNAIDS 95-95-95 targets. After observing sub-optimal treatment indicators in health facilities supported by the Centre for Infectious Disease Research in Zambia (CIDRZ), we piloted a "linkage assessment" tool in facility-based HIV testing settings to uncover barriers to same-day linkage to care and ART initiation among newly identified people living with HIV (PLHIV) and to guide HIV programme quality improvement efforts. METHODS The one-page, structured linkage assessment tool was developed to capture patient-reported barriers to same-day linkage and ART initiation using three empirically supported categories of barriers: social, personal and structural. The tool was implemented in three health facilities, two urban and one rural, in Lusaka, Zambia from 1 November 2017 to 31 January 2018, and administered to all newly identified PLHIV declining same-day linkage and ART. Individuals selected as many reasons as relevant. We used mixed-effects logistic regression modelling to evaluate predictors of citing specific barriers to same-day linkage and ART, and Fisher's Exact tests to assess differences in barrier citation by socio-demographics and HIV testing entry point. RESULTS A total of 1278 people tested HIV positive, of whom 126 (9.9%) declined same-day linkage and ART, reporting a median of three barriers per respondent. Of these 126, 71.4% were female. Females declining same-day ART were younger, on average, (median 28.5 years, interquartile range (IQR): 21 to 37 years) than males (median 34.5 years, IQR: 26 to 44 years). The most commonly reported barrier category was structural, "clinics were too crowded" (n = 33), followed by a social reason, "friends and family will condemn me" (n = 30). The frequency of citing personal barriers differed significantly across HIV testing point (χ2 p = 0.03). Significant predictors for citing ≥1 barrier to same-day ART were >50 years of age (OR: 12.59, 95% CI: 6.00 to 26.41) and testing at a rural facility (OR: 9.92, 95% CI: 4.98 to 19.79). CONCLUSIONS Given differences observed in barriers to same-day ART initiation reported across sex, age, testing point, and facility type, new, tailored counselling and linkage to care approaches are needed, which should be rigorously evaluated in routine programme settings.
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Affiliation(s)
- Jake Pry
- Implementation Science UnitCentre for Infectious Disease Research in Zambia (CIDRZ)LusakaZambia
- Division of Infectious DiseasesSchool of MedicineWashington UniversitySt. LouisMOUSA
| | - Jenala Chipungu
- Implementation Science UnitCentre for Infectious Disease Research in Zambia (CIDRZ)LusakaZambia
| | - Helene J Smith
- Implementation Science UnitCentre for Infectious Disease Research in Zambia (CIDRZ)LusakaZambia
| | - Carolyn Bolton Moore
- Implementation Science UnitCentre for Infectious Disease Research in Zambia (CIDRZ)LusakaZambia
- School of MedicineUniversity of AlabamaBirminghamALUSA
| | - Jacob Mutale
- Implementation Science UnitCentre for Infectious Disease Research in Zambia (CIDRZ)LusakaZambia
| | - Miquel Duran‐Frigola
- Implementation Science UnitCentre for Infectious Disease Research in Zambia (CIDRZ)LusakaZambia
- Joint IRB‐BSC‐CRG Program in Computational BiologyInstitute for Research in Biomedicine (IRB Barcelona)The Barcelona Institute of Science and TechnologyBarcelonaCataloniaSpain
| | - Theodora Savory
- Implementation Science UnitCentre for Infectious Disease Research in Zambia (CIDRZ)LusakaZambia
| | - Michael E Herce
- Implementation Science UnitCentre for Infectious Disease Research in Zambia (CIDRZ)LusakaZambia
- Institute for Global Health & Infectious DiseasesSchool of MedicineUniversity of North CarolinaChapel HillNCUSA
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Tun W, Go V, Yansaneh A. Implementation Science: Helping to Accelerate Progress Toward Achieving the 90-90-90 Goal. AIDS Behav 2019; 23:115-119. [PMID: 31512068 PMCID: PMC6773667 DOI: 10.1007/s10461-019-02649-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Waimar Tun
- HIV and AIDS Program, Population Council, 4301 Connecticut Avenue, NW, Suite 280, Washington, DC, 20008, USA.
| | - Vivian Go
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Aisha Yansaneh
- United States Agency for International Development (USAID), Washington, DC, USA
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