Link to slower access to care: what is the stigma?: an Indian perspective

Factors associated with survival in adult people living with HIV/AIDS (PLHAs) in Mumbai, India (2004-2019): A retrospective cohort study

Background:

Knowledge of factors that affect survival in People living with HIV/AIDS (PLHAs) on anti-retroviral therapy (ART) will help us develop and implement interventions to improve the clinical outcomes and survival in these individuals. The aim of this study was to estimate the survival in PLHAs on ART in the government ART programme in Mumbai, and the factors associated with survival in these individuals.

Methods:

It is a retrospective survival analysis of 28,345 adult PLHAs from 18 government ART centres in Mumbai (registration period 2004–2019). We estimated the mortality rates and their 95% confidence intervals [CIs], plotted the Kaplan Meier Survival curves, estimated incidence rate ratios (IRR) and hazard ratios (HR). There were done for the whole cohort and according to various demographic and clinical characteristics.

Results:

The mortality in PLHAs on ART was 9.04 per 1000 person years. The HR was significantly for those aged 50 years and more at the time of registration (HR: 3.01, 95% CI: 2.37, 3.83; P < 0.001), in those with baseline CD4 count of less than 200 higher hazard (HR: 1.83, 95% CI: 1.47, 2.27; P < 0.001), those with an adherence of 80–95% (HR; 5.58, 95% CI: 4.61, 6.75; P < 0.001) and adherence of <80% (HR: 9.37, 95% CI: 7.74, 11.33; P < 0.001). Furthermore, the hazard was significantly higher in those with TB compared those without TB (HR: 3.28, 95% CI: 2.87, 3.75; P < 0.001). Time from diagnosis (per month increase) to initiation of ART was not significantly associated with mortality.

Conclusions:

Increasing awareness about HIV testing and early detection of HIV in those who have high-risk behaviours, prompt diagnosis and management of TB among those infected, and developing and implementing strategies (such as enhanced counselling, telephone-based applications, messages, or reminders) to ensure ART adherence of more than 95% in those on ART will potentially help improve survival in PLHAs in India.

A mobile health-facilitated behavioural intervention for community health workers improves exclusive breastfeeding and early infant HIV diagnosis in India: a cluster randomized trial

INTRODUCTION

India's national AIDS Control Organization implemented World Health Organization's option B+ HIV prevention of mother-to-child transmission (PMTCT) guidelines in 2013. However, scalable strategies to improve uptake of new PMTCT guidelines to reduce new infection rates are needed. This study assessed impact of Mobile Health-Facilitated Behavioral Intervention on the uptake of PMTCT services.

METHODS

A cluster-randomized trial of a mobile health (mHealth)-supported behavioural training intervention targeting outreach workers (ORWs) was conducted in four districts of Maharashtra, India. Clusters (one Integrated Counselling and Testing Center (ICTC, n = 119), all affiliated ORWs (n = 116) and their assigned HIV-positive pregnant/postpartum clients (n = 1191)) were randomized to standard-of-care (SOC) ORW training vs. the COMmunity home Based INDia (COMBIND) intervention - specialized behavioural training plus a tablet-based mHealth application to support ORW-patient communication and patient engagement in HIV care. Impact on uptake of maternal antiretroviral therapy at delivery, exclusive breastfeeding at six months, infant nevirapine prophylaxis, and early infant diagnosis at six months was assessed using multi-level random-effects logistic regression models.

RESULTS

Of 1191 HIV-positive pregnant/postpartum women, 884 were eligible for primary outcome assessment; 487 were randomized to COMBIND. Multivariable analyses identified no statistically significant differences in any primary outcome by study arm. COMBIND was associated with higher uptake of exclusive breastfeeding at two months (adjusted Odds Ratio (aOR), 2.10; 95% CI 1.06 to 4.15) and early infant diagnosis at six weeks (aOR, 2.19; 95% CI 1.05 to 3.98) than SOC.

CONCLUSIONS

The COMBIND intervention was easily integrated into India's existing PMTCT programme and improved early uptake of two PMTCT components that require self-motivated health-seeking behaviour, thus providing preliminary evidence to support COMBIND as a potentially scalable PMTCT strategy. Further study would identify modifications needed to optimize other PMTCT outcomes.

Challenges and opportunities for outreach workers in the Prevention of Mother to Child Transmission of HIV (PMTCT) program in India

BACKGROUND

The Prevention of Mother-to-Child Transmission of HIV (PMTCT) program in India is one of the largest in the world. It uses outreach workers (ORWs) to facilitate patient uptake of services, however, the challenges faced by the ORWs, and their views about the effectiveness of this program are unknown.

METHODS

The COMmunity-Home Based INDia (COMBIND) Prevention of Mother to Child Transmission of HIV study evaluated an integrated mobile health and behavioral intervention to enhance the capacity of ORWs in India. To understand the challenges faced by ORWs, and their perceptions of opportunities for program improvement, four group discussions were conducted among 60 ORW from four districts of Maharashtra, India, as part of the baseline assessment for COMBIND. Data were qualitatively analyzed using a thematic approach.

RESULTS

Numerous personal-, social-, and structural-level challenges existed for ORW as they engaged with their patients. Personal-level challenges for ORWs included disclosure of their own HIV status and travelling costs for home visits. Personal-level challenges for patients included financial costs of travelling to ART centers, non-adherence to ART, loss of daily wages, non-affordability of infant formula, lack of awareness of the baby's needs, financial dependence on family, four time points (6weeks, 6 months, 12 months and 18 months) for HIV tests, and need for nevirapine (NVP) prophylaxis. Social-level challenges included lack of motivation by patients and/or health care staff, social stigma, and rude behavior of health care staff and their unwillingness to provide maternity services to women in the PMTCT programme. Structural-level challenges included cultural norms around infant feeding, shortages of HIV testing kits, shortages of antiretroviral drugs and infant NVP prophylaxis, and lack of training/knowledge related to PMTCT infant feeding guidelines by hospital staff. The consensus among ORWs was that there was a critical need for tools and training to improve their capacity to effectively engage with patients, and deliver appropriate care, and for motivation through periodic feedback.

CONCLUSIONS

Given the significant challenges in PMTCT programme implementation reported by ORW, novel strategies to address these challenges are urgently needed to improve patient engagement, and access to and retention in care.

Contemporary issues on the epidemiology and antiretroviral adherence of HIV-infected adolescents in sub-Saharan Africa: a narrative review

Introduction

Adolescents are a unique and sometimes neglected group in the planning of healthcare services. This is the case in many parts of sub-Saharan Africa, where more than eight out of ten of the world's HIV-infected adolescents live. Although the last decade has seen a reduction in AIDS-related mortality worldwide, largely due to improved access to effective antiretroviral therapy (ART), AIDS remains a significant contributor to adolescent mortality in sub-Saharan Africa. Although inadequate access to ART in parts of the subcontinent may be implicated, research among youth with HIV elsewhere in the world suggests that suboptimal adherence to ART may play a significant role. In this article, we summarize the epidemiology of HIV among sub-Saharan African adolescents and review their adherence to ART, emphasizing the unique challenges and factors associated with adherence behaviour.

Methods

We conducted a comprehensive search of online databases for articles, relevant abstracts, and conference reports from meetings held between 2010 and 2014. Our search terms included “adherence,” “compliance,” “antiretroviral use” and “antiretroviral adherence,” in combination with “adolescents,” “youth,” “HIV,” “Africa,” “interventions” and the MeSH term “Africa South of the Sahara.” Of 19,537 articles and abstracts identified, 215 met inclusion criteria, and 148 were reviewed.

Discussion

Adolescents comprise a substantial portion of the population in many sub-Saharan African countries. They are at particular risk of HIV and may experience worse outcomes. Although demonstrated to have unique challenges, there is a dearth of comprehensive health services for adolescents, especially for those with HIV in sub-Saharan Africa. ART adherence is poorer among older adolescents than other age groups, and psychosocial, socio-economic, individual, and treatment-related factors influence adherence behaviour among adolescents in this region. With the exception of a few examples based on affective, cognitive, and behavioural strategies, most adherence interventions have been targeted at adults with HIV.

Conclusions

Although higher levels of ART adherence have been reported in sub-Saharan Africa than in other well-resourced settings, adolescents in the region may have poorer adherence patterns. There is substantial need for interventions to improve adherence in this unique population.

Need for multilevel strategies and enhanced acceptance of contraceptive use in order to combat the spread of HIV/AIDS in a Muslim society: a qualitative study of young adults in urban Karachi, Pakistan

This qualitative study explored knowledge, attitudes, beliefs and perceptions of sexual and reproductive health, focusing specifically on contraceptive use and HIV prevention among young unmarried men and women, 17-21 years, in urban Karachi, Pakistan. The main theme, identified as underlying meaning in the focus group discussions was “Societal norms and perceptions create barriers to knowledge and awareness about sexual and reproductive health matters among young adults”. A knowledge gap was revealed concerning HIV/AIDS and contraceptive use among young males and females, who have to rely on media and peers for information seeking. Study participants perceived that HIV/AIDS is incurable and carries a social stigma. It was further revealed, that there is an opposition towards contraceptive use from religious leaders. Young adults in Pakistan are in need of improved knowledge about HIV/AIDS and contraceptive use. Youth clinics and schools/colleges may play a significant role in this regard. The religious leaders need to be informed about the beneficial effects of contraceptives and they should be part of any family planning/contraceptive use program to ensure better community acceptance. At the structural level there is an urgent need for policies targeting the issue of sexual and reproductive health, particularly HIV/AIDS information and contraceptive use to target the young population. The health care services should be able to respond by offering relevant services.

Enhancing HIV medication adherence in India

BACKGROUND

This pilot study evaluated an intervention designed to enhance adherence among those new to antiretroviral therapy.

METHODS

Participants (n = 80) were recruited from a hospital clinic in Chandigarh, India, and randomized to a 3-month group intervention or individual enhanced standard of care followed by crossover of condition and assessed over 6 months. Adherence was measured by prescription refill, pill count, and self-report.

RESULTS

At baseline, 56% of group condition (immediate intervention) and 54% of individual condition (delayed intervention) participants were nonadherent by pill count and 23% of group and 26% of individual condition participants self-reported skipping medication at least once over the last 3 months. From the postintervention to long-term follow-up, adherence in the group condition (immediate intervention) improved in comparison with adherence in the individual condition (delayed intervention; χ(2) = 5.67, P = .02).

CONCLUSIONS

Results support the use of interventions early in treatment to provide information and social support to establish long-term healthy adherence behaviors.