Understanding Sustained Retention in HIV/AIDS Care and Treatment: a Synthetic Review

Cross-sectional study to assess depression among healthcare workers in Lusaka, Zambia during the COVID-19 pandemic

OBJECTIVES

We sought to assess depression among healthcare workers (HCWs) in the context of COVID-19 in Lusaka Province, Zambia.

DESIGN

This cross-sectional study is nested within a larger study, the Person-Centred Public Health for HIV Treatment in Zambia (PCPH), a cluster-randomised trial to assess HIV care and outcomes.

SETTING

The research was conducted in 24 government-run health facilities from 11 August to 15 October 2020 during the first wave of the COVID-19 pandemic in Lusaka, Zambia.

PARTICIPANTS

We used convenience sampling to recruit HCW participants who were previously enrolled in the PCPH study, had more than 6 months' experience working at the facility and were voluntarily willing to participate.

PRIMARY OUTCOME MEASURES

We implemented the well-validated 9-question Patient Health Questionnaire (PHQ-9) to assess HCW depression. We used mixed-effects, adjusted Poisson regression to estimate the marginal probability of HCWs experiencing depression that may warrant intervention (PHQ-9 score ≥5) by healthcare facility.

RESULTS

We collected PHQ-9 survey responses from 713 professional and lay HCWs. Overall, 334 (46.8%, 95% CI 43.1%, 50.6%) HCWs recorded a PHQ-9 score ≥5, indicating the need for further assessment and potential intervention for depression. We identified significant heterogeneity across facilities and observed a greater proportion of HCWs with symptoms of depression in facilities providing COVID-19 testing and treatment services.

CONCLUSIONS

Depression may be a concern for a large proportion of HCWs in Zambia. Further work to understand the magnitude and aetiologies of depression among HCWs in the public sector is needed to design effective prevention and treatment interventions to meet the needs for mental health support and to minimise poor health outcomes.

Patient perceptions of facilitators and barriers to reducing hazardous alcohol use among people living with HIV in East Africa

BACKGROUND

Hazardous alcohol use among people living with HIV is associated with poor outcomes and increased morbidity and mortality. Understanding the hazardous drinking experiences of people living with HIV is needed to reduce their alcohol use.

METHODS

We conducted 60 interviews among people living with HIV in East Africa with hazardous drinking histories. Interviews and Alcohol Use Disorder Identification Test (AUDIT) scores were conducted 41 - 60 months after their baseline assessment of alcohol use to identify facilitators and barriers to reduced alcohol use over time.

RESULTS

People living with HIV who stopped or reduced hazardous drinking were primarily motivated by their HIV condition and desire for longevity. Facilitators of reduced drinking included health care workers' recommendations to reduce drinking (despite little counseling and no referrals) and social support. In those continuing to drink at hazardous levels, barriers to reduced drinking were stress, social environment, alcohol accessibility and alcohol dependency.

CONCLUSIONS

Interventions that capacity-build professional and lay health care workers with the skills and resources to decrease problematic alcohol use, along with alcohol cessation in peer support structures, should be explored.

Uptake of appointment spacing model of care and associated factors among stable adult HIV clients on antiretroviral treatment Northwest Ethiopia

INTRODUCTION

Ethiopia launched an Appointment Spacing Model in 2017, which involved a six-month clinical visit and medication refill cycle. This study aimed to assess the uptake of the Appointment Spacing Model of care and associated factors among stable adult HIV clients on ART in Ethiopia.

METHODS

A cross-sectional study was conducted from October 3 to November 30, 2020 among 415 stable adult ART clients. EpiData version 4.2 was used for data entry and SPSS version 25 was used for cleaning and analysis. A multivariable logistic regression model was fitted to identify associated factors, with CI at 95% with AOR being reported to show the strength of association.

RESULTS

The uptake of the appointment spacing model was 50.1%. Residence [AOR: 2.33 (95% CI: 1.27, 4.26)], monthly income [AOR: 2.65 (95% CI: 1.13, 6.24)], social support [AOR: 2.21 (95% CI: 1.03, 4.71)], duration on ART [AOR: 2.41 (95% CI: 1.48, 3.92)], baseline regimen change [AOR: 2.20 (95% CI: 1.02, 4.78)], viral load [AOR: 2.80 (95% CI: 1.06, 7.35)], and alcohol abstinence [AOR: 2.02 (95% CI: 1.21, 3.37)] were statistically significant.

CONCLUSIONS

The uptake of the ASM was low. Behavioral change communication, engaging income-generating activities, and facility-level service providers' training may improve the uptake.

Durable Viral Suppression Among People with HIV and Problem Substance Use in the Era of Universal Antiretroviral Treatment

This study explored factors associated with durable viral suppression (DVS) among two groups of people living with HIV (PLWH) and problem substance use in the context of universal antiretroviral treatment initiation. Participants (N = 99) were recruited between 2014-2017 from public sexual health clinics [SHC] and a hospital detoxification unit [detox]). DVS (NYC HIV surveillance registry) was defined as two consecutive viral load tests ≤ 200 copies/mL, ≤ 90 days apart, with all other viral loads suppressed over 12 or 18 months. Detox participants were significantly older, with more unstable housing/employment, substance use severity, and longer-term HIV vs. SHC participants. Older age, opioid and stimulant use disorder were significantly associated with lower odds of DVS, while fulltime employment and stable housing were significantly associated with higher odds of DVS at 12-month follow-up. Patterns held at 18-month follow-up. Co-located substance use and HIV services, funding for supportive housing, and collaborative patient-provider relationships could improve DVS among populations with the syndemic of problem substance use, poverty, and long-term HIV.

Attitudes towards and experiences with economic incentives for engagement in HIV care and treatment: Qualitative insights from a randomized trial in Kenya

Growing literature has shown heterogenous effects of conditional cash incentives (CCIs) on HIV care retention. The field lacks insights into reasons why incentives impact various patients in different ways-differences that may be due to variations in psychological and social mechanisms of effect. A deeper understanding of patients' perceptions and experiences of CCIs for retention may help to clarify these mechanisms. We conducted a qualitative study embedded in the ADAPT-R trial (NCT#02338739), a sequential multiple assignment randomized trial (SMART) that evaluated economic incentives to support retention in HIV care among persons living with HIV (PLHIV) initiating antiretroviral therapy in Kenya. Participants who attended their scheduled clinic visits received an incentive of approximately $4 each visit. Interviews were conducted between July 2016 and June 2017 with 39 participants to explore attitudes and experiences with economic incentives conditional on care engagement. Analyses revealed that incentives helped PLHIV prioritize care-seeking by alleviating transport barriers and food insecurity: "I decided to forgo [work] and attend clinic […] the voucher relieved me". Patients who borrowed money for care-seeking reported feeling relieved from the burden of indebtedness to others: "I borrow with confidence that I will pay after my appointment." Incentives fostered their autonomy, and enabled them to support others: "I used the money to buy some clothes and Pampers for the children." Participants who were intrinsically motivated to engage in care ("my life depends on the drugs, not the incentive"), and those who mistrusted researchers, reported being less prompted by the incentive itself. For patients not already prioritizing care-seeking, incentives facilitated care engagement through alleviating transport costs, indebtedness and food insecurity, and also supported social role fulfillment. Conditional cash incentives may be an important cue to action to improve progression through the HIV treatment cascade, and contribute to better care retention.

The Kanyakla study: Randomized controlled trial of a microclinic social network intervention for promoting engagement and retention in HIV care in rural western Kenya

BACKGROUND

Existing social relationships are a potential source of "social capital" that can enhance support for sustained retention in HIV care. A previous pilot study of a social network-based 'microclinic' intervention, including group health education and facilitated HIV status disclosure, reduced disengagement from HIV care. We conducted a pragmatic randomized trial to evaluate microclinic effectiveness.

METHODS

In nine rural health facilities in western Kenya, we randomized HIV-positive adults with a recent missed clinic visit to either participation in a microclinic or usual care (NCT02474992). We collected visit data at all clinics where participants accessed care and evaluated intervention effect on disengagement from care (≥90-day absence from care after a missed visit) and the proportion of time patients were adherent to clinic visits ('time-in-care'). We also evaluated changes in social support, HIV status disclosure, and HIV-associated stigma.

RESULTS

Of 350 eligible patients, 304 (87%) enrolled, with 154 randomized to intervention and 150 to control. Over one year of follow-up, disengagement from care was similar in intervention and control (18% vs 17%, hazard ratio 1.03, 95% CI 0.61-1.75), as was time-in-care (risk difference -2.8%, 95% CI -10.0% to +4.5%). The intervention improved social support for attending clinic appointments (+0.4 units on 5-point scale, 95% CI 0.08-0.63), HIV status disclosure to close social supports (+0.3 persons, 95% CI 0.2-0.5), and reduced stigma (-0.3 units on 5-point scale, 95% CI -0.40 to -0.17).

CONCLUSIONS

The data from our pragmatic randomized trial in rural western Kenya are compatible with the null hypothesis of no difference in HIV care engagement between those who participated in a microclinic intervention and those who did not, despite improvements in proposed intervention mechanisms of action. However, some benefit or harm cannot be ruled out because the confidence intervals were wide. Results differ from a prior quasi-experimental pilot study, highlighting important implementation considerations when evaluating complex social interventions for HIV care.

TRIAL REGISTRATION

Clinical trial number: NCT02474992.

Pre-exposure prophylaxis use among HIV serodiscordant couples: a qualitative study in Mozambique

Background

Pre-exposure prophylaxis (PrEP) has the potential to reduce HIV transmission and stem the HIV epidemic. Unfortunately, PrEP uptake in rural sub-Saharan Africa has been slow and medication adherence has been suboptimal.

Objective

To explore the perspectives, attitudes, and experiences of HIV serodiscordant partners taking PrEP and develop a messaging campaign to improve PrEP uptake in rural Mozambique to reduce HIV transmission among serodiscordant partners.

Methods

In this qualitative study, we interviewed 20 people in serodiscordant relationships using PrEP at a rural health center in Zambézia province, Mozambique and employed inductive and deductive coding to elicit their perspectives, attitudes, and experiences related to learning their partner’s HIV status, barriers to PrEP uptake, obstacles to PrEP adherence, and decisions to disclose their PrEP use with family and friends using thematic analysis.

Results

Our analysis generated nine themes across various levels of the socioecological model. Participants reported a strong desire to stay in the discordant relationship and highlighted the importance of working together to ensure PrEP and antiretroviral therapy adherence, with the majority skeptical that adherence could be achieved without both partners’ support (individual and interpersonal). Although most participants were reticent about sharing their serodiscordant status with family and friends (individual and interpersonal), those who did found their family and friends supportive (interpersonal). Participants suggested increasing community health agent availability to help people navigate HIV prevention and treatment (organizational). We then created three oral stories, using themes from the interviews, with examples from various levels of the socioecological model that will be used to generate support for PrEP use among community members.

Conclusions

Our findings informed oral template stories that will be used to emphasize how couples can work together to improve PrEP uptake and reduce incident HIV infections in serodiscordant couples elsewhere in rural Mozambique.

Improved Viral Suppression With Streamlined Care in the SEARCH Study

Supplemental Digital Content is Available in the Text.

Background:

HIV differentiated service delivery (DSD) models are scaling up in resource-limited settings for stable patients; less is known about DSD outcomes for patients with viremia. We evaluated the effect on viral suppression (VS) of a streamlined care DSD model implemented in the SEARCH randomized universal test and treat trial in rural Uganda and Kenya (NCT:01864603).

Methods:

We included HIV-infected adults at baseline (2013) who were country guideline antiretroviral therapy (ART) eligible (prior ART experience or CD4 ≤ 350) with ≥1 HIV clinic visit between 2013 and 2017 in SEARCH communities randomized to intervention (N = 16) or control (N = 16). We assessed the effect of streamlined care in intervention community clinics (patient-centered care, increased appointment spacing, improved clinic access, reminders, and tracking) on VS at 3 years. Analysis was stratified by the baseline care status: ART-experienced with viremia, ART-naïve with CD4 ≤ 350, or ART-experienced with VS.

Results:

Among 6190 ART-eligible persons in care, year 3 VS was 90% in intervention and 87% in control arms (RR 1.03, 95% CI: 1.01 to 1.06). Among ART-experienced persons with baseline viremia, streamlined care was associated with higher VS (67% vs 47%, RR 1.41, 95% CI: 1.05 to 1.91). Among ART-naïve persons, VS was not significantly higher with streamlined care (83% vs 79%, RR 1.05, 95% CI: 0.95 to 1.16). Among ART-experienced persons with baseline VS, nearly all remained virally suppressed in both arms (97% vs 95%, RR 1.01, 95% CI: 1.00 to 1.03).

Conclusions:

Streamlined care was associated with higher viral suppression among ART-experienced patients with viremia in this randomized evaluation of ART-eligible patients who were in care after universal HIV testing.

SEARCH Human Immunodeficiency Virus (HIV) Streamlined Treatment Intervention Reduces Mortality at a Population Level in Men With Low CD4 Counts

BACKGROUND

We tested the hypothesis that patient-centered, streamlined human immunodeficiency virus (HIV) care would achieve lower mortality than the standard treatment model for persons with HIV and CD4 ≤ 350/uL in the setting of population-wide HIV testing.

METHODS

In the SEARCH (Sustainable East Africa Research in Community Health) Study (NCT01864603), 32 communities in rural Uganda and Kenya were randomized to country-guided antiretroviral therapy (ART) versus streamlined ART care that included rapid ART start, visit spacing, flexible clinic hours, and welcoming environment. We assessed persons with HIV and CD4 ≤ 350/uL, ART eligible in both arms, and estimated the effect of streamlined care on ART initiation and mortality at 3 years. Comparisons between study arms used a cluster-level analysis with survival estimates from Kaplan-Meier; estimates of ART start among ART-naive persons treated death as a competing risk.

RESULTS

Among 13 266 adults with HIV, 2973 (22.4%) had CD4 ≤ 350/uL. Of these, 33% were new diagnoses, and 10% were diagnosed but ART-naive. Men with HIV were almost twice as likely as women with HIV to have CD4 ≤ 350/uL and be untreated (15% vs 8%, respectively). Streamlined care reduced mortality by 28% versus control (risk ratio [RR] = 0.72; 95% confidence interval [CI]: .56, .93; P = .02). Despite eligibility in both arms, persons with CD4 ≤ 350/uL started ART faster under streamlined care versus control (76% vs 43% by 12 months, respectively; P < .001). Mortality was reduced substantially more among men (RR = 0.61; 95% CI: .43, .86; P = .01) than among women (RR = 0.90; 95% CI: .62, 1.32; P = .58).

CONCLUSIONS

After population-based HIV testing, streamlined care reduced population-level mortality among persons with HIV and CD4 ≤ 350/uL, particularly among men. Streamlined HIV care models may play a key role in global efforts to reduce AIDS deaths.

Understanding mobility and sexual risk behaviour among women in fishing communities of Lake Victoria in East Africa: a qualitative study

BACKGROUND

HIV-prevalence and incidence is high in many fishing communities around Lake Victoria in East Africa. In these settings, mobility among women is high and may contribute to increased risk of HIV infection and poor access to effective prevention and treatment services. Understanding the nature and patterns of this mobility is important for the design of interventions. We conducted an exploratory study to understand the nature and patterns of women's mobility to inform the design of HIV intervention trials in fishing communities of Lake Victoria.

METHODS

This was a cross-sectional formative qualitative study conducted in six purposively selected fishing communities in Kenya, Tanzania and Uganda. Potential participants were screened for eligibility on age (18+ years) and having stayed in the fishing community for more than 6 months. We collected data using introductory and focus group discussions, and in-depth interviews with key informants. Data focused on: history and patterns of mobility, migration in and out of fishing communities and the relationship between mobility and HIV infection. Since the interviews and discussions were not audio-recorded, detailed notes were taken and written up into full scripts for analysis. We conducted a thematic analysis using constant comparison analysis.

RESULTS

Participants reported that women in fishing communities were highly mobile for work-related activities. Overall, we categorized mobility as travels over long and short distances or periods depending on the kind of livelihood activity women were involved in. Participants reported that women often travelled to new places, away from familiar contacts and far from healthcare access. Some women were reported to engage in high risk sexual behaviour and disengaging from HIV care. However, participants reported that women often returned to the fishing communities they considered home, or followed a seasonal pattern of work, which would facilitate contact with service providers.

CONCLUSION

Women exhibited circular and seasonal mobility patterns over varying distances and duration away from their home communities. These mobility patterns may limit women's access to trial/health services and put them at risk of HIV-infection. Interventions should be tailored to take into account mobility patterns of seasonal work observed in this study.

Effect of a differentiated service delivery model on virological failure in adolescents with HIV in Zimbabwe (Zvandiri): a cluster-randomised controlled trial

BACKGROUND

Adolescents living with HIV face challenges to their wellbeing and antiretroviral therapy adherence and have poor treatment outcomes. We aimed to evaluate a peer-led differentiated service delivery intervention on HIV clinical and psychosocial outcomes among adolescents with HIV in Zimbabwe.

METHODS

16 public primary care facilities (clusters) in two rural districts in Zimbabwe (Bindura and Shamva) were randomly assigned (1:1) to provide enhanced HIV care support (the Zvandiri intervention group) or standard HIV care (the control group) to adolescents (aged 13-19 years) with HIV. Eligible clinics had at least 20 adolescents in pre-ART or ART registers and were geographically separated by at least 10 km to minimise contamination. Adolescents were eligible for inclusion if they were living with HIV, registered for HIV care at one of the trial clinics, and either starting or already on ART. Exclusion criteria were being too physically unwell to attend clinic (bedridden), psychotic, or unable to give informed assent or consent. Adolescents with HIV at all clinics received adherence support through adult counsellors. At intervention clinics, adolescents with HIV were assigned a community adolescent treatment supporter, attended a monthly support group, and received text messages, calls, home visits, and clinic-based counselling. Implementation intensity was differentiated according to each adolescent's HIV vulnerability, which was reassessed every 3 months. Caregivers were invited to a support group. The primary outcome was the proportion of adolescents who had died or had a viral load of at least 1000 copies per μL after 96 weeks. In-depth qualitative data were collected and analysed thematically. The trial is registered with Pan African Clinical Trial Registry, number PACTR201609001767322.

FINDINGS

Between Aug 15, 2016, and March 31, 2017, 500 adolescents with HIV were enrolled, of whom four were excluded after group assignment owing to testing HIV negative. Of the remaining 496 adolescents, 212 were recruited at Zvandiri intervention sites and 284 at control sites. At enrolment, the median age was 15 years (IQR 14-17), 52% of adolescents were female, 81% were orphans, and 47% had a viral load of at least 1000 copies per μL. 479 (97%) had primary outcome data at endline, including 28 who died. At 96 weeks, 52 (25%) of 209 adolescents in the Zvandiri intervention group and 97 (36%) of 270 adolescents in the control group had an HIV viral load of at least 1000 copies per μL or had died (adjusted prevalence ratio 0·58, 95% CI 0·36-0·94; p=0·03). Qualitative data suggested that the multiple intervention components acted synergistically to improve the relational context in which adolescents with HIV live, supporting their improved adherence. No adverse events were judged to be related to study procedures. Severe adverse events were 28 deaths (17 in the Zvandiri intervention group, 11 in the control group) and 57 admissions to hospital (20 in the Zvandiri intervention group, 37 in the control group).

INTERPRETATION

Peer-supported community-based differentiated service delivery can substantially improve HIV virological suppression in adolescents with HIV and should be scaled up to reduce their high rates of morbidity and mortality.

FUNDING

Positive Action for Adolescents Program, ViiV Healthcare.

Community perspectives of South African adolescents' experiences seeking treatment at local HIV clinics and how such clinics may influence engagement in the HIV treatment cascade: a qualitative study

Despite having the largest antiretroviral treatment (ART) program in the world, only 14% of South African adolescents living with HIV (ALWH) are on ART. The purpose of this study was to identify aspects of the clinic environment that either improve or inhibit ALWH's ability to engage in HIV care. We conducted fifty-nine semi-structured, in-depth interviews with ALWH (n = 20; 13-19 years of age), their caregivers (n = 19), and local stakeholders (n = 20) in Cape Town, South Africa. Data were coded and analyzed using inductive and deductive approaches to content analyses. Codes were grouped into positive and negative aspects of the HIV clinic environment, and into suggestions on how clinic practices could be improved to facilitate ALWH treatment retention and ART adherence. Positive clinic factors included: community co-location; familiarity with clinic staff; and adolescent only/adolescent-friendly clinic spaces. Negative clinic factors included: clinic visit frequency; overcrowding and long wait times; discrimination and stigma; lack of confidentiality; inflexible appointment-scheduling; and staff attitudes. ALWHs' clinic experiences affect their ability to remain in care and adhere to their treatment regimens. These findings support a call for innovative approaches that improve ALWH's clinic experiences and support them as they progress along the HIV treatment cascade.

HIV Testing and Treatment with the Use of a Community Health Approach in Rural Africa

BACKGROUND

Universal antiretroviral therapy (ART) with annual population testing and a multidisease, patient-centered strategy could reduce new human immunodeficiency virus (HIV) infections and improve community health.

METHODS

We randomly assigned 32 rural communities in Uganda and Kenya to baseline HIV and multidisease testing and national guideline-restricted ART (control group) or to baseline testing plus annual testing, eligibility for universal ART, and patient-centered care (intervention group). The primary end point was the cumulative incidence of HIV infection at 3 years. Secondary end points included viral suppression, death, tuberculosis, hypertension control, and the change in the annual incidence of HIV infection (which was evaluated in the intervention group only).

RESULTS

A total of 150,395 persons were included in the analyses. Population-level viral suppression among 15,399 HIV-infected persons was 42% at baseline and was higher in the intervention group than in the control group at 3 years (79% vs. 68%; relative prevalence, 1.15; 95% confidence interval [CI], 1.11 to 1.20). The annual incidence of HIV infection in the intervention group decreased by 32% over 3 years (from 0.43 to 0.31 cases per 100 person-years; relative rate, 0.68; 95% CI, 0.56 to 0.84). However, the 3-year cumulative incidence (704 incident HIV infections) did not differ significantly between the intervention group and the control group (0.77% and 0.81%, respectively; relative risk, 0.95; 95% CI, 0.77 to 1.17). Among HIV-infected persons, the risk of death by year 3 was 3% in the intervention group and 4% in the control group (0.99 vs. 1.29 deaths per 100 person-years; relative risk, 0.77; 95% CI, 0.64 to 0.93). The risk of HIV-associated tuberculosis or death by year 3 among HIV-infected persons was 4% in the intervention group and 5% in the control group (1.19 vs. 1.50 events per 100 person-years; relative risk, 0.79; 95% CI, 0.67 to 0.94). At 3 years, 47% of adults with hypertension in the intervention group and 37% in the control group had hypertension control (relative prevalence, 1.26; 95% CI, 1.15 to 1.39).

CONCLUSIONS

Universal HIV treatment did not result in a significantly lower incidence of HIV infection than standard care, probably owing to the availability of comprehensive baseline HIV testing and the rapid expansion of ART eligibility in the control group. (Funded by the National Institutes of Health and others; SEARCH ClinicalTrials.gov number, NCT01864603.).

Enablers of adherence to clinic appointments for children attending an antiretroviral clinic in Northern Nigeria: Perspectives of caregivers and care providers

BACKGROUND

Nigeria has the highest burden of paediatric HIV infection, and the success of control efforts in the country is crucial to the global control of the HIV epidemic. However, defaults from schedules of care pose a threat to paediatric HIV control in Nigeria. This study was conducted in a pioneer facility for the implementation of the National HIV Prevention and Treatment Programmes.

OBJECTIVE

The objective of this study was to explore factors that facilitate adherence to clinic appointments from perspectives of child caregivers and service providers.

METHODS

This is a qualitative study using in-depth, face-to-face interviews conducted in 2016. Thirty-five participants were purposely sampled to comprise types of caregivers of HIV-exposed/infected children receiving care and from categories of service providers. The interviews were audio recorded, transcribed, thematically analysed and presented using a socioecological model.

RESULTS

The themes that emerged from participants' narratives included advanced education, affluence and residing close to the clinic at the intrapersonal level. Stable family dynamics and support, HIV status disclosure and being a biologic parent or grandparent as caregiver emerged at the interpersonal level. At the community level, disclosure and support were identified, while at the health facility level, positive staff attitude, quality of healthcare and peer support group influence were factors identified to facilitate regular clinic attendance.

CONCLUSION

The factors that enable retention of children in care are multidimensional and intricately connected. Programme improvement initiatives should include regular assessment of clients' perspectives to inform implementation of strategies that could reinforce caregiver confidence in the health system.

Trajectories of HIV-related internalized stigma and disclosure concerns among ART initiators and non-initiators in South Africa

Background

HIV-related stigma among people living with HIV (PLHIV) is associated with worse health outcomes. We used longitudinal data from a multi-site cohort in South Africa to assess changes over time in stigma after HIV diagnosis and determine whether antiretroviral therapy (ART) initiation is associated with stigma reduction.

Methods

We administered the Internalized AIDS-Related Stigma Scale (IARSS, a six-item dichotomous scale questionnaire) at baseline, three months, and six months to newly diagnosed ART-eligible participants between 2014-2015. A confirmatory factor analysis indicated that the IARSS contained a four-item internalized stigma factor (α=0.80) and a two-item disclosure concerns factor (α=0.75). We fitted multiple logistic regression models specifying internalized stigma/disclosure concerns at six months as the outcome and ART initiation as the predictor of interest.

Results

Of the 500 participants (187 men and 313 women) enrolled, 308 (62%) initiated ART. Internalized stigma declined among people entering care (mean score, 1.0 to 0.7, p<0.01); however, disclosure concerns remained unchanged (percentage endorsing either disclosure concern item, 78% to 77%, p=0.23). These findings were similar between ART initiators and non-initiators. We estimated a statistically significant positive association between ART initiation and disclosure concerns at six months (OR=1.88; 95% CI, 1.20-2.94) but not between ART initiation and internalized stigma at six months (OR=1.15; 95% CI, 0.75-1.78).

Conclusions

Among ART-eligible South African PLHIV entering into HIV care, internalized stigma modestly declined over time but disclosure concerns persisted. PLHIV who initiated ART were more likely to have persistent disclosure concerns over time as compared with those who did not start ART.

Addressing Early Retention in Antenatal Care Among HIV-Positive Women Through a Simple Intervention in Kinshasa, DRC: The Elombe "Champion" Standard Operating Procedure

This cluster-randomized study aimed to assess the Elombe ("Champion") standard operating procedure (SOP), implemented by providers and Mentor Mothers, on HIV-positive pregnant women's retention between first and second antenatal visits. Sixteen facilities in Kinshasa were randomly assigned to intervention (SOP) or comparison (no SOP). Effect of the SOP was estimated using relative risk. Women in comparison facilities were more likely to miss second visits (RR 2.5, 95% CI 1.05-5.98) than women in intervention facilities (30.0%, n = 27 vs. 12.0%, n = 9, p < 0.002). Findings demonstrate that a simple intervention can reduce critical early loss to care in PMTCT programs providing universal, lifelong treatment.

Navigating the sustainability landscape: a systematic review of sustainability approaches in healthcare

BACKGROUND

Improvement initiatives offer a valuable mechanism for delivering and testing innovations in healthcare settings. Many of these initiatives deliver meaningful and necessary changes to patient care and outcomes. However, many improvement initiatives fail to sustain to a point where their full benefits can be realised. This has led many researchers and healthcare practitioners to develop frameworks, models and tools to support and monitor sustainability. This work aimed to identify what approaches are available to assess and influence sustainability in healthcare and to describe the different perspectives, applications and constructs within these approaches to guide their future use.

METHODS

A systematic review was carried out following PRISMA guidelines to identify publications that reported approaches to support or influence sustainability in healthcare. Eligibility criteria were defined through an iterative process in which two reviewers independently assessed 20% of articles to test the objectivity of the selection criteria. Data were extracted from the identified articles, and a template analysis was undertaken to identify and assess the sustainability constructs within each reported approach.

RESULTS

The search strategy identified 1748 publications with 227 articles retrieved in full text for full documentary analysis. In total, 62 publications identifying a sustainability approach were included in this review (32 frameworks, 16 models, 8 tools, 4 strategies, 1 checklist and 1 process). Constructs across approaches were compared and 40 individual constructs for sustainability were found. Comparison across approaches demonstrated consistent constructs were seen regardless of proposed interventions, setting or level of application with 6 constructs included in 75% of the approaches. Although similarities were found, no approaches contained the same combination of the constructs nor did any single approach capture all identified constructs. From these results, a consolidated framework for sustainability constructs in healthcare was developed.

CONCLUSIONS

Choosing a sustainability method can pose a challenge because of the diverse approaches reported in the literature. This review provides a valuable resource to researchers, healthcare professionals and improvement practitioners by providing a summary of available sustainability approaches and their characteristics.

TRIAL REGISTRATION

This review was registered on the PROSPERO database: CRD42016040081 in June 2016.

High rates of viral suppression in adults and children with high CD4+ counts using a streamlined ART delivery model in the SEARCH trial in rural Uganda and Kenya

Introduction: The 2015 WHO recommendation of antiretroviral therapy (ART) for all HIV-positive persons calls for treatment initiation in millions of persons newly eligible with high CD4+ counts. Efficient and effective care models are urgently needed for this population. We evaluated clinical outcomes of asymptomatic HIV-positive adults and children starting ART with high CD4+ counts using a novel streamlined care model in rural Uganda and Kenya.

Methods: In the 16 intervention communities of the HIV test-and-treat Sustainable East Africa Research for Community Health Study (NCT01864603), all HIV-positive individuals irrespective of CD4 were offered ART (efavirenz [EFV]/tenofovir disoproxil fumarate + emtricitabine (FTC) or lamivudine (3TC). We studied adults (≥fifteen years) with CD4 ≥ 350/μL and children (two to fourteen years) with CD4 > 500/μL otherwise ineligible for ART by country guidelines. Clinics implemented a patient-centred streamlined care model designed to reduce patient-level barriers and maximize health system efficiency. It included (1) nurse-conducted visits with physician referral of complex cases, (2) multi-disease chronic care (including for hypertension/diabetes), (3) patient-centred, friendly staff, (4) viral load (VL) testing and counselling, (5) three-month return visits and ART refills, (6) appointment reminders, (7) tiered tracking for missed appointments, (8) flexible clinic hours (outside routine schedule) and (9) telephone access to clinicians. Primary outcomes were 48-week retention in care, viral suppression (% with measured week 48 VL ≤ 500 copies/mL) and adverse events.

Results: Overall, 972 HIV-positive adults with CD4+ ≥ 350/μL initiated ART with streamlined care. Patients were 66% female and had median age thirty-four years (IQR, 28–42), CD4+ 608/μL (IQR, 487–788/μL) and VL 6775 copies/mL (IQR, <500–37,003 c/mL). At week 48, retention was 92% (897/972; 2 died/40 moved/8 withdrew/4 transferred care/21/964 [2%] were lost to follow-up). Viral suppression occurred in 778/838 (93%) and 800/972 (82%) in intention-to-treat analysis. Grade III/IV clinical/laboratory adverse events were rare: 95 occurred in 74/972 patients (7.6%). Only 8/972 adults (0.8%) switched ART from EFV to lopinavir (LPV) (n = 2 for dizziness, n = 2 for gynaecomastia, n = 4 for other reasons). Among 83 children, week 48 retention was 89% (74/83), viral suppression was 92% (65/71) and grade III/IV adverse events occurred in 4/83 (4.8%).

Conclusions: Using a streamlined care model, viral suppression, retention and ART safety were high among asymptomatic East African adults and children with high CD4+ counts initiating treatment.

Clinical Trial Number: NCT01864603

Disclosure of Parental HIV Status to Children: Experiences of Adults Receiving Antiretroviral Treatment at an Urban Clinic in Kampala, Uganda

Limited data are available on the experiences of parental HIV disclosure to children in Uganda. We conducted a qualitative study comprising sixteen in-depth interviews and four focus group discussions with parents receiving highly active antiretroviral therapy. Analysis was done using Atlas.ti qualitative research software. Back-and-forth triangulation was done between transcripts of the in-depth interviews and focus group discussions, and themes and subthemes were developed. Barriers to parents' disclosure included perceptions that children are too young to understand what HIV infection means and fears of secondary disclosure by the children. Immediate outcomes of disclosure included children getting scared and crying, although such instances often gave way to more enduring positive experiences for the parents, such as support in adherence to medical care, help in household chores, and a decrease in financial demands from the children. Country-specific interventions are needed to improve the process of parental HIV disclosure to children and this should encompass preparation on how to deal with the immediate psychological challenges associated with the parent's disclosure.

Exploring factors associated with ART adherence and retention in care under Option B+ strategy in Malawi: A qualitative study

Although several studies have documented challenges related to inadequate adherence to antiretroviral therapy (ART) and high loss to follow-up (LTFU) among Option B+ women, there is limited understanding of why these challenges occur and how to address them. This qualitative study examines women's experiences with ART adherence and retention in care. Between July and October 2015, in-depth interviews were conducted with 39 pregnant and lactating women who initiated ART at Bwaila Hospital in Lilongwe, Malawi. Study participants included 14 in care and 25 out of care women, according to facility records. Data were analyzed using an inductive, open-coding approach to thematic analysis. Ten of the respondents (7 out of care, 3 in-care) had stopped and re-started treatment before the interview date. One of the most important factors influencing adherence and retention was the strength of women's support systems. In contrast to women in-care, most out-of-care women lacked emotional and financial support from male partners, received minimal counseling from providers at initiation, lacked designated guardians to assist with medication refills or clinic appointments, and were highly mobile. Mobility led to difficulties in accessing treatment in new settings. The most common reasons women re-started treatment following interruptions were due to providers' counseling and encouragement and the mother's desire to be healthy. Improved counseling at initiation, active follow-up counseling, women's economic empowerment interventions, promotion of peer counseling schemes and meaningful engagement of male partners can help in addressing the identified barriers and promoting sustained retention of Option B+ women.

Nurse-led HIV services and quality of care at health facilities in Kenya, 2014-2016

Objective

To develop a novel measure to characterize human immunodeficiency virus (HIV) programme quality at health facilities in Kenya and explore its associations with patient- and facility-level characteristics.

Methods

We developed a composite indicator to measure quality of HIV care, comprising: assessment of eligibility for antiretroviral therapy (ART); initiation of ART; and retention on ART or in care, if ineligible for ART, for 12 months. We applied the comprehensive retention indicator to routinely collected clinical data from 13 331 patients enrolled in HIV care and treatment at 63 health facilities in the Eastern and Nyanza regions of Kenya from 1 January 2014 to 31 March 2016. We explored the association between facility- and patient-level characteristics and the primary outcome: appropriate staging and management of HIV, and retention in care over 12 months.

Findings

Of the enrolled patients, 8404 (63%) achieved comprehensive retention 12 months after enrolment in care. In univariate analyses, patients at facilities where nurses delivered HIV treatment services (including eligibility assessment, initiation and follow up of ART) had significantly higher comprehensive retention rates at 12 months. In multivariate analyses, after adjusting for both facility- and patient-level characteristics, patients at facilities where nurses initiated ART had significantly higher comprehensive retention in care at 12 months (relative risk, RR: 1.22; 95% confidence interval, CI: 1.00–1.48).

Conclusion

Nurse-led HIV services were significantly associated with quality of care, confirming the central role of nurses in the achievement of global health goals, and the need for further investment in nursing education, training and mentoring.