1
|
Audet CM, Graves E, Shepherd BE, Prigmore HL, Brooks HL, Emílio A, Matino A, Paulo P, Diemer MA, Frisby M, Sack DE, Aboobacar A, Barreto E, Van Rompaey S, De Schacht C. Partner-Based HIV Treatment for Seroconcordant Couples Attending Antenatal and Postnatal Care in Rural Mozambique: A Cluster Randomized Controlled Trial. J Acquir Immune Defic Syndr 2024; 96:259-269. [PMID: 38905476 PMCID: PMC11196005 DOI: 10.1097/qai.0000000000003440] [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: 12/14/2023] [Accepted: 03/25/2024] [Indexed: 06/23/2024]
Abstract
INTRODUCTION There is evidence that a supportive male partner facilitates maternal HIV testing during pregnancy, increases maternal antiretroviral therapy initiation and adherence, and increases HIV-free infant survival. Most male partner engagement clinical strategies have focused on increasing uptake of couple-based HIV testing and counseling. We delivered a couple-based care and treatment intervention to improve antiretroviral therapy adherence in expectant couples living with HIV. METHODS We implemented a cluster randomized controlled trial for seroconcordant couples living with HIV, comparing retention (using a patient's medication possession ratio) in HIV care for a couple-based care and treatment intervention vs. standard of care services in rural Mozambique. The intervention included couple-based treatment, couple-based education and skills building, and couple-peer educator support. RESULTS We recruited 1080 couples to participate in the study. Using a linear mixed effect model with a random effect for clinic, the intervention had no impact on the medication possession ratio among women at 12 months. However, the intervention increased men's medication ratio by 8.77%. Our unadjusted logistic regression model found the odds of an infant seroconverting in the intervention group was 30% less than in the control group, but the results were not statistically significant. DISCUSSION Our study found no difference in maternal outcomes by study arm, but our intervention resulted in an improved medication possession ratio among male partners. We provide a community/clinic-based treatment framework that can improve outcomes among male partners. Further work needs to be done to improve social support for pregnant women and to facilitate prevention of vertical transmission to infants among couples living with HIV.
Collapse
Affiliation(s)
- Carolyn M Audet
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN
- Vanderbilt University Medical Center, Vanderbilt Institute for Global Health, Nashville, TN
| | - Erin Graves
- Vanderbilt University Medical Center, Vanderbilt Institute for Global Health, Nashville, TN
| | - Bryan E Shepherd
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Heather L Prigmore
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Hannah L Brooks
- Vanderbilt University Medical Center, Vanderbilt Institute for Global Health, Nashville, TN
| | | | | | - Paula Paulo
- Friends in Global Health, Quelimane, Mozambique
| | | | - Michael Frisby
- Department of Educational Policy Studies, Georgia State University, Atlanta, GA; and
| | - Daniel E Sack
- Vanderbilt University Medical Center, Vanderbilt Institute for Global Health, Nashville, TN
| | - Arifo Aboobacar
- Provincial Health Directorate of Zambézia, Quelimane, Mozambique
| | | | | | | |
Collapse
|
2
|
Brooks HL, Graves E, De Schacht C, Emílio A, Matino A, Aboobacar A, Audet CM. "If It Weren't for This, We'd Be Sick"-Perspectives From Participants of a Couple-Based HIV Treatment and Support Program During Prenatal and Postpartum Periods in Zambézia Province, Mozambique. J Acquir Immune Defic Syndr 2024; 96:304-310. [PMID: 38032747 PMCID: PMC11128476 DOI: 10.1097/qai.0000000000003351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 11/02/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Engagement in HIV care and treatment services during pregnancy is key to eliminating vertical transmission. One barrier to retention of pregnant and lactating women is insufficient support from male partners. Reframing HIV services as couple-based may increase adherence among men and women. As part of a cluster randomized trial evaluating an intervention offering seroconcordant couples living with HIV joint follow-up in HIV services and sessions with a health counselor and couple peer educators, we assessed participants' perspectives and experiences regarding the intervention. SETTING Zambézia Province is a rural, low-income, and medically underserved region of central Mozambique. METHODS We conducted semistructured interviews with a subset of participants enrolled in the intervention arm. The objectives were to explore participants' (1) experiences with couples-based HIV care and the educational/support sessions; (2) perceived impacts of the intervention; and (3) suggestions for intervention improvement. Interviews conducted by experienced interviewers were audio-recorded, transcribed, and deductively coded. RESULTS Sixty-four participants were interviewed. Participants described the counselor and the peer educators as trustworthy and the sessions as improving their HIV-related knowledge. Receiving joint HIV services was convenient and motivated some participants to remain adherent to care. Participants provided few suggestions to improve the intervention, although a few female participants did state that they wished their male partners had participated more readily in the joint sessions and medication pick-ups at the health facilities. CONCLUSIONS Participants described positive experiences with and perceived benefits from the intervention, making this intervention acceptable within the local context.
Collapse
Affiliation(s)
- Hannah L Brooks
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Erin Graves
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | | | | - Arifo Aboobacar
- Provincial Health Directorate of Zambézia, Quelimane, Mozambique; and
| | - Carolyn M Audet
- Departments of Health Policy and Epidemiology, Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee
| |
Collapse
|
3
|
Graves E, Brooks HL, De Schacht C, Emílio A, Matino A, Aboobacar A, Audet CM. Healthcare Providers' Perspectives on a Novel Couple-Based HIV Treatment Intervention: A Qualitative Assessment of the Facilitators, Barriers, and Proposed Improvements to Implementation in Zambézia Province, Mozambique. AIDS Behav 2024; 28:1370-1383. [PMID: 38151664 PMCID: PMC11197054 DOI: 10.1007/s10461-023-04224-8] [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] [Accepted: 11/15/2023] [Indexed: 12/29/2023]
Abstract
Mozambique has one of the world's highest HIV/AIDS burdens. Despite significant investment in HIV care and treatment, pregnant and lactating women's retention in care remains suboptimal. One reason for poor maternal retention is lack of male partner support. We tested an interventional couple-based HIV care and treatment, including joint clinical appointments and couple-based educational and support sessions provided by a health counselor and peer educators, respectively. Healthcare providers delivering care for seroconcordant individuals were interviewed regarding their perspectives on facilitators and barriers to the couple-based intervention implementation. Analysis of interview responses was done using MAXQDA. Results pertaining to providers' perspectives on implementation and intervention characteristics were organized, interpreted, and contextualized using the Consolidated Framework for Implementation Research (CFIR 2.0), while providers' suggestions for improvements were coded and organized apart from CFIR. Providers felt the intervention was largely compatible with the local culture, and offered a significant advantage over standard individual-based care by facilitating patient follow-up and reducing wait times by prioritizing couples for services. They also believed it facilitated HIV treatment access through the provision of couple-based counseling that encouraged supportive behaviors towards retention. However, providers reported insufficient privacy to deliver couple-based care at some health facilities and concerns that women in difficult relationships may struggle to meaningfully participate. They suggested providing sessions in alternate clinic settings and offering a limited number of women-only visits. The facilitators and barriers described here contribute to informing the design and implementation of future couple-based interventions to improve HIV care for seroconcordant expectant couples.
Collapse
Affiliation(s)
- Erin Graves
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, 2525 West End Ave, Suite 750, Nashville, TN, 37203, USA.
| | - Hannah L Brooks
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, 2525 West End Ave, Suite 750, Nashville, TN, 37203, USA
| | | | | | | | - Arifo Aboobacar
- Provincial Health Directorate of Zambézia, Quelimane, Mozambique
| | - Carolyn M Audet
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, 2525 West End Ave, Suite 750, Nashville, TN, 37203, USA
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA
| |
Collapse
|
4
|
Sack DE, Matino A, Graves E, Emilio A, Shepherd BE, De Schacht C, Audet CM. Correlated depressive symptoms within seroconcordant, expectant partners living with HIV in Zambézia Province, Mozambique: a cross-sectional study. AIDS Care 2023; 35:1732-1740. [PMID: 36473205 PMCID: PMC10241982 DOI: 10.1080/09540121.2022.2151558] [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: 12/08/2021] [Accepted: 11/21/2022] [Indexed: 12/12/2022]
Abstract
Approximately 15% of people with HIV in sub-Saharan Africa have comorbid depression, which impacts treatment outcomes. We describe predictors of baseline depressive symptoms in 1079 female and 1079 male participants in a cluster-randomized trial in Zambézia Province, Mozambique from November 2017 to December 2020. We modeled each partners' depressive symptoms (Patient Health Questionnaire-9 [PHQ-9]) using proportional odds models adjusted for enrollment date, age, body mass index [BMI], partner's PHQ-9 score, district, relationship status, education, occupation, WHO HIV clinical stage, and antiretroviral therapy use history. A post hoc analysis assessed covariate-adjusted rank correlation between partner depressive symptoms. Females were younger than males (median 23 vs. 28 years) and more likely to report no education (20.7% vs. 7.9%). Approximately 10% screened positive for depression (PHQ-9 score ≥ 10). Partner depressive symptoms were predictive of higher participant PHQ-9 scores. A male partner PHQ-9 score of 10 (versus 5) increased the odds that the female partner would have a higher PHQ-9 score (adjusted odds ratio: 7.25, 95% Confidence Interval [CI]: 5.43-9.67). Partner PHQ-9 scores were highly correlated after covariate adjustment (Spearman's rho 0.65, 95% CI 0.57-0.72). Interventions aimed to reduce depressive symptoms and improve HIV-related outcomes during pregnancy should address both partners' depressive symptoms.
Collapse
Affiliation(s)
- Daniel E Sack
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Erin Graves
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Bryan E Shepherd
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Carolyn M Audet
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
| |
Collapse
|
5
|
Tu S, Li C, Zeng D, Shepherd BE. Rank intraclass correlation for clustered data. Stat Med 2023; 42:4333-4348. [PMID: 37548059 PMCID: PMC10592008 DOI: 10.1002/sim.9864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 06/02/2023] [Accepted: 07/17/2023] [Indexed: 08/08/2023]
Abstract
Clustered data are common in biomedical research. Observations in the same cluster are often more similar to each other than to observations from other clusters. The intraclass correlation coefficient (ICC), first introduced by R. A. Fisher, is frequently used to measure this degree of similarity. However, the ICC is sensitive to extreme values and skewed distributions, and depends on the scale of the data. It is also not applicable to ordered categorical data. We define the rank ICC as a natural extension of Fisher's ICC to the rank scale, and describe its corresponding population parameter. The rank ICC is simply interpreted as the rank correlation between a random pair of observations from the same cluster. We also extend the definition when the underlying distribution has more than two hierarchies. We describe estimation and inference procedures, show the asymptotic properties of our estimator, conduct simulations to evaluate its performance, and illustrate our method in three real data examples with skewed data, count data, and three-level ordered categorical data.
Collapse
Affiliation(s)
- Shengxin Tu
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee, USA
| | - Chun Li
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA
| | - Donglin Zeng
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Bryan E. Shepherd
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee, USA
| |
Collapse
|
6
|
Sharkey T, Parker R, Wall KM, Malama K, Pappas-DeLuca K, Tichacek A, Peeling R, Kilembe W, Inambao M, Allen S. Use of "Strengthening Our Vows" Video Intervention to Encourage Negotiated Explicit Sexual Agreements in Zambian Heterosexual HIV Seroconcordant-Negative Couples. ARCHIVES OF SEXUAL BEHAVIOR 2023; 52:2649-2667. [PMID: 37024634 PMCID: PMC10524092 DOI: 10.1007/s10508-023-02590-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 02/09/2023] [Accepted: 03/14/2023] [Indexed: 06/19/2023]
Abstract
Negotiating sexual agreements in combination with couples' voluntary HIV counseling and testing (CVCT) may help further reduce HIV transmission in Zambian concordant HIV-negative couples (CNC). Though CVCT has been shown to reduce HIV transmission in CNC by 47%, approximately half of residual infections occur in this group. We developed a "Strengthening Our Vows" video session to foster communication and negotiation of explicit sexual agreements to reduce concurrent sexual exposures and prevent HIV transmission to the spouse due to unprotected, extramarital sex. CNC were recruited through CVCT services at five clinics in Lusaka and Ndola in 2016. Enrolled CNC attending the facilitated group video sessions were encouraged to discuss sexual agreements at home and return 1-2 weeks later for follow-up assessment. One-fourth of the 580 CNC returning reported a history of extramarital partners and/or a sexually transmitted infection (STI) prior to enrollment. More than 95% reported a friendly, supportive 15-60 min negotiation culminating in an agreement to remain monogamous or disclose sexual contacts and use condoms together until a repeat HIV test 30 days after an outside sexual exposure. Two-thirds of participants identified at least one threat to adherence of their agreements including alcohol use, financial pressures, travel, discord in the home, and post-partum or menstrual abstinence. CNC negotiated explicit sexual agreements to avoid exposure to HIV through concurrent partnerships and protect the spouse in the event of an outside sexual contact. Open communication was a consistent theme to facilitate mutual protective efforts. Long-term follow-up of HIV/STI incidence is ongoing to assess the impact of these agreements.Trial registration This sub-study is part of a trial retrospectively registered on ClinicalTrials.gov (Identifier: NCT02744586) on April 20, 2016.
Collapse
Affiliation(s)
- Tyronza Sharkey
- Rwanda Zambia Health Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA.
- Department of Clinical Research, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London, UK.
| | - Rachel Parker
- Rwanda Zambia Health Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
| | - Kristin M Wall
- Rwanda Zambia Health Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
- Department of Epidemiology, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, USA
| | - Kalonde Malama
- Rwanda Zambia Health Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
| | - Katina Pappas-DeLuca
- Rwanda Zambia Health Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
| | - Amanda Tichacek
- Rwanda Zambia Health Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
| | - Rosanna Peeling
- Department of Clinical Research, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London, UK
| | - William Kilembe
- Rwanda Zambia Health Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
| | - Mubiana Inambao
- Rwanda Zambia Health Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
| | - Susan Allen
- Rwanda Zambia Health Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
| |
Collapse
|
7
|
Sack DE, Shepherd BE, Audet CM, De Schacht C, Samuels LR. Inverse Probability Weights for Quasicontinuous Ordinal Exposures With a Binary Outcome: Method Comparison and Case Study. Am J Epidemiol 2023; 192:1192-1206. [PMID: 37067471 PMCID: PMC10505412 DOI: 10.1093/aje/kwad085] [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: 08/19/2022] [Revised: 01/23/2023] [Accepted: 04/07/2023] [Indexed: 04/18/2023] Open
Abstract
Inverse probability weighting (IPW), a well-established method of controlling for confounding in observational studies with binary exposures, has been extended to analyses with continuous exposures. Methods developed for continuous exposures may not apply when the exposure is quasicontinuous because of irregular exposure distributions that violate key assumptions. We used simulations and cluster-randomized clinical trial data to assess 4 approaches developed for continuous exposures-ordinary least squares (OLS), covariate balancing generalized propensity scores (CBGPS), nonparametric covariate balancing generalized propensity scores (npCBGPS), and quantile binning (QB)-and a novel method, a cumulative probability model (CPM), in quasicontinuous exposure settings. We compared IPW stability, covariate balance, bias, mean squared error, and standard error estimation across 3,000 simulations with 6 different quasicontinuous exposures, varying in skewness and granularity. In general, CBGPS and npCBGPS resulted in excellent covariate balance, and npCBGPS was the least biased but the most variable. The QB and CPM approaches had the lowest mean squared error, particularly with marginally skewed exposures. We then successfully applied the IPW approaches, together with missing-data techniques, to assess how session attendance (out of a possible 15) in a partners-based clustered intervention among pregnant couples living with human immunodeficiency virus in Mozambique (2017-2022) influenced postpartum contraceptive uptake.
Collapse
Affiliation(s)
- Daniel E Sack
- Correspondence to Dr. Daniel E. Sack, Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 750, Nashville, TN 37203 (e-mail: )
| | | | | | | | | |
Collapse
|
8
|
Sack DE, Emílio A, Graves E, Matino A, Paulo P, Aboobacar AU, De Schacht C, Audet CM. Attitudes and perceptions towards postpartum contraceptive use among seroconcordant partners with HIV in rural Mozambique: a qualitative study. Glob Health Res Policy 2023; 8:7. [PMID: 36918959 PMCID: PMC10014407 DOI: 10.1186/s41256-023-00292-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 03/05/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Postpartum contraceptive uptake reduces short interpregnancy intervals, unintended pregnancies, and their negative sequalae: poor maternal and fetal outcomes. Healthy timing and spacing of pregnancy in people living with HIV (PLHIV) also allows time to achieve viral suppression to reduce parent-to-child HIV transmission. There is scant understanding about how couples-based interventions impact postpartum contraceptive uptake among PLHIV in sub-Saharan Africa. METHODS We interviewed 38 recently pregnant people and 26 of their partners enrolled in the intervention arm of the Homens para Saúde Mais (HoPS+) [Men for Health Plus] trial to assess their perceptions of, attitudes towards, and experiences with contraceptive use. Individuals in the HoPS+ intervention arm received joint-as opposed to individual-HIV-related services during pregnancy and postpartum periods, six counseling and skills sessions, and nine sessions with a peer support couple. Our thematic analysis of the 64 in-depth interviews generated 14 deductive codes and 3 inductive codes across themes within the Information, Motivation, and Behavior Model of health behavior change. RESULTS Participants reported accurate and inaccurate information about birth spacing and contraceptive methods. They described personal (health, economic, and religious) and social (gender norms, desired number of children) motivations for deciding whether to use contraceptives-with slightly different motivations among pregnant and non-pregnant partners. Finally, they explained the skills needed to overcome barriers to contraceptive use including how engagement in HoPS+ improved their shared decision-making skills and respect amongst partners-which facilitated postpartum contraceptive uptake. There were also several cases where non-pregnant partners unilaterally made family planning decisions despite disagreement from their partner. CONCLUSIONS These findings suggest that couples-based interventions during pregnancy and post-partum periods aimed at increasing postpartum contraceptive uptake must center pregnant partners' desires. Specifically, pregnant partners should be allowed to titrate the level of non-pregnant partner involvement in intervention activities to avoid potentially emboldening harmful gender-based intercouple decision-making dynamics.
Collapse
Affiliation(s)
- Daniel E Sack
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, 2525 West End Ave, Suite 750, Nashville, TN, 37203, USA.
| | | | - Erin Graves
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, 2525 West End Ave, Suite 750, Nashville, TN, 37203, USA
| | | | - Paula Paulo
- Friends in Global Health, Quelimane, Mozambique
| | | | | | - Carolyn M Audet
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, 2525 West End Ave, Suite 750, Nashville, TN, 37203, USA
| |
Collapse
|
9
|
Frisby MB, Diemer MA, Sack DE, Audet CM. Dyadic Validation of Relational Processes in Seroconcordant Mozambican Couples: Social Support, Physician Trust, and Stigma. AIDS Behav 2022; 26:4135-4143. [PMID: 35689708 PMCID: PMC9940156 DOI: 10.1007/s10461-022-03739-w] [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] [Accepted: 05/26/2022] [Indexed: 11/30/2022]
Abstract
Psychometric instruments can quantify how people living with HIV experience three key barriers to antiretroviral therapy (ART) and retention: partner support, trust in medical professionals, and internalized HIV-related stigma. However, two challenges arise when using these instruments to measure and interpret relational processes among Mozambican couples, especially those participating in a couples intervention. First, relational measures have almost exclusively been developed and normed with Western, middle-class, and/or White adults. Second, traditional measurement approaches neglect the relational processes between partners. Using dyadic modeling, this paper demonstrates metric and scalar invariance for instruments measuring partner support (CFI = 0.964, TLI = 0.965, RMSEA = 0.034, SRMR = 0.052), trust in medical professionals (CFI = 0.978, TLI = 0.980, RMSEA = 0.033, SRMR = 0.039), and internalized HIV-related stigma (CFI = 0.960, TLI = 0.961, RMSEA = 0.050, SRMR = 0.060) within the novel context of seroconcordant HIV+ couples in Zambézia province.
Collapse
Affiliation(s)
| | | | - Daniel E Sack
- Department of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Carolyn M Audet
- Department of Health Policy and Institute for Global Health, Vanderbilt University, Nashville, TN, USA
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt) in affiliation with the School of Public Health at University of the Witwatersrand, Johannesburg, South Africa
| |
Collapse
|
10
|
Jurinsky J, Perkins JM, Kakuhikire B, Nyakato VN, Baguma C, Rasmussen JD, Satinsky EN, Ahereza P, Kananura J, Audet CM, Bangsberg DR, Tsai AC. Ease of marital communication and depressive symptom severity among men and women in rural Uganda: cross-sectional, whole-population study. Soc Psychiatry Psychiatr Epidemiol 2022; 57:343-352. [PMID: 34355265 PMCID: PMC8792190 DOI: 10.1007/s00127-021-02135-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 06/22/2021] [Indexed: 02/03/2023]
Abstract
PURPOSE Depression is a major contributor to the global burden of disease. The extent to which marital communication may influence depression in contexts with little mental health support is unknown. METHODS We conducted a whole-population study of married adult residents of eight villages in a rural region of southwestern Uganda. Depression symptom severity was measured using a modified version of the Hopkins Symptom Checklist for Depression, with > 1.75 classified as a positive screen for probable depression. Respondents were asked to report about ease of marital communication ('never easy', 'easy once in a while', 'easy most of the time' or 'always easy'). Sex-stratified, multivariable Poisson regression models were fit to estimate the association between depression symptom severity and marital communication. RESULTS Among 492 female and 447 male participants (response rate = 96%), 23 women and 5 men reported communication as 'never easy' and 154 women and 72 men reported it as 'easy once in a while'. Reporting communication as 'never easy' was associated with an increased risk of probable depression among women (adjusted relative risk [ARR], 2.06; 95% confidence interval [CI], 1.08-3.93, p = 0.028) and among men (ARR, 7.10; 95% CI 1.70-29.56, p = 0.007). CONCLUSION In this whole-population study of married adults in rural Uganda, difficulty of marital communication was associated with depression symptom severity. Additional research is needed to assess whether communication training facilitated by local leaders or incorporated into couples-based services might be a novel pathway to address mental health burden.
Collapse
Affiliation(s)
| | - Jessica M. Perkins
- Peabody College, Vanderbilt University, Nashville, TN, USA,Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA,Corresponding author: Dr. Jessica M. Perkins, , Phone: (615) 875-3289, Fax: 615-343-2661
| | | | | | - Charles Baguma
- Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Emily N. Satinsky
- Center for Global Health, Massachusetts General Hospital, Boston MA USA
| | - Phionah Ahereza
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Justus Kananura
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Carolyn M. Audet
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA,University of Witwatersrand, Johannesburg, South Africa
| | - David R. Bangsberg
- Mbarara University of Science and Technology, Mbarara, Uganda,Oregon Health & Science University-Portland State University School of Public Health, Portland, OR, USA
| | - Alexander C. Tsai
- Mbarara University of Science and Technology, Mbarara, Uganda,Center for Global Health, Massachusetts General Hospital, Boston MA USA,Harvard Medical School, Boston, MA, USA,Mongan Institute, Massachusetts General Hospital, Boston MA USA
| |
Collapse
|
11
|
Sharkey T, Wall KM, Parker R, Tichacek A, Pappas-DeLuca KA, Kilembe W, Inambao M, Malama K, Hoagland A, Peeling R, Allen S. A cluster randomized trial to reduce HIV risk from outside partnerships in Zambian HIV-Negative couples using a novel behavioral intervention, "Strengthening Our Vows": Study protocol and baseline data. Contemp Clin Trials Commun 2021; 24:100850. [PMID: 34622087 PMCID: PMC8481973 DOI: 10.1016/j.conctc.2021.100850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 08/02/2021] [Accepted: 09/08/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Heterosexual couples contribute to most new HIV infections in areas of generalized HIV epidemics in sub-Saharan Africa. After Couples' Voluntary HIV Counseling and Testing (CVCT), heterosexual concordant HIV negative couples (CNC) in cohabiting unions contribute to approximately 47% of residual new infections in couples. These infections are attributed to concurrent sexual partners, a key driver of the HIV epidemic in Zambia. METHODS/DESIGN Ten Zambian government clinics in two of the largest cities were randomized in matched pairs to a Strengthening Our Vows (SOV) intervention or a Good Health Package (GHP) comparison arm. SOV addressed preventing HIV infection from concurrent partners and protecting spouses after exposures outside the relationship. GHP focused on handwashing; water chlorination; household deworming; and screening for hypertension, diabetes and schistosomiasis. CNC were referred from CVCT services in government clinics. Follow-up includes post-intervention questionnaires and outcome assessments through 60 months. Longitudinal outcomes of interest include self-report and laboratory markers of condomless sex with outside partners and reported sexual agreements. We present baseline characteristics and factors associated with study arm and reported risk using descriptive statistics. RESULTS The mean age of men was 32 and 26 for women. On average, couples cohabited for 6 years and had 2 children. Baseline analyses demonstrated some failures of randomization by study arm which will be considered in future primary analyses of longitudinal data. An HIV/STI risk factor composite was not different in the two study arms. Almost one-quarter of couples had an HIV risk factor at baseline. DISCUSSION In preparation for future biomedical and behavioral interventions in sub-Saharan Africa, it is critical to understand and decrease HIV risk within CNC.
Collapse
Affiliation(s)
- Tyronza Sharkey
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
- London School of Hygiene and Tropical Medicine, UK
| | - Kristin M. Wall
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
- Department of Epidemiology, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
| | - Rachel Parker
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
| | - Amanda Tichacek
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
| | - Katina A. Pappas-DeLuca
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
| | - William Kilembe
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
| | - Mubiana Inambao
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
| | - Kalonde Malama
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
| | - Alexandra Hoagland
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
| | | | - Susan Allen
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
| |
Collapse
|
12
|
Sack DE, Frisby MB, Diemer MA, De Schacht C, Graves E, Kipp AM, Emílio A, Matino A, Barreto E, Van Rompaey S, Wallston KA, Audet CM. Interpersonal reactivity index adaptation among expectant seroconcordant couples with HIV in Zambézia Province, Mozambique. BMC Psychol 2020; 8:90. [PMID: 32859272 PMCID: PMC7456002 DOI: 10.1186/s40359-020-00442-0] [Citation(s) in RCA: 5] [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: 01/16/2020] [Accepted: 07/15/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The ability to understand another's emotions and act appropriately, empathy, is an important mediator of relationship function and health intervention fidelity. We adapted the Interpersonal Reactivity Index (IRI) - an empathy scale - among seroconcordant expectant couples with HIV in the Homens para Saúde Mais (HoPS+) trial - a cluster randomized controlled trial assessing couple-based versus individual treatment on viral suppression - in Zambézia Province, Mozambique. METHODS Using baseline data from 1332 HoPS+ trial participants (666 couples), an exploratory factor analysis assessed culturally relevant questions from the IRI. Because empathy is interdependent among couples, we validated the results of the exploratory factor analysis using a dyadic confirmatory factor analysis (CFA) with dyadic measurement invariance testing. Finally, we assessed the relationship between scores on our final scale and basic demographic characteristics (sex, age, education, and depression) using t-tests. RESULTS We found two subscales: 1) a seven-item cognitive empathy subscale (Cronbach's alpha 0.78) and 2) a six-item affective empathy subscale (Cronbach's alpha 0.73). The dyadic CFA found acceptable model fit and metric invariance across partners (Comparative Fit Index (CFI) = 0.914, Tucker Lewis Index = 0.904, Root Mean Squared Error of Approximation = 0.056, ΔCFI = 0.011). We observed higher cognitive (p: 0.012) and affective (p: 0.049) empathy among males and higher cognitive (p: 0.031) and affective (p: 0.030) empathy among younger participants. More educated participants had higher affective empathy (p: 0.017) and depressed participants had higher cognitive empathy (p: < 0.001). This two-subscale, 13-item version of the IRI measures cognitive and affective empathy in HoPS+ trial participants and adults while accounting for the interdependent nature of empathy within partner dyads. CONCLUSIONS This scale will allow us to assess the interplay between empathy and other psychometric constructs (stigma, social support, etc.) in the HoPS+ trial and how each relates to retention in HIV, adherence to treatment, and prevention of maternal to child HIV transmission. Furthermore, this scale can be adapted for other sub-Saharan African populations, which will allow researchers to better assess HIV-related intervention efficacy. TRIAL REGISTRATION This study is within the context of the HoPS+ trial, registered at ClinicalTrials.gov as number NCT03149237 . Registered May 11, 2017.
Collapse
Affiliation(s)
- Daniel E Sack
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, 2525 West End Ave, Suite 750, Nashville, TN, 37203, USA.
| | | | | | | | - Erin Graves
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, 2525 West End Ave, Suite 750, Nashville, TN, 37203, USA
| | - Aaron M Kipp
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, 2525 West End Ave, Suite 750, Nashville, TN, 37203, USA
| | | | | | | | | | | | - Carolyn M Audet
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, 2525 West End Ave, Suite 750, Nashville, TN, 37203, USA
| |
Collapse
|
13
|
Wall KM, Inambao M, Kilembe W, Karita E, Chomba E, Vwalika B, Mulenga J, Parker R, Sharkey T, Tichacek A, Hunter E, Yohnka R, Streeb G, Corso PS, Allen S. Cost-effectiveness of couples' voluntary HIV counselling and testing in six African countries: a modelling study guided by an HIV prevention cascade framework. J Int AIDS Soc 2020; 23 Suppl 3:e25522. [PMID: 32602618 PMCID: PMC7325504 DOI: 10.1002/jia2.25522] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 03/17/2020] [Accepted: 04/23/2020] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION Couples' voluntary HIV counselling and testing (CVCT) is a high-impact HIV prevention intervention in Rwanda and Zambia. Our objective was to model the cost-per-HIV infection averted by CVCT in six African countries guided by an HIV prevention cascade framework. The HIV prevention cascade as yet to be applied to evaluating CVCT effectiveness or cost-effectiveness. METHODS We defined a priority population for CVCT in Africa as heterosexual adults in stable couples. Based on our previous experience nationalizing CVCT in Rwanda and scaling-up CVCT in 73 clinics in Zambia, we estimated HIV prevention cascade domains of motivation for use, access and effectiveness of CVCT as model parameters. Costs-per-couple tested were also estimated based on our previous studies. We used these parameters as well as country-specific inputs to model the impact of CVCT over a five-year time horizon in a previously developed and tested deterministic compartmental model. We consider six countries across Africa with varied HIV epidemics (South Africa, Zimbabwe, Kenya, Tanzania, Ivory Coast and Sierra Leone). Outcomes of interest were the proportion of HIV infections averted by CVCT, nationwide CVCT implementation costs and costs-per-HIV infection averted by CVCT. We applied 3%/year discounting to costs and outcomes. Univariate and Monte Carlo multivariate sensitivity analyses were conducted. RESULTS We estimated that CVCT could avert between 54% (Sierra Leone) and 62% (South Africa) of adult HIV infections. Average costs-per-HIV infection averted were lowest in Zimbabwe ($550) and highest in South Africa ($1272). Nationwide implementations would cost between 7% (Kenya) and 21% (Ivory Coast) of a country's President's Emergency Plan for AIDS Relief (PEPFAR) budget over five years. In sensitivity analyses, model outputs were most sensitive to estimates of cost-per-couple tested; the proportion of adults in heterosexual couples and HIV prevention cascade domains of CVCT motivation and access. CONCLUSIONS Our model indicates that nationalized CVCT could prevent over half of adult HIV infections for 7% to 21% of the modelled countries' five-year PEPFAR budgets. While other studies have indicated that CVCT motivation is high given locally relevant promotional and educational efforts, without required indicators, targets and dedicated budgets, access remains low.
Collapse
Affiliation(s)
- Kristin M Wall
- Rwanda Zambia HIV Research GroupDepartment of Pathology & Laboratory MedicineSchool of Medicine and Hubert Department of Global HealthRollins School of Public HealthLaney Graduate SchoolEmory UniversityAtlantaGAUSA
- Department of EpidemiologyRollins School of Public HealthLaney Graduate SchoolEmory UniversityAtlantaGAUSA
| | - Mubiana Inambao
- Rwanda Zambia HIV Research GroupDepartment of Pathology & Laboratory MedicineSchool of Medicine and Hubert Department of Global HealthRollins School of Public HealthLaney Graduate SchoolEmory UniversityAtlantaGAUSA
- Department of Obstetrics and GynecologyNdola Central HospitalNdolaZambia
| | - William Kilembe
- Rwanda Zambia HIV Research GroupDepartment of Pathology & Laboratory MedicineSchool of Medicine and Hubert Department of Global HealthRollins School of Public HealthLaney Graduate SchoolEmory UniversityAtlantaGAUSA
| | - Etienne Karita
- Rwanda Zambia HIV Research GroupDepartment of Pathology & Laboratory MedicineSchool of Medicine and Hubert Department of Global HealthRollins School of Public HealthLaney Graduate SchoolEmory UniversityAtlantaGAUSA
| | | | - Bellington Vwalika
- Rwanda Zambia HIV Research GroupDepartment of Pathology & Laboratory MedicineSchool of Medicine and Hubert Department of Global HealthRollins School of Public HealthLaney Graduate SchoolEmory UniversityAtlantaGAUSA
- Department of Obstetrics and GynecologySchool of MedicineUniversity of ZambiaLusakaZambia
| | - Joseph Mulenga
- Rwanda Zambia HIV Research GroupDepartment of Pathology & Laboratory MedicineSchool of Medicine and Hubert Department of Global HealthRollins School of Public HealthLaney Graduate SchoolEmory UniversityAtlantaGAUSA
| | - Rachel Parker
- Rwanda Zambia HIV Research GroupDepartment of Pathology & Laboratory MedicineSchool of Medicine and Hubert Department of Global HealthRollins School of Public HealthLaney Graduate SchoolEmory UniversityAtlantaGAUSA
| | - Tyronza Sharkey
- Rwanda Zambia HIV Research GroupDepartment of Pathology & Laboratory MedicineSchool of Medicine and Hubert Department of Global HealthRollins School of Public HealthLaney Graduate SchoolEmory UniversityAtlantaGAUSA
| | - Amanda Tichacek
- Rwanda Zambia HIV Research GroupDepartment of Pathology & Laboratory MedicineSchool of Medicine and Hubert Department of Global HealthRollins School of Public HealthLaney Graduate SchoolEmory UniversityAtlantaGAUSA
| | - Eric Hunter
- Rwanda Zambia HIV Research GroupDepartment of Pathology & Laboratory MedicineSchool of Medicine and Hubert Department of Global HealthRollins School of Public HealthLaney Graduate SchoolEmory UniversityAtlantaGAUSA
- Department of Pathology & Laboratory MedicineSchool of MedicineEmory UniversityAtlantaGAUSA
- Emory Vaccine CenterYerkes National Primate Research CenterEmory UniversityAtlantaGAUSA
| | - Robert Yohnka
- Rwanda Zambia HIV Research GroupDepartment of Pathology & Laboratory MedicineSchool of Medicine and Hubert Department of Global HealthRollins School of Public HealthLaney Graduate SchoolEmory UniversityAtlantaGAUSA
| | - Gordon Streeb
- Departments of Economics and Political ScienceEmory UniversityAtlantaGAUSA
| | | | - Susan Allen
- Rwanda Zambia HIV Research GroupDepartment of Pathology & Laboratory MedicineSchool of Medicine and Hubert Department of Global HealthRollins School of Public HealthLaney Graduate SchoolEmory UniversityAtlantaGAUSA
| |
Collapse
|
14
|
Hannaford A, Lim J, Moll AP, Khoza B, Shenoi SV. 'PrEP should be for men only': Young heterosexual men's views on PrEP in rural South Africa. Glob Public Health 2020; 15:1337-1348. [PMID: 32207661 DOI: 10.1080/17441692.2020.1744680] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Gaps persist in HIV testing, treatment, and prevention services for men, leading to higher attributable mortality compared to women. We sought to characterise HIV prevention knowledge, risk behaviours, and interest in pre-exposure prophylaxis (PrEP) among young men in rural South Africa. METHODS We conducted interviews with HIV-negative heterosexual men which were thematically analysed to identify key themes. RESULTS Among 31 participants, median age was 26 (IQR23-31), 77% were unemployed, 52% reported previous STI, 84% reported casual sexual partners. Men acknowledged inconsistent condom use with multiple partners, reporting high-risk sexual behaviour despite recognised risk. Mistrust between partners was common. Respondents reported willingness to take PrEP to protect themselves and their partner, though anticipated stigma and structural barriers. Men worried that if their female partner had PrEP, she would become sexually active with others. CONCLUSIONS In rural South Africa, young heterosexual men acknowledged high HIV-risk behaviour, expressed concern about acquiring HIV, and recognised the value of PrEP. Men were often not supportive of their female partners taking PrEP. Implementing HIV prevention services needs to incorporate young men's perspectives and may require gender-specific interventions, including addressing stigma, differentiated service delivery models such as community-based services or adapting facility services to target men.
Collapse
Affiliation(s)
| | - Jamie Lim
- Boston Medical Center, Boston.,Boston Children's Hospital, Boston
| | - Anthony P Moll
- Church of Scotland Hospital, Tugela Ferry, South Africa.,Philanjalo NGO, Tugela Ferry, South Africa
| | | | | |
Collapse
|
15
|
Phillips TK, Myer L. Shifting to the long view: engagement of pregnant and postpartum women living with HIV in lifelong antiretroviral therapy services. Expert Rev Anti Infect Ther 2019; 17:349-361. [PMID: 30978126 DOI: 10.1080/14787210.2019.1607296] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Introduction: The advent of policies promoting lifelong antiretroviral therapy (ART) for all pregnant and postpartum women living with HIV has shifted focus from short-term prevention of mother-to-child transmission (PMTCT) to lifelong engagement in ART services. However, disengagement from care threatens the long-term treatment and prevention benefits of lifelong ART. Areas covered: A framework for considering the unique aspects of ART for pregnant and postpartum women is presented along with a review of the literature on maternal engagement in care in sub-Saharan Africa and a discussion of potential interventions to sustain engagement in lifelong ART. Expert opinion: Engaging women and mothers in ART services for life is critical for maternal health, PMTCT, and prevention of sexual transmission. Evidence-based interventions exist to support engagement in care but most focus on periods of mother-to-child transmission risk. In the long term, life transitions and health-care transfers are inevitable. Thus, interventions that can reach beyond a single facility or provide a bridge between health services should be prioritized. Multicomponent interventions will also be essential to address the numerous intersecting barriers to sustained engagement in ART services.
Collapse
Affiliation(s)
- Tamsin K Phillips
- a Division of Epidemiology & Biostatistics and Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine , University of Cape Town , Cape Town , South Africa
| | - Landon Myer
- a Division of Epidemiology & Biostatistics and Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine , University of Cape Town , Cape Town , South Africa
| |
Collapse
|