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Poteat T, Bothma R, Maposa I, Hendrickson C, Meyer-Rath G, Hill N, Pettifor A, Imrie J. Transgender-Specific Differentiated HIV Service Delivery Models in the South African Public Primary Health Care System (Jabula Uzibone): Protocol for an Implementation Study. JMIR Res Protoc 2024; 13:e64373. [PMID: 39269745 PMCID: PMC11437231 DOI: 10.2196/64373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2024] [Revised: 07/24/2024] [Accepted: 07/25/2024] [Indexed: 09/15/2024] Open
Abstract
BACKGROUND Almost 60% of transgender people in South Africa are living with HIV. Ending the HIV epidemic will require that transgender people successfully access HIV prevention and treatment. However, transgender people often avoid health services due to facility-based stigma and lack of availability of gender-affirming care. Transgender-specific differentiated service delivery (TG-DSD) may improve engagement and facilitate progress toward HIV elimination. Wits RHI, a renowned South African research institute, established 4 TG-DSD demonstration sites in 2019, with funding from the US Agency for International Development. These sites offer unique opportunities to evaluate the implementation of TG-DSD and test their effectiveness. OBJECTIVE The Jabula Uzibone study seeks to assess the implementation, effectiveness, and cost of TG-DSD for viral suppression and prevention-effective adherence. METHODS The Jabula Uzibone study collects baseline and 12-month observation checklists at 8 sites and 6 (12.5%) key informant interviews per site at 4 TG-DSD and 4 standard sites (n=48). We seek to enroll ≥600 transgender clients, 50% at TG-DSD and 50% at standard sites: 67% clients with HIV and 33% clients without HIV per site type. Participants complete interviewer-administered surveys quarterly, and blood is drawn at baseline and 12 months for HIV RNA levels among participants with HIV and tenofovir levels among participants on pre-exposure prophylaxis. A subset of 30 participants per site type will complete in-depth interviews at baseline and 12 months: 15 participants will be living with HIV and 15 participants will be HIV negative. Qualitative analyses will explore aspects of implementation; regression models will compare viral suppression and prevention-effective adherence by site type. Structural equation modeling will test for mediation by stigma and gender affirmation. Microcosting approaches will estimate the cost per service user served and per service user successfully treated at TG-DSD sites relative to standard sites, as well as the budget needed for a broader implementation of TG-DSD. RESULTS Funded by the US National Institutes of Mental Health in April 2022, the study was approved by the Human Research Ethics Committee at University of Witwatersrand in June 2022 and the Duke University Health System Institutional Review Board in June 2023. Enrollment began in January 2024. As of July 31, 2024, a total of 593 transgender participants have been enrolled: 348 are living with HIV and 245 are HIV negative. We anticipate baseline enrollment will be complete by August 31, 2024, and the final study visit will take place no later than August 2025. CONCLUSIONS Jabula Uzibone will provide data to inform HIV policies and practices in South Africa and generate the first evidence for implementation of TG-DSD in sub-Saharan Africa. Study findings may inform the use of TG-DSD strategies to increase care engagement and advance global progress toward HIV elimination goals. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/64373.
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Affiliation(s)
- Tonia Poteat
- Duke University School of Nursing, Durham, NC, United States
| | - Rutendo Bothma
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
| | - Innocent Maposa
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Cheryl Hendrickson
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Gesine Meyer-Rath
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University, Boston, MA, United States
- South African Centre for Epidemiological Modelling and Analysis, Stellenbosch University, Stellenbosch, South Africa
| | - Naomi Hill
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
| | - Audrey Pettifor
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - John Imrie
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
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Lynch I, Fluks L, Manderson L, Isaacs N, Essop R, Praphasawat R, Middleton L, Naemiratch B. Gender and equity considerations in AMR research: a systematic scoping review. Monash Bioeth Rev 2024:10.1007/s40592-024-00194-2. [PMID: 38676854 DOI: 10.1007/s40592-024-00194-2] [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] [Accepted: 03/21/2024] [Indexed: 04/29/2024]
Abstract
Research on gender and antimicrobial resistance (AMR) beyond women's biological susceptibility is limited. A gender and equity lens in AMR research is necessary to promote gender equality and support the effectiveness, uptake, and sustainability of real-world AMR solutions. We argue that it is an ethical and social justice imperative to include gender and related intersectional issues in AMR research and implementation. An intersectional exploration of the interplay between people's diverse identities and experiences, including their gender, socio-economic status, race, disability, age, and sexuality, may help us understand how these factors reinforce AMR risk and vulnerability and ensure that interventions to reduce the risk of AMR do not impact unevenly. This paper reports on the findings of a systematic scoping review on the interlinkages between AMR, gender and other socio-behavioural characteristics to identify priority knowledge gaps in human and animal health in LMICs. The review focused on peer-reviewed and grey literature published between 2017 and 2022. Three overarching themes were gendered division of caregiving roles and responsibilities, gender power relations in decision-making, and interactions between gender norms and health-seeking behaviours. Research that fails to account for gender and its intersections with other lines of disadvantage, such as race, class and ability, risks being irrelevant and will have little impact on the continued and dangerous spread of AMR. We provide recommendations for integrating an intersectional gender lens in AMR research, policy and practice.
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Affiliation(s)
- Ingrid Lynch
- Human Sciences Research Council, Cape Town, South Africa
| | - Lorenza Fluks
- Human Sciences Research Council, Cape Town, South Africa
| | | | - Nazeema Isaacs
- Human Sciences Research Council, Cape Town, South Africa
| | - Roshin Essop
- Human Sciences Research Council, Cape Town, South Africa
| | - Ravikanya Praphasawat
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Lyn Middleton
- University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Bhensri Naemiratch
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
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Kiyingi J, Nabunya P, Kizito S, Nabayinda J, Nsubuga E, Bahar OS, Jennings Mayo-Wilson L, Namuwonge F, Nattabi J, Magorokosho N, Tozan Y, Witte SS, Ssewamala FM. Self-Reported Adherence to Antiretroviral Therapy (ART) Among Women Engaged in Commercial Sex Work in Southern Uganda. AIDS Behav 2023; 27:1004-1012. [PMID: 36066764 PMCID: PMC9974600 DOI: 10.1007/s10461-022-03837-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2022] [Indexed: 11/01/2022]
Abstract
We examined the correlates of self-reported adherence to antiretroviral therapy (ART) among women engaged in commercial sex work (WESW) in Uganda. We used baseline data from a longitudinal study, which recruited 542 WESW in Southern Uganda. We used nested regression models to determine the individual and family, and economic level correlates of self-reported adherence. Study findings show that older age (OR = 1.07, 95% CI = 1.013, 1.139), secondary education (OR = 2.01, 95% CI = 1.306, 3.084), large household size (OR = 1.08, 95% CI = 1.020, 1.136), high family cohesion (OR = 1.06, 95% CI = 1.052, 1.065), and high financial self-efficacy (OR = 1.07, 95% CI = 1.006, 1.130) were associated with good self-reported adherence to ART. Married women (OR=-0.39, 95% CI = 0.197, 0.774), depression (OR = 0.85, 95% CI = 0.744, 0.969), alcohol use (OR = 0.72, 95% CI = 0.548, 0.954), ever been arrested (OR = 0.58, 95% CI = 0.341, 0.997), and high household assets ownership (OR = 0.48, 95% CI = 0.313, 0.724) were associated with poor self-reported adherence to ART. Findings suggest a need to adopt a multi-level approach to address gaps in ART adherence among WESW.
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Affiliation(s)
- Joshua Kiyingi
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, 63130, St. Louis, MO, USA
| | - Proscovia Nabunya
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, 63130, St. Louis, MO, USA
| | - Samuel Kizito
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, 63130, St. Louis, MO, USA
| | - Josephine Nabayinda
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, 63130, St. Louis, MO, USA
| | - Edward Nsubuga
- International Center for Child Health and Development (ICHAD), Masaka, Uganda
| | - Ozge Sensoy Bahar
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, 63130, St. Louis, MO, USA
| | - Larissa Jennings Mayo-Wilson
- University of North Carolina Gillings School of Global Public Health, 170 Rosenau Hall, 27599, Chapel Hill, NC, USA
| | - Flavia Namuwonge
- International Center for Child Health and Development (ICHAD), Masaka, Uganda
| | - Jennifer Nattabi
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, 63130, St. Louis, MO, USA
| | - Natasja Magorokosho
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, 63130, St. Louis, MO, USA
| | - Yesim Tozan
- New York University College of Global Public Health, 14 East 4th street, 3rd floor, 10003, New York, NY, USA
| | - Susan S Witte
- Columbia University School of Social Work, 1255 Amsterdam Avenue, 10027, New York, NY, USA
| | - Fred M Ssewamala
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, 63130, St. Louis, MO, USA.
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REMIEN RH, DĀCUS JD, FARLEY JE, HUGHES JP, GAMBLE T, WANG Z(Z, BATEY DS, MAYER KH, DEL RIO C, BALÁN IC, IRVIN R, MITCHELL KM, CUMMINGS V, ESHLEMAN SH, CONSERVE DF, KNOX J, YU K, BEYRER C. HTPN 078: an enhanced case management study to achieve viral suppression among viremic HIV-positive men who have sex with men in the United States. AIDS 2023; 37:217-231. [PMID: 36541636 PMCID: PMC9983736 DOI: 10.1097/qad.0000000000003411] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES After identifying and recruiting men who have sex with men living with HIV and virally unsuppressed, this study attempted to enhance treatment and care via case management to increase the proportion who achieved viral suppression. DESIGN Participants were randomized into one of two study arms: standard of care (SOC) or enhanced case management (CM) intervention. Participants were followed for 12 months with quarterly study assessments, with blood collected for CD4+ cell count testing, HIV viral load testing (primary prespecified outcome), and plasma storage. METHODS Participants identified via respondent-driven sampling and direct recruitment and were invited to participate in the randomized controlled trial. The CM intervention provided a wide range of support services including, health education, clinical care coordination, medication adherence support, and social service assistance. The month-12 assessment included questions about healthcare utilization, stigma, substance use, and mental health. RESULTS Among the 144 participants virally unsuppressed at baseline, most had had a previous positive HIV test result; were Black, non-Hispanic, gay and bisexual men, aged 22-50. Among the 128 participants at the last study visit, 68 were virally suppressed, with no statistically significant difference between the CM and SOC arms (viral suppression 42% and 53%, respectively; adjusted odds ratio = 0.62 [P = 0.15; 95% confidence interval: 0.32, 1.2]). CONCLUSIONS Reaching targets of at least 90% sustained viral suppression among all people with HIV will likely require more than an individual-level CM approach that addresses barriers to optimal care and treatment at multiple levels.
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Affiliation(s)
- Robert H. REMIEN
- Reprints: Robert H. Remien, PhD, HIV Center for Clinical and Behavioral Studies, Division of Gender, Sexuality and Health, NY State Psychiatric Institute and Columbia University, Department of Psychiatry, Columbia University, Vagelos College of Physicians and Surgeons,
| | - Jagadīśa-devaśrī DĀCUS
- Correspondence: Jagadīśa-devaśrī Dācus, PhD, The Institute for Sexual and Gender Minority Health and Wellbeing at Northwestern Feinberg School of Medicine, 625 N. Michigan Avenue, Room 14-055, Chicago, IL 60611,
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