Antiretroviral Treatment Uptake and Adherence Among Men Who Have Sex With Men and Transgender Women With HIV in Mumbai, India: A Cross-Sectional Study

Adherence to Anti-Retroviral Therapy (ART) and Its Determinants Among People Living with HIV/AIDS at Bonga, Kaffa, South-West Ethiopia

Background

The scaling-up of antiretroviral therapy (ART) is the greatest accomplishment to reduce the burden of acquired immunodeficiency syndromes (AIDS) to date. However, it requires optimal adherence to be effective. Thus, this study was designed to assess the level of adherence of people living with HIV (PLWH) to ART and its determinants in one of the hardest-hit areas with HIV in Ethiopia.

Methods

A health facility-based cross-sectional study design was conducted among adult PLWH, age >18 years, and receiving ART in southwest Ethiopia. Data was collected by face-to-face interviews following the Self-Rating Scale Item for drug adherence and from participants' medical cards. The effects of variables related to socio-demographic and socio-economic factors, disease and medication, health facilities, and patients' behavior on ART adherence were analyzed using a binary logistic regression model. The data was analyzed using R software.

Results

Self-reported good adherence to ART recorded in this study was 73.1% (n =301/412). The risk of poor adherence was significantly higher among those who were divorced, merchants, used ART for longer durationsand were found in stage IV WHO pathogenesis. Contrarily, those who had a positive perception of the effectiveness of ART had significantly better adherence to ART. Longer duration on ART and frequency of pills taken, ≥3 pills per day, were significantly associated with a low CD4+ cell count (<500 cells/mm3). For each unit increase in medication frequency per day, the likelihood of having a high viral load of >1000 copies/mL was 5.35 times higher.

Conclusion

The ART adherence documented in this study was graded as moderately low. Some variables, such as clinical, medical, and behavioral, were found to affect the adherence of people living with HIV to ART. Hence, care providers should be aware of such variables in the process of treatment, follow-up, and monitoring of people living with HIV in the study area.

Anti-retroviral therapy adherence in India (2012-18): A systematic review and meta-analysis

Background

India has 2.1 million people living with HIV/AIDS (PLHIV). The objective of this study was to ascertain the extent of anti-retroviral therapy (ART) adherence and reasons for nonadherence among PLHIV in India.

Methods

We conducted a systematic review and meta-analysis using the following criteria: (1) Observational or experimental studies conducted in India and (2) English language studies. Published during January 2012-June 2018 with data collection during the same period (3). 95% ART adherence rate (primary outcome). We reviewed bibliographic databases (PubMed, Scopus) and extracted relevant data. The forest plot was used to display the meta-analysis results. Analyses were performed in Stata 14 using the "Metaprop_one" function.

Results

A total of 511 records were identified after removing duplicates, 59 full-texts were screened of which 15 studies were included in the meta-analysis. Only one study was conducted in rural India, with <95% adherence reported by all its participants. The PLHIV reported several reasons for their ART nonadherence including forgetfulness (8/15), running out of pills (3/15), distance from the health center and associated travel (2/15), alcohol abuse (3/15), concealment of HIV status from family (2/15, felt stigma (2/15), depressive symptoms (2/15), and fear of side-effects (2/15). The overall pooled estimate of ART adherence was 54.1% (95% confidence interval [CI] 27%-81%), while among facility-based studies, the ≥95% adherence rate was significant higher. 62% (95% CI 46%-0.78%).

Conclusions

Despite the universal provision of free of cost ART to all PLHIV in government health facilities in India, suboptimal adherence to treatment persists in nearly half of these patients.

Effectiveness of instant versus text messaging intervention on antiretroviral therapy adherence among men who have sex with men living with HIV

Objective

This study aimed to compare the effectiveness of instant versus text messaging intervention (TMI) on antiretroviral therapy (ART) adherence among men who have sex with men (MSM) living with HIV.

Methods

This study was conducted in an infectious disease hospital of Jinan, China from October 2020 to June 2021, using non-randomized concurrent controlled design to compare the effectiveness of instant messaging intervention (IMI) versus TMI. The intervention strategies (health messaging, medication reminder, and peer education) and contents were consistent between the two groups, and the difference was service delivery method and type of information. The primary outcome was the proportion of achieving optimal ART adherence, defined as never missing any doses and delayed any doses more than 1 hour.

Results

A total of 217 participants (including 72 in TMI group and 145 in IMI group) were included in the study. The proportion of achieving optimal adherence was higher in IMI group than TMI group at the first follow-up (90.2% versus 77.6%, p = 0.021) and second follow-up (86.5% versus 76.6%, p = 0.083). The effect of IMI versus TMI on improving ART adherence was found not to be statistically significant (risk ratio (RR) = 1.93, 95% confidence interval (CI): 0.95-3.94) in complete-case analysis. However, when excluding participants who did not adhere to the interventions, a significant improvement was observed (RR = 2.77, 95%CI: 1.21-6.38). More participants in IMI group expressed highly rated satisfaction to the intervention services than those in TMI group (67.3% versus 50.0%).

Conclusions

The IMI demonstrated superior efficacy over TMI in improving ART adherence and satisfaction with intervention services. It is suggested that future digital health interventions targeting ART adherence should prioritize instant messaging with multimedia information in areas with Internet access.

Trial registration

The study was registered at the Chinese Clinical Trial Register (ChiCTR), with number [ChiCTR2000041282].

Changes in HIV care continuum indicators among community-based samples of HIV-infected people who inject drugs and men who have sex with men across 21 cities in India

Monitoring key populations' progress towards UNAIDS 90-90-90 targets is essential to achieving HIV/AIDS epidemic control. Using serial cross-sectional data, we evaluated changes in HIV care continuum among people who inject drugs(PWID) and men who have sex with men(MSM) in India. Cross-sectional baseline (2012/2013) and follow-up (2016/2017) samples were recruited using respondent-driven sampling across 21 cities. All participants were tested for HIV and RNA measured in HIV-positive participants. Linear regression was used to model temporal site-level changes in continuum indicators in MSM versus PWID. At baseline, we recruited 2,544 HIV-infected PWID and 1,086 HIV-infected MSM. At follow-up, we recruited 2,517 HIV-infected PWID and 1,763 HIV-infected MSM. At baseline, there were no significant differences in continuum indicators between MSM and PWID. At follow-up, compared to PWID, the proportion of MSM reaching each care continuum indicator-awareness of status, receipt of care, ART use, viral suppression-increased by 15-33 percentage points: 78% of MSM versus 49% of PWID were aware of their status (p < 0.01); 56% of MSM versus 32% of PWID were virologically suppressed (p = 0.05). MSM showed marked improvements across the care continuum, whereas PWID lagged and may require additional intervention. Differential improvement in HIV engagement may necessitate population-specific interventions and routine surveillance to facilitate HIV elimination.

"What's Sex and Gender Got to Do With It?" A Scoping Review of Sex- and Gender-Based Analysis in Pharmacoepidemiologic Studies of Medication Adherence

OBJECTIVES

Medication taking is a complex multidimensional behavior that may be impeded by a range of biological and psychosocial factors, including sex and gender. We aimed to synthesize how sex and gender have been reported and analyzed in pharmacoepidemiologic studies of medication.

METHODS

We searched for English-language peer-reviewed articles of observational studies (eg, cross-sectional, cohort, and case-control) that examined medication adherence among adults and included sex or gender in their reporting.

RESULTS

We included 937 studies among 530 537 287 participants published between the year 1979 and 2021. Most studies were cross-sectional (47%), lasted ≤ 1 year (35%), examined self-reported adherence (53%), did not assess specific adherence problem(s) (40%), and included medications for cardiovascular conditions (24%) or systemic infections (24%). A quarter of studies (25%) used sex and gender interchangeably, more than one third of studies (36%) that reported gender data likely collected data on sex, and < 1% of studies described sex and gender as distinct variables. Studies of cisgender participants more often reported that females/women experienced greater adherence problems often than males/men (31% vs 20%), particularly discontinuation and cost-related nonadherence. Only 21 studies (2%) reported on transgender individuals, and these predominantly examined antiretroviral medications for HIV.

CONCLUSIONS

Our review revealed substantial conflation of sex and gender in studies of medication adherence and a paucity of research among transgender individuals. Moreover, our synthesis showed sex/gender disparities in medication taking with studies reporting greater medication adherence problems among cisgender women and transgender participants than cisgender men.

Intersectional stigma and gender non-affirmation hinder HIV care engagement among transgender women living with HIV in India

Among transgender women living with HIV (TGWLH) in India, little is understood about the mechanisms through which multiple intersecting stigmas impact HIV care engagement, or intervention strategies that might mitigate this impact. We conducted focus groups with TGWLH (N = 30) in three Indian cities and analysed data using theoretical frameworks related to HIV stigma, gender affirmation, and syndemics. Findings revealed that enacted and anticipated stigma due to transgender identity, HIV, or sex work status, and lack of gender affirmation (e.g., misgendering) in healthcare settings delayed ART initiation and promoted care disengagement. Having supportive physicians and counsellors within ART centres and peer outreach workers facilitated ART initiation, adherence, and retention. Findings also revealed that HIV stigma within TGW communities led to concealment of HIV status or syndemic conditions such as depression and alcohol use, thereby affecting care engagement. However, the TGW community itself was also described as a resilience resource, offering emotional, psychological and tangible support that decreased the impact of discrimination on care engagement. HIV care engagement efforts among Indian TGWLH could be strengthened by reducing intersecting stigmas in healthcare settings and within TGW communities, providing gender-affirming and culturally competent healthcare, addressing psychosocial syndemic conditions, and strengthening support within transgender communities.

The need for targeted behavioural HIV-related interventions for transgender women in India: A scoping review

Background & objectives

Transgender women (TGW) in India are at high risk of HIV infection. Despite behavioural interventions aimed at reducing HIV risk, no literature synthesis exists so far to evaluate their potential for reducing HIV incidence in India This review was aimed to identify and evaluate HIV-focussed behaviour change interventions for TGW in India.

Methods

Literature from three databases were reviewed up to June 2, 2021, for studies describing behavioural interventions for HIV prevention among TGW in India. The inclusion criteria were studies that included TGW and reported intervention effects on HIV prevention-related behaviour. Data were analyzed descriptively.

Results

Of the 146 articles screened, only three met the inclusion criteria. All three interventions were at the open pilot trial stage and included other high-risk groups (e.g. men who have sex with men). The interventions used behavioural counselling, increased sexually transmitted infection screening and sexual healthcare visits and leveraged community-based organizations to improve the outcomes. All these interventions showed modest improvements in health-seeking behaviour and access to services. However, none specifically targeted TGW.

Interpretation & conclusions

The scoping review highlights the need for behavioural interventions for HIV prevention tailored to TGW in India. This study emphasizes the need for research to move to the next stage of intervention development and testing utilizing more rigorous evaluation methods, such as a randomized controlled trial.

"I've Learned to Value Myself More": Piloting an Adapted Multilevel Intervention for Transgender Women Sex Workers Living with HIV in the Dominican Republic

Purpose: Transgender (trans) women living with HIV experience suboptimal care and treatment outcomes. We adapted a multilevel intervention to improve HIV outcomes and overall well-being among trans women sex workers living with HIV. The intervention, called Abriendo Puertas (AP; Opening Doors), included: individual counseling, peer navigation, and community mobilization "open houses." The purpose of this article is to describe acceptability and initial outcomes of the adapted AP pilot and explore intervention experiences to inform recommendations for improvement. Methods: After an iterative adaptation process, we recruited 30 trans women sex workers living with HIV to participate in the pilot. We conducted baseline and endline (12-months) surveys to compare HIV care and treatment outcomes and qualitative interviews to assess intervention experiences with a subsample (n=20). Results: Intervention retention was high, with 86.7% of participants (n=26/30) completing both baseline and endline surveys. At endline, there was a significant increase in current anti-retroviral therapy (ART) use (70.0% to 84.6%, p<0.03) and positive, but not significant, trends in missed care appointments in the past 6 months (34.5% to 20.0%, p<0.39) and not having missed any ART doses in the past 4 days (85.7% to 95.5%, p<0.50). Intervention acceptability was high across all components: individual counseling (96.1%), peer navigation (80.8%), and open houses (84.6%). Participants emphasized that trust and being treated with respect allowed them to relax and improve their self-esteem. Limited trust and cohesion among trans women, however, limited more extensive engagement with peer navigation and community mobilization components. Conclusion: Future efforts to strengthen the AP intervention with trans women sex workers should continue to address emotional, instrumental, and informational support needs related to living with HIV through individual counseling, peer navigation, and open houses while also enhancing group-level activities to build trust and generate a collective commitment to promote the well-being of the community.

Increasing HIV treatment access, uptake and use among men who have sex with men in urban Indonesia: evidence from a qualitative study in three cities

Men who have sex with men make up one of four key populations identified as critical to a successful HIV response in Indonesia. Despite international policies supporting HIV treatment in low- and middle-income countries, Indonesia is one of the few countries experiencing low coverage of HIV treatment and little decrease in HIV incidence. There is poor retention in care and low viral suppression rates among key populations such as men who have sex with men. The national government has committed to increasing treatment access and uptake for people with HIV but little is known about how these men themselves view, use and experience these medications. Drawing on qualitative data collected in 2015-16 from 24 HIV-positive men who have sex with men living in three Indonesian cities, we observed multiple intersecting social and contextual factors that can influence effective HIV treatment use. Although shared stories of strong side effects and fear of unwanted disclosure inhibited treatment uptake, social support from 'buddies' helped to navigate healthcare systems and sharing medication among peers enabled adherence. In order to improve treatment uptake and adherence among Indonesian men who have sex with men living with HIV, these divergent effects of the social meanings and practices associated with HIV treatments in Indonesia must be better acknowledged. A more comprehensive understanding of social and community practices within key populations can strengthen national efforts to improve treatment access and increase adherence. Ongoing decentralization of healthcare in Indonesia, and differentiated care models that enable initiation of treatment in community settings and involve non-medical, community-based organizations in the provision of treatment services have the potential to address the needs of individuals who fall into a key population category such as men who have sex with men.

Adherence to Antiretroviral Therapy Among HIV Patients in India: A Systematic Review and Meta-analysis

We conducted a systematic review and meta-analysis to estimate the prevalence of adherence to antiretroviral therapy (ART) in India, the third largest HIV epidemic in the world. We identified peer reviewed literature published between 2007 and 2017 to extract data on ART adherence. We estimated pooled prevalence of adherence to ART using a random-effects model. Thirty-two eligible studies (n = 11,543) were included in the meta-analysis. Studies were mostly clustered in the southern and western Indian states. Overall, 77% (95% Confidence Interval 73-82; I² = 96.80%) of patients had optimum adherence to ART. Women had higher prevalence of optimum adherence compared to men. Depression or anxiety were significant risk factors in seven of the fifteen studies reporting determinants of nonadherence. Studies should be performed to explore the reasons for gender gap in ART adherence and HIV program in India should prioritize mental health issues among HIV patients to improve ART adherence.

Correlates of and barriers to ART adherence among adherence-challenged people living with HIV in southern India

Suboptimal adherence to Antiretroviral Therapy (ART) regimens can lead to the development of drug resistance, virologic and clinical failure, and, on the community level, the spread of drug-resistant HIV. To design effective interventions, it is crucial to understand locally specific barriers to optimal adherence. Self-report data from a cross-sectional sample of 527 adherence-challenged people living with HIV (PLWH) in the South-Indian state of Karnataka showed that they took on average 68% of prescribed doses in the past month. Large majorities of participants encountered individual (95%), social/structural (88%), and clinic/regimen (80%) adherence barriers. Multivariate linear regression analyses of past month adherence showed that disclosure to all adults in the household was positively related to adherence, as was employing a larger number of adherence strategies, perceiving more benefits of ART, and having been on ART for longer. Fears of stigmatization upon disclosure of HIV-status to friends and people at work were negatively related to adherence. These results suggest that some barriers, especially individual-level barriers like forgetfulness are very common and can be targeted with relatively simple individual-level strategies. Other barriers, related to fear of stigma and lack of disclosure may require family- or community-level interventions.