Different delivery models for antiretroviral therapy in sub-Saharan Africa in the context of 'universal access'

Differentiated HIV care in sub-Saharan Africa: a scoping review to inform antiretroviral therapy provision for stable HIV-infected individuals in Kenya

Many gaps in care exist for provision of antiretroviral therapy (ART) in sub-Saharan Africa. Differentiated HIV care tailors provision of ART for patients based on their level of acuity, providing alternatives for where, by whom, and how often care occurs. We conducted a scoping review to assess novel differentiated care models for ART provision for stable HIV-infected adults in sub-Saharan Africa, and how these models can be used to guide differentiated care implementation in Kenya. A systematic search was conducted using PubMed, Embase, Web of Science, Popline, Cochrane Library, and African Index Medicus between January 2006 and January 2017. Grey literature searches and handsearching were also used. We included articles that quantitatively assessed the health, acceptability, and cost-effectiveness of differentiated HIV care. Two reviewers independently performed article screening, data extraction and determination of inclusion for analysis. We included 40 publications involving over 240,000 participants spanning nine countries in sub-Saharan Africa - 54.4% evaluated clinical outcomes, 23.5% evaluated acceptability outcomes, and 22.1% evaluated cost outcomes. Differentiated care models included: facility fast-track drug refills and appointment spacing, facility or community-based ART groups, community ART distribution points or home-based care, and task-shifting or decentralization of care. Studies suggest that these approaches had similar outcomes in viral load suppression and retention in care and were acceptable alternatives to standard HIV care. No clear results could be inferred for studies investigating task shifting and those reporting cost-effectiveness outcomes. Kenya has started to scale up differentiated care models, but further evaluation, quality improvement and research studies should be performed as different models are rolled out.

Nonadherence is Associated with Lack of HIV-Related Knowledge: A Cross-Sectional Study among HIV-Infected Individuals in Guinea-Bissau

BACKGROUND

Poor treatment adherence is a main barrier for effective antiretroviral therapy (ART) globally. HIV-related knowledge may affect understanding and utilization of HIV medical information, hence limited health literacy is a known barrier to treatment adherence.

DESIGN AND METHODS

A cross-sectional study included 494 HIV-infected individuals from the Bissau HIV Cohort in Guinea-Bissau. They completed a questionnaire designed for assessment of adherence and HIV-related knowledge.

RESULTS

A majority were female, 41% were illiterate, 25% did not take the medicine during the last 4 days, and 23% skipped their medicine during weekends. The most frequent reasons for not taking medicine were simply forgetting, side effects, lack of food, and being too ill to attend the clinic. Nonadherent patients had a lower level of HIV-related knowledge.

CONCLUSION

Main barriers for nonadherence were side effects, food insecurity, and simply forgetting. Lack of HIV-related knowledge about ART and HIV may be a barrier to nonadherence.

Family matters: Co-enrollment of family members into care is associated with improved outcomes for HIV-infected women initiating antiretroviral therapy

Background:

Although there is widespread interest in understanding how models of care for delivering antiretroviral therapy (ART) may influence patient outcomes, family-focused approaches have received little attention. In particular, there have been few investigations of whether the co-enrollment of HIV-infected family members may improve adult ART outcomes over time.

Methods:

We examined the association between co-enrollment of HIV-infected family members into care and outcomes of women initiating ART in 12 HIV care and treatment programs across sub-Saharan Africa. Using data from the mother-to-child transmission-(MTCT) Plus Initiative, women starting ART were categorized according to the co-enrollment of an HIV-infected partner and/or HIV-infected child within the same program. Mortality and loss to follow-up were assessed for up to 5 years after women's ART initiation.

Results:

Of the 2877 women initiating ART included in the analysis, 31% (n = 880) had at least 1 HIV-infected family member enrolled into care at the same program, including 24% (n = 689) who had an HIV-infected male partner, and 10% (n = 295) who had an HIV-infected child co-enrolled. There was no significant difference in the risk of death of women by family co-enrollment status (P = 0.286). However, the risk of loss to follow-up was greatest among women who did not have an HIV-infected family member co-enrolled (19% after 36 months on ART) compared with women who had an HIV-infected family member co-enrolled (3%–8% after 36 months on ART) (P < 0.001). These associations persisted after adjustment for demographic and clinical covariates and were consistent across countries and care programs.

Discussion:

These data provide novel evidence for the association between adult outcomes on ART and co-enrollment of HIV-infected family members into care at the same program. Interventions that build on women's family contexts warrant further consideration in both research and policies to promote retention in ART services across sub-Saharan Africa.

Scaling-up access to antiretroviral therapy for children: a cohort study evaluating care and treatment at mobile and hospital-affiliated HIV clinics in rural Zambia

Background

Travel time and distance are barriers to care for HIV-infected children in rural sub-Saharan Africa. Decentralization of care is one strategy to scale-up access to antiretroviral therapy (ART), but few programs have been evaluated. We compared outcomes for children receiving care in mobile and hospital-affiliated HIV clinics in rural Zambia.

Methods

Outcomes were measured within an ongoing cohort study of HIV-infected children seeking care at Macha Hospital, Zambia from 2007 to 2012. Children in the outreach clinic group received care from the Macha HIV clinic and transferred to one of three outreach clinics. Children in the hospital-affiliated clinic group received care at Macha HIV clinic and reported Macha Hospital as the nearest healthcare facility.

Results

Seventy-seven children transferred to the outreach clinics and were included in the analysis. Travel time to the outreach clinics was significantly shorter and fewer caretakers used public transportation, resulting in lower transportation costs and fewer obstacles accessing the clinic. Some caretakers and health care providers reported inferior quality of service provision at the outreach clinics. Sixty-eight children received ART at the outreach clinics and were compared to 41 children in the hospital-affiliated clinic group. At ART initiation, median age, weight-for-age z-scores (WAZ) and CD4⁺ T-cell percentages were similar for children in the hospital-affiliated and outreach clinic groups. Children in both groups experienced similar increases in WAZ and CD4⁺ T-cell percentages.

Conclusions

HIV care and treatment can be effectively delivered to HIV-infected children at rural health centers through mobile ART teams, removing potential barriers to uptake and retention. Outreach teams should be supported to increase access to HIV care and treatment in rural areas.

Assessing the costs and effects of antiretroviral therapy task shifting from physicians to other health professionals in ethiopia

OBJECTIVE

To evaluate the effects, costs, and cost-effectiveness of different degrees of antiretroviral therapy task shifting from physician to other health professionals in Ethiopia.

DESIGN

Two-year retrospective cohort analysis on antiretroviral therapy patients coupled with cost analysis.

INTERVENTIONS

Facilities with minimal or moderate task shifting compared with facilities with maximal task shifting. Maximal task shifting is defined as nonphysician clinicians handling both severe drug reactions and antiretroviral drug regimen changes. Secondary analysis compares health centers to hospitals.

MAIN OUTCOME MEASURES

The primary effectiveness measure is the probability of a patient remaining actively on antiretroviral therapy for 2 years; the cost measure is the cost per patient per year.

RESULTS

All facilities had some task shifting. About 89% of patients were actively on treatment 2 years after antiretroviral treatment (ART) initiation, with no statistically significant differences between facilities with maximal and minimal or moderate task shifting. It cost about $206 per patient per year for ART, with no statistically significant difference between the comparison groups. The cost-effectiveness of maximal task shifting is similar to minimal or moderate task shifting, with the same results obtained using regression to control for facility characteristics.

CONCLUSIONS

Shifting the handling of both severe drug reactions and antiretroviral drug regimen changes from physicians to other clinical officers is not associated with a significant change in the 2-year treatment success rate or the costs of ART care. As an observational study, these results are tentative, and more research is needed in determining the optimal patterns of task shifting.

HIV scale-up in Mozambique: exceptionalism, normalisation and global health

The large-scale introduction of HIV and AIDS services in Mozambique from 2000 onwards occurred in the context of deep political commitment to sovereign nation-building and an important transition in the nation's health system. Simultaneously, the international community encountered a willing state partner that recognised the need to take action against the HIV epidemic. This article examines two critical policy shifts: sustained international funding and public health system integration (the move from parallel to integrated HIV services). The Mozambican government struggles to support its national health system against privatisation, NGO competition and internal brain drain. This is a sovereignty issue. However, the dominant discourse on self-determination shows a contradictory twist: it is part of the political rhetoric to keep the sovereignty discourse alive, while the real challenge is coordination, not partnerships. Nevertheless, we need more anthropological studies to understand the political implications of global health funding and governance. Other studies need to examine the consequences of public health system integration for the quality of access to health care.

Outreach education for integration of HIV/AIDS care, antiretroviral treatment, and tuberculosis care in primary care clinics in South Africa: PALSA PLUS pragmatic cluster randomised trial

OBJECTIVE

To investigate whether PALSA PLUS, an on-site educational outreach programme of non-didactic, case based, iterative clinical education of staff, led by a trainer, can increase access to and comprehensiveness of care for patients with HIV/AIDS.

DESIGN

Cluster randomised trial.

SETTING

Public primary care clinics offering HIV/AIDS care, antiretroviral treatment (ART), tuberculosis care, and ambulatory primary care in Free State province, South Africa.

PARTICIPANTS

Fifteen clinics all implementing decentralisation and task shifting were randomised. The clinics cared for 400,000 general primary care patients and 10,136 patients in an HIV/AIDS/ART programme. There were 150 nurses.

INTERVENTION

On-site outreach education in eight clinics; no such education in seven (control).

MAIN OUTCOME MEASURES

Provision of co-trimoxazole prophylaxis among patients referred to the HIV/AIDS/ART programme, and detection of cases of tuberculosis among those in the programme. Proportion of patients in the programme enrolled through general primary care consultations.

RESULTS

Patients referred to the HIV/AIDS programme through general primary care at intervention clinics were more likely than those at control clinics to receive co-trimoxazole prophylaxis (41%, (2253/5523) v 32% (1340/4210); odds ratio 1.95, 95% confidence interval 1.11 to 3.40), and tuberculosis was more likely to be diagnosed among patients with HIV/AIDS/ART (7% (417/5793) v 6% (245/4343); 1.25, 1.01 to 1.55). Enrolment in the HIV/AIDS and ART programme through HIV testing in general primary care was not significantly increased (53% v 50%; 1.19, 0.51 to 2.77). Secondary outcomes were similar, except for weight gain, which was higher in the intervention group (2.3 kg v 1.9 kg, P<0.001).

CONCLUSION

Though outreach education is an effective and feasible strategy for improving comprehensiveness of care and wellbeing of patients with HIV/AIDS, there is no evidence that it increases access to the ART programme. It is now being widely implemented in South Africa.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN 24820584.

Clinical Markers of Immunodeficiency and Mechanism of Immune Reconstitution Inflammatory Syndrome and Highly Active Antiretroviral Therapy on HIV

Antiretroviral therapy (ART) has improved survival and changed the disease pattern of HIV infection. However, ART may cause serious side effects, such as metabolic and cardiovascular complications. In addition, immune reconstitution inflammatory syndrome (IRIS) is being increasingly reported in relation to ART. The article presents the consensus of a workshop around 4 key issues: (1) the differences in the response of adults and children to highly active antiretroviral therapy, (2) the mechanism of the new HIV entry inhibitors and its effect on oral markers, (3) the pathogenesis of IRIS and the contradictory findings of the possible oral lesions related with IRIS, (4) and the benefits and barriers associated with using ART in the developing and developed world. The consensus of the workshop was that there is a need for future studies on the oral manifestations of HIV in individuals treated with new ARTs—especially, children. IRIS was considered a promising field for future research; as such, workshop attendees recommended formulating an IRIS–oral lesions case definition and following strict criteria for its diagnosis.

What happens to ART-eligible patients who do not start ART? Dropout between screening and ART initiation: a cohort study in Karonga, Malawi

Background

Routine ART programme statistics generally only provide information about individuals who start treatment. We aimed to investigate the outcome of those who are eligible but do not start ART in the Malawi programme, factors associated with this dropout, and reasons for not starting treatment, in a prospective cohort study.

Methods

Individuals having a first screening visit at the ART clinic at Karonga District Hospital, northern Malawi, between September 2005 and July 2006 were interviewed. Study follow-up to identify treatment outcomes was conducted at the clinic and in the community. Logistic regression models were used to identify factors associated with dropout before ART initiation among participants identified as clinically eligible for ART.

Results

88 participants eligible for ART at their first screening visit (out of 633, 13.9%) defaulted before starting ART. Participants with less education, difficulties in dressing, a more delayed ART initiation appointment, and mid-upper arm circumference (MUAC) < 22 cm were significantly less likely to have visited the clinic subsequently. Thirty-five (58%) of the 60 participants who defaulted and were tracked at home had died, 21 before their ART initiation appointment.

Conclusions

MUAC and reported difficulties in dressing may provide useful screening indicators to identify sicker ART-eligible individuals at high risk of dropping out of the programme who might benefit from being brought back quickly or admitted to hospital for observation. Individuals with less education may need adapted health information at screening. Deaths of ART-eligible individuals occurring prior to ART initiation are not included in routine programme statistics. Considering all those who are eligible for ART as a denominator for programme indicators would help to highlight this vulnerable group, in order to identify new opportunities for further improving ART programmes.

How HIV treatment could result in effective prevention

As the number of HIV infections continues to surpass treatment capacity, new HIV prevention strategies are imperative. Beyond individual clinical benefits, by rendering an individual less infectious, expanding access to highly active antiretroviral therapy (HAART) could also have a larger public health impact of curbing new HIV infections. Recent guidelines have moved towards initiating HAART at higher CD4 cell counts, thus increasing the number of individuals in need of treatment. A new treatment strategy is wanting that can simultaneously curb the epidemic and provide necessary treatment to those most in need. A recent debate has centered on whether an expansion of free and universal treatment, regardless of CD4 cell count, could be a means of HIV prevention. In light of the growing access to HAART in resource-limited settings and increasing evidence suggesting the clinical and prevention benefits of initiating treatment at higher CD4 cell counts, it is conceivable that, in the future, HAART will be an integral part of both individual-level clinical treatment programs as well as public health-based HIV prevention interventions.

Antiretroviral therapy for HIV prevention: many concerns and challenges, but are there ways forward in sub-Saharan Africa?

Scientists from the WHO have presented a theoretical mathematical model of the potential impact of universal voluntary HIV testing and counselling followed by immediate antiretroviral therapy (ART). The results of the model suggests that, in a generalised epidemic as severe as that in sub-Saharan Africa (SSA), HIV incidence may be reduced by 95% in 10 years and that this approach may be cost effective in the medium term. This offers a 'ray of hope' to those who have thus far only dreamed of curbing the HIV/AIDS epidemic in SSA, as until now the glaring truth has been pessimistic. When it comes to ART, approximately 7 of 10 people who clinically need ART still do not receive it. From an epidemic point of view, for every person placed on ART an estimated four to six others acquire HIV. The likelihood of achieving the targets of the Millennium Development Goals for 2015 and universal ART access by 2010 are thus extremely low. A new window of opportunity may have now opened, but there are many unanswered feasibility and acceptability issues. In this paper, we highlight four key operational challenges linked to acceptability and feasibility and discuss possible ways forward to address them.

Antiretroviral therapy in Malaysia: identifying barriers to universal access

Despite a good public healthcare infrastructure and greater availability of antiretroviral drugs in Malaysia since 2005, the number of HIV-infected patients receiving treatment remains disproportionately small. Barriers to greater access include a lack of trained human resources to deliver antiretroviral therapy (ART) in a highly individualized and specialized model and, until recently, a lack of treatment for substance abuse in a predominantly injecting drug-use epidemic. However, one of the biggest barriers, and perhaps the most challenging to overcome, is the stigma and discrimination towards HIV-infected people, especially injecting drug users, which prevented many from accessing treatment and care. Increasing and improved access to ART for HIV-infected patients will entail a multipronged strategy that includes the decentralization of clinical care, increased and ongoing training of healthcare workers and support staff, and a comprehensive and intensive effort to reduce stigma and discrimination. Creation of an enabling environment through public education and a well-trained and nonprejudicial healthcare work force, coupled with policy and legal reforms, are essential in ensuring a greater and sustainable access to ART for all.