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DeLong SM, Xu Y, Genberg BL, Nyambura M, Goodrich S, Tarus C, Ndege S, Hogan JW, Braitstein P. Population-Based Estimates and Predictors of Child and Adolescent Linkage to HIV Care or Death in Western Kenya. J Acquir Immune Defic Syndr 2023; 94:281-289. [PMID: 37643416 PMCID: PMC10609679 DOI: 10.1097/qai.0000000000003288] [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: 03/07/2023] [Accepted: 07/17/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Population-level estimates of linkage to HIV care among children and adolescents (CAs) can facilitate progress toward 95-95-95 goals. SETTING This study was conducted in Bunyala, Chulaimbo, and Teso North subcounties, Western Kenya. METHODS Linkage to care was defined among CAs diagnosed with HIV through Academic Model Providing Access to Healthcare (AMPATH)'s home-based counseling and testing initiative (HBCT) by merging HBCT and AMPATH Medical Record System data. Using follow-up data from Bunyala, we examined factors associated with linkage or death, using weighted multinomial logistic regression to account for selection bias from double-sampled visits. Based on the estimated model, we imputed the trajectory for each person in 3 subcounties until a simulated linkage or death occurred or until the end of 8 years when an individual was simulated to be censored. RESULTS Of 720 CAs in the analytic sample, 68% were between 0 and 9 years and 59% were female. Probability of linkage among CAs in the combined 3 subcounties was 48%-49% at 2 years and 64%-78% at 8 years while probability of death was 13% at 2 years and 19% at 8 years. Single or double orphanhood predicted linkage (adjusted odds ratio [aOR]: 2.66, 95% confidence interval [CI]: 1.33 to 5.32) and death (aOR: 9.85 [95% CI: 2.21 to 44.01]). Having a mother known to be HIV-positive also predicted linkage (aOR = 1.94, 95% CI: 0.97 to 3.86) and death (aOR: 14.49, 95% CI: 3.32 to 63.19). CONCLUSION HIV testers/counselors should continue to ensure linkage among orphans and CAs with mothers known to be HIV-positive and also to support other CAs to link to HIV care.
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Affiliation(s)
- Stephanie M. DeLong
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Yizhen Xu
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Becky L. Genberg
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Monicah Nyambura
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Suzanne Goodrich
- Department of Biostatistics, Brown University School of Public Health, Providence, RI; and
| | - Carren Tarus
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Samson Ndege
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Moi University, School of Public Health, Eldoret, Kenya
| | - Joseph W. Hogan
- Department of Biostatistics, Brown University School of Public Health, Providence, RI; and
| | - Paula Braitstein
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Moi University, School of Public Health, Eldoret, Kenya
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Kalinjuma AV, Glass TR, Masanja H, Weisser M, Msengwa AS, Vanobberghen F, Otwombe K. Statistical methods applied for the assessment of the HIV cascade and continuum of care: a systematic scoping review. BMJ Open 2023; 13:e071392. [PMID: 37996221 PMCID: PMC10668296 DOI: 10.1136/bmjopen-2022-071392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 09/28/2023] [Indexed: 11/25/2023] Open
Abstract
OBJECTIVES This scoping review aims to identify and synthesise existing statistical methods used to assess the progress of HIV treatment programmes in terms of the HIV cascade and continuum of care among people living with HIV (PLHIV). DESIGN Systematic scoping review. DATA SOURCES Published articles were retrieved from PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Complete and Excerpta Medica dataBASE (EMBASE) databases between April and July 2022. We also strategically search using the Google Scholar search engine and reference lists of published articles. ELIGIBILITY CRITERIA This scoping review included original English articles that estimated and described the HIV cascade and continuum of care progress in PLHIV. The review considered quantitative articles that evaluated either HIV care cascade progress in terms of the Joint United Nations Programme on HIV and AIDS targets or the dynamics of engagement in HIV care. DATA EXTRACTION AND SYNTHESIS The first author and the librarian developed database search queries and screened the retrieved titles and abstracts. Two independent reviewers and the first author extracted data using a standardised data extraction tool. The data analysis was descriptive and the findings are presented in tables and visuals. RESULTS This review included 300 articles. Cross-sectional study design methods were the most commonly used to assess the HIV care cascade (n=279, 93%). In cross-sectional and longitudinal studies, the majority used proportions to describe individuals at each cascade stage (276/279 (99%) and 20/21 (95%), respectively). In longitudinal studies, the time spent in cascade stages, transition probabilities and cumulative incidence functions was estimated. The logistic regression model was common in both cross-sectional (101/279, 36%) and longitudinal studies (7/21, 33%). Of the 21 articles that used a longitudinal design, six articles used multistate models, which included non-parametric, parametric, continuous-time, time-homogeneous and discrete-time multistate Markov models. CONCLUSIONS Most literature on the HIV cascade and continuum of care arises from cross-sectional studies. The use of longitudinal study design methods in the HIV cascade is growing because such methods can provide additional information about transition dynamics along the cascade. Therefore, a methodological guide for applying different types of longitudinal design methods to the HIV continuum of care assessments is warranted.
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Affiliation(s)
- Aneth Vedastus Kalinjuma
- Department of Interventions and Clinical Trials, Ifakara Health Institute, Ifakara, Dar es Salaam, United Republic of Tanzania
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Tracy Renée Glass
- Medicines Department, Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Honorati Masanja
- Department of Interventions and Clinical Trials, Ifakara Health Institute, Ifakara, Dar es Salaam, United Republic of Tanzania
| | - Maja Weisser
- Department of Interventions and Clinical Trials, Ifakara Health Institute, Ifakara, Dar es Salaam, United Republic of Tanzania
- Medicines Department, Swiss Tropical and Public Health Institute, Basel, Switzerland
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Amina Suleiman Msengwa
- Department of Statistics, University of Dar es Salaam, Dar es Salaam, United Republic of Tanzania
| | - Fiona Vanobberghen
- Medicines Department, Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Kennedy Otwombe
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
- Perinatal HIV Research Unit, Chris Hani Baragwanath Academic Hospital, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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3
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Nicol E, Jama NA, Mehlomakulu V, Hlongwa M, Pass D, Basera W, Bradshaw D. Enhancing linkage to HIV care in the "Universal Test and Treat" era: Barriers and enablers to HIV care among adults in a high HIV burdened district in KwaZulu-Natal, South Africa. BMC Public Health 2023; 23:1756. [PMID: 37689667 PMCID: PMC10492313 DOI: 10.1186/s12889-023-16576-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] [Received: 04/04/2023] [Accepted: 08/21/2023] [Indexed: 09/11/2023] Open
Abstract
Ending AIDS by 2030 would depend on how successful health systems are in linking people living with HIV (PLHIV) into care. The World Health Organization recommended the 'Universal Test and Treat' (UTT) strategy - initiating all individuals testing positive on antiretroviral therapy (ART) irrespective of their CD4 count and clinical staging. This study aimed to explore the enablers and barriers to linkage to HIV care among adults with a new HIV diagnosis in a high-HIV prevalent rural district in South Africa. A qualitative study was undertaken to explore patients' perceptions of enablers and barriers of linkage-to-care, using a life-story narration and dialogue approach. In-depth interviews were conducted with 38 HIV-positive participants sampled from a cohort of 1194 HIV-positive patients recruited from December 2017 to June 2018. Participants were selected based on whether they had been linked to care or not within 3 months of positive HIV diagnosis. Interviews were thematically analysed using a general inductive approach. Of the 38 participants, 22 (58%) linked to care within three months of HIV-positive diagnosis. Factors that facilitated or inhibited linkage-to-care were found at individual, family, community, as well as health systems levels. Enablers included a positive HIV testing experience, and assistance from the fieldwork team. Support from family, and friends, as well as prior community-based education about HIV and ART were also noted. Individual factors such as acceptance of HIV status, previous exposure to PLHIV, and fear of HIV progressing, were identified. Barriers to linkage included, denial of HIV status, dislike of taking pills, and preference for alternative medicine. Negative experiences with counselling and health systems inefficiency were also noted as barriers. Perceived stigma and socio-economic factors, such as lack of food or money to visit the clinic were other barriers. Community-based and health system-level interventions would need to focus on clinic readiness in providing patients with necessary and effective health services such as proper and adequate counselling. This could increase the number of patients who link to care. Finally, interventions to improve linkage-to-care should consider a holistic approach, including training healthcare providers, community outreach and the provision of psychological, social, and financial support.
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Affiliation(s)
- Edward Nicol
- Burden of Disease Research Unit, South African Medical Research Council, P.O. Box 19070, TygerbergCape Town, 7505, South Africa.
- Division of Health Systems and Public Health, Stellenbosch University, Cape Town, South Africa.
| | - Ngcwalisa Amanda Jama
- Burden of Disease Research Unit, South African Medical Research Council, P.O. Box 19070, TygerbergCape Town, 7505, South Africa
- School of Public Health, University of the Western Cape, Bellville, South Africa
| | - Vuyelwa Mehlomakulu
- Burden of Disease Research Unit, South African Medical Research Council, P.O. Box 19070, TygerbergCape Town, 7505, South Africa
| | - Mbuzeleni Hlongwa
- Burden of Disease Research Unit, South African Medical Research Council, P.O. Box 19070, TygerbergCape Town, 7505, South Africa
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Public Health, Societies and Belonging, Human Sciences Research Council, Pretoria, South Africa
| | - Desiree Pass
- Burden of Disease Research Unit, South African Medical Research Council, P.O. Box 19070, TygerbergCape Town, 7505, South Africa
| | - Wisdom Basera
- Burden of Disease Research Unit, South African Medical Research Council, P.O. Box 19070, TygerbergCape Town, 7505, South Africa
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Debbie Bradshaw
- Burden of Disease Research Unit, South African Medical Research Council, P.O. Box 19070, TygerbergCape Town, 7505, South Africa
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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4
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Kouamou V, Gundidza P, Ndhlovu CE, Makadzange AT, Study C. Effects of Gender and Baseline CD4 Count on Post Treatment CD4 Count Recovery and Outcomes in Patients with Advanced HIV Disease: a Retrospective Cohort Study. AIDS Res Hum Retroviruses 2023. [PMID: 36924288 DOI: 10.1089/aid.2022.0117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
Abstract
Presentation to care with advanced HIV disease (AHD) is a significant problem in Sub-Saharan Africa. We evaluated factors associated with immune recovery among individuals presenting to care with AHD in Zimbabwe. We conducted a retrospective evaluation of outcomes among adult (>18 years old) individuals with AHD (CD4 count ≤ 200 cells/mm3) receiving care at 18 outpatient primary care clinics in Harare, Zimbabwe. Baseline and 12-month CD4 count data were extracted from medical records. CD4 count recovery (defined as CD4 count > 200 cells/mm3) after 12 months on NNRTI-based antiretroviral therapy (ART) regimen was determined and factors associated with CD4 count recovery were established using logistic regression. All statistical analysis was performed on SPSS v23. A total of 1338 participant records were included in the analysis. The median interquartile range (IQR) age was 37 (30-43) years and 52% were females. The baseline median (IQR) CD4 count was 50 (28-75) cells/mm3 and was significantly lower among patients with history of cryptococcal meningitis compared to those without (25(10-52) vs 52(32-77), respectively; p=0.0009). The median (IQR) CD4 count at 12 months after ART initiation increased from 50 (28-75) at baseline to 180 (92-290) cells/mm3. Immune recovery with a CD4 count > 200 cells/mm3, was observed in 181/417 (43%). Male gender and low baseline CD4 count were strong predictors of poor immunological recovery on ART. Immunological recovery following ART initiation was 43% among individuals with AHD. Male patients are most vulnerable to persistent immunological failure.
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Affiliation(s)
- Vinie Kouamou
- University of Zimbabwe Faculty of Medicine, 108329, Primary Health Care Sciences, Harare, Harare, Zimbabwe.,Charles River Medical Group, Harare, Zimbabwe;
| | | | - Chiratidzo Ellen Ndhlovu
- Charles River Medical Group, Harare, -, Zimbabwe.,University of Zimbabwe Faculty of Medicine, 108329, Harare, Harare, Zimbabwe;
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5
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Mwango L, Toeque M, Lindsay B, Tembo K, Sakala H, Reggee S, Malunga SM, Kabwe M, Kafunda I, Olufunso A, Mwila A, Okuku J, Kancheya N, Nkwemu K, Mumba D, Hachaambwa L, Sheneberger R, Blanco N, Lavoie M, Stafford KA, Claassen CW. Reaching transgender populations in Zambia for HIV prevention and linkage to treatment using community-based service delivery. J Int AIDS Soc 2022; 25 Suppl 5:e25995. [PMID: 36225155 PMCID: PMC9557009 DOI: 10.1002/jia2.25995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 07/30/2022] [Indexed: 11/07/2022] Open
Abstract
Introduction Transgender and gender‐diverse communities in Zambia are highly vulnerable and experience healthcare differently than cisgender persons. The University of Maryland, Baltimore (UMB) supports projects in Zambia to improve HIV case‐finding, linkage and antiretroviral treatment (ART) for Zambia's transgender community. We describe programme strategies and outcomes for HIV prevention, testing and ART linkage among transgender communities. Methods UMB utilizes a differentiated service delivery model whereby community health workers (CHWs) recruited from key populations (KPs) reach community members through a peer‐to‐peer approach, with the support of local transgender civil society organizations (CSOs) and community gatekeepers. Peer CHWs are trained and certified as HIV testers and psychosocial counsellors to offer counselling with HIV testing and prevention services in identified safe spaces. HIV‐negative people at risk of HIV infection are offered pre‐exposure prophylaxis (PrEP), while those who test positive for HIV are linked to ART services. CHWs collect data using the standardized facility and community tools and a dedicated DHIS2 database system. We conducted a descriptive analysis examining HIV testing and prevention outcomes using proportions and comparisons by time period and geographic strata. Results From October 2020 to June 2021, across Eastern, Lusaka, Western and Southern Provinces, 1860 transgender persons were reached with HIV prevention messages and services. Of these, 424 (23%) were tested for HIV and 78 (18%) tested positive. Of the 346 HIV‐negative persons, 268 (78%) eligible transgender individuals were initiated on PrEP. ART linkage was 97%, with 76 out of the 78 transgender individuals living with HIV initiating treatment. Programme strategies that supported testing and linkage included peer CHWs, social network strategy testing, same‐day ART initiation and local KP CSO support. Challenges included non‐transgender‐friendly environments, stigma and discrimination, the high transiency of the transgender community and the non‐availability of transgender‐specific health services, such as hormonal therapy. Conclusions Peer KP CHWs were able to reach many members of the transgender community, providing safe HIV testing, PrEP services and linkage to care. Focusing on community gatekeepers and CSOs to disburse health messages and employ welcoming strategies supported high linkage to both PrEP and ART for transgender people in Zambia.
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Affiliation(s)
| | - Mona‐Gekanju Toeque
- Maryland Global Initiatives Corporation ZambiaLusakaZambia,Center for International HealthEducationand BiosecurityUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Brianna Lindsay
- Maryland Global Initiatives Corporation ZambiaLusakaZambia,Center for International HealthEducationand BiosecurityUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Kalima Tembo
- Maryland Global Initiatives Corporation ZambiaLusakaZambia
| | - Henry Sakala
- Maryland Global Initiatives Corporation ZambiaLusakaZambia
| | | | | | | | - Ina Kafunda
- Maryland Global Initiatives Corporation ZambiaLusakaZambia
| | | | - Annie Mwila
- Division of Global HIV and TuberculosisU.S. Centers for Disease Control and PreventionLusakaZambia
| | - Jackson Okuku
- Division of Global HIV and TuberculosisU.S. Centers for Disease Control and PreventionLusakaZambia
| | - Nzali Kancheya
- Division of Global HIV and TuberculosisU.S. Centers for Disease Control and PreventionLusakaZambia
| | - Kennedy Nkwemu
- Division of Global HIV and TuberculosisU.S. Centers for Disease Control and PreventionLusakaZambia
| | | | - Lottie Hachaambwa
- Ciheb ZambiaLusakaZambia,Center for International HealthEducationand BiosecurityUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Robb Sheneberger
- Maryland Global Initiatives Corporation ZambiaLusakaZambia,Center for International HealthEducationand BiosecurityUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Natalia Blanco
- Center for International HealthEducationand BiosecurityUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Marie‐Claude Lavoie
- Center for International HealthEducationand BiosecurityUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Kristen A. Stafford
- Center for International HealthEducationand BiosecurityUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Cassidy W. Claassen
- Maryland Global Initiatives Corporation ZambiaLusakaZambia,Center for International HealthEducationand BiosecurityUniversity of Maryland School of MedicineBaltimoreMarylandUSA
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6
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Zhao Y, Li Z, Sheng Y. Timely linkage to care among men who have sex with men newly diagnosed with HIV: A structural equation model integrated HIV-related stigma framework. Nurs Health Sci 2022; 24:643-651. [PMID: 35633137 DOI: 10.1111/nhs.12960] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 05/20/2022] [Accepted: 05/21/2022] [Indexed: 11/27/2022]
Abstract
HIV prevalence among men who have sex with men in China has increased dramatically, and timely linkage to care after being diagnosed with HIV is important to treatment success. This cross-sectional study aims to utilize structural equation modeling to test a hypothesized model of timely linkage to care adapted from the HIV-related stigma framework. Data were collected from 257 men who have sex with men living with HIV. The proportion of participants with timely linkage to care within one month was 63.42%. The model result showed a good fit. Higher HIV-related stigma was significantly associated with a lower level of social support, mental health, maladaptive coping (three mechanism variables), and attitude toward linkage to care. Higher CD4+ T-cell count, disclosure of HIV positivity to sexual partners, and greater convenience of accessing care were related to timely linkage to care (p< 0.05). These model results suggest that enhancing attention to family reactions and social support are needed for further research and interventions to accelerate newly diagnosed people's access to HIV care in China.
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Affiliation(s)
- Yafang Zhao
- Nursing Department, Chinese Academy of Medical Sciences Peking Union Medical College Hospital, Beijing, China
| | - Zhen Li
- Department of ICU, Chinese Academy of Medical Sciences Peking Union Medical College Hospital, Beijing, China
| | - Yu Sheng
- School of Nursing, Peking Union Medical College, Beijing, China
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7
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Nardell MF, Adeoti O, Peters C, Kakuhikire B, Govathson-Mandimika C, Long L, Pascoe S, Tsai AC, Katz IT. Men missing from the HIV care continuum in sub-Saharan Africa: a meta-analysis and meta-synthesis. J Int AIDS Soc 2022; 25:e25889. [PMID: 35324089 PMCID: PMC8944222 DOI: 10.1002/jia2.25889] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 02/01/2022] [Indexed: 02/03/2023] Open
Abstract
Introduction Men are missing along the HIV care continuum. However, the estimated proportions of men in sub‐Saharan Africa meeting the UNAIDS 95‐95‐95 goals vary substantially between studies. We sought to estimate proportions of men meeting each of the 95‐95‐95 goals across studies in sub‐Saharan Africa, describe heterogeneity, and summarize qualitative evidence on factors influencing care engagement. Methods We systematically searched PubMed and Embase for peer‐reviewed articles published between 1 January 2014 and 16 October 2020. We included studies involving men ≥15 years old, with data from 2009 onward, reporting on at least one 95‐95‐95 goal in sub‐Saharan Africa. We estimated pooled proportions of men meeting these goals using DerSimonion‐Laird random effects models, stratifying by study population (e.g. studies focusing exclusively on men who have sex with men vs. studies that did not), facility setting (healthcare vs. community site), region (eastern/southern Africa vs. western/central Africa), outcome measurement (e.g. threshold for viral load suppression), median year of data collection (before vs. during or after 2017) and quality criteria. Data from qualitative studies exploring barriers to men's HIV care engagement were summarized using meta‐synthesis. Results and discussion We screened 14,896 studies and included 129 studies in the meta‐analysis, compiling data over the data collection period. Forty‐seven studies reported data on knowledge of serostatus, 43 studies reported on antiretroviral therapy use and 74 studies reported on viral suppression. Approximately half of men with HIV reported not knowing their status (0.49 [95% CI, 0.41–0.58; range, 0.09–0.97]) or not being on treatment (0.58 [95% CI, 0.51–0.65; range, 0.07–0.97]), while over three‐quarters of men achieved viral suppression on treatment (0.79 [95% CI, 0.77–0.81; range, 0.39–0.97]. Heterogeneity was high, with variation in estimates across study populations, settings and outcomes. The meta‐synthesis of 40 studies identified three primary domains in which men described risks associated with engagement in HIV care: perceived social norms, health system challenges and poverty. Conclusions Psychosocial and systems‐level interventions that change men's perceptions of social norms, improve trust in and accessibility of the health system, and address costs of accessing care are needed to better engage men, especially in HIV testing and treatment.
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Affiliation(s)
- Maria F Nardell
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Oluwatomi Adeoti
- Department of Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Carson Peters
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Bernard Kakuhikire
- Faculty of Business and Management Sciences, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Caroline Govathson-Mandimika
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa.,Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Lawrence Long
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa.,Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa.,Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Sophie Pascoe
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa.,Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Alexander C Tsai
- Harvard Medical School, Boston, Massachusetts, USA.,Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts, USA.,Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ingrid T Katz
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Global Health Institute, Cambridge, Massachusetts, USA
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8
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Nkambule BS, Huang N. Gender, working status, and access to HIV care among people who are HIV positive in Eswatini. AIDS Care 2022; 35:909-916. [PMID: 35254178 DOI: 10.1080/09540121.2022.2049198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
This study investigated the relationship between gender, working status, and access to HIV care and explored whether working status mediates the relationship between gender and access to HIV care. Nationally representative data from the 2016 Swaziland HIV Incidence Measurement Survey used. Sample comprised of 2,826 adults positive for HIV. Both 30-day and 1-year employment records were used to define working status. Access to HIV care was defined using data on both HIV viral load suppression and current antiretroviral therapy (ART) enrollment. People who worked in the past 12 months had a significantly lower likelihood of current ART enrollment (odds ratio [OR] 0.75; 95% confidence interval [CI]: 0.62-0.91) and viral load suppression (OR 0.78; 95% CI: 0.67-0.92). Working in the past 30 days was also significantly associated with current ART enrollment (OR 0.71; 95% CI: 0.59-0.85) and viral load suppression (OR 0.78; 95% CI: 0.66-0.93). The negative influence of working status on access to HIV care (current ART enrollment and viral load suppression) was stronger in men than in women. Working status partially explained the relationship between gender (male) and access to HIV care. Time constraints are a likely explanation for this.
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Affiliation(s)
- Bongi Siyabonga Nkambule
- International Health Program, Institute of Public Health, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Nicole Huang
- Institute of Hospital and Health Care Administration, College of Medicine, National Yang Ming Chiao Tung University, Taipei City, Taiwan (R.O.C)
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9
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Gilbert HN, Wyatt MA, Pisarski EE, Asiimwe S, van Rooyen H, Seeley J, Shahmanesh M, Turyamureeba B, van Heerden A, Adeagbo O, Celum CL, Barnabas RV, Ware NC. How community ART delivery may improve HIV treatment outcomes: Qualitative inquiry into mechanisms of effect in a randomized trial of community-based ART initiation, monitoring and re-supply (DO ART) in South Africa and Uganda. J Int AIDS Soc 2021; 24:e25821. [PMID: 34624173 PMCID: PMC8500674 DOI: 10.1002/jia2.25821] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 08/03/2021] [Indexed: 02/05/2023] Open
Abstract
Introduction UNAIDS fast track targets for ending the AIDS epidemic by 2030 call for viral suppression in 95% of people using antiretroviral therapy (ART) to treat HIV infection. Difficulties in linking to care following a positive HIV test have impeded progress towards meeting treatment targets. Community‐based HIV services may reduce linkage barriers and have been associated with high retention and favourable clinical outcomes. We use qualitative data from The Delivery Optimization of Antiretroviral Therapy (DO ART) Study, a three‐arm randomized trial of community ART initiation, monitoring and re‐supply conducted in western Uganda and KwaZulu‐Natal South Africa, to identify mechanisms through which community ART delivery may improve treatment outcomes, defined as viral suppression in people living with HIV (PLHIV). Methods We conducted open‐ended interviews with a purposeful sample of 150 DO ART participants across study arms and study sites, from October 2016 to November 2019. Interviews covered experiences of: (1) HIV testing; (2) initiating and refilling ART; and (3) participating in the DO ART Study. A combined inductive content analytic and thematic approach was used to characterize mechanisms through which community delivery of ART may have contributed to viral suppression in the DO ART trial. Results The analysis yielded four potential mechanisms drawn from qualitative data representing the perspectives and priorities of DO ART participants. Empowering participants to schedule, re‐schedule and select the locations of community‐based visits via easy phone contact with clinical staff is characterized as flexibility. Integration refers to combining the components of clinic‐based visits into single interaction with a healthcare provider. Providers” willingness to talk at length with participants during visits, addressing non‐HIV as well as HIV‐related concerns, is termed “a slower pace”. Finally, increased efficiency denotes the time savings and increased income‐generating opportunities for participants brought about by delivering services in the community. Conclusions Understanding the mechanisms through which HIV service delivery innovations produce an effect is key to transferability and potential scale‐up. The perspectives and priorities of PLHIV can indicate actionable changes for HIV care programs that may increase engagement in care and improve treatment outcomes.
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Affiliation(s)
- Hannah N Gilbert
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Monique A Wyatt
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Harvard Global, Cambridge, Massachusetts, USA
| | - Emily E Pisarski
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Stephen Asiimwe
- Mbarara University of Science and Technology, Mbarara, Uganda.,Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA.,Integrated Community-based Initiatives, Kabwohe, Uganda
| | - Heidi van Rooyen
- Human Sciences Research Council, KwaZulu-Natal, South Africa.,SAMRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Janet Seeley
- London School of Hygiene and Tropical Medicine, London, UK.,Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Maryam Shahmanesh
- Africa Health Research Institute, KwaZulu-Natal, South Africa.,Institute for Global Health, University College London, London, UK
| | | | - Alastair van Heerden
- Human Sciences Research Council, KwaZulu-Natal, South Africa.,SAMRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Connie L Celum
- Departments of Global Health and Medicine, University of Washington, Seattle, Washington, USA
| | - Ruanne V Barnabas
- Departments of Global Health and Medicine, University of Washington, Seattle, Washington, USA
| | - Norma C Ware
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
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10
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Mishra A, Mshweshwe-Pakela N, Kubeka G, Hansoti B, Mabuto T, Hoffmann CJ. Systems Analysis to Increase HIV Testing Delivery and HIV Diagnosis in Primary Care Clinics in South Africa. J Acquir Immune Defic Syndr 2021; 87:1048-1054. [PMID: 33871412 DOI: 10.1097/qai.0000000000002692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 03/17/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Provider-initiated testing and counseling remains highly underused in many South African health facilities. We implemented a systems analysis to investigate whether simple adjustments to HIV testing services (HTS) delivery can increase HTS provision. SETTING Ten primary care facilities in the Ekurhuleni District in South Africa. METHODS Following a baseline HTS assessment that showed limited offering of HTS by clinicians, clinic staff had the option to adopt several change approaches to increase HTS delivery using existing human resources. Approaches included adjusting HTS timing, strengthening HTS promotion, counsellor management, and implementing reward systems. Evaluation was conducted identically to the baseline study using patient exit interviews to quantify HTS engagement and value stream mapping to map patient flow through the clinic. RESULTS We conducted 2163 exit interviews and followed 352 patients for value stream mapping. After change implementation, a significantly higher proportion of patients reported being offered HTS (742/2163, 34.3% vs. 231/2206, 10.5% during the baseline period; χ2P < 0.001) and having undertaken testing (527/2163, 24.4% vs. 197/2206, 8.9% during the baseline period; χ2P < 0.001) with only a 3-percentage point decrease in HIV-positive yield (14.0% vs. 17.1% during the baseline period). The median time to HTS offer decreased from 77 minutes to 3 minutes after clinic arrival during the intervention (χ2P = 0.001). CONCLUSIONS A systems approach can be an effective and appropriate implementation strategy to augment HTS delivery and increase HIV diagnoses. This low-cost approach may be extended to optimize other aspects of clinic service delivery.
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Affiliation(s)
- Anant Mishra
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | - Griffiths Kubeka
- Implementation Research Division, the Aurum Institute, Johannesburg, South Africa
| | - Bhakti Hansoti
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Tonderai Mabuto
- Implementation Research Division, the Aurum Institute, Johannesburg, South Africa
- The University of the Witwatersrand School of Public Health, Johannesburg, South Africa; and
| | - Christopher J Hoffmann
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Implementation Research Division, the Aurum Institute, Johannesburg, South Africa
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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11
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Anderson JL, Li P, Bukusi EA, Darbes LA, Hatcher AM, Helova A, Kwena ZA, Musoke PL, Owino G, Oyaro P, Rogers AJG, Turan JM. Effects of a Home-Based Intervention on HIV Prevention Health Behaviors in Pregnant/Postpartum Kenyan Women: Estimating Moderating Effects of Depressive Symptoms. AIDS Behav 2021; 25:1026-1036. [PMID: 33057976 DOI: 10.1007/s10461-020-03046-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2020] [Indexed: 01/05/2023]
Abstract
We estimated effects of maternal depressive symptoms, utilizing the Patient Health Questionnaire-8 (PHQ-8), on women's HIV prevention behaviors in Migori County, Kenya. Pregnant women ≥ 18 years old, with gestational age of < 37 weeks, were randomized into standard care or three home visits (2 during pregnancy, 1 postpartum) promoting couple HIV testing and counseling (CHTC) and HIV prevention. Of 105 female participants, 37 (35.24%) reported depressive symptoms and 50 (47.62%) were HIV-positive. Three Poisson regressions with robust variance (univariable, multivariable, and multivariable with depressive symptoms/study arm interaction) were modeled for three outcomes: CHTC, infant HIV testing, health-seeking postpartum. In multivariable analysis with interaction, a moderating trend for the interaction between depressive symptoms and individual health-seeking was observed (p-value = 0.067). Women scoring ≤ 9 (n = 68) on the PHQ-8 and participating in home visits were 1.76 times more likely to participate in individual health-seeking compared to participants in standard care (ARR 1.76, 95% CI 1.17-2.66).
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Affiliation(s)
- Jami L Anderson
- Department of Health Services Administration, School of Health Professions, University of Alabama at Birmingham, SHPB 553, 1716 9th Ave South, Birmingham, AL, 35294, USA.
| | - Peng Li
- School of Nursing, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Elizabeth A Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Lynae A Darbes
- Center for Sexuality and Health Disparities, Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, Ann Arbor, MI, USA
| | - Abigail M Hatcher
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Anna Helova
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
- Sparkman Center for Global Health, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Zachary A Kwena
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Pamela L Musoke
- Center for Social and Behavioral Research, University of Northern Iowa, Cedar Falls, IA, USA
| | - George Owino
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Patrick Oyaro
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Anna Joy G Rogers
- Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Janet M Turan
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
- Sparkman Center for Global Health, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
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12
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Mshweshwe-Pakela N, Hansoti B, Mabuto T, Kerrigan D, Kubeka G, Hahn E, Charalambous S, Hoffmann CJ. Feasibility of implementing same-day antiretroviral therapy initiation during routine care in Ekurhuleni District, South Africa: Retention and viral load suppression. South Afr J HIV Med 2020; 21:1085. [PMID: 32934830 PMCID: PMC7479383 DOI: 10.4102/sajhivmed.v21i1.1085] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 05/07/2020] [Indexed: 11/29/2022] Open
Abstract
Background Same-day initiation (SDI) of antiretroviral therapy (ART) has been advocated as an approach to increase linkage to care and overall ART initiation. Clinical trials have demonstrated impressive benefits. However, questions regarding patient preparedness and retention in care remain for routine implementation of this approach. Objectives In this study, we sought to describe SDI of ART during routine care delivery and compare time to ART initiation on longitudinal care outcomes. Method We performed a retrospective chart review of 100 consecutive individuals, newly diagnosed with HIV, from 10 health facilities across Ekurhuleni, from January to July 2017. Records were reviewed for a period of 1 year post-diagnosis. Abstracted data included demographics, time to ART initiation, clinic visits and laboratory test results (including viral load testing). Results A total of 993 patient records were reviewed, of which 826 were included in the analysis. The majority of patients (752, 91%) had ART initiation recorded, of which 654 (79%) had ART initiated within 30 days, and 224 (27%) had SDI. Uptake of SDI of ART was higher among women (36% vs. 10.4%; p < 0.001) and in younger patients (33.7% in those < 29 years; p < 0.01). Retention in care at 6 months was achieved in 477 (58%) patients. Of those with 6-month viral loads, 350/430 (73%) had a viral load < 400 c/m. Retention in care and viral suppression were similar among those with SDI of ART and later ART initiation. Conclusion Same-day initiation of ART was successfully delivered with similar retention and viral load outcomes as subsequent initiation, providing re-assurance for scale-up of this strategy in routine care.
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Affiliation(s)
| | - Bhakti Hansoti
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, United States of America.,Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States of America
| | - Tonderai Mabuto
- Implementation Research Division, The Aurum Institute, Johannesburg, South Africa.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Deanna Kerrigan
- Department of Sociology, American University, Washington, United States of America
| | - Griffiths Kubeka
- Implementation Research Division, The Aurum Institute, Johannesburg, South Africa
| | - Elizabeth Hahn
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States of America
| | - Salome Charalambous
- Implementation Research Division, The Aurum Institute, Johannesburg, South Africa.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Christopher J Hoffmann
- Implementation Research Division, The Aurum Institute, Johannesburg, South Africa.,Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, United States of America.,Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States of America
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13
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Lifson AR, Workneh S, Hailemichael A, MacLehose RF, Horvath KJ, Hilk R, Sites AR, Shenie T. Advanced HIV Disease among Males and Females Initiating HIV Care in Rural Ethiopia. J Int Assoc Provid AIDS Care 2020; 18:2325958219847199. [PMID: 31104543 PMCID: PMC6748532 DOI: 10.1177/2325958219847199] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Despite recommendations for rapidly initiating HIV treatment, many persons in sub-Saharan
Africa present to care with advanced HIV disease. Baseline survey and clinical data were
collected on 1799 adults newly enrolling at 32 district hospitals and local health HIV
clinics in rural Ethiopia. Among those with complete HIV disease information, advanced HIV
disease (defined as CD4 count <200 cells/mm3 or World Health Organization
[WHO] HIV clinical stage III or IV disease) was present in 66% of males and 56% of females
(P < .001). Males (compared to females) had lower CD4 counts (287
cells/mm3 versus 345 cells/mm3), lower body mass index (19.3
kg/m2 versus 20.2 kg/m2), and more WHO stage III or IV disease
(46% versus 37%), (P < .001). Men reported more chronic diarrhea,
fevers, cough, pain, fatigue, and weight loss (P < .05). Most
initiating care in this resource-limited setting had advanced HIV disease. Men had poorer
health status, supporting the importance of earlier diagnosis, linkage to care, and
initiation of antiretroviral therapy.
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Affiliation(s)
- Alan Raymond Lifson
- 1 Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Sale Workneh
- 2 National Alliance of State and Territorial AIDS Directors, Ethiopian Office, Addis Ababa, Ethiopia
| | - Abera Hailemichael
- 2 National Alliance of State and Territorial AIDS Directors, Ethiopian Office, Addis Ababa, Ethiopia
| | | | - Keith Joseph Horvath
- 1 Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Rose Hilk
- 1 Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Anne Redmond Sites
- 3 National Alliance of State and Territorial AIDS Directors, Global Program, Washington, DC, USA
| | - Tibebe Shenie
- 2 National Alliance of State and Territorial AIDS Directors, Ethiopian Office, Addis Ababa, Ethiopia
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14
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Mabuto T, Woznica DM, Lekubu G, Seatlholo N, Mshweshwe-Pakela N, Charalambous S, Hoffmann CJ. Observational study of continuity of HIV care following release from correctional facilities in South Africa. BMC Public Health 2020; 20:324. [PMID: 32164628 PMCID: PMC7068979 DOI: 10.1186/s12889-020-8417-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 02/26/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND We sought to describe linkage to care, ART continuity, and factors associated with linkage to care among people with HIV following release from incarceration in South Africa. METHODS We conducted a study of South African correctional service community reentrants who were receiving ART at the time of release. The study was implemented in three of 46 correctional service management areas. Participants were enrolled prior to corrections release and followed up to 90 days post-release to obtain self-reported linkage to care status and number of days of ART provided at corrections release. Clinic electronic and paper charts were sought and abstracted to verify self-reported linkage to care. Log-binomial regression, adjusted for facility, was used to identify associations with post-release linkage to care (self-reported and verified). We sought to specifically assess for associations with HIV diagnosis during index incarceration, ART initiation during index incarceration, and duration of incarceration. RESULTS From May 2014 to December 2016, 554 inmates met eligibility and 516 (93%) consented to participate; 391 were released on ART, 40 of whom were excluded from analysis post-release. Of the remaining 351, 301 (86%) were men and the median age was 35 years (interquartile range 30, 40). Linkage to care was self-reported by 227 (64%) and linkage to care could be verified for 121 (34%). At most, 47% of participants had no lapse in ART supply. Initiating ART during the index incarceration showed a trend toward increased self-reported post-release linkage to care. Age > 35 years was associated with increased verified linkage to care while HIV diagnosis outside of a correctional setting and ART initiation during the index incarceration showed trends toward association with increased verified linkage to care. DISCUSSION The results of our study are the first description of retention in care following correctional facility release from an African setting and indicate high levels of attrition during the transition from correctional facility to community care. Initiating ART within a correctional facility did not impair post-release linkage to care.
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Affiliation(s)
- Tonderai Mabuto
- Aurum Institute, Johannesburg, South Africa
- The University of the Witwatersrand School of Public Health, Johannesburg, South Africa
| | - Daniel M Woznica
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, USA
| | - Gloria Lekubu
- Department of Correctional Services, Gauteng Region, South Africa
| | | | | | - Salome Charalambous
- Aurum Institute, Johannesburg, South Africa
- The University of the Witwatersrand School of Public Health, Johannesburg, South Africa
| | - Christopher J Hoffmann
- Aurum Institute, Johannesburg, South Africa.
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, USA.
- Johns Hopkins University School of Medicine, CRB2 Rm 1M11, 1550 Orleans Rd, Baltimore, MD, 21205, USA.
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15
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Maughan-Brown B, Beckett S, Kharsany ABM, Cawood C, Khanyile D, Lewis L, Venkataramani A, George G. Poor rates of linkage to HIV care and uptake of treatment after home-based HIV testing among newly diagnosed 15-to-49 year-old men and women in a high HIV prevalence setting in South Africa. AIDS Care 2020; 33:70-79. [DOI: 10.1080/09540121.2020.1719025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Brendan Maughan-Brown
- Southern Africa Labour and Development Research Unit (SALDRU), University of Cape Town, Rondebosch, South Africa
| | - Sean Beckett
- Health Economics and HIV and AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa
| | - Ayesha B. M. Kharsany
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | | | | | - Lara Lewis
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Atheendar Venkataramani
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Gavin George
- Health Economics and HIV and AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa
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16
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Luong Nguyen LB, Yazdanpanah Y, Maman D, Wanjala S, Vandenbulcke A, Price J, Parker RA, Hennequin W, Mendiharat P, Freedberg KA. Voluntary Community Human Immunodeficiency Virus Testing, Linkage, and Retention in Care Interventions in Kenya: Modeling the Clinical Impact and Cost-effectiveness. Clin Infect Dis 2019; 67:719-726. [PMID: 29746619 PMCID: PMC6094004 DOI: 10.1093/cid/ciy173] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Accepted: 04/02/2018] [Indexed: 01/30/2023] Open
Abstract
Background In southwest Kenya, the prevalence of human immunodeficiency virus (HIV) infection is about 25%. Médecins Sans Frontières has implemented a voluntary community testing (VCT) program, with linkage to care and retention interventions, to achieve the Joint United Nations Program on HIV and AIDS (UNAIDS) 90-90-90 targets by 2017. We assessed the effectiveness and cost-effectiveness of these interventions. Methods We developed a time-discrete, dynamic microsimulation model to project HIV incidence over time in the adult population in Kenya. We modeled 4 strategies: VCT, VCT-plus-linkage to care, a retention intervention, and all 3 interventions combined. Effectiveness outcomes included HIV incidence, years of life saved (YLS), cost (2014 €), and cost-effectiveness. We performed sensitivity analyses on key model parameters. Results With current care, the projected HIV incidence for 2032 was 1.51/100 person-years (PY); the retention and combined interventions decreased incidence to 1.03/100 PY and 0.75/100 PY, respectively. For 100000 individuals, the retention intervention had an incremental cost-effectiveness ratio (ICER) of €130/YLS compared with current care; the combined intervention incremental cost-effectiveness ratio was €370/YLS compared with the retention intervention. VCT and VCT-plus-linkage interventions cost more and saved fewer life-years than the retention and combined interventions. Baseline HIV prevalence had the greatest impact on the results. Conclusions Interventions targeting VCT, linkage to care, and retention would decrease HIV incidence rate over 15 years in rural Kenya if planned targets are achieved. These interventions together would be more effective and cost-effective than targeting a single stage of the HIV care cascade.
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Affiliation(s)
- Liem B Luong Nguyen
- Infection, Antimicrobials, Modelling, Evolution, UMR 1137, INSERM.,University Pierre and Marie Curie University Paris 06.,Paris Diderot University, Sorbonne Paris Cité
| | - Yazdan Yazdanpanah
- Infection, Antimicrobials, Modelling, Evolution, UMR 1137, INSERM.,University Pierre and Marie Curie University Paris 06.,Paris Diderot University, Sorbonne Paris Cité
| | | | | | | | | | - Robert A Parker
- Medical Practice Evaluation Center and Divisions of General Internal Medicine and Infectious Diseases, Massachusetts General Hospital, and Harvard Medical School
| | | | | | - Kenneth A Freedberg
- Medical Practice Evaluation Center and Divisions of General Internal Medicine and Infectious Diseases, Massachusetts General Hospital, and Harvard Medical School.,Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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17
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Abstract
BACKGROUND Home-based counseling and testing (HBCT) achieves earlier HIV diagnosis than other testing modalities; however, retention in care for these healthier patients is unknown. The objective of this study was to determine the association between point of HIV testing and retention in care and mortality. SETTING Academic Model Providing Access to Healthcare (AMPATH) has provided HIV care in western Kenya since 2001. METHODS AMPATH initiated HBCT in 2007. This retrospective analysis included individuals 13 years and older, enrolled in care between January 2008 and September 2016, with data on point of testing. Discrete-time multistate models were used to estimate the probability of transition between the following states: engaged, disengaged, transfer, and death, and the association between point of diagnosis and transition probabilities. RESULTS Among 77,358 patients, 67% women, median age: 35 years and median baseline CD4: 248 cells/mm. Adjusted results demonstrated that patients from HBCT were less likely to disengage [relative risk ratio (RRR) = 0.87, 95% CI: 0.83 to 0.91] and die (RRR = 0.65, 95% CI: 0.55 to 0.75), whereas those diagnosed through provider-initiated counseling and testing were more likely to disengage (RRR = 1.09, 95% CI: 1.07 to 1.12) and die (RRR = 1.13, 95% CI: 1.06 to 1.20), compared with patients from voluntary counseling and testing. Once disengaged, patients from HBCT were less likely to remain disengaged, compared with patients from voluntary counseling and testing. CONCLUSIONS Patients entering care from different HIV-testing programs demonstrate differences in retention in HIV care over time beyond disease severity. Additional research is needed to understand the patient and system level factors that may explain the associations between testing program, retention, and mortality.
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18
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Genberg BL, Hogan JW, Xu Y, Nyambura M, Tarus C, Rotich E, Kafu C, Wachira J, Goodrich S, Braitstein P. Population-based estimates of engagement in HIV care and mortality using double-sampling methods following home-based counseling and testing in western Kenya. PLoS One 2019; 14:e0223187. [PMID: 31577834 PMCID: PMC6774575 DOI: 10.1371/journal.pone.0223187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 09/16/2019] [Indexed: 11/18/2022] Open
Abstract
Introduction Data on engagement in HIV care from population-based samples in sub-Saharan Africa are limited. The objective of this study was to use double-sampling methods to estimate linkage to HIV care, ART initiation, and mortality among all adults diagnosed with HIV by a comprehensive home-based counseling and testing (HBCT) program in western Kenya. Methods HBCT was conducted door-to-door from December 2009 to April 2011 in three sub-counties of western Kenya by AMPATH (Academic Model Providing Access to Healthcare). For those identified as HIV-positive, data were merged with electronic medical records to determine engagement with HIV care. A randomly-drawn follow-up sample of 120 adults identified via HBCT who had not linked to care as of June 2015 in Bunyala sub-county were visited by trained fieldworkers to ascertain HIV care engagement and vital status. Double-sampled data were used to generate, via multinomial regression, predicted probabilities of engagement in care and mortality among those whose status could not be ascertained by matching with the electronic medical records in the three catchments. Results Incorporating information from the double-sampling yielded estimates of prospective linkage to HIV care that ranged from 40–45%. Mortality estimates of those who did not engage in care following HBCT ranged from 12–16%. Among those who linked to care following HBCT, between 72–81% initiated ART. Discussion In settings without universal national identifiers, rates of linkage to care from community-based programs may be subject to substantial underestimation. Follow-up samples of those with missing information can be used to partially correct this bias, as has been demonstrated previously for mortality among those who were lost-to-care programs. There is a need for harmonized data systems across health systems and programs.
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Affiliation(s)
- Becky L. Genberg
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Brown University, Providence, Rhode Island, United States of America
| | - Joseph W. Hogan
- Department of Biostatistics, Brown University School of Public Health, Brown University, Providence, Rhode Island, United States of America
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Yizhen Xu
- Department of Biostatistics, Brown University School of Public Health, Brown University, Providence, Rhode Island, United States of America
| | - Monicah Nyambura
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Caren Tarus
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Elyne Rotich
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Catherine Kafu
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Juddy Wachira
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- College of Health Sciences, School of Medicine, Moi University, Eldoret, Kenya
| | - Suzanne Goodrich
- Division of Infectious Diseases, School of Medicine, Indiana University, Indianapolis, Indiana, United States of America
| | - Paula Braitstein
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- College of Health Sciences, School of Medicine, Moi University, Eldoret, Kenya
- Epidemiology Division, Office of Global Public Health Education & Training, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- * E-mail:
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19
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Mabuto T, Hansoti B, Kerrigan D, Mshweshwe‐Pakela N, Kubeka G, Charalambous S, Hoffmann C. HIV testing services in healthcare facilities in South Africa: a missed opportunity. J Int AIDS Soc 2019; 22:e25367. [PMID: 31599495 PMCID: PMC6785782 DOI: 10.1002/jia2.25367] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 07/11/2019] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION South Africa (SA) has the world's highest burden of HIV infection (approximately 7.2 million), yet it is estimated that 23.5% women and 31.5% of men are unaware that they are living with HIV. The 2015 national South African HIV testing guidelines mandate the universal offer of HIV testing services (HTS) in all healthcare facilities. METHODS A multi-prong approach was used from January 2017 to June 2017 to evaluate the current implementation of HTS in ten facilities in the Ekurhuleni District of SA. First, we conducted patient exit interviews to quantify engagement in HTS services. Second, we systematically mapped the flow of individual patients through the clinic. RESULTS We conducted a total of 2989 exit interviews and followed 568 patients for value stream mapping. Overall self-reported testing acceptance was high at 84.7% (244), but <10% of the patients (288) were offered testing. Female patients were more likely to be offered testing (233/2046, 11.4% vs. 55/943, 5.8% in males; chi-square p < 0.005), and also more likely to accept testing (203/233, 87.1% vs. 41/55, 74.6% in males; chi-square p = 0.02). Value stream mapping revealed that patients offered HIV testing had a total visit time of 51 minutes more (95% CI: 30-72) compared to those not offered testing. CONCLUSIONS The poor delivery of HTS appears to be due to a failure to recommend HTS and the added time burden placed on those accepting testing. There were significant differences in both the offer and acceptance of testing by gender. Health system issues need to be addressed to improve HTS delivery.
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Affiliation(s)
- Tonderai Mabuto
- Implementation Research DivisionThe Aurum InstituteJohannesburgSouth Africa
- The University of the Witwatersrand School of Public HealthJohannesburgSouth Africa
| | - Bhakti Hansoti
- Department of Emergency MedicineJohns Hopkins School of MedicineBaltimoreMDUSA
- Department of International HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
| | | | | | - Griffiths Kubeka
- Implementation Research DivisionThe Aurum InstituteJohannesburgSouth Africa
| | - Salome Charalambous
- Implementation Research DivisionThe Aurum InstituteJohannesburgSouth Africa
- The University of the Witwatersrand School of Public HealthJohannesburgSouth Africa
| | - Christopher Hoffmann
- Department of MedicineJohns Hopkins University School of MedicineBaltimoreMDUSA
- Department of Health, Behavior, and SocietyJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
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Continuum of HIV Care in Rural Mozambique: The Implications of HIV Testing Modality on Linkage and Retention. J Acquir Immune Defic Syndr 2019; 78:527-535. [PMID: 29771786 PMCID: PMC6075879 DOI: 10.1097/qai.0000000000001720] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Supplemental Digital Content is Available in the Text. Introduction: Context-specific improvements in the continuum of HIV care are needed to achieve the UNAIDS target of 90-90-90. This study aimed to assess the linkage to and retention in HIV care according to different testing modalities in rural southern Mozambique. Methods: Adults newly diagnosed with HIV from voluntary counseling and testing, provider-initiated counseling and testing, and home-based HIV testing services were prospectively enrolled between 2014 and 2015 at the Manhiça District. Patients were passively followed up through chart examination. Tracing was performed at 12 months to ascertain causes of loss to follow-up. Fine and Gray competing risk analysis was performed to determine factors associated with the each step of the cascade. Results: Overall linkage to care as defined by having a CD4 count at 3 months was 43.7% [95% confidence interval (CI): 40.8 to 46.6] and 25.2% of all participants initiated antiretroviral therapy. Factors associated with increased linkage in multivariable analysis included testing at voluntary counseling and testing, older age, having been previously tested for HIV, owning a cell phone, presenting with WHO clinical stages III/IV, self-reported illness-associated disability in the previous month, and later calendar month of participant recruitment. Ascertaining deaths and transfers allowed for adjustment of the rate of 12-month retention in treatment from 75.6% (95% CI: 70.2 to 80.5) to 84.2% (95% CI: 79.2 to 88.5). Conclusions: Home-based HIV testing reached a sociodemographically distinct population from that of clinic-based testing modalities but low linkage to care points to a need for facilitated linkage interventions. Distinguishing between true treatment defaulting and other causes of loss to follow-up can significantly change indicators of retention in care.
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Kamaara E, Oketch D, Chesire I, Coats CS, Thomas G, Ransome Y, Willie TC, Nunn A. Faith and healthcare providers' perspectives about enhancing HIV biomedical interventions in Western Kenya. Glob Public Health 2019; 14:1744-1756. [PMID: 31390958 DOI: 10.1080/17441692.2019.1647263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Adult HIV prevalence in Kenya was 5.9% in 2017. However, in the counties of Kisumu, Siaya, and Homa Bay, HIV prevalence was over 15%. Biomedical interventions, including home-based testing and counselling (HBTC), HIV treatment and pre-exposure prophylaxis (PrEP) provide opportunities to reduce HIV transmission, particularly in rural communities with limited access to health services. Faith-based institutions play an important role in the Kenyan social fabric, providing over 40% of all health care services in Kenya, but have played limited roles in promoting HIV prevention interventions. We conducted qualitative interviews with 45 medical professionals and focus groups with 93 faith leaders in Kisumu and Busia Counties, Kenya. We explored their knowledge, opinions, and experiences in promoting biomedical HIV prevention modalities, including HBTC and PrEP. Knowledge about and engagement in efforts to promote HIV prevention modalities varied; few health providers had partnered with faith leaders on HIV prevention programmes. Faith leaders and health providers agreed about the importance of increasing faith leaders' participation in HIV prevention and were positive about increasing their HIV prevention partnerships. Most faith leaders requested capacity building to better understand biomedical HIV prevention modalities and expressed interest in collaborating with clinical partners to spread awareness about HIV prevention modalities.
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Affiliation(s)
- Eunice Kamaara
- Department of Philosophy & Religious Studies, Moi University , Eldoret , Kenya
| | - Dismas Oketch
- Kenya Medical Research Institute (KEMRI)/CDC Clinical Research Center , Kisumu , Kenya
| | - Irene Chesire
- Department of Behavioral Science, School of Medicine, Moi University , Eldoret , Kenya
| | - Cassandra Sutten Coats
- Center for Health Equity Research, Brown University School of Public Health , Providence , RI , USA
| | - Gladys Thomas
- Department of Behavioral and Social Science, Brown University School of Public Health , Providence , RI , USA
| | - Yusuf Ransome
- Department of Social and Behavioral Sciences, Yale School of Public Health , Hartford , CT , USA
| | - Tiara C Willie
- Department of Medicine, Brown University Warren Alpert Medical School , Providence , RI , USA
| | - Amy Nunn
- Center for Health Equity Research, Brown University School of Public Health , Providence , RI , USA.,Department of Behavioral and Social Science, Brown University School of Public Health , Providence , RI , USA
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22
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Sanga ES, Mukumbang FC, Mushi AK, Lerebo W, Zarowsky C. Understanding factors influencing linkage to HIV care in a rural setting, Mbeya, Tanzania: qualitative findings of a mixed methods study. BMC Public Health 2019; 19:383. [PMID: 30953503 PMCID: PMC6451278 DOI: 10.1186/s12889-019-6691-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 03/21/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND In remote rural Tanzania, the rate of linkage into HIV care was estimated at 28% in 2014. This study explored facilitators and barriers to linkage to HIV care at individual/patient, health care provider, health system, and contextual levels to inform eventual design of interventions to improve linkage to HIV care. METHODS We conducted a descriptive qualitative study nested in a cohort study of 1012 newly diagnosed HIV-positive individuals in Mbeya region between August 2014 and July 2015. We conducted 8 focus group discussions and 10 in-depth interviews with recently diagnosed HIV-positive individuals and 20 individual interviews with healthcare providers. Transcripts were analyzed inductively using thematic content analysis. The emergent themes were then deductively fitted into the four level ecological model. RESULTS We identified multiple factors influencing linkage to care. HIV status disclosure, support from family/relatives and having symptoms of disease were reported to facilitate linkage at the individual level. Fear of stigma, lack of disclosure, denial and being asymptomatic, belief in witchcraft and spiritual beliefs were barriers identified at individual's level. At providers' level; support and good patient-staff relationship facilitated linkage, while negative attitudes and abusive language were reported barriers to successful linkage. Clear referral procedures and well-organized clinic procedures were system-level facilitators, whereas poorly organized clinic procedures and visit schedules, overcrowding, long waiting times and lack of resources were reported barriers. Distance and transport costs to HIV care centers were important contextual factors influencing linkage to care. CONCLUSION Linkage to HIV care is an important step towards proper management of HIV. We found that access and linkage to care are influenced positively and negatively at all levels, however, the individual-level and health system-level factors were most prominent in this setting. Interventions must address issues around stigma, denial and inadequate awareness of the value of early linkage to care, and improve the capacity of HIV treatment/care clinics to implement quality care, particularly in light of adopting the 'Test and Treat' model of HIV treatment and care recommended by the World Health Organization.
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Affiliation(s)
- Erica S Sanga
- NIMR-Mwanza Medical Research Centre, P.O Box 1462, Mwanza, Tanzania. .,School of Public Health- University of Western Cape, Cape Town, South Africa. .,NIMR-Mwanza Medical Research Centre (MMRC), Mbeya, Tanzania.
| | - Ferdinand C Mukumbang
- School of Public Health- University of Western Cape, Cape Town, South Africa.,Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Adiel K Mushi
- National Institute for Medical Research (NIMR), London, England
| | - Wondwossen Lerebo
- School of Public Health- University of Western Cape, Cape Town, South Africa.,School of Public Health, Mekelle University, Makelle, Ethiopia
| | - Christina Zarowsky
- School of Public Health- University of Western Cape, Cape Town, South Africa.,University of Montreal Hospital Research Centre and School of Public Health, Universite de Montreal, Montreal, Canada
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23
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Knight J, Wachira J, Kafu C, Braitstein P, Wilson IB, Harrison A, Owino R, Akinyi J, Koech B, Genberg B. The Role of Gender in Patient-Provider Relationships: A Qualitative Analysis of HIV Care Providers in Western Kenya with Implications for Retention in Care. AIDS Behav 2019; 23:395-405. [PMID: 30168005 DOI: 10.1007/s10461-018-2265-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The disproportionate burden of HIV among women in sub-Saharan Africa reflects underlying gender inequities, which also impact patient-provider relationships, a key component to retention in HIV care. This study explored how gender shaped the patient-provider relationship and consequently, retention in HIV care in western Kenya. We recruited and consented 60 HIV care providers from three facilities in western Kenya affiliated with the Academic Model Providing Access to Healthcare (AMPATH). Trained research assistants conducted and audio recorded 1-h interviews in English or Swahili. Data were transcribed and analyzed in NVivo using inductive thematic analysis. Gender constructs, as culturally defined, emerged as an important barrier negatively impacting the patient-provider relationship through three main domains: (1) challenges establishing clear roles and sharing power due to conflicting gender versus patient/provider identities, (2) provider frustration over suboptimal patient adherence resulting from gender-influenced contextual barriers, and (3) negative provider perceptions shaped by differing male and female approaches to communication. Programmatic components addressing gender inequities in the health care setting are urgently needed to effectively leverage the patient-provider relationship and fully promote long-term adherence and retention in HIV care.
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Affiliation(s)
- Jennifer Knight
- Brown University School of Public Health, Providence, RI, USA.
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Juddy Wachira
- School of Medicine, Moi University College of Health Sciences, Eldoret, Kenya
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Catherine Kafu
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Paula Braitstein
- School of Medicine, Moi University College of Health Sciences, Eldoret, Kenya
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Ira B Wilson
- Brown University School of Public Health, Providence, RI, USA
| | | | - Regina Owino
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Jacqueline Akinyi
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Beatrice Koech
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Becky Genberg
- Brown University School of Public Health, Providence, RI, USA
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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24
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Sanga ES, Mukumbang FC, Mushi AK, Olomi W, Lerebo W, Zarowsky C. Processes and dynamics of linkage to care from mobile/outreach and facility-based HIV testing models in hard-to-reach settings in rural Tanzania. Qualitative findings of a mixed methods study. AIDS Res Ther 2018; 15:21. [PMID: 30458874 DOI: 10.1186/s12981-018-0209-8n.pag-n.pag] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 11/08/2018] [Indexed: 05/22/2023] Open
Abstract
BACKGROUND Like other countries, Tanzania instituted mobile and outreach testing approaches to address low HIV testing rates at health facilities and enhance linkage to care. Available evidence from hard-to-reach rural settings of Mbeya region, Tanzania suggests that clients testing HIV+ at facility-based sites are more likely to link to care, and to link sooner, than those testing at mobile sites. This paper (1) describes the populations accessing HIV testing at mobile/outreach and facility-based testing sites, and (2) compares processes and dynamics from testing to linkage to care between these two testing models from the same study context. METHODS An explanatory sequential mixed-method study (a) reviewed records of all clients (n = 11,773) testing at 8 mobile and 8 facility-based testing sites over 6 months; (b), reviewed guidelines; (c) observed HIV testing sites (n = 10) and Care and Treatment Centers (CTCs) (n = 8); (d) applied questionnaires at 0, 3 and 6 months to a cohort of 1012 HIV newly-diagnosed clients from the 16 sites; and (e) conducted focus group discussions (n = 8) and in-depth qualitative interviews with cohort members (n = 10) and health care providers (n = 20). RESULTS More clients tested at mobile/outreach than facility-based sites (56% vs 44% of 11,733, p < 0.001). Mobile site clients were more likely to be younger and male (p < 0.001). More clients testing at facility sites were HIV positive (21.5% vs. 7.9% of 11,733, p < 0.001). All sites in both testing models adhered to national HIV testing and care guidelines. Staff at mobile sites showed more proactive efforts to support linkage to care, and clients report favouring the confidentiality of mobile sites to avoid stigma. Clients who tested at mobile/outreach sites faced longer delays and waiting times at treatment sites (CTCs). CONCLUSIONS Rural mobile/outreach HIV testing sites reach more people than facility based sites but they reach a different clientèle which is less likely to be HIV +ve and appears to be less "linkage-ready". Despite more proactive care and confidentiality at mobile sites, linkage to care is worse than for clients who tested at facility-based sites. Our findings highlight a combination of (a) patient-level factors, including stigma; and (b) well-established procedures and routines for each step between testing and initiation of treatment in facility-based sites. Long waiting times at treatment sites are a further barrier that must be addressed.
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Affiliation(s)
- Erica S Sanga
- NIMR-Mwanza Medical Research Centre (MMRC), Mwanza, Tanzania.
- School of Public Health, University of Western Cape, Cape Town, South Africa.
- NIMR-Mbeya Medical Research Centre (MMRC), Mbeya, Tanzania.
| | - Ferdinand C Mukumbang
- School of Public Health, University of Western Cape, Cape Town, South Africa
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Adiel K Mushi
- National Institute for Medical Research (NIMR), Dar-es-Salaam, Tanzania
| | | | - Wondwossen Lerebo
- School of Public Health, University of Western Cape, Cape Town, South Africa
- School of Public Health, Mekelle University, Mekelle, Ethiopia
| | - Christina Zarowsky
- School of Public Health, University of Western Cape, Cape Town, South Africa
- University of Montreal Hospital Research Centre and School of Public Health, Université de Montréal, Montreal, Canada
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25
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Processes and dynamics of linkage to care from mobile/outreach and facility-based HIV testing models in hard-to-reach settings in rural Tanzania. Qualitative findings of a mixed methods study. AIDS Res Ther 2018; 15:21. [PMID: 30458874 PMCID: PMC6247671 DOI: 10.1186/s12981-018-0209-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 11/08/2018] [Indexed: 12/23/2022] Open
Abstract
Background Like other countries, Tanzania instituted mobile and outreach testing approaches to address low HIV testing rates at health facilities and enhance linkage to care. Available evidence from hard-to-reach rural settings of Mbeya region, Tanzania suggests that clients testing HIV+ at facility-based sites are more likely to link to care, and to link sooner, than those testing at mobile sites. This paper (1) describes the populations accessing HIV testing at mobile/outreach and facility-based testing sites, and (2) compares processes and dynamics from testing to linkage to care between these two testing models from the same study context. Methods An explanatory sequential mixed-method study (a) reviewed records of all clients (n = 11,773) testing at 8 mobile and 8 facility-based testing sites over 6 months; (b), reviewed guidelines; (c) observed HIV testing sites (n = 10) and Care and Treatment Centers (CTCs) (n = 8); (d) applied questionnaires at 0, 3 and 6 months to a cohort of 1012 HIV newly-diagnosed clients from the 16 sites; and (e) conducted focus group discussions (n = 8) and in-depth qualitative interviews with cohort members (n = 10) and health care providers (n = 20). Results More clients tested at mobile/outreach than facility-based sites (56% vs 44% of 11,733, p < 0.001). Mobile site clients were more likely to be younger and male (p < 0.001). More clients testing at facility sites were HIV positive (21.5% vs. 7.9% of 11,733, p < 0.001). All sites in both testing models adhered to national HIV testing and care guidelines. Staff at mobile sites showed more proactive efforts to support linkage to care, and clients report favouring the confidentiality of mobile sites to avoid stigma. Clients who tested at mobile/outreach sites faced longer delays and waiting times at treatment sites (CTCs). Conclusions Rural mobile/outreach HIV testing sites reach more people than facility based sites but they reach a different clientèle which is less likely to be HIV +ve and appears to be less “linkage-ready”. Despite more proactive care and confidentiality at mobile sites, linkage to care is worse than for clients who tested at facility-based sites. Our findings highlight a combination of (a) patient-level factors, including stigma; and (b) well-established procedures and routines for each step between testing and initiation of treatment in facility-based sites. Long waiting times at treatment sites are a further barrier that must be addressed.
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26
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HIV-1 second-line failure and drug resistance at high-level and low-level viremia in Western Kenya. AIDS 2018; 32:2485-2496. [PMID: 30134290 DOI: 10.1097/qad.0000000000001964] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Characterize failure and resistance above and below guidelines-recommended 1000 copies/ml virologic threshold, upon second-line failure. DESIGN Cross-sectional study. METHODS Kenyan adults on lopinavir/ritonavir-based second-line were enrolled at AMPATH (Academic Model Providing Access to Healthcare). Charts were reviewed for demographic/clinical characteristics and CD4/viral load were obtained. Participants with detectable viral load had a second visit and pol genotyping was attempted in both visits. Accumulated resistance was defined as mutations in the second, not the first visit. Low-level viremia (LLV) was detectable viral load less than 1000 copies/ml. Failure and resistance associations were evaluated using logistic and Poisson regression, Fisher Exact and t-tests. RESULTS Of 394 participants (median age 42, 60% women, median 1.9 years on second-line) 48% had detectable viral load; 21% had viral load more than 1000 copies/ml, associated with younger age, tuberculosis treatment, shorter time on second-line, lower CD4count/percentage, longer first-line treatment interruption and pregnancy. In 105 sequences from the first visit (35 with LLV), 79% had resistance (57% dual-class, 7% triple-class; 46% with intermediate-to-high-level resistance to ≥1 future drug option). LLV was associated with more overall and NRTI-associated mutations and with predicted resistance to more next-regimen drugs. In 48 second-visit sequences (after median 55 days; IQR 28-33), 40% accumulated resistance and LLV was associated with more mutation accumulation. CONCLUSION High resistance upon second-line failure exists at levels above and below guideline-recommended virologic-failure threshold, impacting future treatment options. Optimization of care should include increased viral load monitoring, resistance testing and third-line ART access, and consideration of lowering the virologic failure threshold, though this demands further investigation.
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27
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Rentsch CT, Wringe A, Machemba R, Michael D, Urassa M, Todd J, Reniers G, Zaba B. Linkage to care and antiretroviral therapy initiation by testing modality among individuals newly diagnosed with HIV in Tanzania, 2014-2017. Trop Med Int Health 2018; 23:1384-1393. [PMID: 30282113 PMCID: PMC6334504 DOI: 10.1111/tmi.13153] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To measure linkage to care and antiretroviral therapy (ART) initiation among newly diagnosed individuals with HIV in a rural Tanzanian community. METHODS We included all new HIV diagnoses of adults made between 2014 and 2017 during community- or facility-based HIV testing and counselling (HTC) in a rural ward in northwest Tanzania. Community-based HTC included population-level HIV serological testing (sero-survey), and facility-based HTC included a stationary, voluntary HTC clinic (VCT) and an antenatal clinic (ANC) offering provider-initiated HTC (ANC-PITC). Cox regression models were used to compare linkage to care rates by testing modality and identify associated factors. Among those in care, we compared initial CD4 cell counts and ART initiation rates by testing modality. RESULTS A total of 411 adults were newly diagnosed, of whom 10% (27/265 sero-survey), 18% (3/14 facility-based ANC-PITC) and 53% (68/129 facility-based VCT) linked to care within 90 days. Individuals diagnosed using facility-based VCT were seven times (95% CI: 4.5-11.0) more likely to link to care than those diagnosed in the sero-survey. We found no difference in linkage rates between those diagnosed using facility-based ANC-PITC and sero-survey (P = 0.26). Among individuals in care, 63% of those in the sero-survey had an initial CD4 count >350 cells/mm3 vs. 29% of those using facility-based VCT (P = 0.02). The proportion who initiated ART within 1 year of linkage to care was similar for both groups (94% sero-survey vs. 85% facility-based VCT; P = 0.16). CONCLUSIONS Community-based sero-surveys are important for earlier diagnosis of HIV-positive individuals; however, interventions are essential to facilitate linkage to care.
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Affiliation(s)
- Christopher T Rentsch
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Alison Wringe
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Richard Machemba
- The Tazama Project, National Institute for Medical Research, Mwanza, Tanzania
| | - Denna Michael
- The Tazama Project, National Institute for Medical Research, Mwanza, Tanzania
| | - Mark Urassa
- The Tazama Project, National Institute for Medical Research, Mwanza, Tanzania
| | - Jim Todd
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK.,The Tazama Project, National Institute for Medical Research, Mwanza, Tanzania
| | - Georges Reniers
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK.,MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Basia Zaba
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
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Time taken to link newly identified HIV positive clients to care following a home-base index case HIV testing: Experience from two provinces in Zimbabwe. PLoS One 2018; 13:e0201018. [PMID: 30133526 PMCID: PMC6104920 DOI: 10.1371/journal.pone.0201018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Accepted: 07/07/2018] [Indexed: 12/21/2022] Open
Abstract
Background Homebased index case HIV testing (HHTC) has shown higher uptake and good yield than traditional HIV testing methods. World Health Organization has called for increased operational research to evaluate HIV care processes particularly linkage to care. In this paper, we present project results of the time taken to link newly identified PLHIV to care after HHTC in the Manicaland and Midlands provinces of Zimbabwe. Methods We retrospectively reviewed community-facility referral data from the Zimbabwe HIV Care and Treatment project for newly diagnosed PLHIV for the period March–September 2016. A referral slip was given to a client after receiving a positive HIV results and was presented and filed upon reaching a health facility. In July 2016, the project started working with trained expert clients to assist with linkage to care. Data was entered in a spreadsheet and then imported for descriptive statistical analysis with EpiInfoTM Version 7.2.0.1. Odd ratios were used to identify factors associated with linkage to care within seven days. Results Out of 1004 newly identified PLHIV between March and September 2016, 650 (64.7%) were linked to care. The median time taken to be linked to care was four days (Interquartile range 19 days). Overall, 63.1% (410) of PLHIV were linked to care within seven days of diagnosis and 85% within 30 days. PLHIV were more likely to be linked to care within seven days of diagnosis between July and September 2016 (OR = 4.1; p< 0.001), a period when ZHCT started working with expert clients to support linkage to care. Conclusion HHTC resulted in almost 63% of newly diagnosed PLHIV being linked into care within seven days, and 85% within 30 days. Linkage to care within seven days was significantly associated with the period of engaging expert clients in the project. We recommend community based HIV testing programs to work with expert clients to ensure timely linkages of new PLHIV.
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Sabapathy K, Hensen B, Varsaneux O, Floyd S, Fidler S, Hayes R. The cascade of care following community-based detection of HIV in sub-Saharan Africa - A systematic review with 90-90-90 targets in sight. PLoS One 2018; 13:e0200737. [PMID: 30052637 PMCID: PMC6063407 DOI: 10.1371/journal.pone.0200737] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 05/25/2018] [Indexed: 12/03/2022] Open
Abstract
Introduction We aimed to establish how effective community-based HIV testing services (HTS), including home and community location based (non-health facility) HIV testing services (HB-/CLB-HTS), are in improving care in sub-Saharan Africa (SSA), with a view to achieving the 90-90-90 targets. Methods We conducted a systematic review of published literature from 2007–17 which reported on the proportion of individuals who link-to-care and/or initiate ART after detection with HIV through community-based testing. A meta-analysis was deemed inappropriate due to heterogeneity in reporting. Results and discussion Twenty-five care cascades from 6 SSA countries were examined in the final review– 15 HB-HTS, 8 CLB-HTS, 2 combined HB-/CLB-HTS. Proportions linked-to-care over 1–12 months ranged from 14–96% for HB-HTS and 10–79% for CLB-HTS, with most studies reporting outcomes over short periods (3 months). Fewer studies reported ART-related outcomes following community-based testing and most of these studies included <50 HIV-positive individuals. Proportions initiating ART ranged from 23–93%. One study reported retention on ART (76% 6 months after initiation). Viral suppression 3–12 months following ART initiation was 77–85% in three studies which reported this. There was variability in definitions of outcomes, numerators/denominators and observation periods. Outcomes varied between studies even for similar time-points since HTS. The methodological inconsistencies hamper comparisons. Previously diagnosed individuals appear more likely to link-to-care than those who reported being newly-diagnosed. It appears that individuals diagnosed in the community need time before they are ready to link-to-care/initiate ART. Point-of-care (POC) CD4-counts at the time of HTS did not achieve higher proportions linking-to-care or initiating ART. Similarly, follow-up visits to HIV-positive individuals did not appear to enhance linkage to care overall. Conclusion This systematic review summarises the available data on linkage to care/ART initiation following community-based detection of HIV, to help researchers and policy makers evaluate findings. The available evidence suggests that different approaches to community-based HTS including HB-HTS and CLB-HTS, are equally effective in achieving linkage to care and ART initiation among those detected. Engagement and support for newly diagnosed individuals may be key to achieving all three UNAIDS 90-90-90 targets. We also recommend that standardised measures of reporting of steps on the cascade of care are needed, to measure progress against targets and compare across settings.
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Affiliation(s)
- Kalpana Sabapathy
- London School of Hygiene and Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Bernadette Hensen
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Olivia Varsaneux
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sian Floyd
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Richard Hayes
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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Olney JJ, Eaton JW, Braitstein P, Hogan JW, Hallett TB. Optimal timing of HIV home-based counselling and testing rounds in Western Kenya. J Int AIDS Soc 2018; 21:e25142. [PMID: 29883052 PMCID: PMC5993164 DOI: 10.1002/jia2.25142] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 05/22/2018] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Weaknesses in care programmes providing anti-retroviral therapy (ART) persist and are often instigated by late HIV diagnosis and poor linkage to care. We investigated the potential for a home-based counselling and testing (HBCT) campaign to be improved through the optimal timing and enhancement of testing rounds to generate greater health outcomes at minimum cost. METHODS Using a mathematical model of HIV care calibrated to longitudinal data from The Academic Model Providing Access To Healthcare (AMPATH) in Kenya, we simulated HBCT campaigns between 2016 and 2036, assessing the impact and total cost of care for each, for a further 20 years. RESULTS We find that simulating five equally spaced rounds averts 1.53 million disability-adjusted life-years (DALYs) at a cost of $1617 million. By altering the timing of HBCT rounds, a four-round campaign can produce greater impact for lower cost. With "front-loaded" rounds, the cost per DALY averted is reduced by 12% as fewer rounds are required ($937 vs. $1060). Furthermore, improvements to HBCT coverage and linkage to care avert over two million DALYs at a cost per DALY averted of $621 (41% less than the reference scenario). CONCLUSIONS Countries implementing HBCT can reduce costs by optimally timing rounds and generate greater health outcomes through improving linkage, coverage, and retention. Tailoring HBCT campaigns to individual settings can enhance patient outcomes for minimal cost.
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Affiliation(s)
- Jack J Olney
- Centre for Health Economics & Policy Innovation, Imperial College Business School, London, United Kingdom
| | - Jeffrey W Eaton
- Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - Paula Braitstein
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Department of Medicine, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Joseph W Hogan
- Department of Biostatistics and Center for Statistical Sciences, Brown University School of Public Health, Providence, RI, USA
| | - Timothy B Hallett
- Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
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Ruzagira E, Grosskurth H, Kamali A, Baisley K. Brief counselling after home-based HIV counselling and testing strongly increases linkage to care: a cluster-randomized trial in Uganda. J Int AIDS Soc 2018; 20. [PMID: 29052344 PMCID: PMC5810339 DOI: 10.1002/jia2.25014] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 09/25/2017] [Indexed: 11/20/2022] Open
Abstract
Introduction The aim of this study was to determine whether counselling provided subsequent to HIV testing and referral for care increases linkage to care among HIV‐positive persons identified through home‐based HIV counselling and testing (HBHCT) in Masaka, Uganda. Methods The study was an open‐label cluster‐randomized trial. 28 rural communities were randomly allocated (1:1) to intervention (HBHCT, referral and counselling at one and two months) or control (HBHCT and referral only). HIV‐positive care‐naïve adults (≥18 years) were enrolled. To conceal participants’ HIV status, one HIV‐negative person was recruited for every three HIV‐positive participants. Primary outcomes were linkage to care (clinic‐verified registration for care) status at six months, and time to linkage. Primary analyses were intention‐to‐treat using random effects logistic regression or Cox regression with shared frailty, as appropriate. Results Three hundred and two(intervention, n = 149; control, n = 153) HIV‐positive participants were enrolled. Except for travel time to the nearest HIV clinic, baseline participant characteristics were generally balanced between trial arms. Retention was similar across trial arms (92% overall). One hundred and twenty‐seven (42.1%) participants linked to care: 76 (51.0%) in the intervention arm versus 51 (33.3%) in the control arm [odds ratio = 2.18, 95% confidence interval (CI) = 1.26–3.78; p = 0.008)]. There was evidence of interaction between trial arm and follow‐up time (p = 0.009). The probability of linkage to care, did not differ between arms in the first two months of follow‐up, but was subsequently higher in the intervention arm versus the control arm [hazard ratio = 4.87, 95% CI = 1.79–13.27, p = 0.002]. Conclusions Counselling substantially increases linkage to care among HIV‐positive adults identified through HBHCT and may enhance efforts to increase antiretroviral therapy coverage in sub‐Saharan Africa.
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Affiliation(s)
- Eugene Ruzagira
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.,MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda
| | - Heiner Grosskurth
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Anatoli Kamali
- MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda.,International AIDS Vaccine Initiative, New York, USA
| | - Kathy Baisley
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
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Ruzagira E, Baisley K, Kamali A, Grosskurth H. Factors associated with uptake of home-based HIV counselling and testing and HIV care services among identified HIV-positive persons in Masaka, Uganda. AIDS Care 2018; 30:879-887. [PMID: 29463099 PMCID: PMC5964441 DOI: 10.1080/09540121.2018.1441967] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
We investigated uptake of home-based HIV counselling and testing (HBHCT) and HIV care services post-HBHCT in order to inform the design of future HBHCT programmes. We used data from an open-label cluster-randomised controlled trial which had demonstrated the effectiveness of a post-HBHCT counselling intervention in increasing linkage to HIV care. HBHCT was offered to adults (≥18 years) from 28 rural communities in Masaka, Uganda; consenting HIV-positive care naïve individuals were enrolled and referred for care. The trial's primary outcome was linkage to HIV care (clinic-verified registration for care) six months post-HBHCT. Random effects logistic regression was used to investigate factors associated with HBHCT uptake, linkage to care, CD4 count receipt, and antiretroviral therapy (ART) initiation; all analyses of uptake of post-HBHCT services were adjusted for trial arm allocation. Of 13,455 adults offered HBHCT, 12,100 (89.9%) accepted. HBHCT uptake was higher among men [adjusted odds ratio (aOR) 1.20, 95% confidence interval (CI) = 1.07-1.36] than women, and decreased with increasing age. Of 551 (4.6%) persons who tested HIV-positive, 205 (37.2%) were in care. Of those not in care, 302 (87.3%) were enrolled in the trial and of these, 42.1% linked to care, 35.4% received CD4 counts, and 29.8% initiated ART at 6 months post-HBHCT. None of the investigated factors was associated with linkage to care. CD4 count receipt was lower in individuals who lived ≥30 min from an HIV clinic (aOR 0.60, 95%CI = 0.34-1.06) versus those who lived closer. ART initiation was higher in older individuals (≥45 years versus <25 years, aOR 2.14, 95% CI = 0.98-4.65), and lower in single (aOR 0.60, 95% CI = 0.28-1.31) or divorced/separated/widowed (aOR 0.47, 95% CI = 0.23-0.93) individuals versus those married/cohabiting. HBHCT was highly acceptable but uptake of post-HBHCT care was low. Other than post-HBHCT counselling, this study did not identify specific issues that require addressing to further improve linkage to care.
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Affiliation(s)
- Eugene Ruzagira
- a Department Infectious Disease and Epidemiology , London School of Hygiene and Tropical Medicine , London , United Kingdom.,b MRC/UVRI Uganda Research Unit on AIDS , Entebbe , Uganda
| | - Kathy Baisley
- a Department Infectious Disease and Epidemiology , London School of Hygiene and Tropical Medicine , London , United Kingdom
| | - Anatoli Kamali
- b MRC/UVRI Uganda Research Unit on AIDS , Entebbe , Uganda.,c International AIDS Vaccine Initiative , New York , USA
| | - Heiner Grosskurth
- a Department Infectious Disease and Epidemiology , London School of Hygiene and Tropical Medicine , London , United Kingdom
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Factors Associated With Poor Linkage to HIV Care in South Africa: Secondary Analysis of Data From the Thol'impilo Trial. J Acquir Immune Defic Syndr 2017; 76:453-460. [PMID: 28961678 DOI: 10.1097/qai.0000000000001550] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Poor linkage to HIV care is impeding achievement of the Joint United Nations Programme on HIV and AIDS (UNAIDS) 90-90-90 targets. This study aims to identify risk factors for poor linkage-to-care after HIV counseling and testing, thereby informing strategies to achieve 90-90-90. SETTING The Thol'impilo trial was a large randomized controlled trial performed between 2012 and 2015 in South Africa, comparing different strategies to improve linkage-to-care among adults aged ≥18 years who tested HIV-positive at mobile clinic HIV counseling and testing. METHODS In this secondary analysis, sociodemographic factors associated with time to linkage-to-care were identified using Cox regression. RESULTS Of 2398 participants, 61% were female, with median age 33 years (interquartile range: 27-41) and median CD4 count 427 cells/mm (interquartile range: 287-595). One thousand one hundred one participants (46%) had clinic verified linkage-to-care within 365 days of testing HIV-positive. In adjusted analysis, younger age [≤30 vs >40 years: adjusted hazard ratio (aHR): 0.58, 95% CI: 0.50 to 0.68; 31-40 vs >40 years: aHR: 0.81, 95% CI: 0.70 to 0.94, test for trend P < 0.001], being male (aHR: 0.86, 95% CI: 0.76 to 0.98, P = 0.028), not being South African (aHR: 0.79, 95% CI: 0.66 to 0.96, P = 0.014), urban district (aHR: 0.82, 95% CI: 0.73 to 0.93, P = 0.002), being employed (aHR: 0.81, 95% CI: 0.72 to 0.92, P = 0.001), nondisclosure of HIV (aHR: 0.63, 95% CI: 0.56 to 0.72, P < 0.001), and having higher CD4 counts (test for trend P < 0.001) were all associated with decreased hazard of linkage-to-care. CONCLUSION Linkage-to-care was low in this relatively large cohort. Increasing linkage-to-care requires innovative, evidence-based interventions particularly targeting individuals who are younger, male, immigrant, urban, employed, and reluctant to disclose their HIV status.
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Lee H, Hogan JW, Genberg BL, Wu XK, Musick BS, Mwangi A, Braitstein P. A state transition framework for patient-level modeling of engagement and retention in HIV care using longitudinal cohort data. Stat Med 2017; 37:302-319. [PMID: 29164648 DOI: 10.1002/sim.7502] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 08/24/2017] [Accepted: 08/26/2017] [Indexed: 01/10/2023]
Abstract
The human immunodeficiency virus (HIV) care cascade is a conceptual model used to outline the benchmarks that reflects effectiveness of HIV care in the whole HIV care continuum. The models can be used to identify barriers contributing to poor outcomes along each benchmark in the cascade such as disengagement from care or death. Recently, the HIV care cascade has been widely applied to monitor progress towards HIV prevention and care goals in an attempt to develop strategies to improve health outcomes along the care continuum. Yet, there are challenges in quantifying successes and gaps in HIV care using the cascade models that are partly due to the lack of analytic approaches. The availability of large cohort data presents an opportunity to develop a coherent statistical framework for analysis of the HIV care cascade. Motivated by data from the Academic Model Providing Access to Healthcare, which has provided HIV care to nearly 200,000 individuals in Western Kenya since 2001, we developed a state transition framework that can characterize patient-level movements through the multiple stages of the HIV care cascade. We describe how to transform large observational data into an analyzable format. We then illustrate the state transition framework via multistate modeling to quantify dynamics in retention aspects of care. The proposed modeling approach identifies the transition probabilities of moving through each stage in the care cascade. In addition, this approach allows regression-based estimation to characterize effects of (time-varying) predictors of within and between state transitions such as retention, disengagement, re-entry into care, transfer-out, and mortality. Copyright © 2017 John Wiley & Sons, Ltd.
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Affiliation(s)
- Hana Lee
- Department of Biostatistics, Brown University, 121 S. Main Street, Providence, 02912, RI, USA
| | - Joseph W Hogan
- Department of Biostatistics, Brown University, 121 S. Main Street, Providence, 02912, RI, USA.,Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Becky L Genberg
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Maryland, U.S.A
| | - Xiaotian K Wu
- Department of Biostatistics, Brown University, 121 S. Main Street, Providence, 02912, RI, USA
| | - Beverly S Musick
- Division of Biostatistics, School of Medicine, Indiana University, Indiana, USA
| | - Ann Mwangi
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,College of Health Sciences, School of Medicine, Moi University, Eldoret, Kenya
| | - Paula Braitstein
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,College of Health Sciences, School of Medicine, Moi University, Eldoret, Kenya.,Dalla Lana School of Public Health, University of Toronto.,Fairbanks School of Public Health, Indiana University, Indiana, USA.,Regenstrief Institute, Indiana, USA
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Strategies to Accelerate HIV Care and Antiretroviral Therapy Initiation After HIV Diagnosis: A Randomized Trial. J Acquir Immune Defic Syndr 2017; 75:540-547. [PMID: 28471840 DOI: 10.1097/qai.0000000000001428] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Determine the effectiveness of strategies to increase linkage to care after testing HIV positive at mobile HIV testing in South Africa. DESIGN Unmasked randomized controlled trial. METHODS Recruitment of adults testing HIV positive and not currently in HIV care occurred at 7 mobile HIV counseling and testing units in urban, periurban, and rural South Africa with those consenting randomized 1:1:1:1 into 1 of 4 arms. Three strategies were compared with standard of care (SOC): point-of-care CD4 count testing (POC CD4), POC CD4 plus longitudinal strengths-based counseling (care facilitation; CF), and POC CD4 plus transport reimbursement (transport). Participants were followed up telephonically and through clinic records and analyzed with an intention-to-treat analysis. RESULTS From March 2013 to October 2014, 2558 participants were enrolled, of whom 160 were excluded postrandomization. Compared with the SOC arm where 298 (50%) reported having entered care, linkage to care was 319 (52%) for POC CD4, hazard ratio (HR) 1.0 [95% confidence interval (CI): 0.89 to 1.2, P = 0.6]; 331 (55%) for CF, HR: 1.1 (95% CI: 0.84 to 1.3, P = 0.2); and 291 (49%) for transport, HR 0.97 (95% CI: 0.83 to 1.1, P = 0.7). Linkage to care verified with clinical records that occurred for 172 (29%) in the SOC arm; 187 (31%) in the POC CD4 arm, HR: 1.0 (95% CI: 0.86 to 1.3, P = 0.6); 225 (38%) in the CF arm, HR: 1.4 (95% CI: 1.1 to 1.7, P = 0.001); and 180 (31%) in the transport arm, HR: 1.1 (95% CI: 0.88 to 1.3, P = 0.5). CONCLUSIONS CF improved verified linkage to care from 29% to 38%.
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Luseno WK, Iritani B, Zietz S, Maman S, Mbai II, Otieno F, Ongili B, Hallfors DD. Experiences along the HIV care continuum: perspectives of Kenyan adolescents and caregivers. AFRICAN JOURNAL OF AIDS RESEARCH : AJAR 2017; 16:241-250. [PMID: 28978294 PMCID: PMC6138248 DOI: 10.2989/16085906.2017.1365089] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
To be effective, HIV programmes should be responsive to the unique needs of diverse groups of infected adolescents. We highlight a range of adolescent perspectives on HIV services, including those who acquired HIV perinatally or sexually and those who were either in care, had dropped out of care, or had never enrolled in care. We conducted semi-structured interviews with 29 adolescents (aged 15-19) and 14 caregivers in western Kenya. Data were analysed using a descriptive analytical approach. Adolescents who were successfully linked had a supportive adult present during diagnosis; tested during hospitalisation or treatment for a recurrent or severe illness; and initiated treatment soon after diagnosis. Barriers to retention included side effects from HIV drugs, pill burden, and limited access to clean water and nutritious food. Support in family, school, and health facility environments was key for diagnosis, linkage, and retention. We make recommendations that may improve adolescent engagement in HIV services.
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Affiliation(s)
- Winnie K. Luseno
- Pacific Institute for Research and Evaluation (PIRE), 101 Conner Dr., Ste 200, Chapel Hill, NC 27514
| | - Bonita Iritani
- Pacific Institute for Research and Evaluation (PIRE), 101 Conner Dr., Ste 200, Chapel Hill, NC 27514
| | - Susannah Zietz
- Pacific Institute for Research and Evaluation (PIRE), 101 Conner Dr., Ste 200, Chapel Hill, NC 27514
- University of North Carolina, Department of Health Behavior and Health Education, Chapel Hill, 27599
| | - Suzanne Maman
- University of North Carolina, Department of Health Behavior and Health Education, Chapel Hill, 27599
| | | | | | | | - Denise Dion Hallfors
- Pacific Institute for Research and Evaluation (PIRE), 101 Conner Dr., Ste 200, Chapel Hill, NC 27514
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Keane J, Pharr JR, Buttner MP, Ezeanolue EE. Interventions to Reduce Loss to Follow-up During All Stages of the HIV Care Continuum in Sub-Saharan Africa: A Systematic Review. AIDS Behav 2017; 21:1745-1754. [PMID: 27578001 DOI: 10.1007/s10461-016-1532-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The continuum of care for successful HIV treatment includes HIV testing, linkage, engagement in care, and retention on antiretroviral therapy (ART). Loss to follow-up (LTFU) is a significant disruption to this pathway and a common outcome in sub-Saharan Africa. This review of literature identified interventions that have reduced LTFU in the HIV care continuum. A search was conducted utilizing terms that combined the disease state, stages of the HIV care continuum, interventions, and LTFU in sub-Saharan Africa and articles published between January 2010 and July 2015. Thirteen articles were included in the final review. Use of point of care CD4 testing and community-supported programs improved linkage, engagement, and retention in care. There are few interventions directed at LTFU and none that span across the entire continuum of HIV care. Further research could focus on devising programs that include a series of interventions that will be effective through the entire continuum.
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Ruzagira E, Baisley K, Kamali A, Biraro S, Grosskurth H. Linkage to HIV care after home-based HIV counselling and testing in sub-Saharan Africa: a systematic review. Trop Med Int Health 2017; 22:807-821. [PMID: 28449385 DOI: 10.1111/tmi.12888] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Home-based HIV counselling and testing (HBHCT) has the potential to increase HIV testing uptake in sub-Saharan Africa (SSA), but data on linkage to HIV care after HBHCT are scarce. We conducted a systematic review of linkage to care after HBHCT in SSA. METHODS Five databases were searched for studies published between 1st January 2000 and 19th August 2016 that reported on linkage to care among adults newly identified with HIV infection through HBHCT. Eligible studies were reviewed, assessed for risk of bias and findings summarised using the PRISMA guidelines. RESULTS A total of 14 studies from six countries met the eligibility criteria; nine used specific strategies (point-of-care CD4 count testing, follow-up counselling, provision of transport funds to clinic and counsellor facilitation of HIV clinic visit) in addition to routine referral to facilitate linkage to care. Time intervals for ascertaining linkage ranged from 1 week to 12 months post-HBHCT. Linkage ranged from 8.2% [95% confidence interval (CI), 6.8-9.8%] to 99.1% (95% CI, 96.9-99.9%). Linkage was generally lower (<33%) if HBHCT was followed by referral only, and higher (>80%) if additional strategies were used. Only one study assessed linkage by means of a randomised trial. Five studies had data on cotrimoxazole (CTX) prophylaxis and 12 on ART eligibility and initiation. CTX uptake among those eligible ranged from 0% to 100%. The proportion of persons eligible for ART ranged from 16.5% (95% CI, 12.1-21.8) to 77.8% (95% CI, 40.0-97.2). ART initiation among those eligible ranged from 14.3% (95% CI, 0.36-57.9%) to 94.9% (95% CI, 91.3-97.4%). Additional linkage strategies, whilst seeming to increase linkage, were not associated with higher uptake of CTX and/or ART. Most of the studies were susceptible to risk of outcome ascertainment bias. A pooled analysis was not performed because of heterogeneity across studies with regard to design, setting and the key variable definitions. CONCLUSION Only few studies from SSA investigated linkage to care among adults newly diagnosed with HIV through HBHCT. Linkage was often low after routine referral but higher if additional interventions were used to facilitate it. The effectiveness of linkage strategies should be confirmed through randomised controlled trials.
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Affiliation(s)
- Eugene Ruzagira
- London School of Hygiene and Tropical Medicine, London, UK.,MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda
| | - Kathy Baisley
- London School of Hygiene and Tropical Medicine, London, UK
| | - Anatoli Kamali
- MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda.,International AIDS Vaccine Initiative, New York, NY, USA
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Zeh C, Rose CE, Inzaule S, Desai MA, Otieno F, Humwa F, Akoth B, Omolo P, Chen RT, Kebede Y, Samandari T. Laboratory-based performance evaluation of PIMA CD4+ T-lymphocyte count point-of-care by lay-counselors in Kenya. J Immunol Methods 2017; 448:44-50. [PMID: 28529048 DOI: 10.1016/j.jim.2017.05.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 02/24/2017] [Accepted: 05/17/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND CD4+ T-lymphocyte count testing at the point-of-care (POC) may improve linkage to care of persons diagnosed with HIV-1 infection, but the accuracy of POC devices when operated by lay-counselors in the era of task-shifting is unknown. We examined the accuracy of Alere's Pima™ POC device on both capillary and venous blood when performed by lay-counselors and laboratory technicians. METHODS In Phase I, we compared the perfomance of POC against FACSCalibur™ for 280 venous specimens by laboratory technicians. In Phase II we compared POC performance by lay-counselors versus laboratory technicians using 147 paired capillary and venous specimens, and compared these to FACSCalibur™. Statistical analyses included Bland-Altman analyses, concordance correlation coefficient, sensitivity, and specificity at treatment eligibility thresholds of 200, 350, and 500cells/μl. RESULTS Phase I: POC sensitivity and specificity were 93.0% and 84.1% at 500cells/μl, respectively. Phase II: Good agreement was observed for venous POC results from both lay-counselors (concordance correlation coefficient (CCC)=0.873, bias -86.4cells/μl) and laboratory technicians (CCC=0.920, bias -65.7cells/μl). Capillary POC had good correlation: lay-counselors (CCC=0.902, bias -71.2cells/μl), laboratory technicians (CCC=0.918, bias -63.0cells/μl). Misclassification at the 500 cells/μl threshold for venous blood was 13.6% and 10.2% for lay-counselors and laboratory technicians and 12.2% for capillary blood in both groups. POC tended to under-classify the CD4 values with increasingly negative bias at higher CD4 values. CONCLUSIONS Pima™ results were comparable to FACSCalibur™ for both venous and capillary specimens when operated by lay-counselors. POC CD4 testing has the potential to improve linkage to HIV care without burdening laboratory technicians in resource-limited settings.
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Affiliation(s)
- Clement Zeh
- Centers for Disease Control and Prevention (CDC), Atlanta, GA, United States
| | - Charles E Rose
- Centers for Disease Control and Prevention (CDC), Atlanta, GA, United States
| | - Seth Inzaule
- Kenya Medical Research Institute (KEMRI), Kisumu, Kenya
| | - Mitesh A Desai
- Centers for Disease Control and Prevention (CDC), Atlanta, GA, United States
| | | | - Felix Humwa
- Kenya Medical Research Institute (KEMRI), Kisumu, Kenya
| | - Benta Akoth
- Kenya Medical Research Institute (KEMRI), Kisumu, Kenya
| | - Paul Omolo
- Kenya Medical Research Institute (KEMRI), Kisumu, Kenya
| | - Robert T Chen
- Centers for Disease Control and Prevention (CDC), Atlanta, GA, United States.
| | - Yenew Kebede
- Kenya Medical Research Institute (KEMRI), Kisumu, Kenya
| | - Taraz Samandari
- Centers for Disease Control and Prevention (CDC), Atlanta, GA, United States
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Pastakia SD, Manyara SM, Vedanthan R, Kamano JH, Menya D, Andama B, Chesoli C, Laktabai J. Impact of Bridging Income Generation with Group Integrated Care (BIGPIC) on Hypertension and Diabetes in Rural Western Kenya. J Gen Intern Med 2017; 32:540-548. [PMID: 27921256 PMCID: PMC5400758 DOI: 10.1007/s11606-016-3918-5] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 09/08/2016] [Accepted: 10/26/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Rural settings in Sub-Saharan Africa (SSA) consistently report low participation in non-communicable disease (NCD) treatment programs and poor outcomes. OBJECTIVE The objective of this study is to assess the impact of the implementation of a patient-centered rural NCD care delivery model called Bridging Income Generation through grouP Integrated Care (BIGPIC). DESIGN The study prospectively tracked participation and health outcomes for participants in a screening event and compared linkage frequencies to a historical comparison group. PARTICIPANTS Rural Kenyan participants attending a voluntary NCD screening event were included within the BIGPIC model of care. INTERVENTIONS The BIGPIC model utilizes a contextualized care delivery model designed to address the unique barriers faced in rural settings. This model emphasizes the following steps: (1) find patients in the community, (2) link to peer/microfinance groups, (3) integrate education, (4) treat in the community, (5) enhance economic sustainability and (6) generate demand for care through incentives. MAIN MEASURES The primary outcome is the linkage frequency, which measures the percentage of patients who return for care after screening positive for either hypertension and/or diabetes. Secondary measures include retention frequencies defined as the percentage of patients remaining engaged in care throughout the 9-month follow-up period and changes in systolic (SBP) and diastolic blood pressure (DBP) and blood sugar over 12 months. KEY RESULTS Of the 879 individuals who were screened, 14.2 % were confirmed to have hypertension, while only 1.4 % were confirmed to have diabetes. The implementation of a comprehensive microfinance-linked, community-based, group care model resulted in 72.4 % of screen-positive participants returning for subsequent care, of which 70.3 % remained in care through the 12 months of the evaluation period. Patients remaining in care demonstrated a statistically significant mean decline of 21 mmHg in SBP [95 % CI (13.9 to 28.4), P < 0.01] and 5 mmHg drop in DBP [95 % CI (1.4 to 7.6), P < 0.01]. CONCLUSIONS The implementation of a contextualized care delivery model built around the unique needs of rural SSA participants led to statistically significant improvements in linkage to care and blood pressure reduction.
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Affiliation(s)
- Sonak D Pastakia
- Academic Model Providing Access To Healthcare (AMPATH), Eldoret, Kenya.
- Moi Teaching and Referral Hospital, Eldoret, Kenya.
- College of Health Sciences, School of Medicine, Moi University, Eldoret, Kenya.
- College of Pharmacy, Purdue University, West Lafayette, IN, USA.
| | - Simon M Manyara
- Academic Model Providing Access To Healthcare (AMPATH), Eldoret, Kenya
- Moi Teaching and Referral Hospital, Eldoret, Kenya
- College of Pharmacy, Purdue University, West Lafayette, IN, USA
| | | | - Jemima H Kamano
- Academic Model Providing Access To Healthcare (AMPATH), Eldoret, Kenya
- Moi Teaching and Referral Hospital, Eldoret, Kenya
- College of Health Sciences, School of Medicine, Moi University, Eldoret, Kenya
| | - Diana Menya
- College of Health Sciences, School of Public Health, Moi University, Eldoret, Kenya
| | - Benjamin Andama
- Academic Model Providing Access To Healthcare (AMPATH), Eldoret, Kenya
| | - Cleophas Chesoli
- Academic Model Providing Access To Healthcare (AMPATH), Eldoret, Kenya
| | - Jeremiah Laktabai
- Academic Model Providing Access To Healthcare (AMPATH), Eldoret, Kenya
- College of Health Sciences, School of Medicine, Moi University, Eldoret, Kenya
- Webuye District Hospital, Webuye, Kenya
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41
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Determinants of time from HIV infection to linkage-to-care in rural KwaZulu-Natal, South Africa. AIDS 2017; 31:1017-1024. [PMID: 28252526 DOI: 10.1097/qad.0000000000001435] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To estimate time from HIV infection to linkage-to-care and its determinants. Linkage-to-care is usually assessed using the date of HIV diagnosis as the starting point for exposure time. However, timing of diagnosis is likely endogenous to linkage, leading to bias in linkage estimation. DESIGN We used longitudinal HIV serosurvey data from a large population-based HIV incidence cohort in KwaZulu-Natal (2004-2013) to estimate time of HIV infection. We linked these data to patient records from a public-sector HIV treatment and care program to determine time from infection to linkage (defined using the date of the first CD4 cell count). METHODS We used Cox proportional hazards models to estimate time from infection to linkage and the effects of the following covariates on this time: sex, age, education, food security, socioeconomic status, area of residence, distance to clinics, knowledge of HIV status, and whether other household members have initiated antiretroviral therapy. RESULTS We estimated that it would take an average of 4.9 years for 50% of HIV seroconverters to be linked to care (95% confidence intervals: 4.2-5.7). Among all cohort members who were linked to care, the median CD4 cell count at linkage was 350 cells/μl (95% confidence interval: 330-380). Men and participants aged less than 30 years were found to have the slowest rates of linkage-to-care. Time to linkage became shorter over calendar time. CONCLUSION Average time from HIV infection to linkage-to-care is long and needs to be reduced to ensure that HIV treatment-as-prevention policies are effective. Targeted interventions for men and young individuals have the largest potential to improve linkage rates.
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Sanga ES, Lerebo W, Mushi AK, Clowes P, Olomi W, Maboko L, Zarowsky C. Linkage into care among newly diagnosed HIV-positive individuals tested through outreach and facility-based HIV testing models in Mbeya, Tanzania: a prospective mixed-method cohort study. BMJ Open 2017; 7:e013733. [PMID: 28404611 PMCID: PMC5541440 DOI: 10.1136/bmjopen-2016-013733] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Revised: 02/18/2017] [Accepted: 02/27/2017] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE Linkage to care is the bridge between HIV testing and HIV treatment, care and support. In Tanzania, mobile testing aims to address historically low testing rates. Linkage to care was reported at 14% in 2009 and 28% in 2014. The study compares linkage to care of HIV-positive individuals tested at mobile/outreach versus public health facility-based services within the first 6 months of HIV diagnosis. SETTING Rural communities in four districts of Mbeya Region, Tanzania. PARTICIPANTS A total of 1012 newly diagnosed HIV-positive adults from 16 testing facilities were enrolled into a two-armed cohort and followed for 6 months between August 2014 and July 2015. 840 (83%) participants completed the study. MAIN OUTCOME MEASURES We compared the ratios and time variance in linkage to care using the Kaplan-Meier estimator and Log rank tests. Cox proportional hazards regression models to evaluate factors associated with time variance in linkage. RESULTS At the end of 6 months, 78% of all respondents had linked into care, with differences across testing models. 84% (CI 81% to 87%, n=512) of individuals tested at facility-based site were linked to care compared to 69% (CI 65% to 74%, n=281) of individuals tested at mobile/outreach. The median time to linkage was 1 day (IQR: 1-7.5) for facility-based site and 6 days (IQR: 3-11) for mobile/outreach sites. Participants tested at facility-based site were 78% more likely to link than those tested at mobile/outreach when other variables were controlled (AHR=1.78; 95% CI 1.52 to 2.07). HIV status disclosure to family/relatives was significantly associated with linkage to care (AHR=2.64; 95% CI 2.05 to 3.39). CONCLUSIONS Linkage to care after testing HIV positive in rural Tanzania has increased markedly since 2014, across testing models. Individuals tested at facility-based sites linked in significantly higher proportion and modestly sooner than mobile/outreach tested individuals. Mobile/outreach testing models bring HIV testing services closer to people. Strategies to improve linkage from mobile/outreach models are needed.
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Affiliation(s)
- Erica Samson Sanga
- NIMR-Mbeya Medical Research Centre (MMRC), Mbeya, Tanzania
- School of Public Health, University of Western Cape, Cape Town, South Africa
| | - Wondwossen Lerebo
- School of Public Health, University of Western Cape, Cape Town, South Africa
- School of Public Health, Mekelle University, Mekelle, Ethiopia
| | - Adiel K Mushi
- National Institute for Medical Research (NIMR), Dar es Salaam, Tanzania
| | - Petra Clowes
- NIMR-Mbeya Medical Research Centre (MMRC), Mbeya, Tanzania
- Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich (LMU), Munich, Germany
| | | | - Leonard Maboko
- NIMR-Mbeya Medical Research Centre (MMRC), Mbeya, Tanzania
| | - Christina Zarowsky
- School of Public Health, University of Western Cape, Cape Town, South Africa
- University of Montreal Hospital Research Centre and School of Public Health, Université de Montréal, Montreal, Quebec, Canada
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Sharma M, Barnabas RV, Celum C. Community-based strategies to strengthen men's engagement in the HIV care cascade in sub-Saharan Africa. PLoS Med 2017; 14:e1002262. [PMID: 28399122 PMCID: PMC5388461 DOI: 10.1371/journal.pmed.1002262] [Citation(s) in RCA: 144] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Monica Sharma and colleagues discuss evidence-based approaches to improving HIV services for men in sub-Saharan Africa.
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Affiliation(s)
- Monisha Sharma
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
| | - Ruanne V. Barnabas
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- School of Medicine, University of Washington, Seattle, Washington, United States of America
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Connie Celum
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- School of Medicine, University of Washington, Seattle, Washington, United States of America
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Mavegam BO, Pharr JR, Cruz P, Ezeanolue EE. Effective interventions to improve young adults' linkage to HIV care in Sub-Saharan Africa: a systematic review. AIDS Care 2017; 29:1198-1204. [PMID: 28325077 DOI: 10.1080/09540121.2017.1306637] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
HIV/AIDS remains a major public health problem despite the efforts to prevent and decrease its spread. Sub-Saharan Africa (SSA) represents 70% of the global number of people living with HIV and 73% of all HIV/AIDS-related deaths. Young adults age 15-24 years are disproportionately impacted by HIV/AIDS in SSA with 34% of people living with HIV (PLWHIV) and 37% of newly diagnosed individuals being in this age group. It is important that PLWHIV be linked to care to facilitate antiretroviral therapy (ART) initiation and limit the spread of infection. We conducted a systematic literature review to identify effective interventions designed to improve linkage to care among HIV-infected young adults in SSA. One hundred and forty-six titles and abstracts were screened, 28 full-texts were reviewed, and 6 articles met the inclusion and exclusion criteria. Home-based HIV counseling and testing, home-based HIV self-testing, and mobile HIV counseling and testing followed by proper referral of HIV-positive patients to HIV care were effective for improving linkage of young adults to care. Other factors such as referral forms, transportation allowance, home initiation of HIV care, and volunteer escort to the HIV treatment clinic were effective in reducing time to linkage to care. There is a vast need for research and interventions that target HIV-positive young adults in SSA which aim to improve their linkage and access to HIV care. The results of this study illustrate effective interventions in improving linkage to care and reducing time to linkage to care of young adults in SSA.
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Affiliation(s)
| | - Jennifer R Pharr
- a School of Community Health Sciences , University of Nevada , Las Vegas , USA
| | - Patricia Cruz
- a School of Community Health Sciences , University of Nevada , Las Vegas , USA
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An open-label cluster randomised trial to evaluate the effectiveness of a counselling intervention on linkage to care among HIV-infected patients in Uganda: Study design. Contemp Clin Trials Commun 2017; 5:56-62. [PMID: 28424795 PMCID: PMC5389341 DOI: 10.1016/j.conctc.2016.12.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 11/22/2016] [Accepted: 12/07/2016] [Indexed: 11/29/2022] Open
Abstract
Introduction Home-based HIV counselling & testing (HBHCT) is highly acceptable and has the potential to increase HIV testing uptake in sub-Saharan Africa. However, data are lacking on strategies that can effectively link HIV-positive individuals identified through HBHCT to care. This trial was designed to assess the effectiveness of two brief home-based counselling sessions on linkage to care, provided subsequent to referral for care among HIV-positive patients identified through HBHCT in a rural community in Masaka district, Uganda. Methods 28 communities (clusters) were randomly allocated to control (referral only) and intervention (referral and follow-up counselling) arms (n = 14 clusters/arm). Randomisation was stratified on distance from the district capital (≤10 km vs > 10 km) and cluster size (larger single village vs combined small villages), and restricted to ensure balance on selected cluster characteristics. A list of possible allocations was generated and one randomly selected at a public ceremony. HBHCT is being offered to all adults (≥18 years), and HIV-positive individuals not yet in care are eligible for enrolment. The intervention is provided at one and two months post-enrolment. Primary outcomes, assessed 6 months after enrolment, are: the proportion of individuals linking to HIV care within 6 months of HIV diagnosis and time to linkage. The primary analysis will be based on individual-level data. Discussion This study will provide evidence on the impact of a counselling intervention on linkage to care among adults identified with HIV infection through HBHCT. Interpretation of the trial outcomes will be aided by results from an on-going qualitative sub-study.
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Olney JJ, Braitstein P, Eaton JW, Sang E, Nyambura M, Kimaiyo S, McRobie E, Hogan JW, Hallett TB. Evaluating strategies to improve HIV care outcomes in Kenya: a modelling study. Lancet HIV 2016; 3:e592-e600. [PMID: 27771231 PMCID: PMC5121132 DOI: 10.1016/s2352-3018(16)30120-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 08/03/2016] [Accepted: 08/05/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND With expanded access to antiretroviral therapy (ART) in sub-Saharan Africa, HIV mortality has decreased, yet life-years are still lost to AIDS. Strengthening of treatment programmes is a priority. We examined the state of an HIV care programme in Kenya and assessed interventions to improve the impact of ART programmes on population health. METHODS We created an individual-based mathematical model to describe the HIV epidemic and the experiences of care among adults infected with HIV in Kenya. We calibrated the model to a longitudinal dataset from the Academic Model Providing Access To Healthcare (known as AMPATH) programme describing the routes into care, losses from care, and clinical outcomes. We simulated the cost and effect of interventions at different stages of HIV care, including improvements to diagnosis, linkage to care, retention and adherence of ART, immediate ART eligibility, and a universal test-and-treat strategy. FINDINGS We estimate that, of people dying from AIDS between 2010 and 2030, most will have initiated treatment (61%), but many will never have been diagnosed (25%) or will have been diagnosed but never started ART (14%). Many interventions targeting a single stage of the health-care cascade were likely to be cost-effective, but any individual intervention averted only a small percentage of deaths because the effect is attenuated by other weaknesses in care. However, a combination of five interventions (including improved linkage, point-of-care CD4 testing, voluntary counselling and testing with point-of-care CD4, and outreach to improve retention in pre-ART care and on-ART) would have a much larger impact, averting 1·10 million disability-adjusted life-years (DALYs) and 25% of expected new infections and would probably be cost-effective (US$571 per DALY averted). This strategy would improve health more efficiently than a universal test-and-treat intervention if there were no accompanying improvements to care ($1760 per DALY averted). INTERPRETATION When resources are limited, combinations of interventions to improve care should be prioritised over high-cost strategies such as universal test-and-treat strategy, especially if this is not accompanied by improvements to the care cascade. International guidance on ART should reflect alternative routes to programme strengthening and encourage country programmes to evaluate the costs and population-health impact in addition to the clinical benefits of immediate initiation. FUNDING Bill & Melinda Gates Foundation, United States Agency for International Development, National Institutes of Health.
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Affiliation(s)
- Jack J Olney
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK.
| | - Paula Braitstein
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Moi University, College of Health Sciences, School of Medicine, Department of Medicine, Eldoret, Kenya
| | - Jeffrey W Eaton
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Edwin Sang
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | | | | | - Ellen McRobie
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Joseph W Hogan
- Department of Biostatistics and Center for Statistical Sciences, Brown University School of Public Health, Providence, RI, USA
| | - Timothy B Hallett
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
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Irungu EM, Heffron R, Mugo N, Ngure K, Katabira E, Bulya N, Bukusi E, Odoyo J, Asiimwe S, Tindimwebwa E, Celum C, Baeten JM. Use of a risk scoring tool to identify higher-risk HIV-1 serodiscordant couples for an antiretroviral-based HIV-1 prevention intervention. BMC Infect Dis 2016; 16:571. [PMID: 27751179 PMCID: PMC5067880 DOI: 10.1186/s12879-016-1899-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 10/05/2016] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Antiretroviral therapy (ART) and pre-exposure prophylaxis (PrEP) reduce HIV-1 transmission within heterosexual HIV-1 serodiscordant couples. Prioritizing couples at highest HIV-1 transmission risk for ART and PrEP would maximize impact and minimize costs. METHODS The Partners Demonstration Project is an open-label, delivery study of integrated PrEP and ART for HIV-1 prevention among high risk HIV-1 serodiscordant couples in Kenya and Uganda. We evaluated the feasibility of using a validated risk score that weighs a combination of easily measurable factors (age, children, marital status, male circumcision status, condom use, plasma HIV-1 levels) to identify couples at highest risk for HIV-1 transmission for enrollment. Couples scoring ≥5 met the risk score eligibility criteria. RESULTS We screened 1694 HIV-1 serodiscordant couples and enrolled 1013. Of the screened couples, 1331 (78.6 %) scored ≥5 (with an expected incidence >3 % per year) and 76 % of these entered the study. The median age of the HIV-1 uninfected partner was 29 years [IQR 26, 36] and 20 % were <25 years of age. The HIV-1 uninfected partner was male in 67 % of partnerships, 33 % of whom were uncircumcised, 57 % of couples had no children, and 65 % reported unprotected sex in the month prior to enrollment. Among HIV-1 infected partners, 41 % had plasma viral load >50,000 copies/ml. CONCLUSION A risk scoring tool identified HIV-1 serodiscordant couples for a demonstration project of PrEP and ART with high HIV-1 risk. The tool may be feasible for research and public health settings to maximize efficiency and minimize HIV-1 prevention costs.
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Affiliation(s)
- Elizabeth M Irungu
- College of Health Sciences, Jomo Kenyatta University of Agriculture and Technology, P. O. Box 62000-00200, Nairobi, Kenya.
| | - Renee Heffron
- Department of Global Health, University of Washington, 325 Ninth Avenue, Seattle, WA, 98104, USA.,Department of Epidemiology, University of Washington, 325 Ninth Avenue, Seattle, WA, 98104, USA
| | - Nelly Mugo
- Department of Global Health, University of Washington, 325 Ninth Avenue, Seattle, WA, 98104, USA.,Centre for Clinical Research, Kenya Medical Research Institute, Mbagathi Road, Nairobi, Kenya
| | - Kenneth Ngure
- College of Health Sciences, Jomo Kenyatta University of Agriculture and Technology, P. O. Box 62000-00200, Nairobi, Kenya.,Department of Global Health, University of Washington, 325 Ninth Avenue, Seattle, WA, 98104, USA
| | - Elly Katabira
- Department of Medicine, Makerere University, PO Box 7072, Kampala, Uganda.,Infectious Disease Institute, College of Health Sciences, Makerere University , Kampala, Uganda
| | - Nulu Bulya
- Infectious Disease Institute, College of Health Sciences, Makerere University , Kampala, Uganda
| | - Elizabeth Bukusi
- Department of Global Health, University of Washington, 325 Ninth Avenue, Seattle, WA, 98104, USA.,Department of Obstetrics & Gynaecology, University of Nairobi, Uhuru Highway, Nairobi, 00100, Kenya.,Center for Microbiology Research, Kenya Medical Research Institute, Mbagathi Road, Nairobi, Kenya
| | - Josephine Odoyo
- Center for Microbiology Research, Kenya Medical Research Institute, Mbagathi Road, Nairobi, Kenya
| | - Stephen Asiimwe
- Kabwohe Clinical Research Centre, Off Kabwohe-Ishaka HWY next to ICOBI, Kabwohe-Itendero Town Council, Box 347, Bushenyi District Kabwohe, Uganda
| | - Edna Tindimwebwa
- Kabwohe Clinical Research Centre, Off Kabwohe-Ishaka HWY next to ICOBI, Kabwohe-Itendero Town Council, Box 347, Bushenyi District Kabwohe, Uganda
| | - Connie Celum
- Department of Global Health, University of Washington, 325 Ninth Avenue, Seattle, WA, 98104, USA.,Department of Epidemiology, University of Washington, 325 Ninth Avenue, Seattle, WA, 98104, USA.,Department of Medicine, University of Washington, 325 Ninth Avenue, Seattle, WA, 98104, USA
| | - Jared M Baeten
- Department of Global Health, University of Washington, 325 Ninth Avenue, Seattle, WA, 98104, USA.,Department of Epidemiology, University of Washington, 325 Ninth Avenue, Seattle, WA, 98104, USA.,Department of Medicine, University of Washington, 325 Ninth Avenue, Seattle, WA, 98104, USA
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Maman D, Ben-Farhat J, Chilima B, Masiku C, Salumu L, Ford N, Mendiharat P, Szumilin E, Masson S, Etard JF. Factors associated with HIV status awareness and Linkage to Care following home based testing in rural Malawi. Trop Med Int Health 2016; 21:1442-1451. [PMID: 27714902 DOI: 10.1111/tmi.12772] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE HIV diagnosis and linkage to care are the main barriers in Africa to achieving the UNAIDS 90-90-90 targets. We assessed HIV-positive status awareness and linkage to care among survey participants in Chiradzulu District, Malawi. METHOD Nested cohort study within a population-based survey of persons aged 15-59 years between February and May 2013. Participants were interviewed and tested for HIV (and CD4 if found HIV-positive) in their homes. Multivariable regression was used to determine factors associated with HIV-positive status awareness prior to the survey and subsequent linkage to care. RESULTS Of 8277 individuals eligible for the survey, 7270 (87.8%) participated and were tested for HIV. The overall HIV prevalence was 17.0%. Among HIV-positive participants, 77.0% knew their status and 72.8% were in care. Women (adjusted odds ratio [aOR] 6.5, 95% CI 3.2-13.1) and older participants (40-59 vs. 15-29 years, aOR 10.1, 95% CI 4.0-25.9) were more likely to be aware of their positive status. Of those newly diagnosed, 47.5% were linked to care within 3 months. Linkage to care was higher among older participants (40-59 vs. 15-29, adjusted hazard ratio [aHR] 3.39, 95% CI 1.83-6.26), women (aHR 1.73, 95% CI 1.12-2.67) and those eligible for ART (aHR 1.61, 95% CI 1.03-2.52). CONCLUSIONS In settings with high levels of HIV awareness, home-based testing remains an efficient strategy to diagnose and link to care. Men were less likely to be diagnosed, and when diagnosed to link to care, underscoring the need for a gender focus in order to achieve the 90-90-90 targets.
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Affiliation(s)
- D Maman
- Epicentre, Médecins Sans Frontières, Paris, France.
| | - J Ben-Farhat
- Epicentre, Médecins Sans Frontières, Paris, France
| | - B Chilima
- Community Health Sciences Unit, Malawi Ministry of Health, Lilongwe, Malawi
| | - C Masiku
- Médecins Sans Frontières, Lilongwe, Malawi
| | - L Salumu
- Médecins Sans Frontières, Paris, France
| | - N Ford
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland.,Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | | | | | - S Masson
- Epicentre, Médecins Sans Frontières, Paris, France
| | - J F Etard
- Epicentre, Médecins Sans Frontières, Paris, France.,UMI 233, Institut de Recherche pour le Développement, Montpellier, France
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Identifying common barriers and facilitators to linkage and retention in chronic disease care in western Kenya. BMC Public Health 2016; 16:741. [PMID: 27503191 PMCID: PMC4977618 DOI: 10.1186/s12889-016-3462-6] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Accepted: 08/05/2016] [Indexed: 11/27/2022] Open
Abstract
Background Sub-Saharan Africa is increasingly being challenged in providing care and treatment for chronic diseases, both communicable and non-communicable. In order to address the challenges of linkage to and retention in chronic disease management, there is the need to understand the factors that can influence engagement in care. We conducted a qualitative study to identify barriers and facilitators to linkage and retention in chronic care for HIV, tuberculosis (TB) and Hypertension (HTN) as part of the Academic Model Providing Access to Healthcare (AMPATH) program in western Kenya. Methods In-depth interviews and focus group discussions were conducted July 2012-August 2013. Study participants were purposively sampled from three AMPATH clinics and included patients within the AMPATH program receiving HIV, TB, and HTN care, as well as caregivers of children with HIV, community leaders, and healthcare providers. A set of interview guides were developed to explore perceived barriers and facilitators to chronic disease management, particularly related to linkage to and retention in HIV, TB and HTN care. Data were coded and various themes were identified. We organized the concepts and themes generated using the Andersen-Newman Framework of Health Services Utilization. Results A total of 235 participants including 110 individuals living with HIV (n = 50), TB (n = 39), or HTN (n = 21); 24 caregivers; 10 community leaders; and 62 healthcare providers participated. Barriers and facilitators were categorized as predisposing characteristics, enabling resources and need factors. Many of the facilitators and barriers reported in this study were consistently reported across disease categories including personal drive, patient-provider relationships and the need for social and peer support. Conclusions Our findings provide insight into the individual as well as broader structural factors that can deter or encourage linkage and retention that are relevant across communicable and non-communicable chronic diseases. The findings of the present study suggest that interventions should consider the logistical aspects of accessing care in addition to predisposing and need factors that may affect an individuals’ decision to seek out and remain in appropriate care.
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How home HIV testing and counselling with follow-up support achieves high testing coverage and linkage to treatment and prevention: a qualitative analysis from Uganda. J Int AIDS Soc 2016; 19:20929. [PMID: 27357495 PMCID: PMC4928103 DOI: 10.7448/ias.19.1.20929] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 05/17/2016] [Accepted: 05/31/2016] [Indexed: 02/07/2023] Open
Abstract
Introduction The successes of HIV treatment scale-up and the availability of new prevention tools have raised hopes that the epidemic can finally be controlled and ended. Reduction in HIV incidence and control of the epidemic requires high testing rates at population levels, followed by linkage to treatment or prevention. As effective linkage strategies are identified, it becomes important to understand how these strategies work. We use qualitative data from The Linkages Study, a recent community intervention trial of community-based testing with linkage interventions in sub-Saharan Africa, to show how lay counsellor home HIV testing and counselling (home HTC) with follow-up support leads to linkage to clinic-based HIV treatment and medical male circumcision services. Methods We conducted 99 semi-structured individual interviews with study participants and three focus groups with 16 lay counsellors in Kabwohe, Sheema District, Uganda. The participant sample included both HIV+ men and women (N=47) and HIV-uncircumcised men (N=52). Interview and focus group audio-recordings were translated and transcribed. Each transcript was summarized. The summaries were analyzed inductively to identify emergent themes. Thematic concepts were grouped to develop general constructs and framing propositional statements. Results Trial participants expressed interest in linking to clinic-based services at testing, but faced obstacles that eroded their initial enthusiasm. Follow-up support by lay counsellors intervened to restore interest and inspire action. Together, home HTC and follow-up support improved morale, created a desire to reciprocate, and provided reassurance that services were trustworthy. In different ways, these functions built links to the health service system. They worked to strengthen individuals’ general sense of capability, while making the idea of accessing services more manageable and familiar, thus reducing linkage barriers. Conclusions Home HTC with follow-up support leads to linkage by building “social bridges,” interpersonal connections established and developed through repeated face-to-face contact between counsellors and prospective users of HIV treatment and male circumcision services. Social bridges link communities to the service system, inspiring individuals to overcome obstacles and access care.
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