Antiretroviral therapy initiation and adherence in rural South Africa: community health workers' perspectives on barriers and facilitators

Linkage to HIV care and early retention in HIV care among men in the 'universal test-and-treat' era in a high HIV-burdened district, KwaZulu-Natal, South Africa

INTRODUCTION

Despite the numerous efforts and initiatives, males with HIV are still less likely than women to receive HIV treatment. Across Sub-Saharan Africa, men are tested, linked, and retained in HIV care at lower rates than women, and South Africa is no exception. This is despite the introduction of the universal test-and-treat (UTT) prevention strategy anticipated to improve the uptake of HIV services. The aim of this study was to investigate linkage to and retention in care rates of an HIV-positive cohort of men in a high HIV prevalence rural district in KwaZulu-Natal province, South Africa.

METHODS

From January 2018 to July 2019, we conducted an observational cohort study in 18 primary health care institutions in the uThukela district. Patient-level survey and clinical data were collected at baseline, 4-months and 12-months, using isiZulu and English REDCap-based questionnaires. We verified data through TIER.Net, Rapid mortality survey (RMS), and the National Health Laboratory Service (NHLS) databases. Data were analyzed using STATA version 15.1, with confidence intervals and p-value of ≤0.05 considered statistically significant.

RESULTS

The study sample consisted of 343 male participants diagnosed with HIV and who reside in uThukela District. The median age was 33 years (interquartile range (IQR): 29-40), and more than half (56%; n = 193) were aged 18-34 years. Almost all participants (99.7%; n = 342) were Black African, with 84.5% (n = 290) being in a romantic relationship. The majority of participants (85%; n = 292) were linked to care within three months of follow-up. Short-term retention in care (≤ 12 months) was 46% (n = 132) among men who were linked to care within three months.

CONCLUSION

While the implementation of the UTT strategy has had positive influence on improving linkage to care, men's access of HIV treatment remains inconsistent and may require additional innovative strategies.

Support, not blame: safe partner disclosure among women diagnosed with HIV late in pregnancy in South Africa and Uganda

BACKGROUND

HIV partner disclosure rates remain low among pregnant women living with HIV in many African countries despite potential benefits for women and their families. Partner disclosure can trigger negative responses like blame, violence, and separation. Women diagnosed with HIV late in pregnancy have limited time to prepare for partner disclosure. We sought to understand challenges around partner disclosure and non-disclosure faced by women diagnosed with HIV late in pregnancy in South Africa and Uganda and to explore pathways to safe partner disclosure.

METHODS

We conducted in-depth interviews and focus group discussions with pregnant women and lactating mothers living with HIV (n = 109), disaggregated by antenatal care (ANC) initiation before and after 20 weeks of gestation, male partners (n = 87), and health workers (n = 53). All participants were recruited from DolPHIN2 trial sites in Kampala (Uganda) and Gugulethu (South Africa). Topic guides explored barriers to partner disclosure, effects of non-disclosure, strategies for safe disclosure. Using the framework analysis approach, we coded and summarised data based on a socio-ecological model, topic guides, and emerging issues from the data. Data was analysed in NVivo software.

RESULTS

Our findings illustrate pregnant women who initiate ANC late experience many difficulties which are compounded by the late HIV diagnosis. Various individual, interpersonal, community, and health system factors complicate partner disclosure among these women. They postpone or decide against partner disclosure mainly for own and baby's safety. Women experience stress and poor mental health because of non-disclosure while demonstrating agency and resilience. We found many similarities and some differences around preferred approaches to safe partner disclosure among female and male participants across countries. Women and male partners preferred healthcare workers to assist with disclosure by identifying the 'right' time to disclose, mentoring women to enhance their confidence and communication skills, and providing professional mediation for partner disclosure and couple testing. Increasing the number of counsellors and training them on safe partner disclosure was deemed necessary for strengthening local health services to improve safe partner disclosure.

CONCLUSION

HIV diagnosis late in pregnancy amplifies existing difficulties among pregnant women. Late ANC initiation is an indicator for the likelihood that a pregnant woman is highly vulnerable and needs safeguarding. Respective health programmes should be prepared to offer women initiating ANC late in pregnancy additional support and referral to complementary programmes to achieve safe partner disclosure and good health.

Post-intervention perceptions on the antiretroviral therapy community group model in Trans Nzoia County, Kenya

Introduction

the increasing number of people receiving antiretroviral therapy (ART) in sub-Saharan Africa has stressed already overburdened health systems. A care model utilizing community-based peer-groups (ART Co-ops) facilitated by community health workers (CHW) was implemented (2016-2018) to address these challenges. In 2018, a post-intervention study assessed perceptions of the intervention.

Methods

forty participants were engaged in focus group discussions consisting of ART Co-op clients, study staff, and health care providers from Kitale HIV clinic. Data were analyzed thematically for content on the intervention, challenges, and recommendations for improvement.

Results

all participants liked the intervention. However, some reported traveling long distances to attend ART Co-op meetings and experiencing stigma with ART Co-ops participation. The ART Co-op inclusion criteria were considered appropriate; however, additional outreach to deliberately include spouses living with HIV, the disabled, the poor, and HIV pregnant women was recommended. Participants liked CHW-directed quarterly group meetings which included ART distribution, adherence review, and illness identification. The inability of the CHW to provide full clinical care, inconvenient meeting venues, poor timekeeping, and non-attendance behaviors were noted as issues. Participants indicated that program continuation, regular CHW training, rotating meetings at group members´ homes, training ART Co-ops leaders to assume CHW tasks, use of pill diaries to check adherence, nutritional support, and economically empowering members through income generation projects would be beneficial.

Conclusion

the intervention was viewed positively by both clinic staff and clients. They identified specific challenges and generated actionable key considerations to improve access and acceptability of the community-based model of care.

Family influences on oral PrEP use among adolescent girls and young women in Kenya and South Africa

INTRODUCTION

Effective use of oral HIV pre-exposure prophylaxis (PrEP) has been lower among African adolescent girls and young women (AGYW) than among older women, young men who have sex with men, and serodiscordant heterosexual couples in the region. Efforts to build PrEP support have centered around peers and male partners, but the family may also play an important role. This qualitative study aimed to describe family influence on PrEP use among AGYW in in three African cities.

METHODS

POWER (Prevention Options for Women Evaluation Research) was a PrEP demonstration project among 2550 AGYW (16-25 years old) in Johannesburg and Cape Town, South Africa and Kisumu, Kenya conducted from 2017 to 2020. In-depth interviews and focus group discussions were conducted with 136 AGYW participants to explore their PrEP views and experiences, including awareness and interest in PrEP; barriers and facilitators to uptake and use; the influence of family, peers, intimate partners, and community; and the key types of support for their PrEP use. Transcripts were coded and analysed thematically.

RESULTS

The decision to initiate PrEP was associated with fear and anxiety linked to anticipated stigma from family members, and with family's lived HIV experience. Family disclosure, especially to mothers, was important to participants, as most lived with their families and considered it essential for them to obtain their mother's approval to use PrEP. Most family members, particularly mothers, provided instrumental, emotional, informational and appraisal support to participants using PrEP, including reminders, encouragement, and problem-solving. Participants reported that family members with insufficient information about PrEP safety and efficacy and who voiced concerns were a substantial barrier to their use. However, they often became supportive after receiving more PrEP information.

CONCLUSION

Families, particularly mothers, can play an important role in supporting PrEP use. PrEP programmes should leverage family support to help with PrEP persistence by providing basic information to families about PrEP safety and efficacy. AGYW using PrEP should be encouraged to selectively disclose PrEP use to build support and counseled on how to disclose and address family concerns.

HIV Care Profiling and Delivery Status in the Mobile Health Clinics of eThekwini District in KwaZulu Natal, South Africa: A Descriptive Evaluation Study

Mobile health clinics (MHCs) serve as an alternative HIV care delivery method for the HIV-burdened eThekwini district. This study aimed to describe and profile the HIV care services provided by the MHCs through process evaluation. A descriptive cross-sectional quantitative evaluation study was performed on 137 MHCs using total population sampling. An online data collection method using a validated 50-item researcher-developed instrument was administered to professional nurses who are MHC team leaders, following ethical approval from the local university and departments of health. Descriptive statistics were used to analyze the data. The results described that HIV care services are offered in open spaces (43%), community buildings (37%), solid built buildings called health posts (15%), vehicles (9%), and tents (2%) with no electricity (77%), water (55%), and sanitation (64%). Adults (97%) are the main recipients of HIV care in MHCs (90%) offering antiretroviral therapy (95%). Staff, monitoring, and retaining care challenges were noted, with good linkage (91%) and referral pathways (n = 123.90%). In conclusion, the standardization and prioritization of HIV care with specific contextual practice guidelines are vital.

Lung cancer awareness training experiences of community health workers in KwaZulu-Natal, South Africa

BACKGROUND

Lung cancer is the leading cause of cancer mortality worldwide. Awareness interventions in the developing world remain scarce. Community health workers (CHWs) are a critical component towards ensuring efficient delivery of healthcare services in low- and middle-income countries.

AIM

This study explored the experiences of CHWs of their training as lung cancer awareness intervention implementers.

SETTING

The study was conducted in a resource-poor setting, with CHWs from previously disadvantaged communities.

METHODS

On the last day of training, 10 CHWs were requested to voluntarily participate in a focus group discussion regarding their experiences of the training, utilising a discussion guide.

RESULTS

The participants expressed positive experiences with the training. They cited the amenable and conducive learning environment established by the facilitator. The participants felt empowered through the newly acquired knowledge and wanted to help their communities. However, some participants expressed a desire to have other forms of learning incorporated in future training. The participants were also cognisant of existing gaps in their own knowledge that could be elaborated upon in preparation for potential questions by the community. Some participants confirmed their role as agents of change.

CONCLUSION

The authors propose large-scale intervention studies of lung cancer awareness utilising the CHW programme to gather conclusive evidence regarding their effectiveness at a community level.Contribution: This article provides insight into the training of community health workers on lung cancer awareness and future research on the integration of the intervention into already existing programmes.

Exploring how outreach team leaders perceive community health workers' experiences of providing HIV services in KwaZulu-Natal, South Africa

Objectives: In 2018, the KwaZulu-Natal Department of Health launched the ward-based primary health care outreach teams policy framework which sought to expand the community health worker (CHW) programme's provision of longitudinal patient support, including human immunodeficiency virus (HIV) services in communities. This study sought to explore the perceptions of outreach team leaders who supervise CHWs on their experiences of providing HIV services in the province.Study design: This was a qualitative, phenomenology study.Methods: Convenience sampling was done to select one outreach team leader from each of the 11 KwaZulu-Natal health districts to be interviewed using an interview guide. Thematic analysis, guided by the Ritchie and Spencer framework analysis, was used to analyse the data.Results: The challenges faced by CHWs in delivering HIV services were: the absence of individuals when CHWs visited their homes, self-HIV stigma, rejection of CHWs' HIV services due to traditional beliefs, CHW shortages, lack of other resources, low levels of CWH education and a lack of training. On the other hand, the provision of HIV services was fascilitated by: supportive supervision, training, having cell phones and having a positive attitude towards providing HIV services by CHWs that were HIV-positive.Conclusion: The CHWs in KwaZulu-Natal face more challenges than enablers in the provision of HIV services. The delegation of HIV services to CHWs should be aligned with their holistic empowerment by eliminating barriers to the provision of HIV services.

Risk factors for late linkage to care and delayed antiretroviral therapy initiation amongst HIV infected adults in sub-Saharan Africa: a systematic review and meta-analyses

BACKGROUND

Late treatment initiation threatens the clinical and public health benefits of antiretroviral therapy (ART). Quantitative synthesises of the existing evidence related to this is lacking in sub-Saharan Africa (SSA), which would help ascertain the best evidence-based interventions. This review aimed to systematically synthesise the available literature on factors affecting linkage to care and ART initiation amongst HIV-infected adults in SSA.

METHODS

Systematic searches were undertaken on four databases to identify observational studies investigating factors affecting both HIV care outcomes amongst adults (age ≥19 years) in SSA, and were published between January 1, 2015 and June 1, 2021. RevMan-5 software was used to conduct meta-analyses and Mantel-Haenszel statistics to pool outcomes with 95% confidence interval and <0.05 level of significance.

RESULTS

Forty-six studies were included in the systematic review, of which 18 fulfilled requirements for meta-analysis. In both narrative review and meta-analyses, factors related to health care delivery, individual perception and sociodemographic circumstances were associated with late linkage to care and delays in ART initiation.

CONCLUSION

This review identified a range of risk factors for late linkage to care and delayed ART initiation amongst HIV-infected adults in SSA. We recommend implementation of patient-centred intervention approaches to alleviate these barriers.

Understanding Repeat Positive HIV Testing in South Africa Under Changing Treatment Guidelines

Some people with HIV (PWH) test positive multiple times without initiating antiretroviral therapy (ART). We surveyed 496 ART-eligible PWH following routine HIV testing at three clinics in Soweto and Gugulethu, South Africa in 2014-2015. Among repeat positive testers (RPTs) in this cohort, we compared rates of treatment initiation by prior treatment eligibility and assessed psychosocial predictors of treatment initiation in logistic regression models. RPTs represented 33.8% of PWH in this cohort. Less than half of those who reported eligibility for ART on prior testing started treatment upon retesting, in contrast to two thirds of RPTs who were previously ineligible for treatment who started treatment once they learned of their eligibility. Those who reported coping through substance use were more likely to decline treatment versus those not using substances. PWH who test repeatedly represent a vulnerable population at risk for ART non-initiation who may benefit from interventions addressing individualized coping strategies.

Roles, Barriers, and Recommendations for Community Health Workers Providing Community-Based HIV Care in Sub-Saharan Africa: A Review

While the impact of Community Health Workers (CHWs) on home-based human immunodeficiency virus (HIV) care has been documented, barriers and recommendations have not been systematically reviewed. Following the reporting requirements of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we used an aggregative narrative synthesis approach to summarize the results of qualitative studies published between January 1, 2000, and November 6, 2020 in the following databases: PubMed, CINAHL, PsychINFO, Web of Science, and Google Scholar. In total, 17 studies met the selection criteria and were included in the analysis. They reported on a range of roles played by CHWs in HIV care, including education and health promotion; HIV-specific care (HIV testing services; screening for opportunistic infections and acute illness); medication delivery; tracing persons who had defaulted from care; and support (treatment support; referral; home-based care; and psychosocial support). Many different barriers to community-based HIV care were reported and centered on the following themes: Stigma and nondisclosure; inadequate support (lack of resources, inadequate training, inadequate funding, and inadequate monitoring); and health system challenges (patients' preference for more frequent visits and poor integration of CHWs in the wider health care system). Recommendations to mitigate these barriers included: addressing HIV-related stigma; introducing updated and relevant CHW training; strengthening the supervision of CHWs; coordinating care between the home and facilities; incorporating patient-centered mHealth approaches; and committing to the funding and resources needed for successful community-based care. In summary, CHWs are providing a variety of important community-based HIV services but face challenges with regards to training, resources, and supervision.

Geo-analysis: the distribution of community health workers in relation to the HIV prevalence in KwaZulu-Natal province, South Africa

Background

The South African Ward Based Primary Health Care Outreach Team (WBPHCOT) policy framework states that the distribution of community health workers (CHWs) should be proportional to levels of poverty and disease within the population. We aimed to describe the spatial distribution of CHWs in relation to the prevalence of the Human Immunodeficiency Virus (HIV) which has itself been associated with poverty in previous studies.

Methods

This was a descriptive, cross-sectional study in which secondary data was used for geospatial analysis. Based on the extrapolation from the norm of one WBPHCOT per 6000 individuals, we utilized geographic information system (GIS) methods to visualize the distribution of CHWs in relation to the prevalence of HIV in KwaZulu-Natal (KZN). Dot density mapping was used to visualize the random distribution of CHWs in relation to HIV prevalence and population in the districts. The districts’ HIV prevalence, number of PLWH, ratio of CHW: people living with HIV (PLWH), ratio of CHW: population and poverty scores were mapped using choropleth mapping. MapInfo Pro 17.0 was used to map geospatial presentation of the data.

Results

Overall, KZN province showed under allocation of CHWs with a CHW: people ratio of 1: 1156 compared to the estimated norm of 1: 600–1000. At district level, only two of 11 districts met the suggested norm of CHW: PLWH (1: 109–181). This indicates shortages and misallocation of CHWs in the nine remaining districts. Furthermore, our findings showed extensive geospatial heterogeneity with no clear pattern in the distribution of CHWs. There was no relationship between CHW distribution and HIV prevalence or poverty scores in the districts.

Conclusion

This study shows inequality in the distribution of CHWs which may be associated with inequalities in the provision of HIV related services. It is critical to strengthen the response to the HIV epidemic through the appropriate distribution of CHWs especially in those districts with high levels of HIV prevalence and poverty.

Point-of-care viral load tests to detect high HIV viral load in people living with HIV/AIDS attending health facilities

BACKGROUND

Viral load (VL) testing in people living with HIV (PLHIV) helps to monitor antiretroviral therapy (ART). VL is still largely tested using central laboratory-based platforms, which have long test turnaround times and involve sophisticated equipment. VL tests with point-of-care (POC) platforms capable of being used near the patient are potentially easy to use, give quick results, are cost-effective, and could replace central or reference VL testing platforms.

OBJECTIVES

To estimate the diagnostic accuracy of POC tests to detect high viral load levels in PLHIV attending healthcare facilities.

SEARCH METHODS

We searched eight electronic databases using standard, extensive Cochrane search methods, and did not use any language, document type, or publication status limitations. We also searched the reference lists of included studies and relevant systematic reviews, and consulted an expert in the field from the World Health Organization (WHO) HIV Department for potentially relevant studies. The latest search was 23 November 2020.

SELECTION CRITERIA

We included any primary study that compared the results of a VL test with a POC platform to that of a central laboratory-based reference test to detect high viral load in PLHIV on HIV/AIDS care or follow-up. We included all forms of POC tests for VL as defined by study authors, regardless of the healthcare facility in which the test was conducted. We excluded diagnostic case-control studies with healthy controls and studies that did not provide sufficient data to create the 2 × 2 tables to calculate sensitivity and specificity. We did not limit our study inclusion to age, gender, or geographical setting.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the titles, abstracts, and full texts of the search results to identify eligible articles. They also independently extracted data using a standardized data extraction form and conducted risk of bias assessment using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Using participants as the unit of analysis, we fitted simplified univariable models for sensitivity and specificity separately, employing a random-effects model to estimate the summary sensitivity and specificity at the current and commonly reported World Health Organization (WHO) threshold (≥ 1000 copies/mL). The bivariate models did not converge to give a model estimate.

MAIN RESULTS

We identified 18 studies (24 evaluations, 10,034 participants) defining high viral loads at main thresholds ≥ 1000 copies/mL (n = 20), ≥ 5000 copies/mL (n = 1), and ≥ 40 copies/mL (n = 3). All evaluations were done on samples from PLHIV retrieved from routine HIV/AIDS care centres or health facilities. For clinical applicability, we included 14 studies (20 evaluations, 8659 participants) assessing high viral load at the clinical threshold of ≥ 1000 copies/mL in the meta-analyses. Of these, sub-Saharan Africa, Europe, and Asia contributed 16, three, and one evaluation respectively. All included participants were on ART in only nine evaluations; in the other 11 evaluations the proportion of participants on ART was either partial or not clearly stated. Thirteen evaluations included adults only (n = 13), five mixed populations of adults and children, whilst in the remaining two the age of included populations was not clearly stated. The majority of evaluations included commercially available tests (n = 18). Ten evaluations were POC VL tests conducted near the patient in a peripheral or onsite laboratory, whilst the other 10 were evaluations of POC VL tests in a central or reference laboratory setting. The test types evaluated as POC VL tests included Xpert HIV-1 Viral Load test (n = 8), SAMBA HIV-1 Semi-Q Test (n = 9), Alere Q NAT prototype assay for HIV-1 (n = 2) and m-PIMA HIV-1/2 Viral Load test (n = 1). The majority of evaluations (n = 17) used plasma samples, whilst the rest (n = 3) utilized whole blood samples. Pooled sensitivity (95% confidence interval (CI)) of POC VL at a threshold of ≥ 1000 copies/mL was 96.6% (94.8 to 97.8) (20 evaluations, 2522 participants), and pooled specificity (95% CI) was 95.7% (90.8 to 98.0) (20 evaluations, 6137 participants). Median prevalence for high viral load (≥ 1000 copies/mL) (n = 20) was 33.4% (range 6.9% to 88.5%). Limitations The risk of bias was mostly assessed as unclear across the four domains due to incomplete reporting.

AUTHORS' CONCLUSIONS

We found POC VL to have high sensitivity and high specificity for the diagnosis of high HIV viral load in PLHIV attending healthcare facilities at a clinical threshold of ≥ 1000 copies/mL.

Uptake of community‐ versus clinic‐based antiretroviral therapy dispensing in the Central Chronic Medication Dispensing and Distribution program in South Africa

Introduction

South Africa's government‐led Central Chronic Medication Dispensing and Distribution (CCMDD) program offers people living with HIV the option to collect antiretroviral therapy at their choice of community‐ or clinic‐based pick‐up points intended to increase convenience and decongest clinics. To understand CCMDD pick‐up point use among people living with HIV, we evaluated factors associated with uptake of a community‐ versus clinic‐based pick‐up point at CCMDD enrolment.

Methods

We collected baseline data from October 2018 to March 2020 on adults (≥18 years) who met CCMDD clinical eligibility criteria (non‐pregnant, on antiretroviral therapy for ≥1 year and virologically suppressed) as part of an observational cohort in seven public clinics in KwaZulu‐Natal. We identified factors associated with community‐based pick‐up point uptake and fit a multivariable logistic regression model, including age, gender, employment status, self‐perceived barriers to care, self‐efficacy, HIV‐related discrimination, and perceived benefits and challenges of CCMDD.

Results and Discussion

Among 1521 participants, 67% were females, with median age 36 years (IQR 30–44). Uptake of a community‐based pick‐up point was associated with younger age (aOR 1.18 per 10‐year decrease, 95% CI 1.05–1.33), being employed ≥40 hours per week (aOR 1.42, 95% CI 1.10–1.83) versus being unemployed, no self‐perceived barriers to care (aOR 1.42, 95% CI 1.09–1.86) and scoring between 36 and 39 (aOR 1.44, 95% CI 1.03–2.01) or 40 (aOR 1.91, 95% CI 1.39–2.63) versus 10–35 on the self‐efficacy scale, where higher scores indicate greater self‐efficacy. Additional factors included more convenient pick‐up point location (aOR 2.32, 95% CI 1.77–3.04) or hours (aOR 5.09, 95% CI 3.71–6.98) as perceived benefits of CCMDD, and lack of in‐clinic follow‐up after a missed collection date as a perceived challenge of CCMDD (aOR 4.37, 95% CI 2.30–8.31).

Conclusions

Uptake of community‐based pick‐up was associated with younger age, full‐time employment, and systemic and structural factors of living with HIV (no self‐perceived barriers to care and high self‐efficacy), as well as perceptions of CCMDD (convenient pick‐up point location and hours, lack of in‐clinic follow‐up). Strategies to facilitate community‐based pick‐up point uptake should be tailored to patients’ age, employment, self‐perceived barriers to care and self‐efficacy to maximize the impact of CCMDD in decongesting clinics.

‘We have goals but [it is difficult]’. Barriers to antiretroviral therapy adherence among women using alcohol and other drugs living with HIV in South Africa

Background

Methods

Results

Conclusion

Patient or Public Contribution

Challenges experienced by community health workers and their motivation to attend a self-management programme

Background: Community health workers (CHWs) are change agents expected to assist in decreasing the global burden of disease in the communities they serve. However, they themselves have health risk behaviours, which predispose them to non-communicable diseases and thus need to be empowered to make better health choices. There is a gap in literature detailing the challenges faced by CHWs in addressing their own health risk behaviours.Aim: This study aimed to explore the challenges experienced by CHWs in carrying out their daily duties and the motivating factors to join a self-management programme.Setting: The study was conducted in a low socio-economic urban area of the Western Cape, South Africa.Methods: This study used a qualitative exploratory design using in-depth interviews to obtain rich data about the personal and professional challenges that CHWs experience on a daily basis.Results: Five themes emerged with regard to professional challenges (social conditions, mental health of patients, work environment, patient adherence and communication). This cadre identified ineffective self-management as a personal challenge and two themes emerged as motivation for participating in a self-management programme: empowerment and widening perspective.Conclusion: The challenges raised by the CHWs have a direct impact on their role in communities. This study therefore highlights an urgent need for policymakers and leaders who plan training programmes to take intentional strategic action to address their health challenges and to consider utilising a self-management intervention model to improve their overall health status.

HIV-related stigma and uptake of antiretroviral treatment among incarcerated individuals living with HIV/AIDS in South African correctional settings: A mixed methods analysis

Background

Stigma affects engagement with HIV healthcare services. We investigated the prevalence and experience of stigma among incarcerated people living with HIV (PLHIV) in selected South African correctional settings during roll-out of universal test and treat.

Methods

A cross-sectional mixed-methods study design included 219 incarcerated PLHIV and 30 in-depth interviews were conducted with four different types of PLHIV. HIV-related stigma was assessed through survey self-reporting and during the interviews. A descriptive analysis of HIV-related stigma was presented, supplemented with a thematic analysis of the interview transcripts.

Results

ART uptake was high (n = 198, 90.4%) and most reported HIV-related stigma (n = 192, 87.7%). The intersectional stigma occurring due to individual and structural stigma around provision of healthcare in these settings mostly contributed to perceived stigma through involuntary disclosure of HIV status. Interpersonal and intrapersonal factors led to negative coping behaviours. However, positive self-coping strategies and relationships with staff encouraged sustained engagement in care.

Conclusion

We encourage continuous peer support to reduce stigmatization of those infected with HIV and whose status may be disclosed inadvertently in the universal test and treat era.

Implementing 'universal' access to antiretroviral treatment in South Africa: a scoping review on research priorities

‘Universal’ access to antiretroviral treatment (ART) has become the global standard for treating people living with HIV and achieving epidemic control; yet, findings from numerous ‘test and treat’ trials and implementation studies in sub-Saharan Africa suggest that bringing ‘universal' access to ART to scale is more complex than anticipated. Using South Africa as a case example, we describe the research priorities and foci in the literature on expanded ART access. To do so, we adapted Arksey and O’Malley’s six-stage scoping review framework to describe the peer-reviewed literature and opinion pieces on expanding access to ART in South Africa between 2000 and 2017. Data collection included systematic searches of two databases and hand-searching of a sub-sample of reference lists. We used an adapted socio-ecological thematic framework to categorize data according to where it located the challenges and opportunities of expanded ART eligibility: individual/client, health worker–client relationship, clinic/community context, health systems infrastructure and/or policy context. We included 194 research articles and 23 opinion pieces, of 1512 identified, addressing expanded ART access in South Africa. The peer-reviewed literature focused on the individual and health systems infrastructure; opinion pieces focused on changing roles of individuals, communities and health services implementers. We contextualized our findings through a consultative process with a group of researchers, HIV clinicians and programme managers to consider critical knowledge gaps. Unlike the published literature, the consultative process offered particular insights into the importance of researching and intervening in the relational aspects of HIV service delivery as South Africa’s HIV programme expands. An overwhelming focus on individual and health systems infrastructure factors in the published literature on expanded ART access in South Africa may skew understanding of HIV programme shortfalls away from the relational aspects of HIV services delivery and delay progress with finding ways to leverage non-medical modalities for achieving HIV epidemic control.

The role of pharmacy personnel in promoting adherence to antiretroviral therapy in the Eastern Cape: communication barriers and breakthroughs

Background: Many people living with HIV struggle to adhere to their antiretroviral therapy, leading to suboptimal health outcomes and increased costs to the healthcare system. Due to their unique training and position in the health care system, South African pharmacists and pharmacy support personnel have the potential to improve adherence through effective patient counselling. However, they are often underutilised and face multiple barriers to providing these services. The aim of this study was to examine how pharmacists and pharmacy personnel view their impact upon the medication adherence behaviours of people living with and receiving medication therapy for HIV.Methods: The study used an exploratory qualitative research design. Our research team conducted in-depth interviews with 24 pharmacy personnel working in public health clinics in the Eastern Cape of South Africa, then used thematic analysis of the qualitative research data to determine the results.Results: Pharmacy personnel identified three key sets of communication challenges that limited effective patient counselling on antiretroviral therapy. These included environmental barriers presented by clinic design, language barriers between patients and pharmacy personnel, and varying communication styles and education levels of pharmacy staff and patients. Additionally, pharmacy personnel described innovative strategies they use to improve patient-provider communication and address adherence issues.Conclusions: Pharmacy personnel working in public health clinics face daily communication challenges as they attempt to provide counselling to patients with HIV. Both the clinic environment and the complex nature of HIV treatment serve as barriers to patient comprehension. In the face of these challenges, pharmacy personnel do their best to implement strategies that enhance patient counselling and address concerns about adherence. Increased attention should be paid to reducing the barriers to pharmacy-based patient counselling and utilising pharmacy personnel to enhance patient understanding and adherence to antiretroviral therapy.

Community-based care models for arterial hypertension management in non-pregnant adults in sub-Saharan Africa: A scoping review protocol

Introduction: Arterial hypertension (aHT) is the most important cardiovascular risk factor (CVRF) in adults living in sub-Saharan Africa (SSA), leading to an excess of cardiovascular disease (CVD) morbidity and mortality. Life-long aHT service delivery models in the region remain mostly anchored to health facilities and are provided by physicians or nurses, thus limiting access to care. Over the past years, decentralized community-based aHT care models have been piloted, aiming to improve access to prevention, diagnosis, and treatment. Although individual studies suggest that community-based care is well-received and potentially efficacious, a synthesized overview of such care models is missing. Hence, the aim of this scoping review is to map out and summarize existing interventions for community-based aHT diagnosis and care in non-pregnant adults in SSA. Additionally, we will describe outcomes in terms of acceptability, blood pressure control, patient engagement in care, and occurrence of aHT caused end-organ damage. Methods and analysis: We will apply the Arksey and O’Malley scoping review methodology and best practice, as outlined by Levac and the Joanna Briggs Institute scoping review guidelines. The research questions have been identified through a literature review and expert consultation. A systematic literature search will be conducted in four databases using a tailored search strategy, including a supplemental search through backward and forward citation. Abstracts and full text screening as well as the extraction of data will be conducted by two independent reviewers. Discrepancies will be resolved by a third reviewer. Information will be presented in both tabular and narrative form. Ethics and dissemination: This scoping review will summarize findings from existing publications, rather than primary data, and as such, does not require ethics review. Findings will be disseminated through stakeholder meetings, conference presentations, websites, and a peer-reviewed publication.

Twelve-Month Outcomes of Community-Based Differentiated Models of Multimonth Dispensing of ART Among Stable HIV-Infected Adults in Lesotho: A Cluster-Randomized Noninferiority Trial

BACKGROUND

Lesotho adopted the test-and-treat approach for HIV treatment in June 2016, which increased antiretroviral treatment (ART) clinic volume. We evaluated community-based vs. facility-based differentiated models of multimonth dispensing of ART among stable HIV-infected adults in Lesotho.

METHODS

Thirty facilities were randomized to 3 arms, facility 3-monthly ART (3MF) (control), community ART groups (3MC), and 6-monthly community distribution points (6MCD). We estimated risk differences (RDs) between arms using population-averaged generalized estimating equations, controlling for baseline imbalances and specifying for clustering. The primary outcome was retention in ART care by intention-to-treat and virologic suppression as a secondary outcome (ClinicalTrials.gov: NCT03438370).

RESULTS

A total of 5,336 participants were enrolled, with 1898, 1558, and 1880 in 3MF, 3MC, and 6MCD, respectively. Retention in ART care was not different across arms and achieved the prespecified noninferiority limit (-3.25%) between 3MC vs. 3MF (control); 6MCD vs. 3MF; and 6MCD vs. 3MC, adjusted RD = -0.1% [95% confidence interval (CI): -1.6% to 1.5%], adjusted RD = -1.3% (95% CI: -3.0% to 0.5%), and adjusted RD = -1.2% (95% CI: -2.9% to 0.5%), respectively. After 12 months, 98.6% (n = 1503), 98.1% (n = 1126), and 98.3% (n = 1285) were virally load (VL) suppressed in 3MF, 3MC, and 6MCD, respectively. There were no differences in VL between 3MC vs. control and 6MCD vs. control, risk ratio (RR) = 1.00 (95% CI: 0.98 to 1.01) and RR = 1.00 (95% CI: 0.98 to 1.01), respectively.

CONCLUSIONS

There were no differences in retention and VL suppression for stable HIV-infected participants receiving multimonth dispensing of ART within community-based differentiated models when compared with the facility-based standard-of-care model.

Potential challenges to sustained viral load suppression in the HIV treatment programme in South Africa: a narrative overview

Background

South Africa, with one of the highest HIV prevalences in the world, introduced the universal test and treat (UTT) programme in September 2016. Barriers to sustained viral suppression may include drug resistance in the pre-treated population, non-adherence, acquired resistance; pharmacokinetics and pharmacodynamics, and concurrent use of alternative treatments.

Objective

The purpose of this review is to highlight potential challenges to achieving sustained viral load suppression in South Africa (SA), a major expectation of the UTT initiative.

Methodology

Through the PRISMA approach, published articles from South Africa on transmitted drug resistance; adherence to ARV; host genetic factors in drug pharmacokinetics and pharmacodynamics, and interactions between ARV and herbal medicine were searched and reviewed.

Results

The level of drug resistance in the pre-treated population in South Africa has increased over the years, although it is heterogeneous across and within Provinces. At least one study has documented a pre-treated population with moderate (> 5%) or high (> 15%) levels of drug resistance in eight of the nine Provinces. The concurrent use of ARV and medicinal herbal preparation is fairly common in SA, and may be impacting negatively on adherence to ARV. Only few studies have investigated the association between the genetically diverse South African population and pharmacokinetics and pharmacodynamics of ARVs.

Conclusion

The increasing levels of drug resistant viruses in the pre-treated population poses a threat to viral load suppression and the sustainability of first line regimens. Drug resistance surveillance systems to track the emergence of resistant viruses, study the burden of prior exposure to ARV and the parallel use of alternative medicines, with the goal of minimizing resistance development and virologic failure are proposed for all the Provinces of South Africa. Optimal management of the different drivers of drug resistance in the pre-treated population, non-adherence, and acquired drug resistance will be beneficial in ensuring sustained viral suppression in at least 90% of those on treatment, a key component of the 90-90-90 strategy.

Mobility and structural barriers in rural South Africa contribute to loss to follow up from HIV care

Retention in HIV care is crucial to sustaining viral load suppression, and reducing HIV transmission, yet loss to follow-up (LTFU) in South Africa remains substantial. We conducted a mixed methods evaluation in rural South Africa to characterize ART disengagement in neglected rural settings. Using convenience sampling, surveys were completed by 102 PLWH who disengaged from ART (minimum 90 days) and subsequently resumed care. A subset (n = 60) completed individual in-depth interviews. Median duration of ART discontinuation was 9 months (IQR 4-22). Participants had HIV knowledge gaps regarding HIV transmission and increased risk of tuberculosis. The major contributors to LTFU were mobility and structural barriers. PLWH traveled for an urgent family need or employment, and were not able to collect ART while away. Structural barriers included inability to access care, due to lack of financial resources to reach distant clinics. Other factors included dissatisfaction with care, pill fatigue, lack of social support, and stigma. Illness was the major precipitant of returning to care. Mobility and structural barriers impede longitudinal HIV care in rural South Africa, threatening the gains made from expanded ART access. To achieve 90-90-90, future interventions, including emphasis on patient centered care, must address barriers relevant to rural settings.

Seeking care in the context of social health insurance in Kenya and Ghana

BACKGROUND

Social Health Insurance (SHI) is widely used by countries attempting to move toward Universal Health Coverage (UHC). While evidence suggests that SHI is a promising strategy for achieving UHC, low-income countries often struggle to implement and sustain SHI systems. It is therefore important to understand how SHI enrollees use health insurance and how it affects their health-seeking behavior. This paper examines how SHI affects patient decision-making regarding when and where to seek care in Kenya and Ghana, two countries with established SHI systems in sub-Saharan Africa.

METHODS

This paper draws from two datasets collected under the African Health Markets for Equity (AHME) program. One dataset, collected in 2013 and 2017 as part of the AHME qualitative evaluation, consists of 106 semi-structured clinic exit interviews conducted with patients in Ghana and Kenya. This data was analyzed using an inductive, thematic approach. The second dataset was collected internally by the AHME partner organizations. It derives from a cross-sectional survey of social franchise clients at three social franchise networks supported by AHME. Data collection took place from February - May 2018 and in December 2018.

RESULTS

Many clients appreciated that insurance coverage made healthcare more affordable, reported seeking care more frequently when covered with SHI. Clients also noted that the coverage gave them access to a wider variety of providers, but rarely sought out SHI-accredited providers specifically. However, clients sometimes were charged for services that should have been covered by insurance. Due to a lack of understanding of SHI benefits, clients rarely knew they had been charged inappropriately.

CONCLUSIONS

Clients and providers would benefit from education on what is included in the SHI package. Providers should be monitored and held accountable for charging clients inappropriately; in Ghana this should be accompanied by reforms to make government financing for SHI sustainable. Since clients valued provider proximity and both Kenya and Ghana have a dearth of providers in rural areas, both countries should incentivize providers to work in these areas and prioritize accrediting rural facilities into SHI schemes to increase accessibility and reach.

HIV Treatment Outcomes Among Patients Initiated on Antiretroviral Therapy Pre and Post-Universal Test and Treat Guidelines in South Africa

Introduction

Officially rolled out on 01 September 2016, South Africa’s Universal Test and Treat (UTT) policy calls for first-line antiretroviral treatment (ART) initiation among all known HIV-positive patients, irrespective of CD4 cell count. We evaluate treatment outcomes of patients initiated on first-line ART directly before and after the implementation of UTT.

Methods

We analysed prospectively collected clinical cohort data among ART-naïve adult patients within two HIV clinics in Johannesburg, South Africa. We compare two groups: 1) an unexposed pre-UTT group initiating treatment from 01 December 2014 to 31 May 2015; and 2) an exposed UTT group initiating treatment from 01 December 2016 to 31 May 2017. Primary treatment outcomes included lost to follow-up (LTFU) (>90 days late for the last scheduled visit with no subsequent clinical visit). Cox proportional hazards models were used to estimate the association between pre-UTT vs UTT initiation on LTFU by 12 months.

Results

We included 2410 patients. A total of 1267 (52.6%) patients initiated ART before UTT implementation and 1143 (47.4%) after the change in policy. LTFU (adjusted Hazard Ratio (aHR): 1.51; 95% Confidence Interval (CI): 1.16–1.98) between groups and specifically among those initiating with a CD4 cell count ≤500 cells/mm³ (aHR: 1.59; 95% CI: 1.21–2.10) was higher among patients initiating ART under UTT.

Conclusion

LTFU under UTT proved higher than that of previous periods. Patients initiating first-line therapy under the treat-all policy may often start treatment in better health, subsequently not perceiving a direct benefit to treatment which may deter patients from consistent engagement in HIV treatment programmes.

"Our Tradition Our Enemy": A Qualitative Study of Barriers to Women's HIV Care in Jimma, Southwest Ethiopia

Evidence exists that suggests that women are vulnerable to negative HIV treatment outcomes worldwide. This study explored barriers to treatment outcomes of women in Jimma, Southwest Ethiopia. We interviewed 11 HIV patients, 9 health workers, 10 community advocates and 5 HIV program managers from 10 institutions using an in-depth interview guide designed to probe barriers to HIV care at individual, community, healthcare provider, and government policy levels. To systematically analyze the data, we applied a thematic framework analysis using NVivo. In total, 35 participants were involved in the study and provided the following interrelated barriers: (i) Availability— most women living in rural areas who accessed HIV cared less often than men; (ii) free antiretroviral therapy (ART) is expensive—most women who have low income and who live in urban areas sold ART drugs illegally to cover ART associated costs; (iii) fear of being seen by others—negative consequences of HIV related stigma was higher in women than men; (iv) the role of tradition—the dominance of patriarchy was found to be the primary barrier to women’s HIV care and treatment outcomes. In conclusion, barriers related to culture or tradition constrain women’s access to HIV care. Therefore, policies and strategies should focus on these contextual constrains.

Community health care workers in pursuit of TB: Discourses and dilemmas

Community-led tuberculosis (TB) active case finding is widely promoted, heavily funded, but many efforts fail to meet expectations. The underlying reasons why TB symptom screening programs underperform are poorly understood. This study examines Nigerian stakeholders' insights to characterize the mechanisms, enabling structures and influences that lead programs to succeed or fail. Eight focus group discussions were held with Community Health Workers (CWs) from four models of community-based TB screening and referral. In-depth interviews were conducted with 2 State TB program managers, 8 Community based organizations (CBOs), and 6 state TB and Leprosy Local Government supervisors. Transcripts were coded using Framework Analysis to assess how divergent understandings of CWs' roles, expectations, as well as design, political and structural factors contributed to the observed underperformance. Altruism, religious faith, passion, and commitment to the health and well-being of their communities were reasons CWs gave for starting TB symptom screening and referral. Yet politicized or donor-driven CWs' selection processes at times yielded implementers without a firm grounding in TB or the social, cultural, and physical terrain. CWs encountered suspicion, stigma, and hostility in both health facilities and communities. As the interface between the TB program and communities, CWs often bore the brunt of frustrations with inadequate TB services and CBO/iNGO collaboration. Some CWs expended their own social and financial capital to cover gaps in the active case finding (ACF) programs and public health services or curtailed their screening activities. Effective community-led TB active case finding is challenging to design, implement and sustain. Contrary to conventional wisdom, CWs did not experience it as inherently empowering. Sustainable, supportive models that combine meaningful engagement for communities with effective program stewardship and governance are needed. Crucially effective and successful implementation of community-based TB screening and referral requires a functional public health system to which to refer.

Factors influencing adherence to antiretroviral treatment among adults accessing care from private health facilities in Malawi

BACKGROUND

Private health facilities are increasingly being recognized as the neglected partner in the provision of HIV services. The non-adherence rate in the study sites ranged from 19 to 22%. This study explored the factors associated with non-adherence from antiretroviral therapy (ART) among adult patients accessing ART services at two privately owned urban health facilities in Malawi.

METHODS

We conducted a descriptive qualitative approach employing in-depth interviews among adults who either defaulted or were retained in HIV care in two privately owned facilities in Malawi from March to July 2017. We purposively selected participants and interviewed a total of 6 ART providers and 24 ART clients. Data were analyzed manually using a thematic approach.

RESULTS

Overall, participants identified four facilitators for retention in care and four broad categories of barriers namely individual, psychological, drug related and human resource related factors. The factors that facilitated retention in care included follow up visits after missing a visit, adequate information education and counseling, and supportive relationships.

CONCLUSION

The main reason for defaulting from antiretrovirals (ARVs) was fear of disclosing an HIV status to avert potential stigma and discrimination. In implementing ART clinics due consideration and strategies need to be adopted to ensure that privacy and confidentiality is preserved. Although adoption of all the key Malawi Implementing strategies like expert clients and a guardian may optimize retention in care, there is need for prior analysis of how those may lead to unintended disclosure which inadvertently affects adherence. Furthermore, private facilities should orient their clients to the public facilities within the catchment area so that clients have an option for alternative access to HIV care in the event of financial constraints.

Outcomes of patients lost to follow-up after antiretroviral therapy initiation in rural north-eastern South Africa

Objective

The vital status of patients lost to follow‐up often remains unknown in antiretroviral therapy (ART) programmes in sub‐Saharan Africa because medical records are no longer updated once the patient disengages from care. Thus, we aimed to assess the outcomes of patients lost to follow‐up after ART initiation in north‐eastern South Africa.

Methods

Using data from a rural area in north‐eastern South Africa, we estimated the cumulative incidence of patient outcomes (i) after treatment initiation using clinical records, and (ii) after loss to follow‐up (LTFU) using data from clients that have been individually linked to Agincourt Health and Demographic Surveillance System (AHDSS) database. Aside from LTFU, we considered mortality, re‐engagement and migration out of the study site. Cox proportional hazards regression was used to identify covariates of these patient outcomes.

Results

Between April 2014 and July 2017, 3700 patients initiated ART and contributed a total of 6818 person‐years of follow‐up time. Three years after ART initiation, clinical record‐based estimates of LTFU, mortality and documented transfers were 41.0% (95% CI: 38.5–43.4%), 1.9% (95% CI 1.0–3.2%) and 0.1% (95% CI 0.0–0.9%), respectively. Among those who were LTFU, the cumulative incidence of re‐engagement, out‐migration and mortality at 3 years were 38.1% (95% CI 33.1–43.0%), 49.4% (95% CI 43.1–55.3%) and 4.7% (95% CI 3.5–6.2%), respectively. Pregnant or breastfeeding women, foreigners and those who initiated ART most recently were at an increased risk of LTFU.

Conclusion

LTFU among patients starting ART in north‐eastern South Africa is relatively high and has increased in recent years as more asymptomatic patients have initiated treatment. Even though this tendency is of concern in light of the prevention of onwards transmission, we also found that re‐engagement in care is common and mortality among persons LTFU relatively low.

HIV-associated cavernous sinus disease

Introduction

The underlying diagnosis of cavernous sinus disease is difficult to confirm in HIV-coinfected patients owing to the lack of histological confirmation. In this retrospective case series, we highlight the challenges in confirming the diagnosis and managing these patients.

Results

The clinical, laboratory and radiological data of 23 HIV-infected patients with cavernous sinus disease were analysed. The mean age of patients was 38 years. The mean CD4+ count was 390 cells/μL. Clinically, patients presented with unilateral disease (65%), headache (48%), diplopia (30%) and blurred vision (30%). Third (65%) and sixth (57%) nerve palsies in isolation and combination (39%) were most common. Isolated fourth nerve palsy did not occur. Tuberculosis (17%) was the most commonly identified disorder followed by high-grade B-cell lymphoma (13%), meningioma (13%), metastatic carcinoma (13%) and neurosyphilis (7%). In 22% of the patients, there was no confirmatory evidence for a diagnosis. The patients were either treated empirically for tuberculosis or improved spontaneously when antiretroviral therapy was started. Cerebrospinal fluid was helpful in 4/13 (31%) of patients where it was not contraindicated. Only 3/23 (13%) of the patients had a biopsy of the cavernous sinus mass. The outcomes varied, and follow-up was lacking in the majority of patients.

Conclusion

In HIV-infected patients, histological confirmation of cavernous sinus pathology is not readily available for various reasons. In resource-limited settings, one should first actively search for extracranial evidence of tuberculosis, lymphoma, syphilis and primary malignancy and manage appropriately. Only if such evidence is lacking should a referral for biopsy be considered.

Healthcare Workers' Perspectives on the Barriers to Providing HIV Services to Children in Sub-Saharan Africa

Background

In order to accelerate the HIV response to meet the UNAIDS 90-90-90 indicators for children, healthcare workers need to lead a scale-up of HIV services in primary healthcare settings. Such a scale-up will require investigation into existing barriers that prevent healthcare workers from effectively providing those services to children. Furthermore, if the identified barriers are not well understood, designing context-specific and effective public health response programmes may prove difficult.

Objective

This study reviews the current literature pertaining to healthcare workers' perspectives on the barriers to providing HIV services to children in the primary care setting in Sub-Saharan Africa.

Methods

English articles published between 2010 and April 2018 were searched in electronic databases including Sabinet, MEDLINE, PubMed, and Google Scholar. Key search words used during the search were “healthcare workers' perspectives” and “barriers to providing HIV testing to children” OR “barriers to ART adherence AND children” and “barriers to HIV disclosure AND children.” Results. There are various barriers to provider-initiated counselling and testing (PICT) of children and disclosure of HIV status to children, including the following: lack of child-friendly infrastructure at clinics; lack of consensus on legal age of consent for both HIV testing and disclosure; healthcare worker unfamiliarity with HIV testing and disclosure guidelines; lack of training in child psychology; and confusion around the healthcare worker's role, which most believed was only to provide health education and clinical services and to correct false information, but not to participate in disclosure. Additionally, primary caregivers were reported to be a barrier to care and treatment of children as they continue to refuse HIV testing for their children and delay disclosure.

Conclusion

Training, mentoring, and providing healthcare workers with guidelines on how to provide child-focused HIV care have the potential to address the majority of the barriers to the provision of child-friendly HIV services to children. However, the need to educate primary caregivers on the importance of testing children and disclosing to them is equally important.

Social support, disclosure and stigma and the association with non-adherence in the six months after antiretroviral therapy initiation among a cohort of HIV-positive adults in rural KwaZulu-Natal, South Africa

The World Health Organisation (WHO) recommends antiretroviral treatment (ART) initiation at human immunodeficiency virus (HIV) diagnosis. As ART programmes expand, addressing barriers to adherence is vital. Past mixed findings on the association between social support, stigma and non-disclosure with ART adherence highlights the need for further research. The primary aim of this study was to examine how these factors are associated with ART non-adherence in the six months after ART initiation. The secondary aim was to explore how other factors are associated with non-adherence. We conducted secondary analysis of prospective data from HIV-positive adults initiating ART. Social support, disclosure patterns, perceived stigma and other demographic factors were collected at ART initiation and six months follow-up. Logistic regression models were used to examine factors associated with self-reported ART non-adherence in the last six months and the last month before the six month follow-up (“recent”). Non-adherence in the last six months was twenty-five percent and recent non-adherence was nine percent. There was no association between non-adherence and social support, stigma or non-disclosure of HIV status. In the final model the odds of non-adherence in the last six months were significantly higher for those: with incomplete ART knowledge (aOR 2.10, 95%CI 1.21–3.66); who visited a healthcare provider for conditions other than HIV (aOR1.98, 95%CI 1.14–3.43); had higher CD4 counts at ART initiation (CD4 100–199:aOR 2.50, 95%CI 1.30–4.81; CD4 ≥ 200:aOR 2.85, 95%CI 1.10–7.40;referent CD4 < 100 cells/mm³); had tested HIV-positive in the last year (aOR 2.00, 95%CI 1.10–3.72; referent testing HIV-positive outside the last year); experienced a rash/itching secondary to ART (aOR 2.48, 95%CI 1.37–4.52); and significantly lower for those ≥48 years (aOR 0.65, 95%CI 0.46–0.90). Early non-adherence remains a concern. Incorporation of adherence monitoring and ART knowledge enhancement into appointments for ART collection may be beneficial.

Factors affecting adherence to antiretroviral therapy among pregnant women in the Eastern Cape, South Africa

Background

Context-specific factors influence adherence to antiretroviral therapy (ART) among pregnant women living with HIV. Gaps exist in the understanding of the reasons for the variable outcomes of the prevention of mother-to-child transmission (PMTCT) programme at the health facility level in South Africa. This study examined adherence levels and reasons for non-adherence during pregnancy in a cohort of parturient women enrolled in the PMTCT programme in the Eastern Cape, South Africa.

Methods

This was a mixed-methods study involving 1709 parturient women in the Eastern Cape, South Africa. We conducted a multi-centre retrospective analysis of the mother-infant pair in the PMTCT electronic database in 2016. Semi-structured interviews of purposively selected parturient women with self-reported poor adherence (n = 177) were conducted to gain understanding of the main barriers to adherence. Binary logistic regression was used to determine the independent predictors of ART non-adherence.

Results

A high proportion (69.0%) of women reported perfect adherence. In the logistic regression analysis, after adjusting for confounding factors, marital status, cigarette smoking, alcohol use and non-disclosure to a family member were the independent predictors of non-adherence. Analysis of the qualitative data revealed that drug-related side-effects, being away from home, forgetfulness, non-disclosure, stigma and work-related demand were among the main reasons for non-adherence to ART.

Conclusions

Non-adherence to the antiretroviral therapy among pregnant women in this setting is associated with lifestyle behaviours, HIV-related stigma and ART side-effects. In order to eliminate mother-to-child transmission of HIV, clinicians need to screen for these factors at every antenatal clinic visit.

The effectiveness and cost-effectiveness of 3- vs. 6-monthly dispensing of antiretroviral treatment (ART) for stable HIV patients in community ART-refill groups in Zimbabwe: study protocol for a pragmatic, cluster-randomized trial

BACKGROUND

Sub-Saharan Africa is the world region with the greatest number of people eligible to receive antiretroviral treatment (ART). Less frequent dispensing of ART and community-based ART-delivery models are potential strategies to reduce the load on overburdened healthcare facilities and reduce the barriers for patients to access treatment. However, no large-scale trials have been conducted investigating patient outcomes or evaluating the cost-effectiveness of extended ART-dispensing intervals within community ART-delivery models. This trial will assess the clinical effectiveness, cost-effectiveness and acceptability of providing ART refills on a 3 vs. a 6-monthly basis within community ART-refill groups (CARGs) for stable patients in Zimbabwe.

METHODS

In this pragmatic, three-arm, parallel, unblinded, cluster-randomized non-inferiority trial, 30 clusters (healthcare facilities and associated CARGs) are allocated using stratified randomization in a 1:1:1 ratio to either (1) ART refills supplied 3-monthly from the health facility (control arm), (2) ART refills supplied 3-monthly within CARGs, or (3) ART refills supplied 6-monthly within CARGs. A CARG consists of 6-12 stable patients who meet in the community to receive ART refills and who provide support to one another. Stable adult ART patients with a baseline viral load < 1000 copies/ml will be invited to participate (1920 participants per arm). The primary outcome is the proportion of participants alive and retained in care 12 months after enrollment. Secondary outcomes (measured at 12 and 24 months) are the proportions achieving virological suppression, average provider cost per participant, provider cost per participant retained, cost per participant retained with virological suppression, and average patient-level costs to access treatment. Qualitative research will assess the acceptability of extended ART-dispensing intervals within CARGs to both providers and patients, and indicators of potential facility-level decongestion due to the interventions will be assessed.

DISCUSSION

Cost-effective health system models that sustain high levels of patient retention are urgently needed to accommodate the large numbers of stable ART patients in sub-Saharan Africa. This will be the first trial to evaluate extended ART-dispensing intervals within a community-based ART distribution model, and results are intended to inform national and regional policy regarding their potential benefits to both the healthcare system and patients.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT03238846 . Registered on 27 July 2017.

Predictors of loss to follow-up among patients on ART at a rural hospital in KwaZulu-Natal, South Africa

INTRODUCTION

Improved HIV outcomes as a result of expanded antiretroviral therapy (ART) access is threatened by increasing rates of loss to follow up (LTFU) among those on ART, largely reported in urban populations. Some reports suggest that LTFU rates are overestimated due to patient movement to other facilities and inadequate medical records.

STUDY OBJECTIVE

To define the proportion disengaging from HIV care as well as the characteristics of those LTFU in order to design and implement appropriate interventions to increase retention.

METHODS

We performed a retrospective review of patients who discontinued ART at a central hospital ART clinic in rural South Africa and compared with patients receiving care at the 15 primary health clinics (PHCs) to determine the true proportion of those who were LTFU. We also compared those who discontinued ART with those who did not at the central hospital ART clinic to determine predictors of loss to follow up.

RESULTS

Among 3242 patients on ART, 820 were originally marked as LTFU. Among all patients, 272 (8.4%) were found at a clinic on treatment, 56 (1.7%) were found at a clinic from which they had since discontinued treatment, and 10 (0.3%) returned to care between June and July 2016, leaving 475 (14.7%) unaccounted for and thus categorized as 'true' LTFU. Factors found to be associated with discontinuation include being male, age 18-35, having a CD4 count under 200 cells/μL, and being on ART for under six months.

CONCLUSIONS

Young men with low CD4 counts early after ART initiation are at highest risk of ART disengagement in this rural South African HIV clinic. Novel interventions targeting this group are needed to improve retention in care.

Traditional health practitioners' management of HIV/AIDS in rural South Africa in the era of widespread antiretroviral therapy

BACKGROUND

Traditional health practitioners (THPs) have been identified as a key local resource in the fight against human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) in South Africa. However, their approaches to the treatment of people living with HIV (PLHIV) have been met with scepticism by some biomedical practitioners amid increasing access to antiretroviral therapy (ART).

OBJECTIVE

In light of this ambivalence, this study aims to document and identify treatment approaches of THPs to the management of illness among PLHIV in the current era of widespread access to ART.

METHODS

The study was conducted as part of a larger trial of Treatment as Prevention (TasP) in rural northern Kwa-Zulu Natal, intended to treat PLHIV regardless of CD4 count. Nine THPs were enrolled using purposive and snowballing techniques. Repeat group discussions, triangulated with community walks and photovoice techniques, were conducted. A thematic analysis approach was used to analyse the data.

RESULTS

Eight of the nine THPs had received training in biomedical aspects of HIV. THPs showed a multilayered decision-making process in managing illness among PLHIV, influenced by the attributes and choices of the THPs. THPs assessed and managed illness among PLHIV based on THP training in HIV/AIDS, THP type, as well as knowledge and experience in the traditional healing practice. Management of illness depended on the patients' report of their HIV status or willingness to test for HIV.

CONCLUSIONS

THPs' approaches to illness in PLHIV appear to be shifting in light of increasing exposure to HIV/AIDS-related information. Importantly, disclosure of HIV status plays a major role in THPs' management of illness among PLHIV, as well as linkage to HIV testing and care for their patients. Therefore, THPs can potentially enhance the success of ART for PLHIV when HIV status is known.

A qualitative analysis of interprofessional healthcare team members' perceptions of patient barriers to healthcare engagement

Background

Healthcare systems increasingly engage interprofessional healthcare team members such as case managers, social workers, and community health workers to work directly with patients and improve population health. This study elicited perspectives of interprofessional healthcare team members regarding patient barriers to health and suggestions to address these barriers.

Methods

This is a qualitative study employing focus groups and semi-structured interviews with 39 interprofessional healthcare team members in Philadelphia to elicit perceptions of patients’ needs and experiences with the health system, and suggestions for positioning health care systems to better serve patients. Themes were identified using a content analysis approach.

Results

Three focus groups and 21 interviews were conducted with 26 hospital-based and 13 ambulatory-based participants. Three domains emerged to characterize barriers to care: social determinants, health system factors, and patient trust in the health system. Social determinants included insurance and financial shortcomings, mental health and substance abuse issues, housing and transportation-related limitations, and unpredictability associated with living in poverty. Suggestions for addressing these barriers included increased financial assistance from the health system, and building a workforce to address these determinants directly. Health care system factors included poor care coordination, inadequate communication of hospital discharge instructions, and difficulty navigating complex systems. Suggestions for addressing these barriers included enhanced communication between care sites, patient-centered scheduling, and improved patient education especially in discharge planning. Finally, factors related to patient trust of the health system emerged. Participants reported that patients are often intimidated by the health system, mistrusting of physicians, and fearful of receiving a serious diagnosis or prognosis. A suggestion for mitigating these issues was increased visibility of the health system within communities to foster trust and help providers gain a better understanding of unique community needs.

Conclusion

This work explored interprofessional healthcare team members’ perceptions of patient barriers to healthcare engagement. Participants identified barriers related to social determinants of health, complex system organization, and patient mistrust of the health system. Participants offered concrete suggestions to address these barriers, with suggestions supporting current healthcare reform efforts that aim at addressing social determinants and improving health system coordination and adding new insight into how systems might work to improve patient and community trust.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1751-5) contains supplementary material, which is available to authorized users.

"I Have to Push Him with a Wheelbarrow to the Clinic": Community Health Workers' Roles, Needs, and Strategies to Improve HIV Care in Rural South Africa

With a 19.2% HIV prevalence, South Africa has the largest HIV/AIDS epidemic worldwide. Despite a recent scale-up of public sector HIV resources, including community-based programs to expand HIV care, suboptimal rates of antiretroviral therapy (ART) initiation and adherence persist. As community stakeholders with basic healthcare training, community health workers (CHWs) are uniquely positioned to provide healthcare and insight into potential strategies to improve HIV treatment outcomes. The study goal was to qualitatively explore the self-perceived role of the CHW, unmet CHW needs, and strategies to improve HIV care in rural KwaZulu-Natal, South Africa. Focus groups were conducted in May-August 2014, with 21 CHWs working in Msinga subdistrict. Interviews were audio-recorded, transcribed, and translated from Zulu into English. A hybrid deductive and inductive analytical method borrowed from grounded theory was applied to identify emergent themes. CHWs felt they substantially contributed to HIV care provision but were inadequately supported by the healthcare system. CHWs' recommendations included: (1) sufficiently equipping CHWs to provide education, counseling, social support, routine antiretroviral medication, and basic emergency care, (2) modifying clinical practice to provide less stigmatizing, more patient-centered care, (3) collaborating with traditional healers and church leaders to reduce competition with ART and provide more holistic care, and (4) offsetting socioeconomic barriers to HIV care. In conclusion, CHWs can serve as resources when designing and implementing interventions to improve HIV care. As HIV/AIDS policy and practice evolves in South Africa, it will be important to recognize and formally expand CHWs' roles supporting the healthcare system.