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Grebely J, Matthews S, Causer LM, Feld JJ, Cunningham P, Dore GJ, Applegate TL. We have reached single-visit testing, diagnosis, and treatment for hepatitis C infection, now what? Expert Rev Mol Diagn 2024; 24:177-191. [PMID: 38173401 DOI: 10.1080/14737159.2023.2292645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 12/05/2023] [Indexed: 01/05/2024]
Abstract
INTRODUCTION Progress toward hepatitis C virus (HCV) elimination is impeded by low testing and treatment due to the current diagnostic pathway requiring multiple visits leading to loss to follow-up. Point-of-care testing technologies capable of detecting current HCV infection in one hour are a 'game-changer.' These tests enable diagnosis and treatment in a single visit, overcoming the barrier of multiple visits that frequently leads to loss to follow-up. Combining point-of-care HCV antibody and RNA tests should improve cost-effectiveness, patient/provider acceptability, and testing efficiency. However, implementing HCV point-of-care testing programs at scale requires multiple considerations. AREAS COVERED This commentary explores the need for point-of-care HCV tests, diagnostic strategies to improve HCV testing, key considerations for implementing point-of-care HCV testing programs, and remaining challenges for point-of-care testing (including operator training, quality management, connectivity and reporting systems, regulatory approval processes, and the need for more efficient tests). EXPERT OPINION It is exciting that single-visit testing, diagnosis, and treatment for HCV infection have been achieved. Innovations afforded through COVID-19 should facilitate the accelerated development of low-cost, rapid, and accurate tests to improve HCV testing. The next challenge will be to address barriers and facilitators for implementing point-of-care testing to deliver them at scale.
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Affiliation(s)
- Jason Grebely
- The Kirby Institute, UNSW, Sydney, New South Wales, Australia
| | - Susan Matthews
- Flinders University International Centre for Point-of-Care Testing, Flinders Health and Medical Research Institute, Flinders University, Bedford Park, South Australia, Australia
| | - Louise M Causer
- The Kirby Institute, UNSW, Sydney, New South Wales, Australia
| | - Jordan J Feld
- Toronto Centre for Liver Disease, Toronto General Hospital, Toronto, Canada
| | - Philip Cunningham
- Flinders University International Centre for Point-of-Care Testing, Flinders Health and Medical Research Institute, Flinders University, Bedford Park, South Australia, Australia
| | - Gregory J Dore
- The Kirby Institute, UNSW, Sydney, New South Wales, Australia
| | - Tanya L Applegate
- The Kirby Institute, UNSW, Sydney, New South Wales, Australia
- NSW State Reference Laboratory for HIV, St Vincent's Centre for Applied Medical Research, Sydney, New South Wales, Australia
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Mulenga DM, Rosen JG, Banda L, Musheke M, Mbizvo MT, Raymond HF, Keating R, Witola H, Phiri L, Geibel S, Tun W, Pilgrim N. "I Have to Do It in Secrecy": Provider Perspectives on HIV Service Delivery and Quality of Care for Key Populations in Zambia. J Assoc Nurses AIDS Care 2024; 35:27-39. [PMID: 38019138 PMCID: PMC10842367 DOI: 10.1097/jnc.0000000000000443] [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] [Indexed: 11/30/2023]
Abstract
ABSTRACT Key populations (KPs) experience suboptimal outcomes along the HIV care and prevention continua, but there is limited study of the challenges service providers encounter delivering HIV services to KPs, particularly in settings like Zambia, where provision of these services remains legally ambiguous. Seventy-seven providers completed in-depth interviews exploring constraints to HIV service delivery for KPs and recommendations for improving access and care quality. Thematic analysis identified salient challenges and opportunities to service delivery and quality of care for KPs, spanning interpersonal, institutional, and structural domains. Limited provider training in KP-specific needs was perceived to influence KP disclosure patterns in clinical settings, impeding service quality. The criminalization of KP sexual and drug use behaviors, coupled with perceived institutional and legal ambiguities to providing HIV services to KPs, cultivated unwelcoming service delivery environments for KPs. Findings elucidate opportunities for improving HIV service delivery/quality, from decentralized care to expanded legal protections for KPs and service providers.
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Affiliation(s)
| | - Joseph G. Rosen
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | | | | | | | - Henry F. Raymond
- Department of Biostatistics and Epidemiology, School of Public Health, Rutgers University, Piscataway, NJ, USA
| | - Ryan Keating
- Institute for Global Health Sciences, University of California, San Francisco, CA, USA
| | - Harold Witola
- National HIV/AIDS/STI/TB Council, Ministry of Health, Government of the Republic of Zambia, Lusaka, Zambia
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Ludwig-Barron NT, Guthrie BL, Mbogo L, Bukusi D, Sinkele W, Gitau E, Farquhar C, Monroe-Wise A. Barriers and facilitators of HIV and hepatitis C care among people who inject drugs in Nairobi, Kenya: a qualitative study with peer educators. Harm Reduct J 2021; 18:133. [PMID: 34922548 PMCID: PMC8684158 DOI: 10.1186/s12954-021-00580-7] [Citation(s) in RCA: 2] [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: 07/27/2021] [Accepted: 12/01/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND In Kenya, people who inject drugs (PWID) are disproportionately affected by HIV and hepatitis C (HCV) epidemics, including HIV-HCV coinfections; however, few have assessed factors affecting their access to and engagement in care through the lens of community-embedded, peer educators. This qualitative study leverages the personal and professional experiences of peer educators to help identify HIV and HCV barriers and facilitators to care among PWID in Nairobi, including resource recommendations to improve service uptake. METHODS We recruited peer educators from two harm reduction facilities in Nairobi, Kenya, using random and purposive sampling techniques. Semi-structured interviews explored circumstances surrounding HIV and HCV service access, prevention education and resource recommendations. A thematic analysis was conducted using the Modified Social Ecological Model (MSEM) as an underlying framework, with illustrative quotes highlighting emergent themes. RESULTS Twenty peer educators participated, including six women, with 2-months to 6-years of harm reduction service. Barriers to HIV and HCV care were organized by (a) individual-level themes including the competing needs of addiction and misinterpreted symptoms; (b) social network-level themes including social isolation and drug dealer interactions; (c) community-level themes including transportation, mental and rural healthcare services, and limited HCV resources; and (d) policy-level themes including nonintegrated health services, clinical administration, and law enforcement. Stigma, an overarching barrier, was highlighted throughout the MSEM. Facilitators to HIV and HCV care were comprised of (a) individual-level themes including concurrent care, personal reflections, and religious beliefs; (b) social network-level themes including community recommendations, navigation services, family commitment, and employer support; (c) community-level themes including quality services, peer support, and outreach; and (d) policy-level themes including integrated health services and medicalized approaches within law enforcement. Participant resource recommendations include (i) additional medical, social and ancillary support services, (ii) national strategies to address stigma and violence and (iii) HCV prevention education. CONCLUSIONS Peer educators provided intimate knowledge of PWID barriers and facilitators to HIV and HCV care, described at each level of the MSEM, and should be given careful consideration when developing future initiatives. Recommendations emphasized policy and community-level interventions including educational campaigns and program suggestions to supplement existing HIV and HCV services.
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Affiliation(s)
- Natasha T Ludwig-Barron
- Department of Epidemiology, School of Public Health, University of Washington, 3980 15th Ave NE, Box # 351619, Seattle, WA, 98195, USA.
- Department of Global Health, School of Public Health and School of Medicine, University of Washington, 3980 15th Ave NE, Box #351620, Seattle, WA, 98195, USA.
| | - Brandon L Guthrie
- Department of Epidemiology, School of Public Health, University of Washington, 3980 15th Ave NE, Box # 351619, Seattle, WA, 98195, USA
- Department of Global Health, School of Public Health and School of Medicine, University of Washington, 3980 15th Ave NE, Box #351620, Seattle, WA, 98195, USA
| | - Loice Mbogo
- University of Washington Global Assistance Program-Kenya, Nairobi, Kenya
| | - David Bukusi
- VCT and HIV Prevention, Kenyatta National Hospital, Nairobi, Kenya
| | - William Sinkele
- Support for Addictions Prevention and Treatment in Africa (SAPTA), Nairobi, Kenya
| | - Esther Gitau
- Support for Addictions Prevention and Treatment in Africa (SAPTA), Nairobi, Kenya
| | - Carey Farquhar
- Department of Epidemiology, School of Public Health, University of Washington, 3980 15th Ave NE, Box # 351619, Seattle, WA, 98195, USA
- Department of Global Health, School of Public Health and School of Medicine, University of Washington, 3980 15th Ave NE, Box #351620, Seattle, WA, 98195, USA
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Box 356423, Seattle, WA, 98195, USA
| | - Aliza Monroe-Wise
- Department of Global Health, School of Public Health and School of Medicine, University of Washington, 3980 15th Ave NE, Box #351620, Seattle, WA, 98195, USA
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Box 356423, Seattle, WA, 98195, USA
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Han WM, Jiamsakul A, Salleh NAM, Choi JY, Huy BV, Yunihastuti E, Do CD, Merati TP, Gani YM, Kiertiburanakul S, Zhang F, Chan YJ, Lee MP, Chaiwarith R, Ng OT, Khusuwan S, Ditangco R, Kumarasamy N, Sangle S, Ross J, Avihingsanon A. HIV treatment outcomes among people who acquired HIV via injecting drug use in the Asia-Pacific region: a longitudinal cohort study. J Int AIDS Soc 2021; 24:e25736. [PMID: 34021711 PMCID: PMC8140190 DOI: 10.1002/jia2.25736] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 04/13/2021] [Accepted: 04/26/2021] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION Data on HIV treatment outcomes in people who inject drugs (PWID) in the Asia‐Pacific are sparse despite the high burden of drug use. We assessed immunological and virological responses, AIDS‐defining events and mortality among PWID receiving antiretroviral therapy (ART). METHODS We investigated HIV treatment outcomes among people who acquired HIV via injecting drug use in the TREAT Asia HIV Observational Database (TAHOD) between January 2003 and March 2019. Trends in CD4 count and viral suppression (VS, HIV viral load <1000 copies/mL) were assessed. Factors associated with mean CD4 changes were analysed using repeated measures linear regression, and combined AIDS event and mortality were analysed using survival analysis. RESULTS Of 622 PWID from 12 countries in the Asia‐Pacific, 93% were male and the median age at ART initiation was 31 years (IQR, 28 to 34). The median pre‐ART CD4 count was 71 cells/µL. CD4 counts increased over time, with a mean difference of 401 (95% CI, 372 to 457) cells/µL at year‐10 (n = 78). Higher follow‐up HIV viral load and pre‐ART CD4 counts were associated with smaller increases in CD4 counts. Among 361 PWID with ≥1 viral load after six months on ART, proportions with VS were 82%, 88% and 93% at 2‐, 5‐ and 10‐years following ART initiation. There were 52 new AIDS‐defining events and 50 deaths during 3347 person‐years of follow‐up (PYS) (incidence 3.05/100 PYS, 95% CI, 2.51 to 3.70). Previous AIDS or TB diagnosis, lower current CD4 count and adherence <95% were associated with combined new AIDS‐defining event and death. CONCLUSIONS Despite improved outcomes over time, our findings highlight the need for rapid ART initiation and adherence support among PWID within Asian settings.
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Affiliation(s)
- Win Min Han
- Kirby Institute, UNSW, Sydney, Australia.,HIV-NAT, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | | | - Nur Afiqah Mohd Salleh
- Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.,Centre of Excellence for Research in AIDS (CERiA), University of Malaya, Kuala Lumpur, Malaysia
| | - Jun Yong Choi
- Division of Infectious Diseases, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Bui Vu Huy
- National Hospital for Tropical Diseases, Hanoi, Vietnam
| | - Evy Yunihastuti
- Faculty of Medicine, Universitas Indonesia - Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | | | - Tuti P Merati
- Faculty of Medicine, Udayana University & Sanglah Hospital, Bali, Indonesia
| | | | | | - Fujie Zhang
- Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Yu-Jiun Chan
- Taipei Veterans General Hospital, Taipei, Taiwan
| | - Man-Po Lee
- Queen Elizabeth Hospital, Hong Kong, China
| | | | - Oon Tek Ng
- Tan Tock Seng Hospital, Tan Tock Seng, Singapore
| | | | - Rossana Ditangco
- Research Institute for Tropical Medicine, Muntinlupa City, Philippines
| | - Nagalingeswaran Kumarasamy
- Chennai Antiviral Research and Treatment Clinical Research Site (CART CRS), VHS-Infectious Diseases Medical Centre, VHS, Chennai, India
| | - Shashikala Sangle
- BJ Government Medical College and Sassoon General Hospital, Pune, India
| | - Jeremy Ross
- TREAT Asia, amfAR - The Foundation for AIDS Research, Bangkok, Thailand
| | - Anchalee Avihingsanon
- HIV-NAT, Thai Red Cross AIDS Research Centre, Bangkok, Thailand.,Tuberculosis Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Colwill JP, Sherman MI, Siedlecki SL, Burchill CN, Siegmund LA. A grounded theory approach to the care experience of patients with intravenous drug use/abuse-related endocarditis. Appl Nurs Res 2021; 57:151390. [PMID: 33549293 DOI: 10.1016/j.apnr.2020.151390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 08/05/2020] [Accepted: 11/21/2020] [Indexed: 10/22/2022]
Affiliation(s)
| | - Minerva I Sherman
- Heart Vascular and Thoracic Institute, Cardiothoracic Department, Cleveland Clinic, Cleveland, OH, United States of America
| | - Sandra L Siedlecki
- Office of Nursing Research and Innovation, Cleveland Clinic, Cleveland, OH, United States of America
| | | | - Lee Anne Siegmund
- Office of Nursing Research and Innovation, Cleveland Clinic, Cleveland, OH, United States of America
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Mburu G, Ayon S, Mahinda S, Kaveh K. Determinants of Women's Drug Use During Pregnancy: Perspectives from a Qualitative Study. Matern Child Health J 2020; 24:1170-1178. [PMID: 32754861 PMCID: PMC7419458 DOI: 10.1007/s10995-020-02910-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Drug use during pregnancy can have negative effects on maternal and child health. However, there is a dearth of data regarding drug use among pregnant women in Kenya, where illicit drug use is on the rise. In this paper, we report factors influencing women's decisions to use drugs during pregnancy. METHODS In 2015, we conducted in-depth interviews and focus group discussions with 45 women who inject drugs and five key stakeholders involved in provision of services to people who use drugs in coastal Kenya. Inductive thematic analysis was conducted to draw out themes related to key determinants of drug use during pregnancy. RESULTS Four key themes emerged outlining determinants of drug use during pregnancy: (i) the use of drugs to cope with the stress of unexpected pregnancy, (ii) the continued drug use during pregnancy to manage withdrawal, (iii) the dual effect of pregnancy on drug use either as a facilitator or as a moderator of drug use, and (iv) the role of male intimate partner in influencing women's drug use during pregnancy. CONCLUSION Our paper reports women's drug use during pregnancy and the factors influencing this phenomenon. To safeguard the health and well-being of pregnant women and their unborn children, there is a need for education and awareness raising, implementing couple-based harm reduction approaches to leverage on positive male influences, improving availability of drug treatment, and provision of family planning interventions for women who use drugs.
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Affiliation(s)
- Gitau Mburu
- Centre for Global Health Policy, University of Sussex, Falmer, UK.
| | | | | | - Khoshnood Kaveh
- School of Public Health, Yale University, New Haven, CT, USA
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Day E, Broder T, Bruneau J, Cruse S, Dickie M, Fish S, Grillon C, Luhmann N, Mason K, McLean E, Trooskin S, Treloar C, Grebely J. Priorities and recommended actions for how researchers, practitioners, policy makers, and the affected community can work together to improve access to hepatitis C care for people who use drugs. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 66:87-93. [DOI: 10.1016/j.drugpo.2019.01.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 12/21/2018] [Accepted: 01/07/2019] [Indexed: 02/08/2023]
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Guise A, Ndimbii J, Igonya EK, Owiti F, Strathdee SA, Rhodes T. Integrated and differentiated methadone and HIV care for people who use drugs: a qualitative study in Kenya with implications for implementation science. Health Policy Plan 2019; 34:110-119. [PMID: 30789208 PMCID: PMC6481284 DOI: 10.1093/heapol/czz002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2019] [Indexed: 11/13/2022] Open
Abstract
Integrating methadone and HIV care is a priority in many low- and middle-income settings experiencing a growing challenge of HIV epidemics linked to injecting drug use. There is as yet little understanding of how to integrate methadone and HIV care in these settings and how such services can be implemented; such a gap reflects, in part, limitations in theorizing an implementation science of integrated care. In response, we qualitatively explored the delivery of methadone after its introduction in Kenya to understand integration with HIV care. Semi-structured interviews with people using methadone (n = 30) were supplemented by stakeholder interviews (n = 2) and participant observation in one city. Thematic analysis was used, that also drew on Mol's logic of care as an analytical framework. Respondents described methadone clinic-based care embedded in community support systems. Daily observed clinic care was challenging for methadone and stigmatizing for HIV treatment. In response to these challenges, integration evolved and HIV care differentiated to other sites. The resulting care system was acceptable to respondents and allowed for choice over locations and approaches to HIV care. Using Mol's logic of care as an analytical framework, we explore what led to this differentiation in integrated care. We explore co-production and experimentation around HIV care that compares with more limited experimentation for methadone. This experimentation is bounded by available discourses and materials. The study supports continued integration of services whilst allowing for differentiation of these models to adapt to client preferences. Co-location of integrated services must prioritize clinic organization that prevents HIV status disclosure. Our analysis fosters a material perspective for theory of implementation science and integration of services that focuses attention on local experimentation shaped by context.
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Affiliation(s)
- Andy Guise
- Department of Medicine, University of California San Diego, San Diego, 9500 Gilman Drive, La Jolla, CA, USA
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - James Ndimbii
- Kenya AIDS NGOs Consortium, Regent Management Suites, Argwings Kodhek Road, Nairobi, Kenya
| | - Emmy Kageha Igonya
- School of Medicine, University of Nairobi, Kenyatta National Hospital, Nairobi, Kenya
| | - Frederick Owiti
- School of Medicine, University of Nairobi, Kenyatta National Hospital, Nairobi, Kenya
| | - Steffanie A Strathdee
- Department of Medicine, University of California San Diego, San Diego, 9500 Gilman Drive, La Jolla, CA, USA
| | - Tim Rhodes
- Centre for Research on Drugs and Health Behaviour, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, UK
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Being HIV positive and staying on antiretroviral therapy in Africa: A qualitative systematic review and theoretical model. PLoS One 2019; 14:e0210408. [PMID: 30629648 PMCID: PMC6328200 DOI: 10.1371/journal.pone.0210408] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 12/21/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Adherence to antiretroviral therapy (ART) and long-term uninterrupted engagement in HIV care is difficult for HIV-positive people, and randomized trials of specific techniques to promote adherence often show small or negligible effects. Understanding what influences decision-making in HIV-positive people in Africa may help researchers and policy makers in the development of broader, more effective interventions and policies. METHODS We used thematic synthesis and a grounded theory approach to generate a detailed narrative and theoretical model reflecting life with HIV in Africa, and how this influences ART adherence and engagement decisions. We included qualitative primary studies that explored perspectives, perceptions and experiences of HIV-positive people, caregivers and healthcare service providers. We searched databases from 1 January 2013 to 9 December 2016, screened all studies, and selected those for inclusion using purposeful sampling methods. Included studies were coded with Atlas.ti, and we assessed methodological quality across five domains. RESULTS We included 59 studies from Africa in the synthesis. Nine themes emerged which we grouped under three main headings. First, people who are HIV-positive live in a complicated world where they must navigate the challenges presented by poverty, competing priorities, unpredictable life events, social identity, gender norms, stigma, and medical pluralism-these influences can make initiating and maintaining ART difficult. Second, the health system is generally seen as punishing and uninviting and this can drive HIV-positive people out of care. Third, long-term engagement and adherence requires adaptation and incorporation of ART into daily life, a process which is facilitated by: inherent self-efficacy, social responsibilities, previous HIV-related illnesses and emotional, practical or financial support. These factors together can lead to a "tipping point", a point in time when patients choose to either engage or disengage from care. HIV-positive people may cycle in and out of these care states in response to fluctuations in influences over time. CONCLUSION This analysis provides a practical theory, arising from thematic synthesis of research, to help understand the dynamics of adherence to ART and engagement in HIV care. This can contribute to the design of service delivery approaches, and informed thinking and action on the part of policy makers, providers, and society: to understand what it is to be HIV-positive in Africa and how attitudes and the health service need to shift to help those with HIV lead 'normal' lives.
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Eshun-Wilson I, Rohwer A, Hendricks L, Oliver S, Garner P. Being HIV positive and staying on antiretroviral therapy in Africa: A qualitative systematic review and theoretical model. PLoS One 2019; 14:e0210408. [PMID: 30629648 PMCID: PMC6328200 DOI: 10.1371/journal.pone.0210408&type=printable] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 12/21/2018] [Indexed: 05/22/2023] Open
Abstract
BACKGROUND Adherence to antiretroviral therapy (ART) and long-term uninterrupted engagement in HIV care is difficult for HIV-positive people, and randomized trials of specific techniques to promote adherence often show small or negligible effects. Understanding what influences decision-making in HIV-positive people in Africa may help researchers and policy makers in the development of broader, more effective interventions and policies. METHODS We used thematic synthesis and a grounded theory approach to generate a detailed narrative and theoretical model reflecting life with HIV in Africa, and how this influences ART adherence and engagement decisions. We included qualitative primary studies that explored perspectives, perceptions and experiences of HIV-positive people, caregivers and healthcare service providers. We searched databases from 1 January 2013 to 9 December 2016, screened all studies, and selected those for inclusion using purposeful sampling methods. Included studies were coded with Atlas.ti, and we assessed methodological quality across five domains. RESULTS We included 59 studies from Africa in the synthesis. Nine themes emerged which we grouped under three main headings. First, people who are HIV-positive live in a complicated world where they must navigate the challenges presented by poverty, competing priorities, unpredictable life events, social identity, gender norms, stigma, and medical pluralism-these influences can make initiating and maintaining ART difficult. Second, the health system is generally seen as punishing and uninviting and this can drive HIV-positive people out of care. Third, long-term engagement and adherence requires adaptation and incorporation of ART into daily life, a process which is facilitated by: inherent self-efficacy, social responsibilities, previous HIV-related illnesses and emotional, practical or financial support. These factors together can lead to a "tipping point", a point in time when patients choose to either engage or disengage from care. HIV-positive people may cycle in and out of these care states in response to fluctuations in influences over time. CONCLUSION This analysis provides a practical theory, arising from thematic synthesis of research, to help understand the dynamics of adherence to ART and engagement in HIV care. This can contribute to the design of service delivery approaches, and informed thinking and action on the part of policy makers, providers, and society: to understand what it is to be HIV-positive in Africa and how attitudes and the health service need to shift to help those with HIV lead 'normal' lives.
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Affiliation(s)
- Ingrid Eshun-Wilson
- Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
- * E-mail:
| | - Anke Rohwer
- Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Lynn Hendricks
- Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Sandy Oliver
- UCL Institute of Education, University College London, London, United Kingdom
- Africa Centre for Evidence, University of Johannesburg, Johannesburg, South Africa
| | - Paul Garner
- Centre for Evidence Synthesis in Global Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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Abstract
Purpose of review Opioid use disorder (OUD) is a global phenomenon and is on the rise in Africa, denoting a shift from historical patterns of drug transport to internal consumption. In contrast, opioids for clinical pain management in Africa remain among the least available globally. This region also has the highest HIV and HCV disease burden, and the greatest shortages of health workers and addiction treatment. We undertook a systematic review of the literature to describe opioid use in Africa and how it is being addressed. Recent findings A total of 84 articles from 2000 to 2018 were identified. Descriptions of country-specific populations and patterns of opioid misuse were common. A smaller number of articles described interventions to address OUD. Summary OUD occurs in sub-Saharan Africa, with attendant clinical and social costs. Evidence-based policies and health system resources are needed to promote OUD prevention and management, and infectious disease transmission reduction.
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Hakim AJ, MacDonald V, Hladik W, Zhao J, Burnett J, Sabin K, Prybylski D, Garcia Calleja JM. Gaps and opportunities: measuring the key population cascade through surveys and services to guide the HIV response. J Int AIDS Soc 2018; 21 Suppl 5:e25119. [PMID: 30033654 PMCID: PMC6055128 DOI: 10.1002/jia2.25119] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 05/12/2018] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION The UNAIDS 90-90-90 targets to diagnose 90% of people living with HIV, put 90% of them on treatment, and for 90% of them to have suppressed viral load have focused the international HIV response on the goal of eliminating HIV by 2030. They are also a constructive tool for measuring progress toward reaching this goal but their utility is dependent upon data availability. Though more than 25% of new infections are among key populations (KP)- sex workers, men who have sex with men, transgender people, people who inject drugs, and prisoners- and their sex partners, there is a dearth of treatment cascade data for KP. We assess the availability of cascade data and review the opportunities offered by biobehavioral and programme data to inform the HIV response. DISCUSSION The emphasis on the collection of treatment cascade data among the general population in higher prevalence countries has not led to a similar increase in the availability of cascade data for KP. The limited data available for KP highlight large gaps in service uptake across the cascade, particularly in the first 90, awareness of HIV status. Biobehavioral surveys (BBS), with linked population size estimation, provide population-based data on the treatment cascade and should be conducted every two to three years in locations with services for KP. With the inclusion of viral load testing, these surveys are able to monitor the entire treatment cascade among KP regardless of whether these populations access HIV services targeting the general population or KP. BBS also reach people accessing services and those who do not, thereby providing a unique opportunity to learn about barriers to service uptake including stigma and discrimination. At the same time high-quality programme data can play a complementary role in identifying missed opportunities that can be addressed in real-time. CONCLUSIONS Data are more important than ever for guiding the HIV response toward reaching 90-90-90 targets and eliminating HIV, particularly in the face of decreased funding for HIV and specifically for KP. Timely high-quality BBS data can be triangulated with high-quality programme data to provide a comprehensive picture of the epidemic response for KP.
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Affiliation(s)
- Avi Joseph Hakim
- Division of Global HIV and TuberculosisUS Centers for Disease Control and PreventionAtlantaGAUSA
| | | | - Wolfgang Hladik
- Division of Global HIV and TuberculosisUS Centers for Disease Control and PreventionAtlantaGAUSA
| | - Jinkou Zhao
- The Global Fund to Fight AIDS, Tuberculosis and MalariaGenevaSwitzerland
| | - Janet Burnett
- Division of HIV/AIDS PreventionUS Centers for Disease Control and PreventionAtlantaGAUSA
| | - Keith Sabin
- United Nations Joint Programme for HIV/AIDSGenevaSwitzerland
| | - Dimitri Prybylski
- Division of Global HIV and TuberculosisUS Centers for Disease Control and PreventionAtlantaGAUSA
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Ayon S, Ndimbii J, Jeneby F, Abdulrahman T, Mlewa O, Wang B, Ragi A, Mburu G. Barriers and facilitators of access to HIV, harm reduction and sexual and reproductive health services by women who inject drugs: role of community-based outreach and drop-in centers. AIDS Care 2017; 30:480-487. [PMID: 29067855 DOI: 10.1080/09540121.2017.1394965] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
There is limited data regarding women who inject drugs, and how harm-reduction services can be made more women-centered. This study explored experiences of Kenyan women who inject drugs, with regard to access to HIV, harm reduction and sexual and reproductive health (SRH) services. A total of 45 women who inject drugs and 5 key stakeholders participated in-depth interviews and focus group discussions. Thematic analysis of the data revealed that stigma, long distances, lack of confidentiality, user fees, multiple appointments, drug users' unfamiliarity with health facilities, disconnect in communication with healthcare providers, and healthcare providers' lack of understanding of women's needs were factors that impede women's access to health services. Community-based services, comprising of outreach and drop-in centers mitigate these barriers by building trust, educating women on their health and rights, linking women to health facilities, sensitizing health providers on the needs of women who inject drugs, and integrating women's SRH services into community-based harm-reduction outreach. Inclusion of SRH services into community-based harm-reduction activities increased women's interest and access to harm-reduction interventions. These findings underscore the need to strengthen community-based programming for women who inject drugs, and to integrate SRH services into needle and syringe exchange programs.
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Affiliation(s)
- Sylvia Ayon
- a Kenya AIDS NGO Consortium , Nairobi , Kenya
| | | | - Fatma Jeneby
- b Muslim Education and Welfare Association , Mombasa , Kenya
| | | | | | | | - Allan Ragi
- a Kenya AIDS NGO Consortium , Nairobi , Kenya
| | - Gitau Mburu
- e Division of Health Research , University of Lancaster , UK
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Grebely J, Dore GJ, Morin S, Rockstroh JK, Klein MB. Elimination of HCV as a public health concern among people who inject drugs by 2030 - What will it take to get there? J Int AIDS Soc 2017; 20:22146. [PMID: 28782335 PMCID: PMC5577699 DOI: 10.7448/ias.20.1.22146] [Citation(s) in RCA: 111] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 07/13/2017] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Globally, there is a considerable burden of HCV and HIV infections among people who inject drugs (PWID) and transmission of both infections continues. Needle and syringe programme (NSP) and opioid substitution therapy (OST) coverage remains low, despite evidence demonstrating their prevention benefit. Direct-acting antiviral therapies (DAA) with HCV cure >95% among PWID provide an opportunity to reverse rising trends in HCV-related morbidity and mortality and reduce incidence. However, HCV testing, linkage to care, and treatment remain low due to health system, provider, societal, and patient barriers. Between 2015 and 2030, WHO targets include reducing new HCV infections by 80% and HCV deaths by 65%, and increasing HCV diagnoses from <5% to 90% and number of eligible persons receiving HCV treatment from <1% to 80%. This commentary discusses why PWID should be considered as a priority population in these efforts, reasons why this goal could be attainable among PWID, challenges that need to be overcome, and key recommendations for action. DISCUSSION Challenges to HCV elimination as a global health concern among PWID include poor global coverage of harm reduction services, restrictive drug policies and criminalization of drug use, poor access to health services, low HCV testing, linkage to care and treatment, restrictions for accessing DAA therapy, and the lack of national strategies and government investment to support WHO elimination goals. Key recommendations for action include reforming drug policies (decriminalization of drug use and/or possession, or providing alternatives to imprisonment for PWID; decriminalization of the use and provision of sterile needles-syringes; and legalization of OST for people who are opioid dependent), scaling up and improving funding for harm reduction services, making health services accessible for PWID, supporting community empowerment and community-based programmes, improving access to affordable diagnostics and medicines, and eliminating stigma, discrimination, and violence against PWID. CONCLUSIONS The ambitious targets for HCV elimination set by WHO are achievable in many countries, but will require researchers, healthcare providers, policy makers, affected communities, advocates, the pharmaceutical and diagnostics industries, and governments around the world to work together to make this happen.
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Affiliation(s)
- Jason Grebely
- The Kirby Institute, UNSW Sydney, Sydney, Australia
- Executive Board, International Network on Hepatitis in Substance Users, Zurich, Switzerland
| | - Gregory J. Dore
- The Kirby Institute, UNSW Sydney, Sydney, Australia
- Executive Board, International Network on Hepatitis in Substance Users, Zurich, Switzerland
| | - Sébastien Morin
- HIV Programmes and Advocacy, International AIDS Society, Geneva, Switzerland
| | - Jürgen K. Rockstroh
- Department of Medicine I, University Hospital Bonn, Bonn, Germany
- Governing Council, International AIDS Society, Geneva, Switzerland
| | - Marina B. Klein
- Governing Council, International AIDS Society, Geneva, Switzerland
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, Canada
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