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Poku OB, Eschliman EL, Entaile P, Rampa S, Mehta H, Tal D, Silvert L, Li T, Becker TD, Govindasamy D, Stockton MA, Adedimeji A, Ho-Foster A, Blank MB, Dangerfield DT, Yang LH, Murray SM. "It's Better If I Die Because Even in the Hospital, There is a Stigma, People Still Gossip": Gossip as a Culturally Shaped Labeling Process and Its Implications for HIV-Related Stigma in Botswana. AIDS Behav 2023; 27:2535-2547. [PMID: 36646928 PMCID: PMC10350478 DOI: 10.1007/s10461-023-03980-x] [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] [Accepted: 01/05/2023] [Indexed: 01/18/2023]
Abstract
This study qualitatively explores HIV-related gossip as both a manifestation and driver of HIV-related stigma, which is a known barrier to HIV testing and treatment in Botswana. Data were elicited from 5 focus group discussions and 46 semi-structured in-depth interviews with individuals living with HIV and community members with undisclosed serostatus in Gaborone, Botswana in 2017 (n = 84). Directed content analysis using the 'What Matters Most' theoretical framework identified culturally salient manifestations of HIV-related stigma; simultaneous use of Modified Labeling Theory allowed interpretation and stepwise organization of how the social phenomenon of gossip leads to adverse HIV outcomes. Results indicated that HIV-related gossip can diminish community standing through culturally influenced mechanisms, in turn precipitating poor psychosocial well-being and worsened HIV-related outcomes. These harms may be offset by protective factors, such as appearing healthy, accepting one's HIV status, and community education about the harms of gossip.
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Affiliation(s)
- Ohemaa B Poku
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Evan L Eschliman
- Department of Health, Behavior and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Shathani Rampa
- Department of Psychology, Queens College, City University of New York, New York, NY, USA
| | - Haitisha Mehta
- Department of Clinical and Counselling Psychology, Teachers College, Columbia University, New York, NY, USA
| | - Danielle Tal
- Department of Clinical and Counselling Psychology, Teachers College, Columbia University, New York, NY, USA
| | - Lea Silvert
- Department of Clinical and Counselling Psychology, Teachers College, Columbia University, New York, NY, USA
| | - Tingyu Li
- Department of Clinical and Counselling Psychology, Teachers College, Columbia University, New York, NY, USA
| | - Timothy D Becker
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Melissa A Stockton
- Department of Psychiatry, Vagelos College of Physicians and Surgeons Columbia University, New York, NY, USA
- New York State Psychiatric Institute, New York, NY, USA
| | - Adebola Adedimeji
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA
| | | | - Michael B Blank
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Lawrence H Yang
- School of Global Public Health, New York University, New York, NY, USA
- Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Sarah M Murray
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Kiyingi M, Nankabirwa JI, Wiltshire CS, Nangendo J, Kiweewa JM, Katahoire AR, Semitala FC. Perspectives of people living with HIV on barriers to timely ART initiation following referral for antiretroviral therapy: A qualitative study at an urban HIV clinic in Kampala, Uganda. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001483. [PMID: 37494338 PMCID: PMC10370709 DOI: 10.1371/journal.pgph.0001483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 06/20/2023] [Indexed: 07/28/2023]
Abstract
Early initiation of antiretroviral therapy (ART) after HIV diagnosis prevents HIV transmission, progression of HIV to AIDS and improves quality of life. However, little is known about the barriers to timely ART initiation among patients who test HIV positive in settings different from where they will receive HIV treatment, hence are referred in the routine setting. Therefore, we explored the perspectives of people living with HIV on barriers faced to initiate ART following HIV testing and referral for treatment. In this qualitative study, we purposively sampled and enrolled 17 patients attending the Mulago ISS clinic. We selected patients (≥18 years) who previously were received as referrals for HIV treatment and had delayed ART initiation, as ascertained from their records. We conducted in-depth interviews, which were audio recorded, transcribed and translated. We used Atlas.ti version 9 software for data management. Data analysis followed thematic and framework analysis techniques and we adopted the socio-ecological model to categorize final themes. Key themes were found at organizational level including; negative experiences at the place of HIV diagnosis attributed to inadequate counselling and support, unclear communication of HIV-positive results and ambiguous referral procedures; and, long waiting time when patients reached the HIV clinic. At individual level, the themes identified were; immediate denial with late acceptance of HIV-positive results attributed to severe emotional and psychological distress at receiving results, fear of perceived side effects and long duration on ART. At interpersonal level, we found that anticipated and enacted stigma after HIV diagnosis resulted in non-disclosure, discrimination and lack of social support. We found that challenges at entry (during HIV test) and navigation of the HIV care system in addition to individual and interpersonal factors contributed to delayed ART initiation. Interventions during HIV testing would facilitate early ART initiation among patients referred for HIV care.
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Affiliation(s)
- Micheal Kiyingi
- Department of Medicine, Makerere University, Kampala, Uganda
- Makerere University Joint AIDS Program, Makerere University, Kampala, Uganda
| | - Joaniter I. Nankabirwa
- Department of Medicine, Makerere University, Kampala, Uganda
- Infectious Diseases Research Collaboration, Kampala Uganda
| | | | - Joan Nangendo
- Infectious Diseases Research Collaboration, Kampala Uganda
| | - John M. Kiweewa
- Education Department, Fairfield University, Fairfield, Connecticut, United States of America
| | - Anne R. Katahoire
- Child Health Development Center, Makerere University, Kampala, Uganda
| | - Fred C. Semitala
- Department of Medicine, Makerere University, Kampala, Uganda
- Makerere University Joint AIDS Program, Makerere University, Kampala, Uganda
- Infectious Diseases Research Collaboration, Kampala Uganda
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Chihana R, Katumbi C, Dadabhai S, Kaumba A, Mughogho A, Singano V, Mwapasa V, Malisita K. Near-universal same-day linkage to ART care among newly diagnosed adults living with HIV: A cross-sectional study from primary health facilities, in urban Malawi. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001436. [PMID: 37327206 PMCID: PMC10275418 DOI: 10.1371/journal.pgph.0001436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 05/18/2023] [Indexed: 06/18/2023]
Abstract
Malawi HIV treatment guidelines recommend same-day antiretroviral therapy (ART) initiation. Overall 97.9% of Malawians living with HIV (PLHIV) are on ART, same-day ART initiation prevalence and factors that facilitate it have not been fully described. We assessed same-day ART initiation and described individual, health system and health facility infrastructural factors at health facilities supported by expert clients (EC). ECs are lay PLHIV who support other PLHIV. The study was conducted in urban and semi-urban primary health facilities, in Blantyre, Malawi. It was a cross-sectional, descriptive survey of PLHIV and health facility leaders. Eligibility criteria included age ≥ 18 years, new diagnosis of HIV, received counselling from ECs, and offered same-day ART. The study was conducted from December 2018 to June 2021, and 321 study participants enrolled. Mean age (standard deviation) was 33 years (10) with 59% females. In total, 315 (98.1%) initiated same-day ART. Four participants did not because of mental unpreparedness, one wanted to try herbal medicine and one was concerned about stigma related to taking ART. Participants reported health facility accessibility (99%, 318/321), privacy (91%, 292/321) and quality of counselling by EC as excellent (40%, 128/321). Same-day ART was nearly universal. Participants' satisfaction with health services delivery, the presence of EC, and infrastructural characteristics such as adequate privacy were cited as reasons favoring same-day linkage to ART. The most cited reason for not starting same-day ART was mental unpreparedness.
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Affiliation(s)
| | | | | | | | | | | | | | - Ken Malisita
- Ministry of Health, Queen Elizabeth Central Hospital, Blantyre, Malawi
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4
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Zhou Y, Li Y, Xiao X, Qian HZ, Wang H. Perceptions toward antiretroviral therapy and delayed ART initiation among people living with HIV in Changsha, China: mediating effects of treatment willingness. Front Public Health 2023; 11:1105208. [PMID: 37383264 PMCID: PMC10294673 DOI: 10.3389/fpubh.2023.1105208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 05/11/2023] [Indexed: 06/30/2023] Open
Abstract
Introduction Delayed antiretroviral therapy (ART) initiation is associated with poor HIV outcomes and a higher likelihood of HIV transmission. Methods This cross-sectional study assessed the proportion of delayed ART initiation which was defined as initiating ART after 30 days of HIV diagnosis, and evaluated the pathways influencing ART initiation among adult PLWH in Changsha, China who were diagnosed between 2014 and 2022. Results Of 518 participants, 37.8% delayed in initiating ART. Based on the theory of reasoned action (TRA), delayed initiation was indirectly associated with perceptions toward ART through the mediating pathway of patients' treatment willingness, with treatment willingness significantly being the full mediator. Discussion The findings may guide the development of interventions to improve timely uptake of ART in people who are newly diagnosed with HIV.
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Affiliation(s)
- Yaqin Zhou
- Xiangya School of Nursing, Central South University, Changsha, China
| | - Yixuan Li
- Xiangya School of Nursing, Central South University, Changsha, China
| | - Xueling Xiao
- Xiangya School of Nursing, Central South University, Changsha, China
| | - Han-Zhu Qian
- School of Public Health, Yale University, New Haven, CT, United States
| | - Honghong Wang
- Xiangya School of Nursing, Central South University, Changsha, China
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Bergman AJ, McNabb KC, Mlandu K, Akumbom A, Flores DD. Identity management in the face of HIV and intersecting stigmas: A metasynthesis of qualitative reports from sub-Saharan Africa. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0000706. [PMID: 36962951 PMCID: PMC10022386 DOI: 10.1371/journal.pgph.0000706] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 12/06/2022] [Indexed: 02/04/2023]
Abstract
While stigma experienced by people living with HIV (PLWH) is well documented, intersectional stigma and additional stigmatized identities have not received similar attention. The purpose of this metasynthesis is to identify salient stigmatized intersections and their impact on health outcomes in PLWH in sub-Saharan Africa. Using Sandelowski and Barroso's metasynthesis method, we searched four databases for peer-reviewed qualitative literature. Included studies (1) explored personal experiences with intersecting stigmas, (2) included ≥1 element of infectious disease stigma, and (3) were conducted in sub-Saharan Africa. Our multinational team extracted, aggregated, interpreted, and synthesized the findings. From 454 screened abstracts, the 34 studies included in this metasynthesis reported perspectives of at least 1258 participants (282 men, 557 women, and 109 unspecified gender) and key informants. From these studies, gender and HIV was the most salient stigmatized intersection, with HIV testing avoidance and HIV-status denial seemingly more common among men to preserve traditional masculine identity. HIV did not threaten female identity in the same way with women more willing to test for HIV, but at the risk of abandonment and withdrawal of financial support. To guard against status loss, men and women used performative behaviors to highlight positive qualities or minimize perceived negative attributes. These identity management practices ultimately shaped health behaviors and outcomes. From this metasynthesis, the Stigma Identity Framework was devised for framing identity and stigma management, focusing on role expectation and fulfillment. This framework illustrates how PLWH create, minimize, or emphasize other identity traits to safeguard against status loss and discrimination. Providers must acknowledge how stigmatization disrupts PLWH's ability to fit into social schemas and tailor care to individuals' unique intersecting identities. Economic security and safety should be considered in women's HIV care, while highlighting antiretrovirals' role in preserving strength and virility may improve care engagement among men.
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Affiliation(s)
- Alanna J Bergman
- Center for Infectious Disease and Nursing Innovation, School of Nursing, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Katherine C McNabb
- Center for Infectious Disease and Nursing Innovation, School of Nursing, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Khaya Mlandu
- Izikhuba Unjani Clinic, Mngungundlovu, South Africa
| | - Alvine Akumbom
- Johns Hopkins University School of Nursing, Baltimore, Maryland, United States of America
| | - Dalmacio Dennis Flores
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, United States of America
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Nyblade L, Ndirangu JW, Speizer IS, Browne FA, Bonner CP, Minnis A, Kline TL, Ahmed K, Howard BN, Cox EN, Rinderle A, Wechsberg WM. Stigma in the health clinic and implications for PrEP access and use by adolescent girls and young women: conflicting perspectives in South Africa. BMC Public Health 2022; 22:1916. [PMID: 36242000 PMCID: PMC9563466 DOI: 10.1186/s12889-022-14236-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 08/02/2022] [Accepted: 09/22/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Globally, an urgent need exists to expand access to HIV prevention among adolescent girls and young women (AGYW), but the need is particularly acute in sub-Saharan Africa. Oral pre-exposure prophylaxis (PrEP) offers an effective HIV prevention method. In many countries, however, accessing PrEP necessitates that AGYW visit their local health clinic, where they may face access challenges. Some countries have implemented youth-friendly services to reduce certain challenges in local health clinics, but barriers to access persist, including clinic stigma. However, evidence of clinic stigma toward AGYW, particularly with respect to PrEP service delivery, is still limited. This mixed methods study explores stigma toward AGYW seeking clinic services, in particular PrEP, from the perspective of both clinic staff (clinical and nonclinical) and AGYW who seek services at clinic sites in Tshwane province, South Africa. METHODS Six focus group discussions were conducted with AGYW (43 total participants) and four with clinic staff (42 total participants) and triangulated with survey data with AGYW (n = 449) and clinic staff (n = 130). Thematic analysis was applied to the qualitative data and descriptive statistics were conducted with the survey data. RESULTS Four common themes emerged across the qualitative and quantitative data and with both AGYW and clinic staff, although with varying degrees of resonance between these two groups. These themes included (1) clinic manifestations of stigma toward AGYW, (2) concerns about providing PrEP services for AGYW, (3) healthcare providers' identity as mothers, and (4) privacy and breaches of confidentiality. An additional theme identified mainly in the AGYW data pertained to stigma and access to healthcare. CONCLUSION Evidence is needed to inform strategies for addressing clinic stigma toward AGYW, with the goal of removing barriers to PrEP services for this group. While awareness has increased and progress has been achieved around the provision of comprehensive, youth-friendly sexual and reproductive health services, these programs need to be adapted for the specific concerns of young people seeking PrEP services. Our findings point to the four key areas noted above where programs seeking to address stigma toward AGYW in clinics can tailor their programming.
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Affiliation(s)
- Laura Nyblade
- Global Health Division, RTI International, Washington, DC USA
| | - Jacqueline W. Ndirangu
- Substance Use, Gender, and Applied Research Program, RTI International, Research Triangle Park, NC USA
| | - Ilene S. Speizer
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | - Felicia A. Browne
- Substance Use, Gender, and Applied Research Program, RTI International, Research Triangle Park, NC USA
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | - Courtney Peasant Bonner
- Substance Use, Gender, and Applied Research Program, RTI International, Research Triangle Park, NC USA
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | - Alexandra Minnis
- Women’s Global Health Imperative, RTI International, Berkeley, CA USA
- School of Public Health, University of California, Berkeley, CA USA
| | - Tracy L. Kline
- Social Statistics Program, RTI International, Research Triangle Park, NC USA
| | - Khatija Ahmed
- Setshaba Research Centre, Tshwane, South Africa
- Department of Medical Microbiology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Brittni N. Howard
- Substance Use, Gender, and Applied Research Program, RTI International, Research Triangle Park, NC USA
| | - Erin N. Cox
- Substance Use, Gender, and Applied Research Program, RTI International, Research Triangle Park, NC USA
| | - Abigail Rinderle
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | - Wendee M. Wechsberg
- Substance Use, Gender, and Applied Research Program, RTI International, Research Triangle Park, NC USA
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
- Department of Psychology, North Carolina State University, Raleigh, NC USA
- Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC USA
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7
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Tefera E, Mavhandu-Mudzusi AH. Experiences of Antiretroviral Therapy Initiation Among HIV-Positive Adults in Ethiopia: A Descriptive Phenomenological Design. HIV AIDS (Auckl) 2022; 14:243-254. [PMID: 35637644 PMCID: PMC9148206 DOI: 10.2147/hiv.s361913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 05/12/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Eden Tefera
- Department of Midwifery, College of Medicine and Health Sciences, Ambo University, Ambo, Ethiopia
- Correspondence: Eden Tefera, Email
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Montebatsi M, Lavoie MCC, Blanco N, Marima R, Sebina K, Mangope J, Ntwayagae O, Whittington A, Letebele M, Lekone P, Hess KL, Thomas V, Ramaabya D, Ramotsababa M, Stafford KA, Ndwapi N. Improving same-day antiretroviral therapy in Botswana: effects of a multifaceted national intervention. AIDS 2022; 36:533-538. [PMID: 34873088 DOI: 10.1097/qad.0000000000003139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In 2019, the Botswana Ministry of Health and Wellness (MOHW) implemented an HIV national Reboot program, which was needed for refocusing and intensifying efforts for achieving epidemic control. The strategies deployed as part of Reboot were reviewed and evaluated for their effect on same-day and within-seven-days (fast-track initiation) antiretroviral therapy (ART) initiation among adults newly identified with HIV. METHODS We conducted a retrospective cohort analysis of patients aged 18 years or older who were newly diagnosed with HIV from October 2018 to September 2019 across 41 health facilities. We used generalized linear mixed models, adjusting for clustering by facility, to assess the association of the Reboot with same-day or within-seven-days ART initiation (fast-track initiation). RESULTS From October 2018 to January 2019, 28% (636/2269) of newly diagnosed HIV patients were initiated the same day of diagnosis, and 56% (1260/2269) were initiated within seven days. Following the launch of Reboot (February to September 2019), 59% (2092/3553) were initiated the same day of diagnosis, and 77% (2752/3553) were initiated within seven days. Clients were 2.08 (adjusted risk ratio 95% confidence interval 1.79-2.43) times more likely to be initiated the same day of diagnosis and 1.39 (adjusted risk ratio 95% confidence interval 1.28-1.52) times more likely to be initiated within seven days than before Reboot after adjusting for sex and age. CONCLUSION In Botswana, a multifaceted national intervention improved timely ART initiation. Identifying and implementing different client-centered strategies to facilitate ART initiation is critical to preventing AIDS-related complications and prevent ongoing transmission.
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Affiliation(s)
- Milton Montebatsi
- Botswana-University of Maryland School of Medicine Health Initiative (Bummhi), Gaborone, Botswana
| | - Marie-Claude C Lavoie
- Center for International Health, Education, and Biosecurity, Institute of Human Virology-University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Natalia Blanco
- Center for International Health, Education, and Biosecurity, Institute of Human Virology-University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Reson Marima
- Botswana-University of Maryland School of Medicine Health Initiative (Bummhi), Gaborone, Botswana
| | - Kagiso Sebina
- Botswana-University of Maryland School of Medicine Health Initiative (Bummhi), Gaborone, Botswana
| | - Justin Mangope
- Botswana-University of Maryland School of Medicine Health Initiative (Bummhi), Gaborone, Botswana
| | - Ookeditse Ntwayagae
- Botswana-University of Maryland School of Medicine Health Initiative (Bummhi), Gaborone, Botswana
| | - Anna Whittington
- Center for International Health, Education, and Biosecurity, Institute of Human Virology-University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Mpho Letebele
- US Centers for Disease Control and Prevention, (CDC), CDC- Botswana
| | - Phenyo Lekone
- US Centers for Disease Control and Prevention, (CDC), CDC- Botswana
| | - Kristen L Hess
- US Centers for Disease Control and Prevention, (CDC), CDC- Botswana
| | - Vasavi Thomas
- US Centers for Disease Control and Prevention, (CDC), CDC- Botswana
| | - Dinah Ramaabya
- Botswana Ministry of Health and Wellness, (MOHW), Gaborone, Botswana
| | | | - Kristen A Stafford
- Center for International Health, Education, and Biosecurity, Institute of Human Virology-University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ndwapi Ndwapi
- Botswana-University of Maryland School of Medicine Health Initiative (Bummhi), Gaborone, Botswana
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Opio M, Akello F, Twongyeirwe DK, Opio D, Aceng J, Namagga JK, Kabakyenga JK. Perspectives on linkage to care for patients diagnosed with HIV: A qualitative study at a rural health center in South Western Uganda. PLoS One 2022; 17:e0263864. [PMID: 35239667 PMCID: PMC8893616 DOI: 10.1371/journal.pone.0263864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 01/29/2022] [Indexed: 11/18/2022] Open
Abstract
Linkage to care for newly diagnosed human immunodeficiency virus (HIV) patients is important to ensure that patients have good access to care. However, there is little information about factors influencing linkage to care for HIV patients. We aimed to identify existing measures in place that promote linkage to care and to explore facilitators and barriers to linkage to care for clients diagnosed with HIV/acquired immune deficiency syndrome at a rural health center in Uganda. This descriptive qualitative study enrolled 33 purposively selected participants who included expert clients, linkage facilitators, heads of families with people living with HIV, and health workers. Data were collected using in-depth interviews that were audio-recorded, transcribed, and translated. The data were manually analyzed to generate themes. The following four themes were generated: 1) availability of services that include counseling, testing, treatment, follow-up, referral, outreach activities, and support systems. 2) Barriers to linkage to care were at the individual, health facility, and community levels. Individual-level barriers were socioeconomic status, high transport costs, fear of adverse drug effects, fear of broken relationships, and denial of positive results or treatment, while health facility barriers were reported to be long waiting time, negative staff attitude, and drug stock outs. Community barriers were mostly due to stigma experienced by HIV clients, resulting in discrimination by community members. 3) Facilitators to linkage to care were positive staff attitudes, access to information, fear of death, and support from others. 4) Suggestions for improving service delivery were shortening waiting time, integrating HIV services, increasing staff numbers, and intensifying outreaches. Our findings highlight the importance of stakeholder involvement in linkage to care. Access and linkage to care are positively and negatively influenced at the individual, community, and health facility levels. However, integration of HIV services and intensifying outreaches are key to improving linkage to care.
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Affiliation(s)
- Mark Opio
- Department of Nursing, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Florence Akello
- Department of Nursing, Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - David Opio
- Department of Nursing, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Juliet Aceng
- Department of Medical Laboratory Science, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Jane Kasozi Namagga
- Department of Nursing, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Jerome Kahuma Kabakyenga
- Maternal Newborn and Child Health Institute, Mbarara University of Science and Technology, Mbarara, Uganda
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10
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Bao L, Li C, Li R, Yang S. Causal Structural Learning on MPHIA Individual Dataset. J Am Stat Assoc 2022; 117:1642-1655. [PMID: 36620488 PMCID: PMC9817037 DOI: 10.1080/01621459.2022.2077209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The Population-based HIV Impact Assessment (PHIA) is an ongoing project that conducts nationally representative HIV-focused surveys for measuring national and regional progress toward UNAIDS' 90-90-90 targets, the primary strategy to end the HIV epidemic. We believe the PHIA survey offers a unique opportunity to better understand the key factors that drive the HIV epidemics in the most affected countries in sub-Saharan Africa. In this article, we propose a novel causal structural learning algorithm to discover important covariates and potential causal pathways for 90-90-90 targets. Existing constrained-based causal structural learning algorithms are quite aggressive in edge removal. The proposed algorithm preserves more information about important features and potential causal pathways. It is applied to the Malawi PHIA (MPHIA) data set and leads to interesting results. For example, it discovers age and condom usage to be important for female HIV awareness; the number of sexual partners to be important for male HIV awareness; and knowing the travel time to HIV care facilities leads to a higher chance of being treated for both females and males. We further compare and validate the proposed algorithm using BIC and using Monte Carlo simulations, and show that the proposed algorithm achieves improvement in true positive rates in important feature discovery over existing algorithms.
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Affiliation(s)
- Le Bao
- Department of Statistics, The Pennsylvania State University, University Park, PA 16802, USA
| | - Changcheng Li
- School of Mathematical Sciences, Dalian University of Technology, Dalian, P.R. China
| | - Runze Li
- Department of Statistics, The Pennsylvania State University, University Park, PA 16802, USA
| | - Songshan Yang
- Institute of Statistics and Big Data, Renmin University of China, Beijing, P.R. China
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11
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Long-Distance Travel for HIV-Related Care-Burden or Choice?: A Mixed Methods Study in Tanzania. AIDS Behav 2021; 25:2071-2083. [PMID: 33415657 DOI: 10.1007/s10461-020-03136-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2020] [Indexed: 10/22/2022]
Abstract
Decentralization of HIV care across sub-Saharan Africa has increased access to anti-retroviral therapy (ART). Although traveling for care has traditionally been viewed as a barrier, some individuals may choose to travel for care due to stigma and fear of HIV status disclosure. We sought to understand the prevalence of traveling long distances for HIV care, as well as reasons for engaging in such travel. Using a concurrent embedded mixed-methods study design, individuals receiving care at two HIV care and treatment clinics in Tanzania completed a quantitative survey (n = 196), and a sub-set of participants reporting long-distance travel for care were interviewed (n = 31). Overall 58.2% of participants (n = 114/196) reported knowing of a closer clinic than the one they chose to attend. Having experienced enacted stigma was significantly associated with traveling for care (OR 2.31, 95% CI 1.12, 4.75, p = 0.02). Reasons for clinic choice centered on three main themes: clinic familiarity, quality of care, and stigma. Traveling for care was often viewed as an enabling strategy for remaining engaged in care by helping overcome other barriers, including stigma and suboptimal quality of care.
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Nicolau V, Cortes R, Lopes M, Virgolino A, Santos O, Martins A, Faria N, Reis AP, Santos C, Maltez F, Pereira ÁA, Antunes F. HIV Infection: Time from Diagnosis to Initiation of Antiretroviral Therapy in Portugal, a Multicentric Study. Healthcare (Basel) 2021; 9:797. [PMID: 34202051 PMCID: PMC8306717 DOI: 10.3390/healthcare9070797] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 06/03/2021] [Accepted: 06/21/2021] [Indexed: 11/17/2022] Open
Abstract
The benefits of antiretroviral therapy (ART) for persons living with HIV (PLWH) are well established. Rapid ART initiation can lead to improved clinical outcomes. Portugal has one of the highest rates of new HIV diagnoses in the European Union, and an average time until ART initiation above the recommendations established by the national guideline according to data from the first two years after its implementation in 2015, with no more recent data available after that. This study aimed to evaluate time from the first hospital appointment until ART initiation among newly diagnosed HIV patients in Portugal between 2017 and 2018, to investigate differences between hospitals, and to understand the experience of patient associations in supporting the navigation of PLWH throughout referral and linkage to the therapeutic process. To answer to these objectives, a twofold design was followed: a quantitative approach, with an analysis of records from five Portuguese hospitals, and a qualitative approach, with individual interviews with three representatives of patient associations. Overall, 847 and 840 PLWH initiated ART in 2017 and in 2018, respectively, 21 days (median of the two years) after the first appointment, with nearly half coming outside the mainstream service for hospital referral, and with observed differences between hospitals. In 2017-2018, only 38.0% of PLWH initiated ART in less than 14 days after the first hospital appointment. From the interviews, barriers of administrative and psychosocial nature were identified that may hinder access to ART. Patient associations work to offer a tailored support to patients' navigation within the health system, which can help to reduce or overcome those potential barriers. Indicators related to time until ART initiation can be used to monitor and improve access to specialized care of PLWH.
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Affiliation(s)
- Vanessa Nicolau
- Escola Nacional de Saúde Pública, Universidade Nova de Lisboa, Av. Padre Cruz, 1600-560 Lisboa, Portugal
| | - Rui Cortes
- Lean Health Portugal, Campus da Faculdade de Ciências da Universidade de Lisboa, Campo Grande, 1749-016 Lisboa, Portugal; (R.C.); (M.L.)
| | - Maria Lopes
- Lean Health Portugal, Campus da Faculdade de Ciências da Universidade de Lisboa, Campo Grande, 1749-016 Lisboa, Portugal; (R.C.); (M.L.)
| | - Ana Virgolino
- Instituto de Saúde Ambiental, Faculdade de Medicina, Universidade de Lisboa, Av. Professor Egas Moniz, 1649-028 Lisboa, Portugal; (A.V.); (O.S.); (F.M.); (Á.A.P.); (F.A.)
- Laboratório Associado TERRA, Faculdade de Medicina, Universidade de Lisboa, Av. Professor Egas Moniz, 1649-028 Lisboa, Portugal
| | - Osvaldo Santos
- Instituto de Saúde Ambiental, Faculdade de Medicina, Universidade de Lisboa, Av. Professor Egas Moniz, 1649-028 Lisboa, Portugal; (A.V.); (O.S.); (F.M.); (Á.A.P.); (F.A.)
- Laboratório Associado TERRA, Faculdade de Medicina, Universidade de Lisboa, Av. Professor Egas Moniz, 1649-028 Lisboa, Portugal
- Unbreakable Idea Research, 2550-426 Painho, Portugal
| | - António Martins
- Centro Hospitalar Universitário de São João, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal;
| | - Nancy Faria
- Serviço de Saúde da Região Autónoma da Madeira, Av. Luís de Camões 6180, 9000-177 Funchal, Portugal; (N.F.); (A.P.R.)
| | - Ana Paula Reis
- Serviço de Saúde da Região Autónoma da Madeira, Av. Luís de Camões 6180, 9000-177 Funchal, Portugal; (N.F.); (A.P.R.)
| | - Catarina Santos
- Hospital de Cascais, Av. Brigadeiro Victor Novais Gonçalves, 2755-009 Alcabideche, Portugal;
| | - Fernando Maltez
- Instituto de Saúde Ambiental, Faculdade de Medicina, Universidade de Lisboa, Av. Professor Egas Moniz, 1649-028 Lisboa, Portugal; (A.V.); (O.S.); (F.M.); (Á.A.P.); (F.A.)
- Laboratório Associado TERRA, Faculdade de Medicina, Universidade de Lisboa, Av. Professor Egas Moniz, 1649-028 Lisboa, Portugal
- Centro Hospitalar de Lisboa Central, Hospital Curry Cabral, Rua da Beneficência, nº 8, 1069-166 Lisboa, Portugal
| | - Álvaro Ayres Pereira
- Instituto de Saúde Ambiental, Faculdade de Medicina, Universidade de Lisboa, Av. Professor Egas Moniz, 1649-028 Lisboa, Portugal; (A.V.); (O.S.); (F.M.); (Á.A.P.); (F.A.)
- Laboratório Associado TERRA, Faculdade de Medicina, Universidade de Lisboa, Av. Professor Egas Moniz, 1649-028 Lisboa, Portugal
- Centro Hospitalar Universitário Lisboa Norte, Hospital de Santa Maria, Av. Professor Egas Moniz, 1649-035 Lisboa, Portugal
| | - Francisco Antunes
- Instituto de Saúde Ambiental, Faculdade de Medicina, Universidade de Lisboa, Av. Professor Egas Moniz, 1649-028 Lisboa, Portugal; (A.V.); (O.S.); (F.M.); (Á.A.P.); (F.A.)
- Laboratório Associado TERRA, Faculdade de Medicina, Universidade de Lisboa, Av. Professor Egas Moniz, 1649-028 Lisboa, Portugal
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Implementation of Universal HIV Testing and Treatment to Reduce HIV Incidence in Botswana: the Ya Tsie Study. Curr HIV/AIDS Rep 2021; 17:478-486. [PMID: 32797382 DOI: 10.1007/s11904-020-00523-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE OF REVIEW Antiretroviral treatment (ART) can dramatically reduce the risk of HIV transmission, but the feasibility of scaling up HIV testing, linkage and treatment to very high population levels, and its impact on population HIV incidence, were unknown. We review key findings from a community-randomized trial in which we evaluated the impact of "universal test and treat" (UTT) on population HIV incidence in Botswana, a resource-constrained country with both high HIV prevalence and high ART coverage before study inception. RECENT FINDINGS We conducted a community-randomized trial (the "Ya Tsie" trial or Botswana Combination Prevention Project (BCPP)) in 30 villages in Botswana from 2013 to 2018, with the goal of determining whether a combination of prevention interventions-with a focus on universal HIV testing and treatment-would reduce population-level HIV incidence. The intervention included universal HIV testing (home-based and mobile), active linkage to HIV care and treatment with patient tracing for persons not linking, universal ART coverage, rapid ART start (at the first clinic visit), and enhanced male circumcision services. Botswana had very high HIV diagnosis, treatment, and viral suppression levels (approaching the UNAIDS "90-90-90" targets) prior to intervention roll-out. By study end, we were able to exceed the overall 95-95-95 coverage target of 86%: an estimated 88% of all persons living with HIV were on ART and had viral suppression in the Ya Tsie intervention arm. In addition, annual HIV incidence was 30% lower in the intervention arm as compared with the control arm over a 29-month follow-up period. With universal HIV testing and relatively simple linkage activities, it was possible to achieve one of the highest reported population levels of HIV diagnosis, linkage to care, and viral suppression globally and to reduce population HIV incidence by about one-third over a short period of time (< 3 years). We were able to significantly increase population viral suppression and to decrease HIV incidence even in a resource-constrained setting with pre-existing very high testing and treatment coverage. Universal community-based HIV testing and tracing of individuals through the HIV care cascade were key intervention components.
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Moges NA, Adesina OA, Okunlola MA, Berhane Y. Barriers and Facilitators of Same-Day Antiretroviral Therapy Initiation Among People Newly Diagnosed with HIV in Ethiopia: Qualitative Study Using the Transtheoretical Model of Behavioral Change. J Multidiscip Healthc 2020; 13:1801-1815. [PMID: 33293823 PMCID: PMC7719330 DOI: 10.2147/jmdh.s282116] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 11/25/2020] [Indexed: 01/08/2023] Open
Abstract
Purpose HIV test and treat approach is currently a strategy used as a part of the prevention and control program in Ethiopia. The strategy adopts initiating antiretroviral therapy (ART) on the same-day as HIV diagnosis or in the next visit. However, there is little evidence on barriers and facilitators of same-day (ART) initiation in Ethiopia. Therefore, this study aimed to investigate barriers and facilitators of same-day (ART) initiation in the northwest Ethiopia. Patients and Methods A qualitative study was conducted in East Gojjam Zone in northwest Ethiopia. Purposively selected HIV patients, healthcare workers, and treatment assistants participated in the qualitative study. Data were collected through in-depth interviews and focus group discussions (FGDs). Coding was done via ATLAS.ti software thematically. The interviews and FGDs were conducted in Amharic (local language) and then transcribed verbatim and translated into English. Coding was done via ATLAS.ti software. The thematic analysis approach was employed using the constructs of the transtheoretical behavioral model (TTM) to show stages of change that newly HIV diagnosed experienced in the course of preparation for treatment initiation. Results A total of 19 patients, 12 treatment supporters, and 9 healthcare workers participated in the qualitative study. Shocking due to the test result, having no symptoms, mistrust of the test result, and seeking spiritual healing from holy water were the major barriers to start ART in the same-day of diagnosis or within the next visit. Conclusion During HIV diagnosis, more barriers were observed in the early stages, while treatment facilitators emerged in the later stages of TTM. The TTM model can be applied to characterize where participants were in the stages of change.
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Affiliation(s)
- Nurilign Abebe Moges
- Department of Public Health, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia.,Pan African University, Life and Earth Sciences Including Health and Agriculture Institute (PAULESI), University of Ibadan, Ibadan, Nigeria
| | - Olubukola Adeponle Adesina
- Department of Obstetrics and Gynecology, College of Medicine, University of Ibadan, Ibadan, Nigeria.,Department of Obstetrics and Gynecology, University College Hospital, Ibadan, Nigeria
| | - Micheal A Okunlola
- Department of Obstetrics and Gynecology, College of Medicine, University of Ibadan, Ibadan, Nigeria.,Department of Obstetrics and Gynecology, University College Hospital, Ibadan, Nigeria
| | - Yemane Berhane
- Department of Epidemiology, Addis Continental Institute of Public Health, Addis Ababa, Ethiopia
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Brault MA, Spiegelman D, Abdool Karim SS, Vermund SH. Integrating and Interpreting Findings from the Latest Treatment as Prevention Trials. Curr HIV/AIDS Rep 2020; 17:249-258. [PMID: 32297219 DOI: 10.1007/s11904-020-00492-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE OF REVIEW In 2018-2019, studies were published assessing the effectiveness of reducing HIV incidence by expanding HIV testing, linkage to HIV treatment, and assistance to persons living with HIV to adhere to their medications (the "90-90-90" strategy). These tests of "treatment as prevention" (TasP) had complex results. RECENT FINDINGS The TasP/ANRS 12249 study in South Africa, the SEARCH study in Kenya and Uganda, and one comparison (arms A to C) of the HPTN 071 (PopART) study in South Africa and Zambia did not demonstrate a community impact on HIV incidence. In contrast, the Botswana Ya Tsie study and the second comparison (arms B to C) of PopART indicated significant ≈ 30% reductions in HIV incidence in the intervention communities where TasP was expanded. We discuss the results of these trials and outline future research and challenges. These include the efficient expansion of widespread HIV testing, better linkage to care, and viral suppression among all persons living with HIV. A top implementation science priority for the next decade is to determine what strategies to use in specific local contexts.
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Affiliation(s)
- Marie A Brault
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, USA.
| | - Donna Spiegelman
- Department of Biostatistics; Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Salim S Abdool Karim
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Sten H Vermund
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
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