How can we achieve person-centred care for people living with HIV/AIDS? A qualitative interview study with healthcare professionals and patients in Ghana

Lived experiences of people living with HIV and hypertension or diabetes access to care in Ethiopia: a phenomenological study

BACKGROUND

People living with HIV (PLWH) are more likely to develop hypertension and diabetes than people without HIV. Previous studies have shown that HIV stigma, discrimination and exclusion make it difficult for PLWH to access care for hypertension and diabetes.

OBJECTIVES

This study aimed to explore the lived experiences of PLWH with comorbid hypertension or diabetes to access hypertension and diabetes care in southern Ethiopia.

DESIGN

We conducted a qualitative study using a semistructured interview guide for an in-depth, in-person interview.

SETTINGS

From 5 August to 25 September 2022, PLWH with comorbid hypertension or diabetes were purposefully selected from five primary healthcare (PHC) facilities in the Wolaita zone of southern Ethiopia.

PARTICIPANTS

A total of 14 PLWH with comorbid hypertension or diabetes who were receiving antiretroviral therapy from PHC were interviewed. Among them, 10 were women, and 4 were men.

METHODS

In-person, in-depth interviews were conducted. Qualitative data analysis software (NVivo V.12) was used to assist with the data organisation, and Colaizzi's (1978) inductive thematic analyses were conducted to explore key concepts.

RESULT

This study yielded two main themes: Theme 1: barriers to accessing care as individual barriers to access (low awareness of non-communicable diseases, misperceptions, lack of health insurance and cost of treatment); healthcare system barriers (shortage of supplies, drugs and equipment; long wait times; lack of integrated services; absence of routine screening and lack of respect from providers); community barriers (lack of support from families, friends and the community) and stigma and discrimination access to hypertension and diabetes. Theme 2: accessibility facilitators (support from family, friends and organisations; health insurance coverage).

CONCLUSION

PLWH recommended that access to services can be improved by service integration, awareness-raising activities, no user fee charges for hypertension and diabetes care and routine screening.

Stakeholder Priorities for ART Initiation and Early Retention Interventions in Malawi: A Qualitative Study Comparing International and National Perspectives

Background

New or returning ART clients are often ineligible for differentiated service delivery (DSD) models, though they are at increased risk of treatment interruption and may benefit greatly from flexible care models. Stakeholder support may limit progress on development and scale-up of interventions for this population. We qualitatively explored stakeholder perceptions of and decision-making criteria regarding DSD models for new or returning ART clients in Malawi.

Methods

We conducted in-depth interviews with internationally based stakeholders (from foundations, multilateral organizations, and NGOs) and Malawi-based stakeholders (from the Malawi Ministry of Health and PEPFAR implementing partners). The interviews included two think-aloud scenarios in which participants rated and described their perceptions of 1) the relative importance of five criteria (cost, effectiveness, acceptability, feasibility, and equity) in determining which interventions to implement for new or returning ART clients and 2) their relative interest in seven potential interventions (monetary incentives, nonmonetary incentives, community-based care, ongoing peer/mentor support and counseling, eHealth, facility-based interventions, and multimonth dispensing) for the same population. The interviews were completed in English via video conference and were audio-recorded. Transcriptions were coded using ATLAS.ti version 9. We examined the data using thematic content analysis and explored differences between international and national stakeholders.

Results

We interviewed twenty-two stakeholders between October 2021 and March 2022. Thirteen were based internationally, and nine were based in Malawi. Both groups prioritized client acceptability but diverged on other criteria: international stakeholders prioritized effectiveness, and Malawi-based stakeholders prioritized cost, feasibility, and sustainability. Both stakeholder groups were most interested in facility-based DSD models, such as multimonth dispensing and extended facility hours. Nearly all the stakeholders described person-centered care as a critical focus for any DSD model implemented.

Conclusions

National and international stakeholders support DSD models for new or returning ART clients. Client acceptability and long-term sustainability should be prioritized to address the concerns of nationally based stakeholders. Future studies should explore the reasons for differences in national and international stakeholders' priorities and how to ensure that local perspectives are incorporated into funding and programmatic decisions.

Defining multimorbidity in people with HIV - what matters most?

PURPOSE OF REVIEW

Although multimorbidity (defined as the coexistence of multiple conditions) presents significant health challenges to people with HIV, there is currently no consensus on how it should be defined among this population. This review aimed to examine the definition of multimorbidity in existing studies among people with HIV ( n  = 22).

RECENT FINDINGS

Variation in the definition of multimorbidity (in terms of the number and nature of conditions included) across studies among people with HIV was observed, with less than half (45%) reporting a selection criteria for conditions. The number of conditions considered ranged from 4 to 65. Certain conditions (e.g. stroke, myocardial infarction and chronic kidney disease) and risk factors (e.g. hypertension) were more frequently included, while other symptoms (e.g. joint pain, peripheral neuropathy and sleeping problems) and mental health conditions (e.g. anxiety and panic attacks) were rarely included in the definition of multimorbidity.

SUMMARY

The definition of multimorbidity among people with HIV is highly variable, with certain conditions overlooked. We propose recommendations that researchers should consider when defining multimorbidity among this population to not only enable comparisons between studies/settings but also to ensure studies consider a person-centred approach that can accurately capture multimorbidity among people with HIV.

Between empathy and anger: healthcare workers' perspectives on patient disengagement from antiretroviral treatment in Khayelitsha, South Africa - a qualitative study

BACKGROUND & OBJECTIVES

The benefits of long-term adherence to antiretroviral therapy (ART) are countered by interruptions in care or disengagement from care. Healthcare workers (HCWs) play an important role in patient engagement and negative or authoritarian attitudes can drive patients to disengage. However, little is known about HCWs' perspectives on disengagement. We explored HCWs' perspectives on ART disengagement in Khayelitsha, a peri-urban area in South Africa with a high HIV burden.

METHOD

Semi-structured interviews were conducted with 30 HCWs in a primary care HIV clinic to explore their perspectives of patients who disengage from ART. HCWs interviewed included clinical (doctors and nurses) and support staff (counsellors, social workers, data clerks, security guards, and occupational therapists). The interview guide asked HCWs about their experience working with patients who interrupt treatment and return to care. Transcripts were audio-recorded, transcribed, and analysed using an inductive thematic analysis approach.

RESULTS

Most participants were knowledgeable about the complexities of disengagement and barriers to sustaining engagement with ART, raising their concerns that disengagement poses a significant public health problem. Participants expressed empathy for patients who interrupted treatment, particularly when the challenges that led to their disengagement were considered reasonable by the HCWs. However, many also expressed feelings of anger and frustration towards these patients, partly because they reported an increase in workload as a result. Some staff, mainly those taking chronic medication themselves, perceived patients who disengage from ART as not taking adequate responsibility for their own health.

CONCLUSION

Lifelong engagement with HIV care is influenced by many factors including disclosure, family support, and HCW interactions. Findings from this study show that HCWs had contradictory feelings towards disengaged patients, experiencing both empathy and anger. Understanding this could contribute to the development of more nuanced interventions to support staff and encourage true person-centred care, to improve patient outcomes.

The challenge of dealing with non-AIDS comorbidities for people living with HIV: Perspectives and experiences of patients and healthcare providers

As the cohort of People Living with HIV (PLHIV) ages, so does the spectrum and burden of non-AIDS define HIV-associated conditions (NARC). PLHIV are likely to need different and increased healthcare services. It requires health systems to adapt to this disease trend and conform to a chronic care model, which respects the distinct needs of the ageing population. In this article, we explore the lived experiences of PLHIV and their healthcare providers in managing the challenges of dealing with NARC in Arba Minch, Southern Ethiopia. This study utilises interpretative substantive methods, encompassing qualitative interviews and Focus Group Discussions. The Normalisation Practice Theory (NPT) guided the semi-structured questions concerning routine screenings and current models of HIV care for ageing individuals. The main structural challenges in providing adequate geriatric care included: (i) the lack of awareness of the risk of NARCs; (ii) the absence of blended care; (iii) an HIV-centred approach exclusive of multidisciplinary care; and (iv) financial constraints. In an era with increasing NARCs, traditional HIV care models must adapt to the emerging challenges of a 'greying' and growing population.

Shared decision-making and person-centred care approaches in three African regions

Five years ago, we published a 'wake-up' paper on shared decision-making (SDM) in West Africa. In the current paper, our overview has been expanded to more African regions (central and north, in addition to the west) as well as to person-centred care (PCC) approaches. While these concepts are known in all regions to varying degrees, results indicate that most known SDM and PCC efforts originate from West Africa. In general, the focus seems to be predominantly on partnership-driven healthcare programs, such as COVID-19 infection; HIV/AIDS and maternal/neonatal care; and patient-provider communication and patient participation instead of comprehensive SDM approaches. The findings also indicate the absence of SDM training for African health professionals beyond specific healthcare programs, but some education on decision-making or critical appraisal of health information in primary or undergraduate health schools is carried out in certain African countries. Building on these sectoral initiatives, future directions include developing research and training programs in the perspective of scaling effective approaches.

Client-led care in HIV: perspectives from community and practice

OBJECTIVES

While current antiretroviral and care strategies can effectively suppress HIV, achieving optimal quality of life (QoL) requires a wider consideration of clients' well-being, the complexity of individuals' lives and social determinants of health. The objective of this commentary was to develop a definition of client-led care in the Australian context and its key supporting principles for people living with HIV (PLHIV).

METHODS

The authors used two sources of evidence to support their HIV community experience with client-led care: (1) a scoping review of the literature, and (2) consultations with colleagues who were PLHIV advocates or HIV specialist physicians. The findings from the scoping review and consultations were summarised and the key principles of client-led care compared with those identified by the authors.

RESULTS

Seven articles met the inclusion criteria for qualitative analysis in the scoping review. Five PLHIV advocates and three HIV specialist physicians were consulted. Key principles supporting client-led care identified by the authors based on their experience centred around the themes of: (1) clients and healthcare providers working in partnership, (2) information and communication, (3) coordinating access to care, (4) building trust, and (5) respect for client's needs and preferences. The principles identified by the authors were supported by those of the scoping review and colleague consultations.

CONCLUSIONS

A client-led approach can complement conventional HIV care strategies and enable empowerment and greater engagement with care, potentially improving the care continuum and overall QoL for individuals living with HIV who can, and want to, lead their own care.

Consensus statement on the role of health systems in advancing the long-term well-being of people living with HIV

Health systems have improved their abilities to identify, diagnose, treat and, increasingly, achieve viral suppression among people living with HIV (PLHIV). Despite these advances, a higher burden of multimorbidity and poorer health-related quality of life are reported by many PLHIV in comparison to people without HIV. Stigma and discrimination further exacerbate these poor outcomes. A global multidisciplinary group of HIV experts developed a consensus statement identifying key issues that health systems must address in order to move beyond the HIV field's longtime emphasis on viral suppression to instead deliver integrated, person-centered healthcare for PLHIV throughout their lives.

Symptom prevalence, burden and correlates among people living with HIV in Vietnam: a two-centre self-report study

Physical and psychological symptoms among people living with HIV (PLWH) adversely affect quality of life and treatment adherence. Study objectives were: (i) to determine validity and reliability of a Vietnamese translation of the Memorial Symptom Assessment Scale-Short Form (MSAS-SF) among PLWH in Vietnam; (ii) to measure prevalence and burden of physical and psychological symptoms using the MSAS-SF including the Global Distress Index (GDI), Physical Distress subscale (PHYS), and Psychological Distress subscale (PSY); (iii) to identify symptom burden risk factors. We recruited 567 patients. Cronbach's alpha scores were: total MSAS-SF 0.91, GDI 0.83, PHYS 0.85, PSYCH 0.81. The scale showed good discriminant validity (low vs high function) (p < 0.001). The mean number of symptoms was 7.66, and the most prevalent were "worrying" (41.6%), "lack of energy" (40.6%), "feeling irritable" (40.4%), and "feeling sad" (39.2%). Monthly income below the poverty line was independently associated with increased: GDI,, PHYS, and PSY and a greater number of symptoms. The Vietnamese version of the MSAS-SF is valid to measure symptom prevalence and burden in HIV-positive populations. Here is a high symptom prevalence and burden among PLWH in Vietnam, especially those living in poverty, and a great need for palliative care integrated with HIV treatment.

Are patient outcomes improved by models of professionally-led community HIV management which aim to be person-centred? A systematic review of the evidence

UNAIDS advocates person-centred care (PCC) for people living with HIV/AIDS (PLWHA) to improve outcomes and wellbeing. We appraised the evidence of person-centred models of community HIV care delivered or led by trained healthcare professionals and its impact on care outcomes. A systematic review was conducted in line with PRISMA guidance. Six electronic databases (CINAHL, Embase, PubMed, Medline, PsycINFO and Web of Science) were searched from January 1980 to April 2019. We included primary studies of any design of PCC models; for adults aged ≥15 years; that were delivered or led by trained HCP. Data were extracted including study location, design, quality, outcomes measured and effectiveness. Five out of 1393 studies met the inclusion criteria, of which four were from a high-income country and one a lower-middle income country. Of the PCC components (physical, psychological, social and spiritual wellbeing) delivered alongside HIV clinical management, one study delivered 2, two studies delivered 3 and two studies delivered all 4 components. This review highlights the lack of outcome evidence for person-centred HIV care, and of concurrent focus on all domains of concern for PLWHA within interventions. Clear articulation of the meaning, practice of PCC and implementation strategies are needed to meet policy recommendations.