Factors influencing uptake of HIV care and treatment among children in South Africa - a qualitative study of caregivers and clinic staff

Sub-optimal satisfaction of people living with HIV and AIDS regarding their care in Burkina Faso, West Africa

People living with HIV (PLHIV) satisfaction regarding to care could play an important role in the elimination of HIV epidemic by 2030. We assessed Burkina Faso PLHIV satisfaction regarding to their care, and identified its associated factors. A representative nationwide cross-sectional study was performed in 2021-2022 in 30 HIV/AIDS care sites. PLHIV aged at least 18 years, receiving ART for six months or plus were included. Individual and structural data were collected using a questionnaire administered by trained investigators. Satisfaction with HIV/AIDS care was explored using six components (reception, waiting time to medical visit, care environment, sharing updated information on HIV AIDS, answering to PLHIV questions, and providing tailored care and advice to PLHIV needs). Factors associated with satisfaction were identified using logistic regressions. 448 PLHIV were considered in this analysis. Median age was 46 years. Overall satisfaction regarding to care was 40,8% (95% confidence interval 95% CI 36.2-45.6). Specifically, it was 90.6, 54.9, 85.3, 75.7, 90.8, and 93.3% regarding to reception, waiting time, care environment, sharing updated information, answering to PLHIV questions, and providing tailored care and advice to PLHIV needs, respectively. Attending to medical visits in community-based organization (CBO) and private clinics (adjusted odds ratio aOR 1.82, 95% CI 1.14-2.93, P#x003C;0.001), as well as in tertiary hospitals (aOR 2.37, 95% CI 1.45-3.87, P=0.001) were positively associated with PLHIV satisfaction. Burkina Faso PLHIV are generally unsatisfied with care. HIV national authorities should promote HIV care in CBO clinics model in the delivery of HIV services in others public sites.

Delivery of index-linked HIV testing for children: learnings from a qualitative process evaluation of the B-GAP study in Zimbabwe

BACKGROUND

Index-linked HIV testing for children, whereby HIV testing is offered to children of individuals living with HIV, has the potential to identify children living with undiagnosed HIV. The "Bridging the Gap in HIV Testing and Care for Children in Zimbabwe" (B-GAP) study implemented and evaluated the provision of index-linked HIV testing for children aged 2-18 years in Zimbabwe. We conducted a process evaluation to understand the considerations for programmatic delivery and scale-up of this strategy.

METHODS

We used implementation documentation to explore experiences of the field teams and project manager who delivered the index-linked testing program, and to describe barriers and facilitators to index-linked testing from their perspectives. Qualitative data were drawn from weekly logs maintained by the field teams, monthly project meeting minutes, the project coordinator's incident reports and WhatsApp group chats between the study team and the coordinator. Data from each of the sources was analysed thematically and synthesised to inform the scale-up of this intervention.

RESULTS

Five main themes were identified related to the implementation of the intervention: (1) there was reduced clinic attendance of potentially eligible indexes due to community-based differentiated HIV care delivery and collection of HIV treatment by proxy individuals; (2) some indexes reported that they did not live in the same household as their children, reflecting the high levels of community mobility; (3) there were also thought to be some instances of 'soft refusal'; (4) further, delivery of HIV testing was limited by difficulties faced by indexes in attending health facilities with their children for clinic-based testing, stigma around community-based testing, and the lack of familiarity of indexes with caregiver provided oral HIV testing; (5) and finally, test kit stockouts and inadequate staffing also constrained delivery of index-linked HIV testing.

CONCLUSIONS

There was attrition along the index-linked HIV testing cascade of children. While challenges remain at all levels of implementation, programmatic adaptations of index-linked HIV testing approaches to suit patterns of clinic attendance and household structures may strengthen implementation of this strategy. Our findings highlight the need to tailor index-linked HIV testing to subpopulations and contexts to maximise its effectiveness.

Considerations to Improve Pediatric HIV Testing and Close the Treatment Gap in 16 African Countries

BACKGROUND

In 2019, South Africa, Nigeria, Tanzania, Democratic Republic of Congo, Uganda, Mozambique, Zambia, Angola, Cameroon, Zimbabwe, Ghana, Ethiopia, Malawi, Kenya, South Sudan and Côte d'Ivoire accounted for 80% of children living with HIV (CLHIV) not receiving HIV treatment. This manuscript describes pediatric HIV testing to inform case-finding strategies.

METHODS

We analyzed US President's Emergency Plan for AIDS Relief monitoring, evaluation, and reporting data (October 1, 2018 to September 30, 2019) for these 16 countries. Number of HIV tests and positive results were reported by age band, country, treatment coverage and testing modality. The number needed to test (NNT) to identify 1 new CLHIV 1-14 years was measured by testing modality and country. The pediatric testing gap was estimated by multiplying the estimated number of CLHIV unaware of their status by NNT per country.

RESULTS

Among children, 6,961,225 HIV tests were conducted, and 101,762 CLHIV were identified (NNT 68), meeting 17.6% of the pediatric testing need. Index testing accounted for 13.0% of HIV tests (29.7% of positive results, NNT 30), provider-initiated testing and counseling 65.9% of tests (43.6% of positives, NNT 103), and universal testing at sick entry points 5.3% of tests (6.5% of positives, NNT 58).

CONCLUSIONS

As countries near HIV epidemic control for adults, the need to increase pediatric testing continues. Each testing modality - PITC, universal testing at sick entry points, and index testing - offers unique benefits. These results illustrate the comparative advantages of including a strategic mix of testing modalities in national programs to increase pediatric HIV case finding.

The barriers and facilitators of HIV-exposed infant testing as perceived by HIV-positive mothers in Botswana: A qualitative study

Background

Despite high rates of HIV testing and enrolment of HIV-positive pregnant women on antiretroviral therapy in Botswana, coverage for HIV-exposed infant (HEI) testing remains suboptimal. Many factors can contribute to suboptimal HEI testing rates, but they have seldom been thoroughly investigated in Botswana. Therefore, the aim of this study was to explore the experiences and perspectives of HIV-positive mothers on the barriers and facilitators of HEI testing to inform interventions to promote HEI testing in Botswana.

Methods

We conducted focus group discussions (FGDs) with HIV-positive mothers who gave birth in 2016 at the three largest public hospitals in Botswana. FGDs were held in Maun, Francistown, and Gaborone from September 2019 to March 2020. The maximum variation sampling method was used to select the participants using information that was abstracted from birth registers and other medical records at the study sites. Mothers were asked to describe their HEI testing experiences, what made it easy or difficult for them to return the HEI for testing, and what needs to be done to improve HEI testing in Botswana. A thematic approach was used to analyse the data.

Results

Fifteen FGDs with 142 mothers (aged 21–52 years) were held. Participants identified several facilitators to HEI testing, including a mother with adequate knowledge of PMTCT, intensive tracking of HEI by healthcare workers (HCWs), positive attitudes of HCWs toward clients, and social support from significant others. Staff shortages at health care facilities, frequent stock-outs of HIV test kits, fear of stigma, fear of positive test results for the child, and transportation challenges were identified as key barriers to HEI testing. Increasing staffing at healthcare facilities, having adequate supplies of HIV test kits, enhanced HEI tracking, easing access to HEI testing services in rural areas, and providing quality PMTCT education were among the proposed interventions to promote HEI testing.

Conclusion

Optimizing HEI testing in Botswana will require multi-level interventions at the policy, health system, community, interpersonal, and individual levels.

Home-based HIV Testing for Children: A Useful Complement for Caregivers with More Children, Who are Male, and with an HIV Negative Partner

Expanding index and family-based testing (HBT) is a priority for identifying children living with HIV. Our study characterizes predictors that drive testing location choice for children of parents living with HIV. Kenyan adults living with HIV were offered a choice of HBT or clinic-based testing (CBT) for any of their children (0-12 years) of unknown HIV status. Multilevel generalized linear models were used to identify correlates of choosing HBT or CBT for children and testing all versus some children within a family, including caregiver demographics, HIV history, social support, cost, and child demographics and HIV prevention history. Among 244 caregivers living with HIV and their children of unknown HIV status, most (72%) caregivers tested children using CBT. In multivariate analysis, female caregivers [aRR 0.52 (95% CI 0.34-0.80)] were less likely to choose HBT than male caregivers. Caregivers with more children requiring testing [aRR 1.23 (95% CI 1.05-1.44)] were more likely to choose HBT than those with fewer children requiring testing. In subgroup univariate analysis, female caregivers with a known HIV negative spouse were significantly more likely to choose HBT over CBT than those with a known HIV positive spouse [RR 2.57 (95% CI 1.28-5.14), p = 0.008], no association was found for male caregivers. Child demographics and clinical history was not associated with study outcomes. Caregiver-specific factors were more influential than child-specific factors in caregiver choice of pediatric HIV testing location. Home-based testing may be preferable to families with higher child care needs and may encourage pediatric HIV testing if offered as an alternative to clinic testing.

Exploring the mechanism through which a child-friendly storybook addresses barriers to child-participation during HIV care in primary healthcare settings in KwaZulu-Natal, South Africa

Background

Healthcare workers (HCWs) in South Africa widely use job-aids as practical tools to enhance the provision of HIV services, thereby improving patient-provider interactions during the care process. Job-aids are visual support materials that provide appropriate information using graphics and words in a simple and yet effective manner. We explored the mechanism through the KidzAlive Talk tool storybook (Talk tool), a child-centred job-aid for HCWs that facilitates child-participation during HIV consultations in primary healthcare (PHC) clinics implementing the KidzAlive model.

Methods

The study was conducted in PHC clinics across four districts; namely: uMkhanyakude, Zululand, uMgungundlovu, and eThekwini in KwaZulu-Natal (KZN), South Africa. We conducted in-depth interviews with children (n = 30), their primary caregivers (PCGs) (n = 30), and KidzAlive trained and mentored HCWs (n = 20). Data were collected in both English and isiZulu languages through user-specific, structured in-depth interviews. All the interviews were audio-recorded (with participants’ assent and consent, respectively). Data were transcribed verbatim, prior to translating the isiZulu transcripts to English. Translations were done by a member of the research team competent in both languages. Electronic data were imported to NVivo 10 for analysis and subsequently analysed using a thematic analysis method followed by a constant comparative and modified grounded theory analysis method.

Results

The findings identified the following barriers to child-participation: Primary caregiver limiting the child’s involvement due to fear of traumatising them; HCWs’ limited knowledge and skills to deliver child-centred HIV care; childhood developmental stage-related limitations and healthcare institutional paternalism. The Talk tool addresses the above barriers by using simple language and terminology to cater for children at various stages of development; alleviating HCWs’ and PCGs’ fear of possible psychological harm to the child; using storytelling and colourful cartoon illustrations for child edutainment; Being versatile by allowing for multiple utility and tackling institutional paternalism that limit child-involvement in the process of care.

Conclusions

This study provided evidence on how the Talk tool storybook addresses barriers to child-participation in the HIV care process. The evidence generated from this study is compelling enough to recommend the scale-up of this innovation in low-resource settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10483-8.

Screening Algorithms to Reduce Burden of Pediatric HIV Testing: A Systematic Review and Meta-analysis

BACKGROUND

The accuracy of symptom screening to identify children eligible for further HIV testing in generalized epidemics has been examined in several studies. We performed a systematic review and meta-analysis of these studies.

METHODS

We screened 5 databases and abstracts from 4 HIV/AIDS conferences. Studies were included if they were performed in clinical settings, included children of 0-15 years old, and used a signs/symptoms screen to determine eligibility for HIV testing. The primary outcomes were sensitivity and specificity of the screening tools. A meta-analysis was performed to evaluate the utility of a screening tool in the outpatient setting.

RESULTS

Our search returned 5529 database results and approximately 6700 conference abstracts, of which 36 articles were reviewed and 7 met criteria for inclusion. All were prospective or cross-sectional studies that developed and/or validated a screening tool to identify children at higher risk for being HIV infected. Sensitivity of the screening tools ranged from 71% to 96%, whereas specificity ranged from 25% to 99%. Meta-analysis of studies evaluating outpatient screening tools revealed a sensitivity of 81.4%, with a specificity of 69.4% for detecting HIV infection.

CONCLUSIONS

Few studies have evaluated the use of screening tools for HIV diagnosis in children. Screening tools that exist showed only moderate sensitivity and specificity and missed a substantial number of HIV-infected children in high-prevalence areas. In outpatient settings, the use of a screening tool may help reduce the number of HIV tests needed to identify an HIV-infected child, but at the cost of missed diagnoses. Further studies are needed to determine whether this represents a resource-saving mechanism.

Correlates of Uptake of Antiretroviral Therapy in HIV-Positive Orphans and Vulnerable Children Aged 0-14 Years in Tanzania

Background

In 2018, only 65% of Tanzanian children aged 0–14 years living with human immunodeficiency virus (HIV) were on treatment, suggesting that challenges exist. This study explores factors associated with uptake of antiretroviral therapy (ART) among HIV-positive orphans and vulnerable children (OVC).

Methods

Data are from the USAID Kizazi Kipya project that aims to increase the uptake of HIV/AIDS and other health and social services by OVC and their caregivers. HIV-positive OVC aged 0–14 years who were enrolled in the project from January 2017 to September 2018 were analyzed. ART status (off ART or on ART) was the outcome variable. Multivariate analysis was performed using multilevel logistic regression.

Results

Of the 10,047 HIV-positive OVC aged 0–14 years analyzed, 93.5% were currently on ART at enrollment. In the multivariate analysis, OVC with male caregivers were 4-times more likely than those with female caregivers to be on ART (OR=4.03, 95% CI=1.49–10.90). OVC with HIV-positive caregivers were 12-times more likely than those with HIV-negative caregivers to be on ART (OR=12.0, 95% CI=3.81–37.70). OVC with caregivers who did not disclose their HIV status were 74% less likely to be on ART than OVC of HIV-negative caregivers (OR=0.26, 95% CI=0.08–0.90). OVC living in urban areas were more than 5-times as likely as their rural counterparts to be on ART (OR=5.55, 95% CI=2.21–14.0).

Conclusion

The majority of the OVCLHIV in the current study were currently on ART (93.5%) at enrollment. However, uptake of ART by the OVC was dependent on factors external to themselves. Advancing ART uptake may require targeting OVC of female caregivers, OVC of HIV-negative caregivers, as well as OVC of caregivers of undisclosed HIV statu, and rural areas.

Validation of an HIV/AIDS Stigma Measure for Children Living with HIV and Their Families

BACKGROUND

There are few validated tools to measure stigma, particularly among children living with HIV and their families.

METHODS

This study was nested within a larger study that followed 240 child-caregiver dyads (children aged 10-15 years) at 8 clinics in western Kenya. The stigma instrument was administered to all child-caregiver dyads at 2 time points 6 months apart. The primary end point was to construct validity assessed by comparison to criterion constructs using generalized estimating equation models.

RESULTS

Mean age of child participants was 12.3 years and 52% were female. Generally, caregivers reported experiencing higher levels of HIV stigma compared to their children. Children (9%) and caregivers (14%) reported that HIV stigma made them feel stressed, anxious, and depressed. Child and caregiver stigma items showed high construct validity by emotional and behavioral outcomes.

CONCLUSIONS

The stigma instrument showed high validity when compared to emotional and behavioral outcomes.

Social and Structural Determinants of Household Support for ART Adherence in Low- and Middle-Income Countries: A Systematic Review

Adherence to HIV antiretroviral therapy (ART) is a crucial factor in health outcomes for people living with HIV (PLWH). Interventions to support ART adherence are increasingly focused on the household as a source of social support. This review aims to examine the social and structural determinants of support for ART adherence within households and families in low- and middle-income countries (LMICs). The review methodology followed the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Seven databases were searched for peer-reviewed literature. The terms searched thematically covered (1) ART adherence, (2) household and family and (3) support and care. Thirty-three studies conducted in 15 LMICs were selected and a mixed methods synthesis was undertaken. Social and structural determinants affected the type, quality and amount of support for PLWH of all ages, which affected PLWH's ART adherence. Gender norms affected the type of support that household members give to PLWH. Education moderated household support for ART adherence through literacy and language skills. Cultural context, religious beliefs, and social norms reinforced or undermined household support for ART adherence. Stigma affected disclosure, generated secrecy around giving medication and impeded access to support from the community. Supporting PLWH exacerbated economic hardship for household members. Health system dysfunction negatively impacted trust and communication between household members and health professionals. Intersecting social and structural determinants particularly affected the care given by household members who were older, female, with little education and low socioeconomic status. Household members were able to overcome some of these barriers when they received support themselves. Household interventions to support PLWH's ART adherence should take structural factors into account to have maximum impact.

Health care worker perspectives on TB case finding and HIV services among pediatric TB patients in Tanzania

BACKGROUND: Tuberculosis (TB) and human immunodeficiency virus (HIV) infection in children are of concern due to the high morbidity and mortality they engender. Tanzania is working to improve TB and HIV case identification and treatment, as well as linkage of TB and HIV care in pediatric patients.METHODS: In-depth interviews were conducted in March 2016 at 10 high TB burden clinics in five districts of Tanzania to identify the barriers to pediatric TB diagnosis and HIV care. Health care workers (HCWs) at TB clinics who provided informed consent were administered interviews which were analyzed.RESULTS: Of 41 HCWs interviewed, 26 reported receiving pediatric TB training. Barriers to TB diagnosis included low community awareness, stigma and late presentation to the clinic. Barriers to HIV testing included children attending the TB clinic with someone who was not their parent/guardian and shortages of HIV rapid test kits. HCWs stressed the need for improved community education because it was perceived that some caregivers did not understand the importance of prompt TB and HIV treatment in children (although most were eager for a resolution of their child's illness).CONCLUSIONS: Efforts are needed to ensure effective TB and HIV diagnosis and treatment of children, provision of broader HCW and community education, enhanced TB-HIV contact tracing, and ensuring a continuous supply of HIV rapid test kits.

Viral load testing among women on 'option B+' in Mazowe, Zimbabwe: How well are we doing?

BACKGROUND

Globally, ten percent of new HIV infections are among children and most of these children acquire infection through mother-to-child transmission. To prevent this, lifelong ART among pregnant and breast feeding (PBF) women living with HIV, irrespective of the WHO clinical stage, was adopted (option B+). There is limited cohort-wise assessment of VL testing among women on 'option B+'.

OBJECTIVE

Among a pregnancy cohort on antiretroviral therapy in public hospitals and clinics of Mazowe district, Zimbabwe (2017), to determine the i) proportion undergoing VL testing anytime up to six months post child birth and associated factors; ii) turnaround time (TAT) from sending the specimen to results receipt and VL suppression among those undergoing VL testing.

METHODS

This was a cohort study involving secondary programme data. Modified Poisson regression using robust variance estimates was used to determine the independent predictors of VL testing.

RESULTS

Of 1112 women, 354 (31.8%, 95% CI: 29.2-34.6) underwent VL testing: 113 (31.9%) during pregnancy, 124 (35%) within six months of child birth and for 117 (33.1%), testing period was unknown. Of 354, VL suppression was seen in 334 (94.4%) and 13 out of 20 with VL non-suppression underwent repeat VL testing. Among those with available dates (125/354), the median TAT was 93 days (IQR 19.3-255). Of 1112, VL results were available between 32 weeks and child birth in 31 (2.8%) women. When compared to hospitals, women registered for antenatal care in clinics were 36% less likely to undergo VL testing [aRR: 0.64 (95% CI: 0.53, 0.76)].

CONCLUSION

Among women on option B+, the uptake of HIV VL testing was low with unacceptably long TAT. VL suppression among those tested was satisfactory. There is an urgent need to prioritize VL testing among PBF women and to consider use of point of care machines. There is a critical need to strengthen the recording and local utilisation of routine clinic data in order to successfully monitor progress of healthcare services provided.

Healthcare-related factors affecting the management of HIV infected patients: a systematic review of qualitative evidence

Human immunodeficiency virus (HIV) infection is a major health concern that is associated with high mortality and socioeconomic burden on both patients and healthcare authorities. This systematic review aimed to qualitatively explore the healthcare-related factors influencing the management of HIV in adult patients. Seven online databases (PubMed, Embase, Google Scholar, CINAHL, PsycInfo, PsycExtra, and International Pharmaceutical Abstract) were searched. Articles published in English language between September 2000 and September 2018 were eligible for inclusion. Quality assessment tool developed by the EPPI-Centre was used to assess the quality of the included studies. A cross-case thematic analysis was conducted using NVivo 10. A total of 30 studies were included in the review. The qualitative analysis identified four major themes influencing the management of HIV: awareness of healthcare professionals (HCPs), attitudes of HCPs, lack of healthcare infrastructure, and stigma associated with HIV. The findings of this review suggest that people living with HIV are at an increased risk of experiencing poor disease management due to various healthcare-related factors. HCPs and policy makers should acknowledge the presence of these factors with the aim of providing quality care to people living with HIV.

Care pathways during a child's final illness in rural South Africa: Findings from a social autopsy study

BACKGROUND

Half of under-5 deaths in South Africa occur at home, however the reasons remain poorly described and data on the care pathways during fatal childhood illness is limited. This study aimed to better describe care-seeking behavior in fatal childhood illness and to assess barriers to healthcare and modifiable factors that contribute to under-5 deaths in rural South Africa.

METHODS

We conducted a social autopsy study on all under-5 deaths in two rural South African health and demographic surveillance system sites. Descriptive analyses based on the Pathways to Survival Framework were used to characterise how caregivers move through the stages of seeking and providing care for children during their final illness and to identify modifiable factors that contributed to death.

FINDINGS

Of 53 deaths, 40% occurred outside health facilities. Rates of antenatal and perinatal preventative care-seeking were high: over 70% of mothers had tested for HIV, 93% received professional assistance during delivery and 79% of children were reportedly immunised appropriately for age. Of the 48 deaths tracked through the stages of the Pathways to Survival Framework, 10% died suddenly without any care, 23% received home care of whom 80% had signs of severe or possibly severe illness, and 85% sought or attempted to seek formal care outside the home. Although half of all children left the first facility alive, only 27% were referred for further care.

CONCLUSIONS

Modifiable factors for preventing deaths during a child's final illness occur both inside and outside the home. The most important modifiable factors occurring inside the home relate to caregivers' recognition of illness and appreciation of urgency in response to the severity of the child's symptoms and signs. Outside the home, modifiable factors relate to inadequate referral and follow-up by health professionals. Further research should focus on identifying and overcoming barriers to referral.

Family Testing: An Index Case Finding Strategy to Close the Gaps in Pediatric HIV Diagnosis

Despite significant advances in pediatric HIV treatment, too many children remain undiagnosed and thus without access to lifesaving antiretroviral therapy. It is critical to identify these children and initiate antiretroviral therapy as early as possible. Although the children of HIV-infected adults are at higher risk of infection, few access HIV testing services because of missed opportunities in existing case finding programs. Family testing is an index case finding strategy through which HIV-infected patients are systematically screened to identify family members with unknown HIV status. By specifically targeting a high-risk population, family testing is a pragmatic, high-yield, and efficient approach to identify previously undiagnosed HIV-infected children and link them to care before they become symptomatic. Despite this, incorporation of family testing into national guidelines and implementation of this case finding approach is variable. In this article, we review the evidence base for family testing, describe its challenges, and provide guidance and sample tools for program managers aiming to integrate family testing into existing health systems.

Equity of child and adolescent treatment, continuity of care and mortality, according to age and gender among enrollees in a large HIV programme in Tanzania

Introduction

Global scale up of anti‐retroviral therapy (ART) has led to expansion of HIV treatment and prevention across sub‐Saharan Africa. However, age and gender‐specific disparities persist leading to failures in fulfillment of Sustainability Development Goals, including SDG3 (achieving healthy lives and wellbeing for all, at all ages) and SDG5 (gender equality). We assessed ART initiation and adherence, loss to follow‐up, all‐cause death and early death, according to SDG3 and SDG5 indicators among a cohort of HIV‐infected children and adolescents enrolled in care in Dar‐es‐Salaam, Tanzania

Methods

SDG3 indicators included young (<5 years) and older paediatric children (5 to <10 years), early adolescent (10 to <15 years) and late adolescent (15 to <20 years) age group divisions and the SDG5 indicator was gender. Associations of age group and gender with ART initiation, loss to follow‐up and all‐cause death, were analysed using Cox proportional hazards regression and with adherence, using generalized estimating equations (GEE) with the Poisson distribution. Associations of age group and gender with early death were analysed, using log‐Poisson regression with empirical variance.

Results

A total of 18,315 enrollees with at least one clinic visit were included in this cohort study. Of these 7238 (40%) were young paediatric , 4169 (23%) older paediatric, 2922 (16%) early adolescent and 3986 (22%) late adolescent patients at enrolment. Just over half of paediatric and early adolescents and around four fifths of the late adolescents were female. Young paediatric patients were at greater risk of early death, being almost twice as likely to die within 90 days. Males were at greater risk of early death once initiated on ART (HR 1.35, 95% CI 1.09, 1.66)), while females in late adolescence were at greatest risk of late death (HR 2.44 [1.60, 3.74] <0.01). Late adolescents demonstrated greater non‐engagement in care (RR 1.21 (95% CI 1.16, 1.26)). Among both males and females, early paediatric and late adolescent groups experienced significantly greater loss to follow‐up.

Conclusion

These findings highlight equity concerns critical to the fulfillment of SDG3 and SDG5 within services for children and adolescents living with HIV in sub‐Saharan Africa. Young paediatric and late adolescent age groups were at increased risk of late diagnosis, early death, delayed treatment initiation and loss of continuity of care. Males were more likely to die earlier. Special attention to SDG3 and SDG5 disparities for children and adolescents living with HIV will be critical for fulfillment of the 2030 SDG agenda.

Barriers to antiretroviral therapy initiation for HIV-positive children aged 2-18 months in Swaziland

Although early antiretroviral therapy (ART) reduces HIV-related mortality in children by up to 75%, almost half of HIV-positive children younger than 1 year old in Swaziland do not initiate ART. This study was conducted to identify barriers to early ART initiation among HIV-positive infants. This was a case-control study among HIV-positive infants, aged 2 to 18 months, who either did not initiate ART (cases), or initiated ART (controls), during 18 months after testing. Multivariable logistic regression showed that infants who visited the clinic every month, or every 2 months, were 5.78 and 6.20 times more likely to initiate ART than those who visited less often (OR 5.78, 95% CI 1.82-18.33 and OR 6.20, 95% CI 1.30-29.60 respectively). Children who lived ≤30 and 31-60 minutes from the nearest clinic were 84% and 79% less likely respectively to initiate ART (OR 0.16, 95% CI 0.03-0.78 and OR 0.21, 95% CI 0.04-0.98) compared with those who lived more than 60 minutes away. Children who received immunisation after 6 months were 22.59 times more likely to initiate ART (OR 22.59, 95% CI 7.00-21.72) than those who did not. Infants of caregivers who had excellent or good relationships with their healthcare provider were 4.32 times more likely to initiate ART (OR 4.32, 95% CI 1.01-18.59) than those of caregivers who had average or poor relationships with healthcare providers. The significant predictors of ART initiation identified in this study should be regarded as priority areas for intervention among HIV-positive women in Swaziland.

Retention of HIV exposed infants in care at Arua regional referral hospital, Uganda: a retrospective cohort study

Background

Retention of HIV Exposed Infants (HEIs) in care ensures adequate care. Data on retention of HEIs at large referral hospitals in Uganda is limited. We investigated the retention level of HEIs and associated factors.

Methods

We conducted a retrospective cohort study on 352 HEIs in care (January 2014 and April 2015) at Arua Regional Referral Hospital, North-western Uganda. Electronic medical data were retrieved and analyzed with Stata. Chi-square, Fisher’s exact, and Students t-tests were used for bivariate analysis. Logistic regression was performed to determine factors independently associated with retention.

Results

236 (67.0%) HEIs were delivered in a health facility and 306 (86.9%) received Nevirapine prophylaxis from birth until 6-weeks. Of mothers, 270 (76.7%) were 25–46 years, 202 (57.4%) attended antenatal care (ANC) at recent pregnancy, and 328 (93.2%) were on life-long anti-retroviral therapy. At 18-months, 277 (78.7%) HEIs were retained in care. Maternal age (25–46 years) (Adjusted Odds Ratio (AOR), 2.32; 95% CI, 1.32–4.06), ANC attendance during recent pregnancy (AOR, 2.01; 95% CI, 1.19–4.3.41) and Nevirapine prophylaxis initiation from birth until 6-weeks (AOR, 3.07; 95% CI, 1.50–6.26) were associated with retention.

Conclusion

Retention was suboptimal. Older maternal age, ANC visits at last pregnancy, and timely NVP initiation increased retention.

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

Background

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

Objective

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

Methods

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

Conclusion

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

Brief Report: Disclosure, Consent, Opportunity Costs, and Inaccurate Risk Assessment Deter Pediatric HIV Testing: A Mixed-Methods Study

BACKGROUND

Prompt child HIV testing and treatment is critical; however, children are often not diagnosed until symptomatic. Understanding factors that influence pediatric HIV testing can inform strategies to increase testing.

METHODS

A mixed-methods study was conducted at a tertiary hospital in Nairobi, Kenya. Three focus group discussions with health care workers (HCWs) and 18 in-depth interviews with HIV-infected adults with children of unknown status were analyzed using thematic analysis. A structured questionnaire was administered to 116 HIV-infected caregivers of children of unknown status to triangulate qualitative findings.

RESULTS

Analysis revealed 3 key periods of the pediatric HIV testing process: decision to test, test visit, and posttest. Key issues included: decision to test: inaccurate HIV risk perception for children, challenges with paternal consent, lack of caregiver HIV status disclosure to partners or older children; test experience: poor understanding of child consent/assent and disclosure guidelines, perceived costs of testing and care, school schedules, HCW discomfort with pediatric HIV testing; and posttest: pessimism regarding HIV-infected children's prognosis, caregiver concerns about their own emotional health if their child is positive, and challenges communicating about HIV with children. Concerns about all 3 periods influenced child testing decisions. In addition, 3 challenges were unique to pediatric HIV: inaccurate HIV risk perception for children; disclosure, consent, and permission; and costs and scheduling.

CONCLUSIONS

Pediatric HIV testing barriers are distinct from adult barriers. Uptake of pediatric HIV testing may be enhanced by interventions to address misconceptions, disclosure services, psychosocial support addressing concerns unique to pediatric testing, child-focused HCW training, and alternative clinic hours.

Determination of medication adherence and related factors among people living with HIV/AIDS in a Turkish university hospital

Background/aim

Widespread use of antiretroviral treatment (ART) has led to decrease in the incidence of HIV/AIDS-related mortality. Besides the availability of ART, medication adherence is essential for treatment success. There is a scarcity of data reported from Turkey regarding ART adherence among people living with HIV/AIDS (PLWHA). Therefore, this study was undertaken to determine medication adherence and related factors among PLWHA in Turkey.

Materials and methods

The sample consisted of 158 PLWHA, who were being followed up at Infectious Diseases Outpatient Clinic of Hacettepe University Hospital. Data were collected using an individual questionnaire and the Turkish version of the Morisky Medication Adherence Scale.

Results

The median patient age was 38 years, 80.4% were male, and 51.3% were married. The median duration of both HIV infection and ART was 3 years. Sixty-one percent used two drug regimens. Sixty-one percent were highly adherent to ART while 37.9% were moderately adherent. The absence/presence of social support resources, disease duration, ART duration, and being informed about the ART regimen were statistically associated with medication adherence.

Conclusion

Our results suggest that medication adherence is excellent among Turkish PLWHA. Interventions, including effective social support, and continuous counseling about ART, might further boost the adherence of PLWHA.

What Influences Linkage to Care After Home-Based HIV Counseling and Testing?

To maximize the benefits of test and treat strategies that utilize community-based HIV testing, clients who test positive must link to care in a timely manner. However, linkage rates across the HIV treatment cascade are typically low and little is known about what might facilitate or hinder care-seeking behavior. This qualitative study was conducted within a home-based HIV counseling and testing (HBHCT) intervention in South Africa. In-depth interviews were conducted with 30 HBHCT clients who tested HIV positive to explore what influenced their care-seeking behavior. A set of field notes for 196 additional HBHCT clients who tested HIV positive at home were also reviewed and analyzed. Content analysis showed that linkage to care is influenced by a myriad of factors at the individual, relationship, community, and health system levels. These factors subtly interact and at times reinforce each other. While some factors such as belief in test results, coping ability, social support, and prior experiences with the health system affect clients’ desire and motivation to seek care, others such as limited time and resources affect their agency to do so. To ensure that the benefits of community-based testing models are realized through timely linkage to care, programs and interventions must take into account and address clients’ emotions, motivation levels, living situations, relationship dynamics, responsibilities, and personal resources.

A qualitative analysis of the barriers to antiretroviral therapy initiation among children 2 to 18 months of age in Swaziland

HIV/AIDS remains one of the leading causes of death among children under 5 years old in Swaziland. Although studies have shown that early initiation of infants and children diagnosed with HIV on antiretroviral therapy (ART) significantly reduces mortality, many children do not initiate ART until the later stages of disease. This study was designed to collect qualitative data from mothers and caregivers of HIV-positive children to identify the barriers to ART initiation. Focus group discussion (FGD) sessions were conducted in siSwati between July and September 2014 among caregivers of aged children 2-18 months in Swaziland who did or did not initiate ART between January 2011 and December 2012 after HIV DNA PCR-positive diagnosis of the infants. Denial, guilt, lack of knowledge, tuberculosis (TB)/HIV co-infection, HIV-related stigma, lack of money, and distance to clinics were reported by the participants as barriers to ART initiation. The findings further revealed that non-initiation on ART was not linked to a negative perception of the treatment. Findings suggest a need to improve sensitivity among healthcare workers as well as education and counselling services that will facilitate the ART initiation process.

[Seroprevalence and factors associated with Voluntary Counselling and Testing (VCT) for HIV among children in Lubumbashi, Democratic Republic of the Congo]

Introduction

Malgré le dépistage du VIH proposé lors de la naissance ou au cours des consultations préscolaires, la proportion des enfants qui croissent ou décèdent sous statut sérologique au VIH inconnu est importante en République Démocratique du Congo (RDC). L’objectif de cette étude était de déterminer la séroprévalence au cours d’un dépistage volontaire et d’identifier les facteurs associés à l’acceptation du conseil et dépistage du VIH (CDV) en dehors de la maladie ou de toute exposition au VIH dans une population pédiatrique à Lubumbashi, RDC.

Méthodes

Il s’agissait d’une étude prospective transversale à visée analytique menée du 1^er août 2006 au 31 septembre 2007. Elle avait été réalisée dans 4 centres communautaires de CDV répartis dans 4 zones de santé de la ville de Lubumbashi en RDC (Lubumbashi, Ruashi, Kampemba et de Kenya). L’étude avait consisté à faire le dépistage volontaire du VIH chez les enfants de moins de 15 ans. Les caractéristiques sociodémographiques et les paramètres relatifs au conseil et dépistage volontaire ont été étudiés. Les analyses statistiques descriptives usuelles et une régression logistique ont été réalisées.

Résultats

Sur 463 enfants dépistés du VIH, 41 (8,9%; IC 95%: 6,5%-11,9%) ont été testés positifs. L’acceptation du conseil et dépistage volontaire du VIH en dehors de la maladie ou de l’exposition au VIH était significativement plus élevée lorsque l’enfant était âgé de plus de 2 ans (Odds ratio ajusté (ORa) = 3,6 [IC 95%: 1,1-12,2]), lorsque le statut sérologique du VIH des parents était négatif ou inconnu (ORa = 27,4 [IC 95%: 9,4-80,0]), lorsque l’un ou l’autre ou les deux parents biologiques étaient en vie (ORa = 24,9 [IC 95%: 2,4-250,8]) et lorsque la connaissance du lieu de dépistage était fait par des moyens autres que le professionnel de santé (ORa = 2,9 [IC 95%: 1,0-7,9]).

Conclusion

Notre étude montre une forte prévalence du VIH chez les enfants justifiant la nécessité de réaliser le CDV qui est significativement accepté par leurs parents et tuteurs dans la ville de Lubumbashi.

Qualitative exploration of psychological reactions and coping strategies of breastfeeding mothers living with HIV in the Greater Accra Region of Ghana

Background

Exploring the psychological reactions of breastfeeding mothers living with Human Immunodeficiency Virus (HIV) is an important step which may improve guidelines for counselling. The purpose of this study was to explore the psychological reactions and coping strategies of breastfeeding mothers living with HIV in the Greater Accra Region of Ghana.

Methods

Qualitative descriptive exploratory design was used to explore the psychological experiences and coping strategies of 13 breastfeeding mothers living with HIV in a main referral public hospital, at the greater Accra Region of Ghana. An interview guide was designed and piloted before it was used to collect data between November, 2014 and February, 2015. Data was content analyzed for themes and subthemes to emerge.

Results

The two major themes that emerged included psychological reactions and coping strategies. Some of the subthemes were fear, anxiety, blame, hope, denial, prayer and trust in positive situations of life.

Conclusion

The women used denial, prayer and hope in ART, among others to cope with their emotions. This highlights the need for HIV counsellors to detect signs of denial since it can lead to non-adherence to ART as well as relapse. Health workers should therefore put the coping strategies in context during counselling of mothers in this category.

Missed opportunities for timely diagnosis of pediatric lupus in South Africa: a qualitative study

BACKGROUND

Systemic Lupus Erythematosus (SLE) is a serious multisystem autoimmune disease, which is more aggressive in children and people of African descent. In South Africa, pediatric SLE (pSLE) patients are at high risk for severe disease. Similar to pSLE worldwide, South African children and adolescents with SLE require subspecialized medical care. The aim of this study is to describe the care-seeking experiences of families and examine factors that contribute to delays in the diagnosis of pSLE. Specifically, we sought to identify factors to inform interventions that support the timely referral and diagnosis of pediatric SLE patients in South Africa.

METHODS

In-depth, semi-structured interviews were conducted with 22 caregivers of pSLE patients recruited from two government hospitals in Cape Town, South Africa in 2014. Interviews were audio-recorded, transcribed, and analyzed for themes related to barriers to diagnosis.

RESULTS

Six themes were identified and classified as either caregiver or health system barriers to diagnosis. Caregiver barriers included lack of knowledge regarding SLE, financial difficulties, and the social stigma of SLE. Health system barriers were lack of trained staff, a complex medical system, and misdiagnosis.

CONCLUSION

Caregivers reported missed opportunities for diagnosing pSLE in their children. Raising public awareness may improve caregiver awareness and reduce stigma of pSLE. Improving family education at diagnosis holds potential to increase patient-physician trust and mitigate fear. Education modules for primary care providers at initial point of contact with the health care system may improve recognition of early pSLE and facilitate expedited referral to a specialist.

Talking to children about their HIV status: a review of available resources, tools, and models for improving and promoting pediatric disclosure

As children living with HIV (CLHIV) grow into adolescence and adulthood, caregivers and healthcare providers are faced with the sensitive challenge of when to disclose to a CLHIV his or her HIV status. Despite WHO recommendations for CLHIV to know their status, in countries most affected by HIV, effective resources are often limited, and national guidance on disclosure is often lacking. To address the need for effective resources, gray and scientific literature was searched to identify existing tools and resources that can aid in the disclosure process. From peer-reviewed literature, seven disclosure models from six different countries were identified. From the gray literature, 23 resources were identified including children's books (15), job aides to assist healthcare providers (5), and videos (3). While these existing resources can be tailored to reflect local norms and used to aid in the disclosure process, careful consideration must be taken in order to avoid damaging disclosure practices.

Living with HIV in West Bengal, India: perceptions of infected children and their caregivers

Children living with HIV (CLH) face several physical and psychological challenges. The impact of the disease is not limited to the affected CLH, but also affects their caregivers and family members. We qualitatively explored the experiences, knowledge, concerns, and perceptions of primary caregivers and triangulated those aspects with those expressed by their CLH. We conducted 34 in-depth interviews (IDI) with primary caregivers of 8- to 15-year-old CLH residing in West Bengal, India. Four focus group discussions (FGD) with CLH were held, two each with children aged 8-12 and 13-15 years. Participants were recruited with the help of a community-based organization providing need-based services to adults and CLH. Five major themes shared by caregivers and children were identified, including concerns about HIV, medications, discriminatory behaviors, having a "healthy mind", and the advantages and limitations of available HIV-related health services. Two primary themes exclusively from IDI with caregivers were caregiving challenges and concerns about the future of their CLH. Indian CLH and their caregivers face many daily challenges, and there are many unmet but relevant expectations. Caregiving goes beyond the child-caregiver dynamic, and is intertwined with the local community and the healthcare and support system structures. The current study underscores the need for comprehensive care programs focusing on improving support to both CLH and caregivers.

Enroling and retaining human immunodeficiency virus (HIV) patients in their care: A metasynthesis of qualitative studies

OBJECTIVES

To report the findings of a metasynthesis review of qualitative studies on patient and provider experiences and perspectives on linkage and retention in HIV care.

DESIGN

The review is an extraction, aggregation, interpretation and synthesis of qualitative findings based on the Sandelowski and Barroso method.

DATA SOURCES

A search of the literature was conducted in the databases Cumulative Index to Nursing and Allied Health, PubMed and PsycInfo for articles published from 2008 to 2013. Inclusion criteria were qualitative research articles published in English from across the world and in peer-reviewed journals. Literature reviews, conference abstracts and grey literature were excluded from this metasynthesis.

REVIEW METHODS

The review consisted of a) comprehensive search, b) study classification, c) abstraction of findings, d) synthesis. Of the 4640 citations screened, 69 articles were included for this metasynthesis.

RESULTS

69 unique articles from 44 countries were included. This metasynthesis takes into account the perspectives of at least 2263 HIV-positive participants (740 men, 1008 women, 78 transgender individuals and 437 unspecified sex) and 994 healthcare providers, family members and community members. The most salient barriers and facilitators to HIV linkage and retention in HIV care affirm ecological factors that are mostly beyond individual patients' control. Triadic streams of influence concurrently affect care engagement that include a person's psychological state upon diagnosis and their informational challenges (intrapersonal stream); one-on-one interactions with providers and their immediate community (social stream); and life demands, overall quality of care experiences and other structural barriers (cultural-attitudinal stream). Each stream's influence on HIV care engagement varies at any given point to reflect an individual's evolving and unique experiences with HIV infection throughout the illness trajectory.

CONCLUSION

There is sufficient evidence that detail how to best link and retain patients in HIV care. Themes identified indicate going beyond individual-level factors and towards shifting attention and resources to systems that patients navigate. Forceful structural-level actions are needed to correct these long-identified barriers and enhance care engagement facilitators.

Non-Uptake of HIV Testing in Children at Risk in Two Urban and Rural Settings in Zambia: A Mixed-Methods Study

This article investigates reasons why children who were considered at risk of HIV were not taken for HIV testing by their caregivers. Qualitative and quantitative data collected in Zambia from 2010–11 revealed that twelve percent of caregivers who stated that they had been suspecting an HIV infection in a child in their custody had not had the child tested. Fears of negative reactions from the family were the most often stated reason for not testing a child. Experience of pre-existing conflicts between the couple or within the family (aOR 1.35, 95% CI 1.00–1.82) and observed stigmatisation of seropositive children in one’s own neighbourhood (aOR 1.69, 95% CI1.20–2.39) showed significant associations for not testing a child perceived at risk of HIV. Although services for HIV testing and treatment of children have been made available through national policies and programmes, some women and children were denied access leading to delayed diagnosis and treatment–not on the side of the health system, but on the household level. Social norms, such as assigning the male household head the power to decide over the use of healthcare services by his wife and children, jeopardize women’s bargaining power to claim their rights to healthcare, especially in a conflict-affected relationship. Social norms and customary and statutory regulations that disadvantage women and their children must be addressed at every level–including the community and household–in order to effectively decrease barriers to HIV related care.

Delays in Initiation of Antiretroviral Therapy Among HIV-infected Children in Rural Zambia

BACKGROUND

Although care and treatment are available to many HIV-infected children, barriers remain that delay initiation of antiretroviral therapy (ART). Minimizing these barriers is critical to starting ART at earlier ages.

METHODS

Reasons for delay were evaluated among 200 children younger than 15 years of age initiating treatment in an HIV clinic in rural Zambia from 2011 to 2013.

RESULTS

The median age of children at ART eligibility was 2.9 years, and 49% were male. After being determined eligible, 60% of children delayed ART initiation for a median of 28 days (interquartile range: 14, 75). Primary reasons for delay included waiting for test results, adherence issues and concurrent treatment for tuberculosis. When reasons for delay were categorized by type, 36% of children had family-related delays, 32% had delays because of clinic logistics, 27% had health-related delays and 6% had other or no identified reasons for delay. The median time between eligibility and ART initiation was shortest for children with delays because of clinic logistics (median: 18 days; interquartile range: 14, 35). Children with family-related delays tended to be older and orphaned, whereas children with delays because of clinic logistics tended to be younger, and children with health-related delays tended to have more advanced disease. In the first year of ART, no association was found between adherence and type of delay. CD4 T-cell percentages and weight-for-age Z scores were lower for children with health-related delays.

CONCLUSIONS

Strategies to reduce delays in ART initiation will need to address a diverse set of issues, so children can benefit from earlier treatment.

Missed opportunities of inclusion in a cohort of HIV-infected children to initiate antiretroviral treatment before the age of two in West Africa, 2011 to 2013

INTRODUCTION

The World Health Organization (WHO) 2010 guidelines recommended to treat all HIV-infected children less than two years of age. We described the inclusion process and its correlates of HIV-infected children initiated on early antiretroviral therapy (EART) at less than two years of age in Abidjan, Côte d'Ivoire, and Ouagadougou, Burkina Faso.

METHODS

All children with HIV-1 infection confirmed with a DNA PCR test of a blood sample, aged less than two years, living at a distance less than two hours from the centres and whose parents (or mother if she was the only legal guardian or the legal caregiver if parents were not alive) agreed to participate in the MONOD ANRS 12206 project were included in a cohort to receive EART based on lopinavir/r. We used logistic regression to identify correlates of inclusion.

RESULTS

Among the 217 children screened and referred to the MONOD centres, 161 (74%) were included and initiated on EART. The main reasons of non-inclusion were fear of father's refusal (48%), mortality (24%), false-positive HIV infection test (16%) and other ineligibility reasons (12%). Having previously disclosed the child's and mother's HIV status to the father (adjusted odds ratio (aOR): 3.20; 95% confidence interval (95% CI): 1.55 to 6.69) and being older than 12 months (aOR: 2.05; 95% CI: 1.02 to 4.12) were correlates of EART initiation. At EART initiation, the median age was 13.5 months, 70% had reached WHO Stage 3/4 and 57% had a severe immune deficiency.

CONCLUSIONS

Fear of stigmatization by the father and early competing mortality were the major reasons for missed opportunities of EART initiation. There is an urgent need to involve fathers in the care of their HIV-exposed children and to promote early infant diagnosis to improve their future access to EART and survival.

Prevention and care of paediatric HIV infection in Ouagadougou, Burkina Faso: knowledge, attitudes and practices of the caregivers

BACKGROUND

The paediatric Human Immunodeficiency Virus (HIV) epidemic still progresses because of operational challenges in implementing prevention of mother-to-child HIV transmission (PMCT) programs. We assessed the knowledge, attitudes and practices (KAP) of children's caregivers regarding mother-to-child transmission (MTCT) of HIV, paediatric HIV infection, early infant diagnosis (EID), and paediatric antiretroviral treatment in Ouagadougou, Burkina Faso.

METHODS

We undertook a qualitative survey in the four public hospitals managing HIV exposed or infected children, in Ouagadougou in 2011. A sociologist used a semi-structured questionnaire to interview caregivers of children less than 5 years old attending the paediatrics wards on their KAP. Study participants were divided into four groups as follows: those who did not yet know their children's HIV infection status, those who were waiting for their children's HIV test results, those who were waiting for antiretroviral treatment, and those who were already on antiretroviral treatment.

RESULTS

A total of 37 caregivers were interviewed. The mean age was 32.5 years, and 29 (78 %) were mothers. Twenty seven (73 %) caregivers had primary or higher level of education, and 15 (40 %) described their occupation as "housewife". Overall, 36 (97 %) of caregivers knew that the main route of HIV transmission for infants was through MTCT and 14 (38 %) specified that it occurred during pregnancy or delivery. Five percent thought that MTCT of HIV occurred during conception. PMTCT interventions could help prevent infant HIV infection according to 32 (87 %) caregivers. Thirty five percent of caregivers stated EID as a prevention strategy. Fifty-four percent of the participants believed that replacement feeding option would prevent MTCT of HIV; 24 (65 %) stated that they would prefer medical practitioners seek caregivers' consent before carrying out any HIV-test for their child, and that caregivers' consent was not compulsory before antiretroviral treatment. All caregivers thought that it was necessary to treat HIV-infected children, although they did not know what interventions could be done.

CONCLUSIONS

This study highlighted the low level of caregivers' knowledge on paediatric HIV prevention and care in Ouagadougou. Awareness programs targeting caregivers need to be strengthened in order to improve the uptake of HIV early infant diagnosis and care.

I don't know what I am doing because I am doing everything: perceptions and experiences of nurses about HIV counselling and testing among children in Free State Province, South Africa

Although HIV/AIDS constitute a significant health burden among children in South Africa, testing and counselling of exposed children are inadequate. It is therefore imperative that factors relating to paediatric HCT services offered by health workers are examined. This study was conducted to explore and describe the perceptions and experiences of trained professional nurses regarding HIV counselling and testing among children. We conducted six focus group discussions among trained professional nurses in health facilities in a district in Free State Province, South Africa. All verbatim transcripts were analysed with a thematic approach and emergent codes were applied. Forty-seven trained professional nurses participated in the study and two of them were males. The age of the participants ranges from 38 to 60 years while the median age was 50 years. Most participants in the focus groups explained how HCT occurs during regular health talks and that lay counsellors are doing most of the counselling. While a few participants thought that children should not be bothered with HCT, most of them seek consent from caregivers for HIV test for children. While children whose parents are negative are usually not tested, most children are tested only when they become ill. Identified barriers to HCT among children include refusal of consent, work overload, lack of encouragement, and poor record keeping. Participants recommended improvement of issues relating to community mobilization and increasing trained staff strength for optimal paediatric HCT service delivery. Developing guidance and policies with respect to obtaining consent, recruiting more health providers, and addressing structural issues in the society to reduce stigma and discrimination were identified as key priority issues by majority of the participants. The perspectives of these participants who provide paediatric HCT services offer vital insight which may be useful to inform policy interventions.

A comprehensive review of the barriers and promoters health workers experience in delivering prevention of vertical transmission of HIV services in sub-Saharan Africa

Despite significant biomedical and policy advances, 199,000 infants and young children in sub-Saharan Africa (SSA) became infected with HIV in 2013, indicating challenges to implementation of these advances. To understand the nature of these challenges, we sought to (1) characterize the barriers and facilitators that health workers encountered delivering prevention of vertical transmission of HIV (PVT) services in SSA and (2) evaluate the use of theory to guide PVT service delivery. The PubMed and CINAHL databases were searched using keywords barriers, facilitators, HIV, prevention of vertical transmission of HIV, health workers, and their synonyms to identify relevant studies. Barriers and facilitators were coded at ecological levels according to the Determinants of Performance framework. Factors in this framework were then classified as affecting motivation, opportunity, or ability, per the Motivation-Opportunity-Ability (MOA) framework in order to evaluate domains of health worker performance within each ecological level. We found that the most frequently reported challenges occurred within the health facility level and spanned all three MOA domains. Barriers reported in 30% or more of studies from most proximal to distal included those affecting health worker motivation (stress, burnout, depression), patient opportunity (stigma), work opportunity (poor referral systems), health facility opportunity (overburdened workload, lack of supplies), and health facility ability (inadequate PVT training, inconsistent breastfeeding messages). Facilitators were reported in lower frequencies than barriers and tended to be resolutions to challenges (e.g., quality supervision, consistent supplies) or responses to an intervention (e.g., record systems and infrastructure improvements). The majority of studies did not use theory to guide study design or implementation. Interventions addressing health workers' multiple ecological levels of interactions, particularly the health facility, hold promise for far-reaching impact as distal factors influence more proximal factors. Incorporating theory that considers factors beyond the health worker will strengthen endeavors to mitigate barriers to PVT service delivery.

Factors associated with access to HIV care services in eastern Uganda: the Kumi home based HIV counseling and testing program experience

Background

The HIV/AIDS health challenge continues to ravage many resource-constrained countries of the world. Approximately 75 % of all the global HIV/AIDS related deaths totaling 1.6 (1.4–1.9) million in 2012 occurred in sub-Saharan Africa, Uganda contributed 63,000 (52,000–81,000) to these deaths. Most of the morbidity and mortality associated with HIV/AIDS can be averted if individuals with HIV/AIDS have improved access to HIV care and treatment. The aim of this study therefore, was to explore the factors associated with access to HIV care services among HIV seropositive clients identified by a home based HIV counseling and testing program in Kumi district, eastern Uganda.

Methods

In a cross sectional study conducted in February 2009, we explored predictor variables: socio-demographics, health facility and community factors related to access to HIV care and treatment. The main outcome measure was reported receipt of cotrimoxazole for prophylaxis.

Results

The majority [81.1 % (284/350)] of respondents received cotrimoxazole prophylaxis (indicating access to HIV care). The main factors associated with access to HIV care include; age 25–34 years (AOR = 5.1, 95 % CI: 1.5–17.1), male sex (AOR = 2.3, 95 % CI: 1.2–4.4), urban residence (AOR = 2.5, CI: 1.1–5.9) and lack of family support (AOR = 0.5, CI: 0.2–0.9).

Conclusions

There was relatively high access to HIV care and treatment services at health facilities for HIV positive clients referred from the Kumi home based HIV counseling and testing program. The factors associated with access to HIV care services include; age group, sex, residence and having a supportive family. Stakeholders involved in providing HIV care and treatment services in similar settings should therefore consider these socio-demographic variables as they formulate interventions to improve access to HIV care services.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-015-0379-6) contains supplementary material, which is available to authorized users.

Behavior change communication and mobile populations: the evaluation of a cross-border HIV/AIDS communication strategy amongst migrants from Swaziland

This study investigates the effect of being exposed to the Soul City Southern Africa Regional OneLove campaign, a behavior change communication program, on sexual behavior and condom use among a mobile population in Swaziland. Data for this study come from a nationally representative sample of 845 individuals who reported traveling to neighboring countries for at least two weeks at any time in the previous two years. Respondents were asked about exposure to the campaign through television, radio, booklets, posters, and advertisements both in Swaziland and in the other countries where they had traveled in the previous two years. Odds ratios were used to estimate the relationships between the HIV/AIDS outcomes of interest and program exposure for the full sample as well as separately for males and females. The program had no effect on reducing known risky behaviors such as having multiple sexual partners. However, men exposed in Swaziland only (AOR = 3.4, CI 1.2-9.4) and in Swaziland and another country (AOR = 2.8, CI 1.0-7.7) were more likely to report using a condom at last sex. In the full sample, those exposed in Swaziland were more likely to report using a condom at last sex (AOR = 2.6, CI 1.3-5.3) and a condom at last sex with a regular partner (AOR = 2.3, CI 1.1-4.8). Men who reported multiple sexual partnerships and who were exposed in Swaziland and another country were nine times as likely to report condom at last sex than men with no exposure. Respondents exposed in Swaziland and another country were more likely to have been tested for HIV; this was true for the total population (AOR = 2.9, CI 1.1-7.9) and for men separately (AOR = 3.3, CI 1.1-10.1). These findings provide support for more regional HIV prevention programs in Southern Africa as a way to increase positive behaviors among mobile populations.

Linkage to care following a home-based HIV counselling and testing intervention in rural South Africa

Introduction

Efforts to increase awareness of HIV status have led to growing interest in community-based models of HIV testing. Maximizing the benefits of such programmes requires timely linkage to care and treatment. Thus, an understanding of linkage and its potential barriers is imperative for scale-up.

Methods

This study was conducted in rural South Africa. HIV-positive clients (n=492) identified through home-based HIV counselling and testing (HBHCT) were followed up to assess linkage to care, defined as obtaining a CD4 count. Among 359 eligible clients, we calculated the proportion that linked to care within three months. For 226 clients with available data, we calculated the median CD4. To determine factors associated with the rate of linkage, Cox regression was performed on a subsample of 196 clients with additional data on socio-demographic factors and personal characteristics.

Results

We found that 62.1% (95% CI: 55.7 to 68.5%) of clients from the primary sample (n=359) linked to care within three months of HBHCT. Among those who linked, the median CD4 count was 341 cells/mm³ (interquartile range [IQR] 224 to 542 cells/mm³). In the subsample of 196 clients, factors predictive of increased linkage included the following: believing that drugs/supplies were available at the health facility (adjusted hazard ratio [aHR] 1.78; 95% CI: 1.07 to 2.96); experiencing three or more depression symptoms (aHR 2.09; 95% CI: 1.24 to 3.53); being a caregiver for four or more people (aHR 1.93; 95% CI: 1.07 to 3.47); and knowing someone who died of HIV/AIDS (aHR 1.68; 95% CI: 1.13 to 2.49). Factors predictive of decreased linkage included the following: younger age – 15 to 24 years (aHR 0.50; 95% CI: 0.28 to 0.91); living with two or more adults (aHR 0.52; 95% CI: 0.35 to 0.77); not believing or being unsure about the test results (aHR 0.48; 95% CI: 0.30 to 0.77); difficulty finding time to seek health care (aHR 0.40; 95% CI: 0.24 to 0.67); believing that antiretroviral treatment can make you sick (aHR 0.56; 95% CI: 0.35 to 0.89); and drinking alcohol (aHR 0.52; 95% CI: 0.34 to 0.80).

Conclusions

The findings highlight barriers to linkage following an increasingly popular model of HIV testing. Further, they draw attention to ways in which practical interventions and health education strategies could be used to improve linkage to care.

Access to HIV prevention and care for HIV-exposed and HIV-infected children: a qualitative study in rural and urban Mozambique

Background

Follow-up of HIV-exposed children for the delivery of prevention of mother-to-child transmission services and for early diagnosis and treatment of HIV infection is critical to their survival. Despite efforts, uptake of postnatal care for these children remains low in many sub-Saharan African countries.

Methods

A qualitative study was conducted in three provinces in Mozambique to identify motivators and barriers to improve uptake of and retention in HIV prevention, care and treatment services for HIV-exposed and HIV-infected children. Participant recommendations were also gathered. Individual interviews (n = 79) and focus group discussions (n = 32) were conducted with parents/caregivers, grandmothers, community leaders and health care workers. Using a socioecological framework, the main themes identified were organized into multiple spheres of influence, specifically at the individual, interpersonal, institutional, community and policy levels.

Results

Study participants reported factors such as seeking care outside of the conventional health system and disbelief in test results as barriers to use of HIV services. Other key barriers included fear of disclosure at the interpersonal level and poor patient flow and long waiting time at the institutional level. Key facilitators for accessing care included having hope for children’s future, symptomatic illness in children, and the belief that health facilities were the appropriate places to get care.

Conclusions

The results suggest that individual-level factors are critical drivers that influence the health-seeking behavior of caregivers of HIV-exposed and HIV-infected children in Mozambique. Noted strategies are to provide more information and awareness on the benefits of early pediatric testing and treatment with positive messages that incorporate success stories, to reach more pregnant women and mother-child pairs postpartum, and to provide counseling during tracing visits. Increasing uptake and retention may be achieved by improving patient flow at the institutional level at health facilities, by addressing concerns with family decision makers, and by working with community leaders to support the uptake of services for HIV-exposed children for essential preventive care.

Barriers to provider-initiated testing and counselling for children in a high HIV prevalence setting: a mixed methods study

BACKGROUND

There is a substantial burden of HIV infection among older children in sub-Saharan Africa, the majority of whom are diagnosed after presentation with advanced disease. We investigated the provision and uptake of provider-initiated HIV testing and counselling (PITC) among children in primary health care facilities, and explored health care worker (HCW) perspectives on providing HIV testing to children.

METHODS AND FINDINGS

Children aged 6 to 15 y attending six primary care clinics in Harare, Zimbabwe, were offered PITC, with guardian consent and child assent. The reasons why testing did not occur in eligible children were recorded, and factors associated with HCWs offering and children/guardians refusing HIV testing were investigated using multivariable logistic regression. Semi-structured interviews were conducted with clinic nurses and counsellors to explore these factors. Among 2,831 eligible children, 2,151 (76%) were offered PITC, of whom 1,534 (54.2%) consented to HIV testing. The main reasons HCWs gave for not offering PITC were the perceived unsuitability of the accompanying guardian to provide consent for HIV testing on behalf of the child and lack of availability of staff or HIV testing kits. Children who were asymptomatic, older, or attending with a male or a younger guardian had significantly lower odds of being offered HIV testing. Male guardians were less likely to consent to their child being tested. 82 (5.3%) children tested HIV-positive, with 95% linking to care. Of the 940 guardians who tested with the child, 186 (19.8%) were HIV-positive.

CONCLUSIONS

The HIV prevalence among children tested was high, highlighting the need for PITC. For PITC to be successfully implemented, clear legislation about consent and guardianship needs to be developed, and structural issues addressed. HCWs require training on counselling children and guardians, particularly male guardians, who are less likely to engage with health care services. Increased awareness of the risk of HIV infection in asymptomatic older children is needed.

Provider-initiated HIV testing and counselling for children

Mary-Ann Davies and Emma Kalk reflect on recent research by Rashida Ferrand and colleagues into barriers to provider-initiated HIV testing for older children in Zimbabwe. Please see later in the article for the Editors' Summary

Adolescent HIV disclosure in Zambia: barriers, facilitators and outcomes

INTRODUCTION

As adolescents living with HIV gain autonomy over their self-care and begin to engage in sexual relationships, their experiences of being informed about their HIV status and of telling others about their HIV status may affect their ability to cope with having the disease.

METHODS

In 2010, we conducted a qualitative study among adolescents aged 10-19 living with HIV in Zambia, and with their parents and health care providers. Through interviews and focus group discussions, we explored the disclosure of HIV status to adolescents living with HIV; adolescents' disclosure of their status to others; and the impact of both forms of disclosure on adolescents.

RESULTS

Our study identified three main barriers to disclosure of HIV status: local norms that deter parents from communicating with their children about sexuality; fear of HIV stigma; and an underlying presumption that adolescents would not understand the consequences of a HIV diagnosis on their lives and relationships. With regard to adolescents' disclosure of their HIV status to their sexual partners, our study identified fear of rejection as a common barrier. In rare cases, open family conversations about HIV helped adolescents come to terms with a HIV diagnosis. Findings indicated that disclosure had various outcomes at the individual and interpersonal levels. At the individual level, some adolescents described being anxious, depressed and blaming themselves after being told they had HIV. At the interpersonal level, disclosure created opportunities for adolescents to access adherence support and other forms of psychosocial support from family members and peers. At the same time, it occasionally strained adolescents' sexual relationships, although it did not always lead to rejection.

CONCLUSIONS

There is a need for public health interventions that guide adolescents living with HIV, their parents and families through the disclosure process. Such interventions should help parents to assess and understand the evolving cognitive capacity and maturity of their adolescents in order to determine the appropriate time to inform them of their HIV-positive status. Such interventions should also mitigate the risk of HIV stigma, as well as local norms that may prevent discussions of sexuality within families. Adolescents who have been informed of their HIV status should be provided with on-going support to prevent disclosure from negatively affecting their psychological and sexual wellbeing. Further research is needed to explore the potential role of trusted family members in contributing to the disclosure process.

Linkage, initiation and retention of children in the antiretroviral therapy cascade: an overview

In 2012, there were an estimated 2 million children in need of antiretroviral therapy (ART) in the world, but ART is still reaching fewer than 3 in 10 children in need of treatment. [1, 7] As more HIV-infected children are identi&filig;ed early and universal treatment is initiated in children under 5 regardless of CD4, the success of pediatric HIV programs will depend on our ability to link children into care and treatment programs, and retain them in those services over time. In this review, we summarize key individual, institutional, and systems barriers to diagnosing children with HIV, linking them to care and treatment, and reducing loss to follow-up (LTFU). We also explore how linkage and retention can be optimally measured so as to maximize the impact of available pediatric HIV care and treatment services.

Beyond early infant diagnosis: case finding strategies for identification of HIV-infected infants and children

There are 3.4 million children infected with HIV worldwide, with up to 2.6 million eligible for treatment under current guidelines. However, roughly 70% of infected children are not receiving live-saving HIV care and treatment. Strengthening case finding through improved diagnosis strategies, and actively linking identified HIV-infected children to care and treatment is essential to ensuring that these children benefit from the care and treatment available to them. Without attention or advocacy, the majority of these children will remain undiagnosed and die from complications of HIV. In this article, we summarize the challenges of identifying HIV-infected infants and children, review currently available evidence and guidance, describe promising new strategies for case finding, and make recommendations for future research and interventions to improve identification of HIV-infected infants and children.

Stigma in AIDS nursing care in sub-saharan Africa and the Caribbean

Some nurses who provide AIDS care, in addition to experiencing stigma themselves, also exhibit negative attitudes and perpetrate stigma and discrimination toward persons living with HIV (PLWHAs). We used a participatory research approach to explore the nature, context, and influence of stigma on the nursing care provided to PLWHAs in four low- and middle-income countries: Jamaica, Kenya, South Africa, and Uganda. Eighty-four registered nurses, enrolled nurses, and midwives participated in interviews and 79 participated in 11 focus groups. Nurses were very aware of the stigma and discrimination that AIDS evoked, and made adjustments to their care to decrease the manifestation of AIDS stigma. Despite the assurance that PLWHAs were treated equally, and that universal precautions were used consistently, we found that in reality, nurses sometimes made decisions about nursing care that were based on the appearance of the patient or knowledge of his or her status.

Pediatric AIDS in the elimination agenda

Scott Kellerman and colleagues argue that the scope of the current HIV elimination agenda must be broadened in order to ensure access to care and treatment for all children living with HIV. Please see later in the article for the Editors' Summary

Factors underlying taking a child to HIV care: implications for reducing loss to follow-up among HIV-infected and -exposed children

OBJECTIVE

With the aim of reducing pediatric loss to follow-up (LTFU) from HIV clinical care programs in sub-Saharan Africa, we sought to understand the personal and socio-cultural factors associated with the behavior of caregivers taking HIV-infected and -exposed children for care in western Kenya.

METHODS

Between May and August, 2010, in-depth interviews were conducted with 26 purposively sampled caregivers caring for HIV-infected (7), HIV-exposed (17) and HIV-unknown status (2) children, documented as LTFU from an urban and rural HIV care clinic. All were women with a majority (77%) being biological parents. Interviews were audio-recorded, transcribed and content analyzed.

RESULTS

Thematic content analysis of the women's perceptions revealed that their decision about routinely taking their children to HIV care involved multiple levels of factors including: (1) intrapersonal: transport costs, food availability, time constraints due to work commitment, disclosure of HIV status for both mother and child, perception that child is healthy and religious beliefs; (2) interpersonal: unsupportive male partner, stigma by the family and family conflicts; (3) community: cultural norms, changing community dynamics and perceived stigma; (4) health care system: clinic location, lack of patient-centered care, delays at the clinic and different appointment schedules (mother and child). Furthermore, the factors across these different levels interacted with each other in a complex way, illustrating the challenges women face in taking their children to HIV care.

CONCLUSION

The complexity and interconnectedness of the factors underlying retention of children in HIV care perceived by these women caregivers suggests that interventions to reduce pediatric LTFU need to be holistic and address multiple socio-ecological levels. Patient-centered care that integrates a family-centered approach to HIV pediatric care is recommended.

The Prevalence of Disclosure of HIV Status to HIV-Infected Children in Western Kenya

BACKGROUND

As antiretroviral therapy (ART) allows the world's 2.3 million human immunodeficiency virus (HIV)-infected children to grow and thrive, these children need to be informed of their HIV status. Neither the prevalence of disclosure to children nor its impact has been evaluated in most resource-limited settings.

METHODS

We conducted a prospective assessment of a random sample of HIV-infected children ages 6-14 years enrolled in HIV care at a large referral clinic in Eldoret, Kenya. Clinicians administered questionnaires to children and caregivers independently at routine clinic visits to assess disclosure status, ART adherence, stigma, and depression. Children's demographic and clinical characteristics were extracted from chart review. We calculated descriptive statistics and performed logistic regression to assess the association between disclosure and other characteristics.

RESULTS

Two hundred seventy children-caregiver dyads completed questionnaires. The mean child age was 9.3 years (standard deviation 2.6); 49% were male, and 42% were orphans. 11.1% of children had been informed of their HIV status (N = 30). Of those under 10 years, 3.3% knew their status, whereas 9.2% of 10- to 12-year-olds and 39.5% of 13- to 14-year-olds knew they had HIV. Only age was significantly associated with disclosure status in both bivariate analyses (P < .0001) and multiple logistic regression (odds ratio 1.67, 95% confidence interval 1.36-2.05) when considering social demographics, disease stage variables, adherence, stigma measures, and depression.

CONCLUSIONS

Rates of informing children in western Kenya of their HIV status are low, even among older children. Guiding families through developmentally appropriate disclosure processes should be a key facet of long-term pediatric HIV management.

Disclosure of HIV status to children in resource-limited settings: a systematic review

Introduction

Informing children of their own HIV status is an important aspect of long-term disease management, yet there is little evidence of how and when this type of disclosure takes place in resource-limited settings and its impact.

Methods

MEDLINE, EMBASE and Cochrane Databases were searched for the terms hiv AND disclos* AND (child* OR adolesc*). We reviewed 934 article citations and the references of relevant articles to find articles describing disclosure to children and adolescents in resource-limited settings. Data were extracted regarding prevalence of disclosure, factors influencing disclosure, process of disclosure and impact of disclosure on children and caregivers.

Results

Thirty-two articles met the inclusion criteria, with 16 reporting prevalence of disclosure. Of these 16 studies, proportions of disclosed children ranged from 0 to 69.2%. Important factors influencing disclosure included the child's age and perceived ability to understand the meaning of HIV infection and factors related to caregivers, such as education level, openness about their own HIV status and beliefs about children's capacities. Common barriers to disclosure were fear that the child would disclose HIV status to others, fear of stigma and concerns for children's emotional or physical health. Disclosure was mostly led by caregivers and conceptualized as a one-time event, while others described it as a gradual process. Few studies measured the impact of disclosure on children. Findings suggested adherence to antiretroviral therapy (ART) improved post-disclosure but the emotional and psychological effects of disclosure were variable.

Conclusions

Most studies show that a minority of HIV-infected children in resource-limited settings know his/her HIV status. While caregivers identify many factors that influence disclosure, studies suggest both positive and negative effects for children. More research is needed to implement age- and culture-appropriate disclosure in resource-limited settings.