A qualitative study of patient motivation to adhere to combination antiretroviral therapy in South Africa

Motivation, responsibilities, and experiences of HIV/AIDS counselors in the Volta Region of Ghana: a descriptive phenomenological study

BACKGROUND

The provision of professional counseling services for persons living with human immunodeficiency virus (PLHIV) is crucial in the prevention and treatment continuum of the disease. However, for counselors of people infected with the human immunodeficiency virus (HIV) leading to acquired immune deficiency syndrome (AIDS) to give their best, their motivations to become counselors and the challenges they face in their line of duty need to be contextually understood and addressed. We ascertained the roles, motivations, and experiences of HIV/AIDS counselors in the Volta Region of Ghana to inform HIV/AIDS counseling decision-making in the region and the country.

METHODS

A phenomenological study conducted among sixteen (16) HIV/AIDS counselors from five HIV/AIDS sentinel sites in the Volta region of Ghana, recruited through a purposive sampling approach and interviewed to ascertain their HIV/AIDS counseling-related experiences. The data were thematically analyzed using the Atlas. ti software, and sub-themes supported with verbatim quotes.

RESULTS

Five motives for becoming an HIV/AIDS counselor were found. These include being randomly assigned to the unit, developing interest in the job, because of the status of a relative, witnessing bad attitudes of healthcare providers, and seeing HIV- clients lacking knowledge of the condition. The study found that these counselors performed six core roles: providing nutritional counseling, educating clients on HIV, treatment, and medication provision, conducting testing and comprehensive counseling of clients, providing social support to clients, and offering financial support to clients. The experiences these counselors had were boosting clients' health status, counseling clients back to a normal mental state, cooperation from clients, participants gaining knowledge on HIV through counseling, counseling clients to accept their status, and when a client delivered an HIV-negative baby. Their negative experiences included clients denying their HIV status, clients defaulting on their treatment, uncooperative clients, death of clients due to fear of breach of confidentiality, self-stigmatization among clients, and the myths some people hold towards HIV/AIDS.

CONCLUSION

By organizing capacity-building training programs for HIV/AIDS counselors in the Volta region and addressing the negative experiences they encounter, they could be empowered to provide effective counseling, curative, and social services to people living with HIV in the region, leading to improved health outcomes.

Perceptions of patients and healthcare providers regarding barriers and enablers of HIV anti-retroviral therapy among women at a regional hospital in Ghana: implications for national HIV/AIDS control

BACKGROUND

The Acquired Immune Deficiency Syndrome (AIDS) pandemic has created a lot of devastation over the last four decades and continues to be a public health threat. Anti-retroviral treatment (ART), a group of medications that people who have been diagnosed with the Human Immunodeficiency Virus (HIV) infection take, has been shown to be efficacious and has significantly improved the fight against the disease. In Ghana, women carry a higher prevalence and incidence of HIV. The study's objectives were to understand the experiences of women living with HIV/AIDS on ART and determine the barriers and enablers for ART uptake from the perspective of both the females living with HIV and their healthcare providers in the Upper East Regional Hospital of Ghana.

METHODS

This was a qualitative study that used interviews to acquire data from women living with HIV on the perceived barriers and enablers for ART. The Upper East Regional Hospital in Ghana was the study site. We used a phenomenological approach to explore the lived experiences, perceptions, and meanings associated with ART among women. We collected data until we reached thematic saturation, interviewing a total of sixteen women living with HIV. We conducted a focus group discussion with nine healthcare workers providing care at the ART clinic. Data were analysed using thematic analysis.

RESULTS

Women living with HIV and their healthcare providers viewed an environment that provided encouragement and support from healthcare workers and patients' relatives, the ability to conceal HIV status, peer counselling, and the perceived benefits of therapy as enablers of ART uptake and medication adherence. The following were barriers to ART uptake and adherence: ill health, forgetfulness, long distances to ART clinics, cultural and spiritual beliefs, and fear of stigma.

CONCLUSIONS

Enablers of ART uptake should be expanded upon and encouraged so that women living with HIV/AIDS can access drugs in a timely and stress-free manner. On the other hand, the barriers identified can be addressed through education, the expansion of healthcare infrastructure, and the economic empowerment of women.

Experiences of people living with HIV in low- and middle-income countries and their perspectives in self-management: a meta-synthesis

INTRODUCTION

Availability of anti-retroviral treatment has changed HIV in to a manageable chronic disease, making effective self-management essential. However, only a few studies in low- and middle-income countries (LMICs) reported experiences of people living with HIV (PLWH) on self-management.

METHODS

This meta-synthesis of qualitative studies investigated perspectives of PLWH in LMICs on self-management. Various databases, including PubMed, EMBASE, EBSCO, and CINHAL, were searched through June 2022. Relevant additional articles were also included using cross-referencing of the identified papers. We used a thematic synthesis guided by the "Model of the Individual and Family Self-Management Theory" (IFSMT).

RESULT

PLWH in LIMICs experience a variety of challenges that restrict their options for effective self-management and compromises their quality of life. The main ones include: misconceptions about the disease, poor self-efficacy and self-management skills, negative social perceptions, and a non-patient-centered model of care that reduces the role of patients. The experiences that influenced the ability to practice self-management are summarized in context (the condition itself, physical and environmental factors, individual and family factors) and process factors (knowledge and beliefs, relationship with the health care worker, self-regulation skills and abilities, and social facilitation). Context and process greatly impacted quality of life through the self-management practices of the patients.

CONCLUSION AND RECOMMENDATION

PLWH encounter multiple challenges, are not empowered enough to manage their own chronic condition, and their needs beyond medical care are not addressed by service providers. Self-management practice of these patients is poor, and service providers do not follow service delivery approaches that empower patients to be at the center of their own care and to achieve an effective and sustainable outcome from treatment. These findings call for a comprehensive well thought self-management interventions.

Medication Adherence in Cancer Patients: A Comprehensive Review

Cancer is a complex disease that can affect different parts of the body. The rates of cancer have shown an increasing trend in the past decade. A majority of cancers are detected late, therefore becoming untreatable and resulting in significant mortality. Additionally, the lack of awareness about cancers, their risk factors, diagnostic modalities, and preventive measures contributes to increased burden among people. Despite significant developments in the therapeutic and comprehensive management of cancers, the cause for concern is the lack of medication adherence. This is majorly attributed to the adverse effects of the medication, the cost of the drugs, and other reasons. This review comprehensively discusses various aspects of cancer medication adherence that include therapeutic modalities for treating cancers, factors influencing medication adherence, barriers, and facilitators to medication adherence.

Enhancing linkage to HIV care in the "Universal Test and Treat" era: Barriers and enablers to HIV care among adults in a high HIV burdened district in KwaZulu-Natal, South Africa

Ending AIDS by 2030 would depend on how successful health systems are in linking people living with HIV (PLHIV) into care. The World Health Organization recommended the 'Universal Test and Treat' (UTT) strategy - initiating all individuals testing positive on antiretroviral therapy (ART) irrespective of their CD4 count and clinical staging. This study aimed to explore the enablers and barriers to linkage to HIV care among adults with a new HIV diagnosis in a high-HIV prevalent rural district in South Africa. A qualitative study was undertaken to explore patients' perceptions of enablers and barriers of linkage-to-care, using a life-story narration and dialogue approach. In-depth interviews were conducted with 38 HIV-positive participants sampled from a cohort of 1194 HIV-positive patients recruited from December 2017 to June 2018. Participants were selected based on whether they had been linked to care or not within 3 months of positive HIV diagnosis. Interviews were thematically analysed using a general inductive approach. Of the 38 participants, 22 (58%) linked to care within three months of HIV-positive diagnosis. Factors that facilitated or inhibited linkage-to-care were found at individual, family, community, as well as health systems levels. Enablers included a positive HIV testing experience, and assistance from the fieldwork team. Support from family, and friends, as well as prior community-based education about HIV and ART were also noted. Individual factors such as acceptance of HIV status, previous exposure to PLHIV, and fear of HIV progressing, were identified. Barriers to linkage included, denial of HIV status, dislike of taking pills, and preference for alternative medicine. Negative experiences with counselling and health systems inefficiency were also noted as barriers. Perceived stigma and socio-economic factors, such as lack of food or money to visit the clinic were other barriers. Community-based and health system-level interventions would need to focus on clinic readiness in providing patients with necessary and effective health services such as proper and adequate counselling. This could increase the number of patients who link to care. Finally, interventions to improve linkage-to-care should consider a holistic approach, including training healthcare providers, community outreach and the provision of psychological, social, and financial support.

"I'm Getting Life from the Treatment": Perceptions of Life and Death Among Middle-Aged and Older Medication-Adherent Persons Living with HIV in Rural South Africa

The widespread availability of health information and treatment for HIV in Southern Africa does not reach all populations. Few programs and materials are developed with middle-aged and older rural individuals living with HIV as the target audience, despite this being a growing population. This vacuum inevitably exacerbates the disjuncture between clinical and experiential knowledge. This study uses in-depth interviews from 2018 with middle-aged and older rural South Africans who self-report medication adherence to ART in order to explore experiences of living with HIV and beliefs about anti-retroviral treatment (ART). Participants revealed a general sense of vulnerability as a major motivation for HIV medication adherence. A majority of the participants believed that death was imminent if they defaulted on ART at any point in time. Although the availability of ART brought hope to many, HIV was still perceived as a death sentence, particularly if ART adherence was imperfect. The study findings suggest a need to examine the psychosocial component of community programs for middle-aged and older people living with HIV. For this growing population that experienced the full course of the epidemic, more research is needed on the burden of psychological and mental health issues emerging from the need for long-term HIV medication adherence.

Provider perspectives on the use of motivational interviewing and problem-solving counseling paired with the point-of-care nucleic acid test for HIV care

Aims

To evaluate provider perspectives on the use of a point-of-care nucleic acid test (POC NAT) and preferential opinions for motivational interviewing (MI) or problem-solving counseling (PSC) as an ultra-brief intervention for patients experiencing challenges to antiretroviral therapy (ART) adherence.

Methods

A qualitative study was conducted among providers at an HIV care clinic in Seattle, Washington. Ten in-depth interviews with HIV care providers were completed, which explored determinants of acceptability, feasibility and preferences for a combined adherence counseling and POC NAT intervention for patients living with HIV. Interviews were analyzed through consensus coding and the Five A’s Framework to inform thematic analysis.

Results

Providers favored the use of a combined adherence counseling technique and POC NAT for their non-adherent patients living with HIV. Providers believed the intervention was an improvement on current assessment and advising practices. However, concerns about extended wait times for the POC NAT results influenced perceptions about feasibility around clinic flow and incorporation into clinic practice. Providers believed that acceptability of POC NAT implementation would be enhanced by including a subset of patient populations whom tend to be in the clinic for longer periods, and in tandem face greater ART adherence challenges.

Conclusion

The GAIN Study will be the first project to evaluate the implementation of POC NAT in the U.S. Continued formative work is ongoing and may illustrate how best to address feasibility and concern around the two-hour time to result. The planned GAIN study will incorporate some of the findings found in this qualitative study and pilot this intervention, including a time-in-motion analyses of clinic flow, which may help reduce perceived wide-scale adaptation of POC NAT and ART adherence counselling among PLHW. Future work, including a shorter time to results and/or lower limit detection could make a significant improvement in the provision of HIV care.

Factors associated with readiness to start antiretroviral therapy (ART) among young people (15-24 years) at four HIV clinics in Mulago Hospital, Uganda

Introduction

Globally, the HIV burden continues to rise among young people despite the discovery of ART. This study assessed demographic and psycho-social factors among young people associated with readiness to be initiated on ART.

Methods

A quantitative cross-sectional study was conducted among newly diagnosed HIV positive young people aged 15-24 years at 4 HIV clinics at Mulago Hospital. Readiness was measured as a self-report by the individual to the question, "How ready do you feel to start ART?

Results

Of the 231 young people enrolled, the mean age (SD) was 20.7years (+/-2.8) and most were female (66.2%). Majority were very ready (53.3%) and very motivated (51.1%) to start ART. Higher treatment readiness was associated with being female (95% CI [5.62, 8.31], p=0.003), thinking that ART cures HIV (95% CI [0.43, 0.86], p=0.005), history of having unprotected sex (95% CI [0.79, 0.87], p=<0.001), anticipating negative HIV results (95% CI [0.26, 0.88], p=0.017), internalized stigma (95% CI [0.83, 0.98], p=0.018) and knowledge of positive ART effects for others (95% CI [0.84, 0.93], p=<0.001).

Conclusions

Understanding the underlying factors associated with ART readiness among young people can inform strategies to support and increase individuals' readiness to initiate ART and early engagement in care.

Factors Contributing to Medication Adherence in Patients with a Chronic Condition: A Scoping Review of Qualitative Research

Introduction: Medication adherence continues to be a significant challenge in healthcare, and there is a shortage of effective interventions in this area. This scoping review studied the patient-related factors of medication adherence. Methods: We searched Medline Ovid, Scopus, and Cochrane Library from January 2009 to June 2021 to find the most recent original qualitative studies or systematic reviews that addressed the patient-related factors of medication adherence in treating chronic conditions. We used the PRISMA-ScR checklist to ensure the quality of the study. Results: The initial search revealed 4404 studies, of which we included 89 qualitative studies in the scoping review. We inductively organized the patient-related factors causing barriers, as well as the facilitators to medication adherence. The studies more often dealt with barriers than facilitators. We classified the factors as patient-specific, illness-specific, medication-related, healthcare and system-related, sociocultural, as well as logistical and financial factors. Information and knowledge of diseases and their treatment, communication, trust in patient-provider relationships, support, and adequate resources appeared to be the critical facilitators in medication adherence from the patient perspective. Discussion and conclusions: Patients are willing to discuss their concerns about medications. Better communication and better information on medicines appear to be among the critical factors for patients. The findings of this scoping review may help those who plan further interventions to improve medication adherence.

"I got tested at home, the help came to me": acceptability and feasibility of home-based TB testing of household contacts using portable molecular diagnostics in South Africa

OBJECTIVE

The effectiveness of household contact investigations is limited by low referral uptake for clinic-based TB testing by symptomatic household contacts. We qualitatively investigated the acceptability and perceived benefits of home-based TB testing using a portable GeneXpert-I instrument (GX-I) in an urban South African township.

METHODS

In-depth interviews were conducted with household contacts tested and those that observed testing. Semi-structured interviews explored household contact's understanding of TB, perceptions of the GX-I device and testing procedures, confidentiality, willingness to refer others, and views on home- vs. clinic-based testing. Focus group discussions with home-based TB testing implementing staff assessed operational considerations for scale-up. Data were analysed using a constant comparison approach to qualitatively evaluate the acceptability and feasibility of home-based TB testing.

RESULTS

Thirty in-depth interviews and two focus group discussions were conducted. Observing one's own sputum being tested resulted in an emergent trust in home-based TB testing, the GX-I device and one's test results. Home-based TB testing was considered convenient, helped to overcome apathy towards testing and mitigated barriers to clinic-based testing. Perceptions that home-based TB testing contributes to improved household and community health resulted in an emergent theme of alleviation of health insecurities. Operational concerns regarding inadvertent disclosure of one's diagnosis to household members and time spent in people's homes were identified.

CONCLUSIONS

Home-based TB testing was acceptable and feasible. Individuals expressed belief in the machine by being able to witness the testing process. Though most themes mirrored qualitative studies of home-based HIV testing, the alleviation of health insecurities theme is unique to home-based TB testing. Future research must evaluate the impact of home-based TB testing on case finding yield, time-to-treatment initiation and household outcomes.

Daily struggle to take antiretrovirals: a qualitative study in Papuans living with HIV and their healthcare providers

OBJECTIVE

The aim of the study was to explore the experiences of Papuans living with HIV to take antiretroviral therapy (ART) from the patient and the healthcare providers (HCPs) perspective.

DESIGN

This was a qualitative study covering all five tribes located in Papua Provinces one of two Indonesian provinces on Papua Island. Semistructured interviews were conducted with Papuans living with HIV and their HCPs. Interviews were transcribed verbatim and coded to find themes.

RESULTS

Overall, we conducted interviews with 13 Papuans living with HIV (mean age: 33 years, 61% female) and 14 HCPs (mean age: 42 years, 64% female) within five customary areas. HCPs included three physicians, nine nurses, two others. Two main themes were identified: (1) personal factors and (2) healthcare environment-related factors. Personal factors were beliefs and knowledge of ART, stigma from family, community and HCPs as well as practical problems such as transportation because of long distance. Within the theme of healthcare environment, the competences and attitudes of HCPs were particularly relevant. The findings are important in refining HIV treatment strategies implemented in Papua, especially when extending HIV care provided by community centres.

CONCLUSIONS

Despite free access to ART, Papuans living with HIV struggle to remain on treatment. Considering local culture and religion in strategies to reduce stigma should be a priority.

Bibliometric analysis of literature in AIDS-related stigma and discrimination

Stigma and discrimination are major barriers in the global fight against human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS). The aim of this study was to create an analytical inventory of worldwide research output in AIDS-related stigma and discrimination. SciVerse Scopus was used for the study period from 1980 to 2017 to retrieve literature in AIDS-related stigma and discrimination. Results were presented as bibliometric tables and maps. In total, 2,509 documents were retrieved. Approximately 40% (n = 990) of the retrieved documents were published in the last 5 years (2013-2017). Retrieved documents received an average of 19.8 citations per article and had an average of 3.2 authors per article. The Hirsh index of the retrieved documents was 94. Most frequently encountered topics were mental health, adherence, adolescents, women, disclosure, and Africa. The USA contributed to 1,226 (48.9%) documents while the African region contributed to 531 (21.2%) documents. Research collaboration among most active countries was relatively low. Authors and institutions from the USA dominated this field. AIDS Care was the most active journal in publishing documents in this field with 307 (13.4%) documents while documents published in Social Medicine journal received the highest citations. Research in AIDS-related stigma and discrimination had witnessed a noticeable increase in the past decade, but the overall number of publications is considered insignificant relative to the size of the problem and the global number of infected people. There was a relative underpresentation of literature from African region despite the fact that more than two-thirds of HIV-infected people in the world are living in Africa.

Adherence to Combined Antiretroviral Therapy and Associated Factors Among People Living with HIV Attending Nekemte Specialized Hospital, Oromia, Ethiopia: A Cross-Sectional Study

Background

For people living with HIV, to have sustainable viral suppression and better clinical outcomes, they should have a high level of adherence to antiretroviral therapy. In the treatment of human immune deficiency, antiretroviral therapy adherence became the major challenge in both developed and developing countries. The level of antiretroviral therapy differs across the settings. This study aimed to assess the level of combined ART adherence and associated factors among adult people living with HIV attending Nekemte Specialized Hospital, Ethiopia.

Methods

The institution-based cross-sectional quantitative study was conducted from August 2017 to September 2017. A total number of 284 clients participated in the study and a simple random sampling technique was used to allocate study participants. Data were entered into Excel and exported to SPSS version 20 for analysis. Bivariate analysis was conducted to identify candidate variables for multivariate analysis at p-value <0.2. Multiple logistic regression analysis was conducted to determine the predictors of non-adherence to ART. P-value <0.05 was considered to indicate statistical significance.

Results

About 81% of the study participants adhered to combined anti-retroviral therapy. Mentioned reasons for missing ART medications were simply forgot to take medication (44.4%), lack of transportation (21%), to avoid side effects (11.4%), do not want significant others to notice taking medication (11.4%) and felt sick (11.4%). Not using reminder (AOR=4.98 (1.65, 15.02)), poor knowledge on ART (AOR=2.79 (1.49, 5.25)), and engaging in unprotected sexual intercourse (AOR=2.16 (1.15, 4.05)) were significantly associated with non-adherence to combined ART.

Conclusion

About 81% of study participants adhered to combined ART, and poor knowledge about ART, engaging in unprotected sexual intercourse and not using the reminder were significantly associated with nonadherence to combined ART. Efforts to increase adherence levels should be encouraged.

Promoters and inhibitors of treatment adherence among HIV/AIDS patients receiving antiretroviral therapy in Ghana: Narratives from an underserved population

Adherence to antiretroviral therapy (ART) is essential to achieving an improved cluster of differentiation-4 (CD4) count, viral load, and quality of life while preventing drug resistance. Medication adherence among people living with Human Immunodeficiency Virus (HIV) is influenced by different factors. Several studies have identified adherence promoters and inhibitors that emanate from the internal and external environment. We conducted six (6) individual in-depth interviews and three (3) focus group discussions to explore adherence behaviour among patients diagnosed with HIV in a teaching hospital in Accra, Ghana. Participants were drawn from the intervention arm of a mobile phone adherence intervention program. They had been enrolled in the study for at least six (6) months before the interviews are conducted. Results revealed that participants adhered to treatment irrespective of prompts from significant others. Adherence promoters included perception of ART as part of daily routines, benefits of the ART, awareness of regimen, access to food, and transparency. Adherence inhibitors were forgetfulness, secrecy, waiting time, religious beliefs, and sleep. People living with HIV (PLWHIV) have the personal motivation to take medication; however, negative perceptions about HIV must be addressed to ensure optimum adherence behaviour.

Long-term adherence to antiretroviral therapy in a South African adult patient cohort: a retrospective study

Background

South Africa has the highest HIV prevalence and supports the largest antiretroviral therapy (ART) programme globally. With the introduction of a test and treat policy, ensuring long term optimal adherence to ART (≥95%) is essential for successful patient and public health outcomes. The aim of this study was to assess long-term ART adherence to inform best practices for chronic HIV care.

Method

Long-term ART adherence was retrospectively analysed over a median duration of 5 years (interquartile range [IQR]: 5.3–6.5) in patients initially enrolled in a randomised controlled trial assessing tuberculosis and HIV treatment integration and subsequently followed post-trial in an observational cohort study in Durban, South Africa. The association between baseline patient characteristics and adherence over time was estimated using generalized estimating equations (GEE). Adherence was assessed using pharmacy pill counts conducted at each study visit and compared to 6 monthly viral load measurements. A Kaplan Meier survival analysis was used to estimate time to treatment failure. The McNemar test (with exact p-values) was used to determine the effect of pill burden and concurrent ART and tuberculosis treatment on adherence.

Results

Of the 270 patients included in the analysis; 54.8% were female, median age was 34 years (IQR:29–40) and median time on ART was 70 months (IQR = 64–78). Mean adherence was ≥95% for each year on ART. Stable patients provided with an extended 3-month ART supply maintained adherence > 99%. At study end, 96 and 94% of patients were optimally adherent and virologically suppressed, respectively. Time since ART initiation, female gender and primary breadwinner status were significantly associated with ≥95% adherence to ART. The cumulative probability of treatment failure was 10.7% at 5 years after ART initiation. Concurrent ART and tuberculosis treatment, or switching to a second line ART regimen with higher pill burden, did not impair ART adherence.

Conclusion

Optimal long-term adherence with successful treatment outcomes are possible within a structured ART programme with close adherence monitoring. This adherence support approach is relevant to a resource limited setting adopting a test and treat strategy.

Maternal Motivation to Take Preventive Therapy in Antepartum and Postpartum Among HIV-Positive Pregnant Women in South Africa: A Choice Experiment

HIV-positive pregnant women who are initiated on lifelong antiretroviral therapy (ART) and isoniazid preventive therapy (IPT) have lower adherence rates after delivery. We quantified maternal motivation to take preventive therapy before and after delivery among pregnant women newly diagnosed with HIV. We enrolled pregnant women (≥ 18 years) with a recent HIV diagnosis (< 6 months) at 14 public primary health clinics in Matlosana, South Africa and followed them in the postpartum period. Participants received eight choice tasks comparing two mutually exclusive sub-sets of seven possible benefits related to preventive therapy identified through literature reviews and key informant interviews. Data was analyzed using conditional logit regression in the antepartum versus postpartum periods. Coefficients are reported with 95% confidence intervals (CI). Sixty-five women completed surveys both at enrollment and in the postpartum period. All women were already on ART, while 21 (32%) were receiving IPT at enrollment. The mean CD4 count was 436 (± 246) cells/mm3. In the antepartum period, preventing HIV transmission to partners was the most important benefit (coefficients (ß) = 0.87, 95% CI 0.64, 1.11), followed by keeping healthy for family (ß = 0.75, 95% CI 0.52, 0.97). Such prioritization significantly decreased in the postpartum period (p < 0.001). Compared to other motivators, keeping a high CD4 count was least prioritized in the antepartum period (ß = 0.19, 95% CI - 0.04, 0.43) but was most prioritized in the postpartum period (ß = 0.39, 95% CI 0.21, 0.57). These results highlight that messages on family might be particularly salient in the antepartum period, and keeping CD4 count high in the postpartum period. Understanding maternal motivation may help to design targeted health promotion messages to HIV-positive women around the time of delivery.

Promoting mental health of students living with HIV using appreciative inquiry

Living with HIV poses many challenges. This is especially true for students living with HIV (SLHIV) within a university setting. The challenges faced by SLHIV makes it difficult for them to see new possibilities in living with the virus. The purpose of the study was to describe the experiences of being a student living with HIV and being a practitioner caring for them by using Appreciative Inquiry which incorporated individual interviews. A qualitative, exploratory, descriptive and contextual research design was applied in this study. Purposeful sampling was utilised to select participants in accordance with specific criteria. Individual interviews using the 4-D model of Appreciative Inquiry, were conducted with SLHIV and practitioners caring for them. The individual interviews were transcribed verbatim and analysed into themes and categories which were verified separately by an independent coder, who is experienced in qualitative research, and further confirmed by research participants through member checking. Themes and categories derived from the data were discussed, and the findings were positioned in terms of relevant literature and the results of similar studies. The study concluded that when SLHIV and practitioners caring for them, embarked on a journey of discovering their strengths in living with HIV and dealing with SLHIV respectively, they start to see new possibilities and potential to effect change to help students manage their HIV infection more effectively.

"Even if you're HIV-positive there's life after if you take your medication": experiences of people on long-term ART in South Africa: a short report

South Africa's national antiretroviral treatment (ART) programme, initiated in 2004, is the largest HIV treatment programme in the world with an estimated 4.2 million people on ART. Today, an HIV diagnosis is no longer associated with certain death, but is rather a manageable chronic disease, with all HIV-positive patients now eligible to receive treatment. In this study, we explore patient experiences at the onset of the ART programme, including facilitators and barriers around decision-making along the HIV care cascade (HIV testing, ART initiation, retention, and adherence). We conducted twenty-four in-depth interviews among adults (≥18 years old) who initiated ART between April 2004 and March 2005 and were alive, on treatment at enrolment (October 2015-March 2016) at a large public-sector clinic in Johannesburg, South Africa. Data were analysed using a thematic analysis approach. Patients cited physical wellbeing, responsibility for raising children, supportive clinic staff and noticeable improvements in health on ART as key facilitators to continued care. In contrast, changing clinic conditions, fear of side-effects and stigma were mentioned as barriers. This study provides a unique lens through which to evaluate factors associated with long-term retention and adherence to ART at a crucial time in ART programming when more people will be initiating life-long treatment. We must continue to focus on supportive and empathetic clinic environments, more convenient ways to access medication for patients, and developing tools or interventions that continue to address the issues of stigma and discrimination and build the support networks for all those on treatment.

Patient costs incurred by people living with HIV/AIDS prior to ART initiation in primary healthcare facilities in Gauteng, South Africa

PURPOSE

To quantify costs to patients of accessing HIV care prior to ART initiation.

MATERIALS AND METHODS

Using a cross-sectional study design, costs incurred by HIV-positive patients prior to ART initiation were estimated at urban primary healthcare facilities in South Africa. Costs included direct costs, indirect (productivity) costs, carer and coping costs (value of assets sold and money borrowed). The percentage of individual income spent on healthcare was calculated and compared by patient income tertiles and CD4 count strata.

RESULTS

289 patients (69% female, mean age 37 (SD: 10) years, median CD4 317 (IQR: 138-494) cells/mm3) were interviewed. The total mean monthly cost of pre-ART care was US$15.71. Indirect costs accounted for $2.59 (16.49%) of this when time was valued using the patient's reported income. The mean monthly patient costs were $31.61, $12.78, $12.65 and $11.93 for those with a CD4 count <100, 101-350, 351-500 and >500 cells/mm3 respectively. The percentage of individual income spent on healthcare was 7.25% for those with a CD4 count <100 cells/mm3 and 4.05% for those with a CD4 count >500 cells/mm3.

CONCLUSIONS

Despite the provision of charge-free services at public clinics, care prior to ART initiation can be costly, particularly for the poor and unemployed. Our study adds to the growing body of evidence that highlights the need to consider policies to reduce the economic barriers to HIV service access, particularly for low income or unwell patient groups, such as improving access to disability grants.

Trajectories of HIV-related internalized stigma and disclosure concerns among ART initiators and non-initiators in South Africa

Background

HIV-related stigma among people living with HIV (PLHIV) is associated with worse health outcomes. We used longitudinal data from a multi-site cohort in South Africa to assess changes over time in stigma after HIV diagnosis and determine whether antiretroviral therapy (ART) initiation is associated with stigma reduction.

Methods

We administered the Internalized AIDS-Related Stigma Scale (IARSS, a six-item dichotomous scale questionnaire) at baseline, three months, and six months to newly diagnosed ART-eligible participants between 2014-2015. A confirmatory factor analysis indicated that the IARSS contained a four-item internalized stigma factor (α=0.80) and a two-item disclosure concerns factor (α=0.75). We fitted multiple logistic regression models specifying internalized stigma/disclosure concerns at six months as the outcome and ART initiation as the predictor of interest.

Results

Of the 500 participants (187 men and 313 women) enrolled, 308 (62%) initiated ART. Internalized stigma declined among people entering care (mean score, 1.0 to 0.7, p<0.01); however, disclosure concerns remained unchanged (percentage endorsing either disclosure concern item, 78% to 77%, p=0.23). These findings were similar between ART initiators and non-initiators. We estimated a statistically significant positive association between ART initiation and disclosure concerns at six months (OR=1.88; 95% CI, 1.20-2.94) but not between ART initiation and internalized stigma at six months (OR=1.15; 95% CI, 0.75-1.78).

Conclusions

Among ART-eligible South African PLHIV entering into HIV care, internalized stigma modestly declined over time but disclosure concerns persisted. PLHIV who initiated ART were more likely to have persistent disclosure concerns over time as compared with those who did not start ART.

O CUIDADO PARA PESSOAS COM HIV/AIDS SOB A ÓTICA DE AGENTES COMUNITÁRIOS DE SAÚDE

Resumo Este estudo buscou investigar a experiência de atuação dos agentes comunitários de saúde em relação aos indivíduos que vivem com HIV/Aids em áreas de risco social. Trata-se de uma pesquisa de natureza qualitativa, realizada no ano de 2015 com agentes comunitários atuantes em município de médio porte do estado de São Paulo, Brasil. A produção das narrativas foi realizada pelo método do grupo focal, interpretadas e analisadas por meio da análise temática de conteúdo. O preconceito apresentou-se como a principal causa das dificuldades de atuação dos agentes; porém, a criação do vínculo com os usuários, aliada à conquista da confiança, foi a principal potencialidade nas ações desses profissionais. Torna-se essencial o rompimento da barreira gerada pelo preconceito para uma efetiva atuação dos agentes comunitários de saúde nos territórios, para que possam colaborar com o acolhimento desses usuários e com a redução dos efeitos da vulnerabilidade existente.

How clinicians experience a simulated antiretroviral therapy adherence exercise: A qualitative study

Background

With the shift of paediatric antiretroviral therapy (ART) from tertiary to primary health care, there has been a need to train clinicians working in primary health care facilities to support adherence to treatment. An adherence simulation exercise was included in a course on paediatric human immunodeficiency virus (HIV) and tuberculosis (TB) to stimulate health care providers’ awareness and generate empathy of complex paediatric adherence practices.

Aim

The aim of this study was to describe the experience of clinicians completing the simulation exercise and to assess whether enhancing their empathy with patients and treatment supporters would improve their perceived clinical and counselling skills.

Setting

The study was conducted at the Faculty of Medicine and Health Sciences, Stellenbosch University, and a guesthouse in Cape Town.

Methods

The adherence module used blended learning methodology consisting of face-to-face contact sessions and distance learning. A qualitative thematic approach was used to understand the participant experiences through focus-group discussions and semi-structured interviews.

Results

Three thematic clusters emerged, namely, experiences of the simulated exercise, patient–provider relationships and adherence strategies. Their experiences were both positive and challenging, especially when a ‘caregiver and/or treatment supporter’ scenario encouraged participants to reflect on their own relationships with their patients. Clinicians had also considered how empathy fits into their scope of responsibilities. Text messaging and adherence counselling strategies were identified.

Conclusion

Simulated learning activities have the potential to create awareness of relationships between clinicians and their patients and generate ideas and discussion that could lead to improvements in clinical practice, and adherence promotion strategies.

Global research output on HIV/AIDS-related medication adherence from 1980 to 2017

BACKGROUND

"Human Immunodeficiency Virus (HIV)" and Acquired Immunodeficiency Syndrome (AIDS) are global health burden. Medication adherence in people living with HIV (PLWH) is a key element in reducing morbidity and mortality. Quantitative and qualitative assessment of research activity helps identify research gaps as well as efforts implemented to improve adherence behaviors in PLWH. The aim of the current study was to assess and analyze literature on HIV/AIDS-related medication adherence using bibliometric methods.

METHODS

SciVerse Scopus was used to accomplish the purpose of the current study. The study period included all times up to 2017. The analysis was restricted to documents published in academic journals.

RESULTS

Search strategy retrieved 3021 documents with an average of 32.5 citations per document, an h-index of 136, and an average of 4.4 authors per documents. The volume of literature on HIV/AIDS-related medication adherence constituted 1.3% of the overall HIV/AIDS literature. There was a significant (p < 0.01; r = 0.9) correlation between the growth of publications in AIDS-related stigma and medication adherence. The regions of America (567.9) had the highest research output per one million infected people (567.9) followed by the European region (314.3), Western Pacific Region (70.7), Eastern Mediterranean region (31.4), South East Asia (34.0), and Africa (19.3). Geographical distribution of publications showed an active contribution of certain countries in the Southern and Eastern region of Sub-Saharan Africa. Harvard University (8.4%; n = 254) was the most active institution. The top cited documents focused on the impact of adherence on disease outcome and the impact of text messages on improving medication adherence.

CONCLUSION

Research on medication adherence in PLWH showed regional variations. International research collaboration with high burden regions such as Sub-Saharan Africa needs to be strengthened to achieve the global target of ending AIDS as a public health threat by 2030.

"My future is bright…I won't die with the cause of AIDS": ten-year patient ART outcomes and experiences in South Africa

INTRODUCTION

South Africa is moving into a new era of HIV treatment with "treat all" policies where people may be on treatment for most of their lives. We need to understand treatment outcomes and facilitators of long-term antiretroviral treatment (ART) adherence and retention-in-care in the South African context. In one of the first studies to investigate long-term treatment outcomes in South Africa, we aimed to describe ten-year patient outcomes at a large public-sector HIV clinic in Johannesburg and explore patient experiences of the treatment programme over this time in order to ascertain factors that may aid or hinder long-term adherence and retention.

METHODS

We conducted a cohort analysis (n = 6644) and in-depth interviews (n = 24) among HIV-positive adults initiating first-line ART between April 2004 and March 2007. Using clinical records, we ascertained twelve-month and ten-year all-cause mortality and loss to follow-up (LTF). Cox proportional hazards regression was used to identify baseline predictors of attrition (mortality and LTF (>3 months late for the last scheduled visit)) at twelve months and ten years. Twenty-four patients were purposively selected and interviewed to explore treatment programme experiences over ten years on ART.

RESULTS

Excluding transfers, 79.5% (95% confidence intervals (CI): 78.5 to 80.5) of the cohort were alive, in care at twelve months dropping to 35.1% (95% CI: 33.7 to 36.4) at ten years. Over 44% of deaths occurred within 12 months. Ten-year all-cause mortality increased, while LTF decreased slightly, with age. Year and age at ART initiation, sex, nationality, baseline CD4 count, anaemia, body mass index and initiating regimen were predictors of ten-year attrition. Among patients interviewed, the pretreatment clinic environment, feelings of gratitude and good fortune, support networks, and self-efficacy were facilitators of care; side effects, travel and worsening clinical conditions were barriers. Participants were generally optimistic about their futures and were committed to continued care.

CONCLUSIONS

This study demonstrates the complexities of long-term chronic HIV treatment with declining all-cause mortality and increasing LTF over ten years. Barriers to long-term retention still present a significant challenge. As more people become eligible for ART in South Africa under "treatment for all," new healthcare delivery challenges will arise; interventions are needed to ensure long-term programme successes continue.

Why do people living with HIV not initiate treatment? A systematic review of qualitative evidence from low- and middle-income countries

BACKGROUND

Many people living with HIV (PLWH) who are eligible for antiretroviral therapy (ART) do not initiate treatment, leading to excess morbidity, mortality, and viral transmission. As countries move to treat all PLWH at diagnosis, it is critical to understand reasons for non-initiation.

METHODS

We conducted a systematic review of the qualitative literature on reasons for ART non-initiation in low- and middle-income countries. We screened 1376 titles, 680 abstracts, and 154 full-text reports of English-language qualitative studies published January 2000-April 2017; 20 met criteria for inclusion. Our analysis involved three steps. First, we used a "thematic synthesis" approach, identifying supply-side (facility) and demand-side (patient) factors commonly cited across different studies and organizing these factors into themes. Second, we conducted a theoretical mapping exercise, developing an explanatory model for patients' decision-making process to start (or not to start) ART, based on inductive analysis of evidence reviewed. Third, we used this explanatory model to identify opportunities to intervene to increase ART uptake.

RESULTS

Demand-side factors implicated in decisions not to start ART included feeling healthy, low social support, gender norms, HIV stigma, and difficulties translating intentions into actions. Supply-side factors included high care-seeking costs, concerns about confidentiality, low-quality health services, recommended lifestyle changes, and incomplete knowledge of treatment benefits. Developing an explanatory model, which we labeled the Transdisciplinary Model of Health Decision-Making, we posited that contextual factors determine the costs and benefits of ART; patients perceive this context (through cognitive and emotional appraisals) and form an intention whether or not to start; and these intentions may (or may not) be translated into actions. Interventions can target each of these three stages.

CONCLUSIONS

Reasons for not starting ART included consistent themes across studies. Future interventions could: (1) provide information on the large health and prevention benefits of ART and the low side effects of current regimens; (2) reduce stigma at the patient and community levels and increase confidentiality where stigma persists; (3) remove lifestyle requirements and support patients in integrating ART into their lives; and (4) alleviate economic burdens of ART. Interventions addressing reasons for non-initiation will be critical to the success of HIV "treat all" strategies.

Maternal priorities for preventive therapy among HIV-positive pregnant women before and after delivery in South Africa: a best-worst scaling survey

INTRODUCTION

Pregnant women newly diagnosed with HIV during pregnancy are often lost to follow up and their adherence rates drop after delivery. We quantified changes in priorities related to isoniazid preventive therapy (IPT) and antiretroviral therapy (ART) among pregnant women living with HIV.

METHODS

We enrolled pregnant women recently diagnosed with HIV from 14 primary health clinics during pregnancy and followed them after delivery in Matlosana, South Africa. Best-worst scaling (BWS) was used to determine the women's priorities out of 11 attributes related to preventive therapy in the ante- versus postpartum periods. Aggregate BWS scores were calculated based on the frequency with which participants selected each attribute as the best or worst among five options (across multiple choice sets). Individual BWS scores were also calculated and rescaled from 0 (always selected as worst) to 10 (always selected as best), and changes in BWS scores in the ante- versus postpartum periods were compared, using a paired t-test. Factors associated with the changes in BWS scores were examined in multiple linear regressions. Spearman's rho was used to compare the ranking of attributes.

RESULTS

Out of a total of 204 participants, 154 (75.5%) completed the survey in the postpartum at the median 15 (IQR: 11 to 27) weeks after delivery. Trust in healthcare providers was most highly prioritized both in the ante- (individual BWS Score = 7.34, SE = 0.13) and postpartum periods (BWS = 7.21 ± 0.11), followed by living a long life (BWS = 6.77 ± 0.09 in the ante- vs. BWS = 6.86 ± 0.10 in the postpartum). Prevention for infants' health was more prioritized in the post- (BWS = 6.54 ± 0.09) versus antepartum periods (BWS = 6.11 ± 0.10) (p = 0.05). This change was associated with IPT initiation at enrolment (regression coefficient = 0.78 ± 0.33, p = 0.001). Difficulty in daily pill-uptake was significantly more prioritized in the postpartum (BWS = 5.03 ± 0.11) than in the antepartum (BWS = 4.43 ± 0.10) (p < 0.01). Transportation cost and worry about side effects of pills were least prioritized. Overall ranking of attributes was similar in both time periods (spearman's rho = 0.90).

CONCLUSIONS

Comprehensive interventions to build trust in healthcare providers and support adherence may increase uptake of preventive therapy. Counselling needs to emphasize medication benefits for both maternal and infant health among HIV-positive pregnant women.

"I found that I was well and strong": Women's motivations for remaining on ART under Option B+ in Malawi

Most Malawian women who start ART under Option B+ are still in care three years later, a higher than average adherence rate for life-threatening chronic disease treatments, worldwide (50%). We asked 75 Malawian on ART their motivations for remaining in treatment, and what barriers they overcame. Focus groups and interviews included 75 women on ART for 6+ months, at 12 health facilities. Four main motivations for continuing ART emerged: 1) evidence that ART improved their own and their children's health; 2) strong desire to be healthy and keep their children healthy; 3) treatment was socially supported; 4) HIV/ART counselling effectively showed benefits of ART and told women what to expect. Women surmounted the following barriers: 1) stigma; 2) health care system; 3) economic; 4) side effects. Women stayed on ART because they believed it works. Future interventions should focus on emphasizing ART's effectiveness, along with other services they provide.

The effect of partner HIV status on motivation to take antiretroviral and isoniazid preventive therapies: a conjoint analysis

Antiretroviral therapy (ART) and isoniazid preventive therapy (IPT) are important to reduce morbidity and mortality among people newly diagnosed of HIV. The successful uptake of ART and IPT requires a comprehensive understanding of patients' motivation to take such therapies. Partners also play an important role in the decision to be initiated and retained in care. We quantified patients' motivation to take preventive therapies (ART and IPT) and compared by partner HIV status among people newly diagnosed of HIV. We enrolled and surveyed adults (≥18 years) with a recent HIV diagnosis (<6 months) from 14 public primary care clinics in Matlosana, South Africa. Participants received eight forced-choice tasks comparing two mutually exclusive sub-sets of seven possible benefits related to preventive therapies. A linear probability model was fitted to estimate the probability of prioritizing each benefit. Tests of concordance were conducted across partner HIV status (no partner, HIV- or unknown, or HIV+). A total of 424 people completed surveys. At the time of interview, 272 (64%) were on ART and 334 (79%) had a partner or spouse. Keeping themselves healthy for their family was the most important motivator to take preventive therapies (p < 0.001). Preventing HIV transmission to partners was also highly prioritized among participants with current partners independent of partner's HIV status (p < 0.001), but it was least prioritized among those without current partners (p = 0.72). Keeping themselves healthy was less prioritized. We demonstrate that social responsibility such as supporting family and preventing HIV transmission to partners may pose greater motivation for ART and IPT initiation and adherence compared to individual health benefits. These messages should be emphasized to provide effective patient-centered care and counseling.

Navigating the risks of prevention of mother to child transmission (PMTCT) of HIV services in Kibera, Kenya: Barriers to engaging and remaining in care

Within the first year of implementation, 43% of women who tested HIV positive at their first antenatal care visit were no longer retained and being followed in the free prevention of mother to child transmission (PMTCT) of HIV program offered by the Kenyan Ministry of Health and Médecins Sans Frontières in the informal settlement of Kibera, Nairobi. This study aimed to explore barriers to enrolling and remaining engaged in PMTCT services throughout the pregnancy and postpartum periods. Qualitative data from 31 focus group discussions and 35 in-depth interviews across six stakeholder groups that included women, men, and PMTCT service providers were analyzed. Using an inductive exploratory approach, four researchers coded the data and identified key themes. Five themes emerged from the data that may influence attrition from PMTCT service in this setting: 1) HIV in the context of Kibera, 2) knowledge of HIV status, 3) knowledge of PMTCT, 4) disclosure of HIV status, and 5) male partner support for PMTCT services. A new HIV diagnosis during pregnancy immediately triggered an ongoing risk assessment of perceived hazards in the home, community, and clinic environments that could occur as a result of female participation in PMTCT services. Male partners were a major influence in this risk assessment, but were generally unaware of PMTCT services. To preserve relationships with male partners, meet community expectations of womanhood, and maintain confidentiality while following recommendations of healthcare providers, women had to continuously weigh the risks and benefits of PMTCT services and interventions. Community-based HIV testing and PMTCT education, male involvement in antenatal care, and counseling customized to assist each woman in her own unique risk assessment, may improve uptake of and retention in care and optimize the HIV prevention benefit of PMTCT interventions.

A Framework for Health Communication Across the HIV Treatment Continuum

Supplemental Digital Content is Available in the Text.

Background:

As test and treat rolls out, effective interventions are needed to address the determinants of outcomes across the HIV treatment continuum and ensure that people infected with HIV are promptly tested, initiate treatment early, adhere to treatment, and are virally suppressed. Communication approaches offer viable options for promoting relevant behaviors across the continuum.

Conceptual Framework:

This article introduces a conceptual framework, which can guide the development of effective health communication interventions and activities that aim to impact behaviors across the HIV treatment continuum in low- and medium-income countries. The framework includes HIV testing and counseling, linkage to care, retention in pre-antiretroviral therapy and antiretroviral therapy initiation in one single-stage linkage to care and treatment, and adherence for viral suppression. The determinants of behaviors vary across the continuum and include both facilitators and barriers with communication interventions designed to focus on specific determinants presented in the model. At each stage, relevant determinants occur at the various levels of the social–ecological model: intrapersonal, interpersonal, health services, community, and policy. Effective health communication interventions have mainly relied on mHealth, interpersonal communication through service providers and peers, community support groups, and treatment supporters.

Discussion:

The conceptual framework and evidence presented highlight areas across the continuum where health communication can significantly impact treatment outcomes to reach the 90-90-90 goals by strategically addressing key behavioral determinants. As test and treat rolls out, multifaceted health communication approaches will be critical.

Access to HIV Care and Resilience in a Long-Term Conflict Setting: A Qualitative Assessment of the Experiences of Living with Diagnosed HIV in Mogadishu, Somali

Background: Human Immunodeficiency Virus (HIV) continues to take a heavy toll on the lives of many people, with the worst impact on health and wellbeing for the affected individuals in fragile states. The HIV situation in Somalia is not clearly known and experiences of the people living with HIV in this war-torn region are often unexpressed. This pilot qualitative study sought to explore the experiences of people diagnosed with HIV living in Mogadishu, and their resilience in access to care and social support. Methods: Participants were recruited through drug dispensers at the HIV clinic in Banadir Hospital. Face-to-face in-depth interviews were conducted in Somali in May 2013 among patients who were receiving antiretroviral therapy (ART) from the HIV clinic in Mogadishu. These were tape-recorded, transcribed, and translated for content analysis. Results: Three women and four men who were living with HIV shared the following narratives. Their perception was that they had either got HIV from their spouses or through health care contamination. They were very knowledgeable about the realities of HIV, how the medication works, nutritional requirements, and drug adherence. They were always willing to go an extra mile to secure a good life for themselves. However, the external HIV stigma impacted their access to care. They faced challenges in their homes and at work which compelled them to seek support from non-governmental organizations (NGOs) or close family members. This stigma often affected their disclosure to the wider community due to the uncertainty of the repercussions, leading to a life of extreme loneliness and financial difficulties. The participants’ coping mechanisms included living together and starting their own NGO for support with very strong optimism about their prognosis. Conclusions: The people diagnosed with HIV living in Mogadishu are highly knowledgeable about HIV transmission, the realities of living with a diagnosed HIV infection, and the efficacy of HIV treatment. Our small sample suggests adequate access to ART through NGOs. However, widespread HIV stigma limits HIV status disclosure to families and communities, which creates a risk of self-isolation and ill health. Still, affected individuals have developed resilient mechanisms for managing the risks. They strive to remain employed for economic security, adhere to HIV treatment, engage in support groups, and maintain the utmost optimism about their prognosis.

Good Health and Moral Responsibility: Key Concepts Underlying the Interpretation of Treatment as Prevention in South Africa and Zambia Before Rolling Out Universal HIV Testing and Treatment

Gauging community responses to the WHO 2015 recommendation to provide antiretroviral treatment (ART) to all people living with HIV (PLHIV) is critical. There is limited qualitative evidence on the acceptability of this Universal Test and Treat (UTT) strategy or community understanding of the impact of ART on reducing HIV transmission, promoted as Treatment as Prevention (TasP). This article explores early understanding of UTT and TasP in 21 urban communities in South Africa and Zambia in 2013 before a community randomized trial of combination prevention-HPTN 071 (PopART). It draws on participatory research conducted in each community, which carried out group discussions and interviews with 1202 respondents and 203 structured observations. Participants were largely unfamiliar with the concepts of UTT and TasP. They were concerned about an accompanying de-emphasis on sexual behavior change. Treatment and prevention seemed, at first glance, to be experienced separately. With the exception of the prevention of mother-to-child transmission, prevention seldom came into discussions about ART. This was partly because this science had not yet been explained to many and also because it was not an easy fit. Contemplating the link between treatment and prevention, participants emphasized both PLHIV taking care of themselves through good health and preventing disease progression and the moral responsibility of PLHIV to prevent HIV transmission. To avoid igniting moralizing and blaming when introducing UTT and TasP, we should capitalize on the "taking care of yourself" legacy while boosting public responsibility through broad antistigma education and patient empowerment efforts.

Predicting the Need for Third-Line Antiretroviral Therapy by Identifying Patients at High Risk for Failing Second-Line Antiretroviral Therapy in South Africa

Although third-line antiretroviral therapy (ART) is available in South Africa's public sector, its cost is substantially higher than first and second line. Identifying risk factors for failure on second-line treatment remains crucial to reduce the need for third-line drugs. We conducted a case-control study including 194 adult patients (≥18 years; 70 cases and 124 controls) who initiated second-line ART in Johannesburg, South Africa. Unconditional logistic regression was used to assess predictors of virologic failure (defined as 2 consecutive viral load measures ≥1000 copies/mL, ≥3 months after switching to second line). Variables included a social instability index, ART adherence, self-reported as well as diagnosed adverse drug reactions (ADRs), HIV disclosure, depression, and factors affecting access to HIV clinics. Overall 60.0% of cases and 54.0% of controls were female. Mean ages of cases and controls were 41.8 ± 9.6 and 43.3 ± 8.0, respectively. Virologic failure was predicted by ART adherence <90% [odds ratio (OR) 4.7; 95% confidence interval (95% CI): 2.1-10.5], younger age (<40 years of age; OR 0.6; 95% CI: 0.3-1.1), high social instability (OR 3.8; 95% CI: 1.30-11.5), self-reported ADR (OR 1.9; 95% CI: 1.0-3.5), disclosure to friends/colleagues rather than partner/relatives (OR 3.4; 95% CI: 1.3-9.1), and medium/high depression compared to low/no depression (OR 4.4; 95% CI: 1.5-13.4). Our results suggest complex socioeconomic factors contributing to risk of virologic failure, possibly by impacting ART adherence, among patients on second-line therapy in South Africa. Identifying patients with possible indicators of nonadherence could facilitate targeted interventions to reduce the risk of second-line treatment failure and mitigate the demand for third-line regimens.

Patient-reported barriers and facilitators to antiretroviral adherence in sub-Saharan Africa

OBJECTIVE

The aim of this study was to identify the range and frequency of patient-reported barriers and facilitators to antiretroviral treatment (ART) adherence in sub-Saharan Africa (SSA).

DESIGN

Studies from 2005 to 2016 were identified by searching 10 electronic databases and through additional hand and web-searching.

METHODS

Inclusion criteria were HIV-positive adults taking ART based in any SSA country, qualitative study or quantitative survey and included at least one patient-reported barrier or facilitator to ART adherence. Exclusion criteria were only including data from treatment-naive patients initiating ART, only single-dose treatment, participants residing outside of SSA and reviews.

RESULTS

After screening 11 283 records, 154 studies (161 papers) were included in this review. Forty-three barriers and 30 facilitators were reported across 24 SSA countries. The most frequently identified barriers across studies were forgetting (n = 76), lack of access to adequate food (n = 72), stigma and discrimination (n = 68), side effects (n = 67) and being outside the house or travelling (n = 60). The most frequently identified facilitators across studies were social support (n = 60), reminders (n = 55), feeling better or healthier after taking ART (n = 35), disclosing their HIV status (n = 26) and having a good relationship with a health provider (n = 22).

CONCLUSION

This review addresses the gap in knowledge by collating all the patient-reported barriers and facilitators to ART adherence in SSA. Current barriers measures need to be adapted or new tools developed to include the wide variety of factors identified. The factors that have the greatest impact need to be isolated so interventions are developed that reduce the barriers and enhance the facilitators.

Health Provider Views on Improving Antiretroviral Therapy Adherence Among Men Who Have Sex with Men in Coastal Kenya

HIV-positive Kenyan men who have sex with men (MSM) are a highly stigmatized group facing barriers to care engagement and antiretroviral therapy (ART) adherence. Because care providers' views are important in improving outcomes, we sought the perspective of those serving MSM patients on how to optimize ART adherence in a setting where same-sex behavior is criminalized. We conducted 4 focus group discussions with a total of 29 healthcare workers (HCWs) experienced in providing HIV care to MSM. The semistructured, open-ended topic guide used was based on an access-information-motivation-proximal cues model of adherence, with added focus on trust in providers, stigma, and discrimination. Detailed facilitator notes and transcripts were translated into English and reviewed for common themes. The HCW identified adherence challenges of MSM patients that are similar to those of the general population, including HIV-related stigma and lack of disclosure. In addition, HCWs noted challenges specific to MSM, such as lack of access to MSM-friendly health services, economic and social challenges due to stigma, difficult relationships with care providers, and discrimination at the clinic and in the community. HCWs recommended clinic staff sensitivity training, use of trained MSM peer navigators, and stigma reduction in the community as interventions that might improve adherence and health outcomes for MSM. Despite noting MSM-specific barriers, HCWs recommended strategies for improving HIV care for MSM in rights-constrained settings that merit future research attention. Most likely, multilevel interventions incorporating both individual and structural factors will be necessary.

Barriers to HIV testing, linkage to care, and treatment adherence: a cross-sectional study from a large urban center of Brazil

OBJECTIVE

Early, continued engagement with the HIV treatment continuum can help achieve viral suppression, though few studies have explored how risk factors for delays differ across the continuum. The objective of this study was to identify predictors of delayed diagnosis, delayed linkage to care, and nonadherence to treatment in the city of Salvador, Bahia, Brazil.

METHODS

Data were collected during 2010 in a cross-sectional study with a sample (n = 1 970) of HIV-infected individuals enrolled in care. Multiple logistic regression analyses identified sociodemographic variables, behaviors, and measures of health service quality that were associated with delayed diagnosis, delayed linkage to care, and treatment nonadherence.

RESULTS

For delayed diagnosis, male gender (adjusted odds ratio (AOR), 3.02; 95% confidence interval (CI), 2.0-4.6); age 45 years and older (AOR, 1.67; 95% CI, 1.1-2.5); and provider-initiated testing (AOR, 3.00; 95% CI, 2.1-4.4) increased odds, while drug use (AOR, 0.29; 95% CI, 0.2-0.5) and receiving results in a private space (AOR, 0.37; 95% CI, 0.2-0.8) decreased odds. For delayed linkage to care, unemployment (AOR, 1.42; 95% CI, 1.07-1.9) and difficulty understanding or speaking with a health care worker (AOR, 1.61; 95% CI, 1.2-2.1) increased odds, while posttest counseling (AOR, 0.49; 95% CI, 0.3-0.7) decreased odds. For nonadherence, experiencing verbal or physical discrimination related to HIV (AOR, 1.94; 95% CI, 1.3-3.0) and feeling mistreated or not properly attended to at HIV care (AOR, 1.60; 95% CI, 1.0-2.5) increased odds, while posttest counseling (AOR, 0.34; 95% CI, 0.2-0.6) decreased odds.

CONCLUSIONS

More attention is needed on how policies, programs, and research can provide tailored support across the treatment continuum.

Can Short-Term Use of Electronic Patient Adherence Monitoring Devices Improve Adherence in Patients Failing Second-Line Antiretroviral Therapy? Evidence from a Pilot Study in Johannesburg, South Africa

High levels of adherence are required to achieve the full benefit of ART. We assess the effectiveness of electronic adherence monitoring devices among patients failing second-line ART, as measured by viral load suppression. Cohort study of Wisepill™ real-time adherence monitoring in addition to intensified adherence counselling over 3 months in adults with a viral load ≥400 copies/ml on second-line ART in Johannesburg, South Africa between August 2013 and January 2014. Patients were sent SMS reminders upon missing a scheduled dose. We compared outcomes to earlier historical cohorts receiving either intensified adherence counselling or adherence counselling alone. Overall, 63 % of the participants (31/49) took >80 % of their prescribed medication; this dropped from 76 to 53 and 49 % at 1, 2 and 3 months post-enrolment respectively. Compared to those with good adherence (>80 %), participants with poor adherence (≤80 %) had a higher risk for a subsequently elevated viral load ≥400 copies/ml (relative risk (RR) 1.47 95 % CI 0.97–2.23). Participants found the intervention “acceptable and useful” but by 6 months after eligibility they were only slightly more likely to be alive, in care and virally suppressed compared to those who received intensified adherence counselling (44.9 vs. 38.5 %; RR 1.19; 95 % CI 0.85–1.67) or adherence counselling alone (44.9 vs. 40.9 %; RR 1.12; 95 % CI 0.81–1.56). In patients with an elevated viral load on second-line ART electronic adherence monitoring was associated with a modest, but not significant, improvement in viral suppression.

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

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

Model of socio-cultural dimensions involved in adherence to antiretroviral therapy for HIV/AIDS in public health care centers in Chile

In Chile, over 14,000 adults are living with HIV receive antiretroviral therapy (HAART). Adequate adherence to HAART has a major impact on survival. There is little consensus on the causes of poor adherence, due to the unique and diverse sociocultural parameters involved in the issue. The objective of this study was to identify sociocultural dimensions that serve as barriers or facilitators to HAART adherence among persons living with HIV/AIDS (PLHIV) in Chile. A qualitative study design, with an exploratory followed by a descriptive phase was conducted. The study population consisted of adults living with HIV/AIDS, with and without HAART. A theoretical sample was designed and three gender profiles defined: women, men, and transwomen. Data collection methods included in-depth interviews by anthropologists in seven public health care centers for PLHIV. The model of sociocultural dimensions indicated that factors associated with family, expectations, gender/sexuality, affect, relationship with HIV, HAART, work, social support and networks, and stigma and discrimination influenced adherence, with different patterns among profiles. This study found that adherence is a dynamic category. It is crucial to consider sociocultural factors in developing strategies to improve HAART adherence.

The uncertainty of treatment: Women's use of HIV treatment as prevention in Malawi

In countries throughout sub-Saharan Africa, antiretroviral therapy is seen as the solution to not only treat existing patients, but also to prevent the future spread of HIV. New policies for the prevention of mother-to-child transmission place women on lifelong treatment as soon as they are tested HIV positive. This article looks at how women understand this prescription for lifelong treatment. Drawing on interviews with HIV-positive women in Lilongwe, Malawi (N = 65) during July-September 2014, I examine the process of making treatment decisions, and why - despite increased access - women refuse or stop treatment. Using treatment for preventative purposes transforms the experience of HIV from an acute to a chronic condition where both the symptoms of disease and the efficacy of treatment are unclear. Women look for evidence of the cost and benefit of treatment through their personal experiences with illness and drug-taking. For some women, the benefits were clearer: they interpreted past illnesses as signs of HIV infection, and felt healthier and more economically productive afterwards. For others, taking treatment sometimes led to marital problems, and side effects made them feel worse and disrupted their ability to work. While women understand the health benefits of antiretroviral therapy, taking treatment does not always make sense in their present circumstances when there are costly physical and economic repercussions. This study builds on existing sociological research on medical decision-making by situating decisions in a broader political economy of changing HIV policies, economic conditions, and everyday uncertainty.