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Pellowski JA, Jensen D, Tsawe N, Colvin C, Cu-Uvin S, Operario D, Lurie M, Harrison A, Myer L, Knight L. Womandla Health: development and rationale of a behavioral intervention to support HIV treatment adherence among postpartum women in South Africa. BMC Womens Health 2023; 23:649. [PMID: 38057777 PMCID: PMC10701937 DOI: 10.1186/s12905-023-02817-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 11/28/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND While Option B + has made great strides in eliminating vertical transmission of HIV and improving access to lifelong antiretroviral therapy (ART) for women, the postpartum period remains a risk period for disengagement from HIV care and non-adherence. METHODS Longitudinal qualitative data was collected from 30 women living with HIV in Cape Town, South Africa from pregnancy through 1 year postpartum to examine key barriers and facilitators to HIV treatment adherence across this transition. Participants were also asked about their preferences for behavioral intervention content, format, and scope. The intervention development process was guided by Fernandez et al.'s Intervention Mapping process and was informed by the qualitative data, the wider literature on ART adherence, and Transition Theory. RESULTS The Womandla Health Intervention is a multicomponent intervention consisting of four individual sessions with a lay health worker and four peer group sessions, which span late pregnancy and early postpartum. These sessions are guided by Transition Theory and utilize motivational interviewing techniques to empower women to ascertain their own individual barriers to HIV care and identify solutions and strategies to overcome these barriers. CONCLUSIONS This intervention will be tested in a small scale RCT. If successful, findings will provide an innovative approach to HIV treatment by capitalizing on the transition into motherhood to bolster self-care behaviors, focusing on ART adherence and also women's overall postpartum health and psychosocial needs.
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Affiliation(s)
- Jennifer A Pellowski
- School of Public Health, Brown University, Providence, USA.
- School of Public Health, University of Cape Town, Cape Town, South Africa.
| | - Destry Jensen
- School of Public Health, Brown University, Providence, USA
| | - Nokwazi Tsawe
- School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Christopher Colvin
- School of Public Health, University of Cape Town, Cape Town, South Africa
- School of Medicine, University of Virginia, Charlottesville, USA
| | - Susan Cu-Uvin
- The Warren Alpert Medical School of Brown University, Providence,, USA
| | - Don Operario
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Mark Lurie
- School of Public Health, Brown University, Providence, USA
- School of Public Health, University of Cape Town, Cape Town, South Africa
| | | | - Landon Myer
- School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Lucia Knight
- School of Public Health, University of Cape Town, Cape Town, South Africa
- School of Public Health, University of the Western Cape, Cape Town, South Africa
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GOVERE SABINAM, MANYANGADZE TAWANDA, KALINDA CHESTER, CHIMBARI MOSESJ. An assessment on the implementation of same day antiretroviral therapy initiation in eThekwini clinics, KwaZulu-Natal, South Africa. J Public Health Afr 2023; 14:2179. [PMID: 38162327 PMCID: PMC10755505 DOI: 10.4081/jphia.2023.2179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 07/05/2022] [Indexed: 01/03/2024] Open
Abstract
The World Health Organization (WHO) recommends same-day initiation (SDI) of antiretroviral therapy (ART) for all individuals diagnosed with HIV irrespective of CD4+ count or clinical stage. Implementation of program is still far from reaching its goals. This study assessed the level of implementation of same day ART initiation. A longitudinal study was conducted at four primary healthcare clinics in eThekwini municipality KwaZulu-Natal. Data was collected between June 2020 to October 2020 using a data extraction form. Data on individuals tested HIV positive, number of SDI of ART; and clinicians working on UTT program were compiled from clinic registers, and Three Interlinked Electronic Registers.Net (TIER.Net). Non-governmental organisations (NGO) supporting the facility and services information was collected. Among the 403 individuals who tested HIV positive, 279 (69.2%) were initiated on ART on the same day of HIV diagnosis from the four facilities. There was a significant association between health facility and number of HIV positive individuals initiated on SDI (chi-square=10.59; P-value=0.008). There was a significant association between facilities with support from all NGOs and ART SDI (chi-square=10.18; P-value=0.015. There was a significant association between staff provision in a facility and SDI (chi-square=7.51; P-value=0.006). Urban areas clinics were more likely to have high uptake of SDI compared to rural clinics (chi-square=11,29; P-value=0.003). Implementation of the Universal Test and Treat program varies by facility indicating the need for the government to monitor and standardize implementation of the policy if the program is to yield success.
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Affiliation(s)
- SABINA M. GOVERE
- School of Nursing and Public Health, Discipline of Public Health Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - TAWANDA MANYANGADZE
- School of Nursing and Public Health, Discipline of Public Health Medicine, University of KwaZulu-Natal, Durban, South Africa
- Geography Department, Faculty of Science and Engineering, Bindura University of Science Education, Private Bag, Bindura, Zimbabwe
| | - CHESTER KALINDA
- School of Nursing and Public Health, Discipline of Public Health Medicine, University of KwaZulu-Natal, Durban, South Africa
- Bill and Joyce Cummings Institute of Global Health and Institute of Global Health Equity Research (IGHER), University of Global Health Equity Kigali Heights, Kigali
| | - MOSES J. CHIMBARI
- School of Nursing and Public Health, Discipline of Public Health Medicine, University of KwaZulu-Natal, Durban, South Africa
- Department of Public Health, Great Zimbabwe University, Masvingo, Zimbabwe
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Larson BA, Tsikhutsu I, Bii M, Halim N, Agaba P, Sugut W, Muli J, Sawe F. The effects of revised peer-counselor support on the PMTCT cascade of care: results from a cluster-randomized trial in Kenya (the EMMA study). BMC Infect Dis 2023; 23:257. [PMID: 37098468 PMCID: PMC10127503 DOI: 10.1186/s12879-023-08246-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 04/12/2023] [Indexed: 04/27/2023] Open
Abstract
BACKGROUND This study evaluated the effect of revisions to existing peer-counselor services, called Mentor Mothers (MM), at maternal and child health clinics on medication adherence for women living with HIV (WLWH) in Kenya and on early infant HIV testing. METHODS The Enhanced Mentor Mother Program study was a 12-site, two-arm cluster-randomized trial enrolling pregnant WLWH from March 2017 to June 2018 (with data collection through September 2020). Six clinics were randomized to continued MM-supported standard care (SC). Six clinics were randomized to the intervention arm (INT = SC plus revised MM services to include more one-on-one interactions). Primary outcomes for mothers were defined as: (PO1) the proportion of days covered (PDC) with antiretroviral therapy (ART) ≥ 0.90 during the last 24-weeks of pregnancy; and (PO2) ≥ 0.90 PDC during the first 24-weeks postpartum. Secondary outcomes were infant HIV testing according to national guidelines (at 6, 24, and 48 weeks). Crude and adjusted risk differences between study arms are reported. RESULTS We enrolled 363 pregnant WLHV. After excluding known transfers and subjects with incomplete data extraction, data were analyzed for 309 WLWH (151 SC, 158 INT). A small share achieved high PDC during the prenatal and postnatal periods (0.33 SC/0.24 INT achieved PO1; 0.30 SC/0.31 INT achieved PO2; crude or adjusted risk differences were not statistically significant). In addition, ~ 75% in both study arms completed viral load testing during year two after enrollment, with > 90% suppressed in both arms. For infants, ≥ 90% in both arms had at least one HIV test through study follow up (76 weeks) but testing on schedule according to PMTCT guidelines was uncommon. CONCLUSIONS While national guidelines in Kenya recommended that all HIV-infected pregnant women take a daily antiretroviral regimen for life following a HIV diagnosis, results presented here indicate that a minor share achieved high medication coverage during the prenatal and postnatal periods analyzed. In addition, adjustments to Mentor-Mother services showed no improvement in study outcomes. The lack of effect for this behavioral intervention is relatively consistent with the existing literature to improve mother-infant outcomes along the PMTCT care cascade. CLINICAL TRIAL NUMBER NCT02848235. Date of first trial registration 28/07/2016.
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Affiliation(s)
- Bruce A Larson
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA, 02118, USA.
| | - Isaac Tsikhutsu
- Kenya Medical Research Institute, Kericho, Kenya/U.S. Army Medical Research Directorate-Africa, Nairobi, Kenya
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
- HJF Medical Research International, Kericho, Kenya
| | - Margaret Bii
- Kenya Medical Research Institute, Kericho, Kenya/U.S. Army Medical Research Directorate-Africa, Nairobi, Kenya
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
- HJF Medical Research International, Kericho, Kenya
| | - Nafisa Halim
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA, 02118, USA
| | - Patricia Agaba
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - William Sugut
- Kenya Medical Research Institute, Kericho, Kenya/U.S. Army Medical Research Directorate-Africa, Nairobi, Kenya
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
- HJF Medical Research International, Kericho, Kenya
| | - Jane Muli
- Kenya Medical Research Institute, Kericho, Kenya/U.S. Army Medical Research Directorate-Africa, Nairobi, Kenya
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
- HJF Medical Research International, Kericho, Kenya
| | - Fredrick Sawe
- Kenya Medical Research Institute, Kericho, Kenya/U.S. Army Medical Research Directorate-Africa, Nairobi, Kenya
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
- HJF Medical Research International, Kericho, Kenya
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Mwamba C, Beres LK, Topp SM, Mukamba N, Simbeza S, Sikombe K, Mody A, Geng E, Holmes CB, Kennedy CE, Sikazwe I, Denison JA, Bolton Moore C. 'I need time to start antiretroviral therapy': understanding reasons for delayed ART initiation among people diagnosed with HIV in Lusaka, Zambia'. Ann Med 2022; 54:830-836. [PMID: 35311423 PMCID: PMC8942536 DOI: 10.1080/07853890.2022.2051069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Rapid antiretroviral therapy (ART) initiation can improve patient outcomes such as viral suppression and prevent new infections. However, not everyone who can start ART does so immediately. METHODS We conducted a qualitative study to inform interventions supporting rapid initiation in the 'Test and Start' era. We purposively sampled 20 adult patients living with HIV and a previous gap in care from ten health facilities in Lusaka, Zambia for interviews. We inductively analysed transcripts using a thematic, narrative approach. In their narratives, seven participants discussed delaying ART initiation. RESULTS Drawing on messages gleaned from facility-based counselling and community information, many cited greater fear of rapid sickness or death due to imperfect adherence or treatment side effects than negative health consequences due to delayed initiation. Participants described needing time to 'prepare' their minds for a lifetime treatment commitment. Concerns about inadvertent HIV status disclosure during drug collection discouraged immediate initiation, as did feeling healthy, and worries about the impact of ART initiation on relationship dynamics. CONCLUSION Findings suggest that counselling messages should accurately communicate treatment risks, without perpetuating fear-based narratives about HIV. Identifying and managing patient-specific concerns and reasons for the 'need for time' may be important for supporting individuals to rapidly accept lifelong treatment.Key messagesFear-based adherence messaging in health facilities about the dangers of missing a treatment dose or changing the time when ART is taken contributes to Zambian patients' refusals of immediate ART initiationResponsive health systems that balance a stated need for time to accept one's diagnosis and prepare to embark on a lifelong treatment plan with interventions to identify and manage patient-specific treatment related fears and concerns may support more rapid ART initiationPerceived social stigma around HIV continues to be a significant challenge for treatment initiation.
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Affiliation(s)
- Chanda Mwamba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Laura K Beres
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Stephanie M Topp
- College of Public Health, Medical & Veterinary Sciences, James Cook University, Townsville, Australia
| | - Njekwa Mukamba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Sandra Simbeza
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Kombatende Sikombe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.,Department of Public Health Environments and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Aaloke Mody
- Washington University School of Medicine in St. Louis, MO, USA
| | - Elvin Geng
- Washington University School of Medicine in St. Louis, MO, USA
| | | | - Caitlin E Kennedy
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Julie A Denison
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Bantie B, Seid A, Kerebeh G, Alebel A, Dessie G. Loss to follow-up in "test and treat era" and its predictors among HIV-positive adults receiving ART in Northwest Ethiopia: Institution-based cohort study. Front Public Health 2022; 10:876430. [PMID: 36249247 PMCID: PMC9557930 DOI: 10.3389/fpubh.2022.876430] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 08/29/2022] [Indexed: 01/21/2023] Open
Abstract
Background People living with HIV/AIDS are enrolled in lifelong Anti-Retroviral Treatment (ART) irrespective of their clinical staging as well as CD4 cell count. Although this "Universal Test and Treat" strategy of ART was found to have numerous benefits, loss from follow-up and poor retention remained a long-term challenge for the achievement of ART program targets. Hence, this study is aimed at addressing the much-needed effect of the test and treat strategy on the incidence of loss to follow-up (LTFU) in Ethiopia. Method and materials An institution-based follow-up study was conducted on 513 adults (age ≥15) who enrolled in ART at a public health institution in Bahir Dar City, Northwest Ethiopia. Data were extracted from the charts of selected patients and exported to Stata 14.2 software for analysis. Basic socio-demographic, epidemiological, and clinical characteristics were described. The Kaplan-Meier curve was used to estimate the loss to follow-up free (survival) probability of HIV-positive adults at 6, 12, 24, and 48 months of ART therapy. We fitted a multivariable Cox model to determine the statistically significant predictors of LTFU. Result The incidence density of LTFU was 9.7 per 100 person-years of observation (95% CI: 7.9-11.9 per 100 PYO). Overall, LTFU is higher in the rapid ART initiation (24% in rapid initiated vs. 11.3% in lately initiated, AHR 2.08, P = 0.004), in males (23% males vs. 14.7% females, AHR1.96, P = 0.004), in singles (34% single vs. 11% married, with AHR1.83, P = 0.044), in non-disclosed HIV-status (33% non-disclosed 11% disclosed, AHR 2.00 p = 0.001). Patients with poor/fair ART adherence were also identified as another risk group of LTFU (37% in poor vs. 10.5% in good adherence group, AHR 4.35, P = 0.001). Conclusion The incidence of LTFU in this universal test and treat era was high, and the highest figure was observed in the first 6 months. Immediate initiation of ART in a universal test and treat strategy shall be implemented cautiously to improve patient retention and due attention shall be given to those high-risk patients.
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Affiliation(s)
- Berihun Bantie
- Department of Adult Health Nursing, College of Medicine and Health Science, Debre Tabor University, Debre Tabor, Ethiopia,*Correspondence: Berihun Bantie
| | - Awole Seid
- Department of Adult Health Nursing, School of Health Science, College of Medicine and Health Science, Bahir Dar University, Bahir Dar, Ethiopia
| | - Gashaw Kerebeh
- Department of Pediatrics and Child Health Nursing, College of Medicine and Health Science, Debre Tabor University, Debre Tabor, Ethiopia
| | - Animut Alebel
- School of Public Health, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - Getenet Dessie
- Department of Adult Health Nursing, School of Health Science, College of Medicine and Health Science, Bahir Dar University, Bahir Dar, Ethiopia
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O'Laughlin KN, Greenwald K, Rahman SK, Faustin ZM, Ashaba S, Tsai AC, Ware NC, Kambugu A, Bassett IV. A Social-Ecological Framework to Understand Barriers to HIV Clinic Attendance in Nakivale Refugee Settlement in Uganda: a Qualitative Study. AIDS Behav 2021; 25:1729-1736. [PMID: 33263892 PMCID: PMC8081685 DOI: 10.1007/s10461-020-03102-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2020] [Indexed: 12/21/2022]
Abstract
The social-ecological model proposes that efforts to modify health behaviors are influenced by constraints and facilitators at multiple levels. We conducted semi-structured interviews with 47 clients in HIV care and 8 HIV clinic staff to explore how such constraints and facilitators (individual, social environment, physical environment, and policies) affect engaging in HIV clinical care in Nakivale Refugee Settlement in Uganda. Thematic analysis revealed that participants were motivated to attend the HIV clinic because of the perceived quality of services and the belief that antiretroviral therapy improves health. Barriers to clinic attendance included distance, cost, unemployment, and climate. Those that disclosed their status had help in overcoming barriers to HIV care. Nondisclosure and stigma disrupted community support in overcoming these obstacles. Interventions to facilitate safe disclosure, mobilize social support, and provide more flexible HIV services may help overcome barriers to HIV care in this setting.
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Affiliation(s)
- Kelli N O'Laughlin
- Departments of Emergency Medicine and Global Health, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA.
| | - Kelsy Greenwald
- Harvard Affiliated Emergency Medicine Residency, Boston, MA, USA
| | | | | | | | - Alexander C Tsai
- Mbarara University of Science and Technology, Mbarara, Uganda
- Center for Global Health, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Norma C Ware
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Andrew Kambugu
- Makerere University, Infectious Diseases Institute, Kampala, Uganda
| | - Ingrid V Bassett
- Center for Global Health, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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"This is My Life We are Talking About": Adaptive Strategies for HIV Care Retention and Treatment Adherence Among Postpartum Women Living with HIV in Cape Town, South Africa. Matern Child Health J 2021; 24:1454-1463. [PMID: 32816255 DOI: 10.1007/s10995-020-02995-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Retaining postpartum women living with HIV in ongoing care is critical for the health of the mother-child dyad but low adherence to antiretroviral therapy (ART) and retention in HIV care are a global concern. This issue is particularly salient in South Africa, where approximately 50% of women fall out of the care cascade by 6 months postpartum. The purpose of this secondary analysis is to understand the strategies that women use to navigate HIV care during the postpartum period. METHODS This study was conducted in Gugulethu, in Cape Town, South Africa. In-depth interviews were conducted with 21 study participants at 18-months postpartum. Participants were interviewed about their perceptions and experiences of their postpartum HIV care, and barriers and facilitators to their adherence and retention. RESULTS All participants reported using care navigation strategies across a spectrum of individual, interpersonal and structural levels to remain retained in care and adherent to ART. Participants expressed the importance of individual empowerment and knowledge of treatment benefits for their HIV care. Interpersonal relationships were discussed as a pathway to access both psychosocial and tangible support. Participants described overcoming structural barriers to care through creative problem solving and identified opportunities for care delivery improvement. DISCUSSION Participants described a wide range of overlapping and interconnected care navigation strategies. Consistent with the assets model, participants discussed their own capacity and that of their communities to engage in lifelong HIV care. Better understanding of potentially successful individual care navigation strategies should guide future intervention work. TRIAL REGISTRATION ClinicalTrials.gov NCT01933477.
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Phillips TK, Teasdale CA, Geller A, Ng'eno B, Mogoba P, Modi S, Abrams EJ. Approaches to transitioning women into and out of prevention of mother-to-child transmission of HIV services for continued ART: a systematic review. J Int AIDS Soc 2021; 24:e25633. [PMID: 33372730 PMCID: PMC7771153 DOI: 10.1002/jia2.25633] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 09/22/2020] [Accepted: 10/08/2020] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Women living with HIV are required to transition into the prevention of mother-to-child transmission of HIV (PMTCT) services when they become pregnant and back to ART services after delivery. Transition can be a vulnerable time when many women are lost from HIV care yet there is little guidance on the optimal transition approaches to ensure continuity of care. We reviewed the available evidence on existing approaches to transitioning women into and out of PMTCT, outcomes following transition and factors influencing successful transition. METHODS We searched PubMed and SCOPUS, as well as abstracts from international HIV-focused meetings, from January 2006 to July 2020. Studies were included that examined three points of transition: pregnant women already on ART into PMTCT (transition 1), pregnant women living with HIV not yet on ART into treatment services (transition 2) and postpartum women from PMTCT into general ART services after delivery (transition 3). Results were grouped and reported as descriptions of transition approach, comparison of outcomes following transition and factors influencing successful transition. RESULTS & DISCUSSION Out of 1809 abstracts located, 36 studies (39 papers) were included in this review. Three studies included transition 1, 26 transition 2 and 17 transition 3. Approaches to transition were described in 26 studies and could be grouped into the provision of information at the point of transition (n = 8), strengthened communication or linkage of data between services (n = 4), use of transition navigators (n = 12), and combination approaches (n = 4). Few studies were designed to directly assess transition and only nine compared outcomes between transition approaches, with substantial heterogeneity in study design, setting and outcomes. Four themes were identified in 25 studies reporting on factors influencing successful transition: fear, knowledge and preparedness, clinic characteristics and the transition requirements and process. CONCLUSIONS This review highlights that, despite the need for women to transition into and out of PMTCT services for continued ART in many settings, there is very limited evidence on optimal transition approaches. Ongoing operational research is required to identify sustainable and acceptable transition approaches and service delivery models that support continuity of HIV care during and after pregnancy.
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Affiliation(s)
- Tamsin K Phillips
- Division of Epidemiology and BiostatisticsSchool of Public Health & Family MedicineUniversity of Cape TownCape TownSouth Africa
- Centre for Infectious Diseases Epidemiology & ResearchSchool of Public Health & Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Chloe A Teasdale
- ICAP‐Columbia UniversityMailman School of Public HealthNew YorkNYUSA
- Department of EpidemiologyMailman School of Public HealthNew YorkNYUSA
- Department of Epidemiology and BiostatisticsCUNY Graduate School of Public Health & Health PolicyNew YorkNYUSA
| | - Amanda Geller
- US Centers for Disease Control and Prevention (CDC)AtlantaGAUSA
| | | | - Pheposadi Mogoba
- Centre for Infectious Diseases Epidemiology & ResearchSchool of Public Health & Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Surbhi Modi
- US Centers for Disease Control and Prevention (CDC)AtlantaGAUSA
| | - Elaine J Abrams
- ICAP‐Columbia UniversityMailman School of Public HealthNew YorkNYUSA
- Department of EpidemiologyMailman School of Public HealthNew YorkNYUSA
- College Physicians and SurgeonsColumbia UniversityNew YorkNYUSA
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Mbeya Munkhondya TE, Smyth RMD, Lavender T. Facilitators and barriers to retention in care under universal antiretroviral therapy (Option B+) for the Prevention of Mother to Child Transmission of HIV (PMTCT): A narrative review. INTERNATIONAL JOURNAL OF AFRICA NURSING SCIENCES 2021. [DOI: 10.1016/j.ijans.2021.100372] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Mgbako O, E. Sobieszczyk M, Olender S, Gordon P, Zucker J, Tross S, Castor D, H. Remien R. Immediate Antiretroviral Therapy: The Need for a Health Equity Approach. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17197345. [PMID: 33050039 PMCID: PMC7579579 DOI: 10.3390/ijerph17197345] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/02/2020] [Accepted: 10/05/2020] [Indexed: 12/27/2022]
Abstract
Immediate antiretroviral therapy (iART), defined as same-day initiation of ART or as soon as possible after diagnosis, has recently been recommended by global and national clinical care guidelines for patients newly diagnosed with human immunodeficiency virus (HIV). Based on San Francisco’s Rapid ART Program Initiative for HIV Diagnoses (RAPID) model, most iART programs in the US condense ART initiation, insurance acquisition, housing assessment, and mental health and substance use evaluation into an initial visit. However, the RAPID model does not explicitly address structural racism and homophobia, HIV-related stigma, medical mistrust, and other important factors at the time of diagnosis experienced more poignantly by African American, Latinx, men who have sex with men (MSM), and transgender patient populations. These factors negatively impact initial and subsequent HIV care engagement and exacerbate significant health disparities along the HIV care continuum. While iART has improved time to viral suppression and linkage to care rates, its association with retention in care and viral suppression, particularly in vulnerable populations, remains controversial. Considering that in the US the HIV epidemic is sharply defined by healthcare disparities, we argue that incorporating an explicit health equity approach into the RAPID model is vital to ensure those who disproportionately bear the burden of HIV are not left behind.
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Affiliation(s)
- Ofole Mgbako
- Division of Infectious Disease, Department of Internal Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA; (M.E.S.); (S.O.); (P.G.); (J.Z.); (D.C.)
- HIV Center for Clinical and Behavioral Studies, NY State Psychiatric Institute and Columbia University, New York, NY 10032, USA; (S.T.); (R.H.R.)
- Correspondence:
| | - Magdalena E. Sobieszczyk
- Division of Infectious Disease, Department of Internal Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA; (M.E.S.); (S.O.); (P.G.); (J.Z.); (D.C.)
| | - Susan Olender
- Division of Infectious Disease, Department of Internal Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA; (M.E.S.); (S.O.); (P.G.); (J.Z.); (D.C.)
| | - Peter Gordon
- Division of Infectious Disease, Department of Internal Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA; (M.E.S.); (S.O.); (P.G.); (J.Z.); (D.C.)
| | - Jason Zucker
- Division of Infectious Disease, Department of Internal Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA; (M.E.S.); (S.O.); (P.G.); (J.Z.); (D.C.)
| | - Susan Tross
- HIV Center for Clinical and Behavioral Studies, NY State Psychiatric Institute and Columbia University, New York, NY 10032, USA; (S.T.); (R.H.R.)
| | - Delivette Castor
- Division of Infectious Disease, Department of Internal Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA; (M.E.S.); (S.O.); (P.G.); (J.Z.); (D.C.)
| | - Robert H. Remien
- HIV Center for Clinical and Behavioral Studies, NY State Psychiatric Institute and Columbia University, New York, NY 10032, USA; (S.T.); (R.H.R.)
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Daniels J, De Vos L, Mogos W, Olivier D, Shamu S, Mudau M, Klausner J, Medina-Marino A. Factors influencing sexually transmissible infection disclosure to male partners by HIV-positive pregnant women in Pretoria townships, South Africa: a qualitative study. Sex Health 2020; 16:274-281. [PMID: 31072453 DOI: 10.1071/sh18177] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 02/19/2019] [Indexed: 11/23/2022]
Abstract
Background Sexually transmissible infections (STI) may increase the risk of mother-to-child transmission (MTCT) of HIV. However, diagnostic testing and targeted treatment of STI (STI-TT) during pregnancy is not standard care in South Africa. METHODS A qualitative study was nested in a STI-TT intervention to investigate motivating and enabling factors associated with STI test results disclosure to sexual partners. A semi-structured interview protocol covered partner communication, HIV and STI disclosure, financial security and relationships dynamics. Interviews were conducted in participants' preferred language, audio-recorded, transcribed into English and analysed using a constant comparison approach. The study was conducted in two townships in Pretoria, South Africa. RESULTS Twenty-eight HIV-positive pregnant women were interviewed. Based on the interviews, two disclosure experiences for women were identified - those with vulnerable experiences and those with self-enabling experiences within their partnerships. Vulnerable women discussed intimate partner violence (IPV) and fear of relationship dissolution as factors influencing their test result disclosure. Self-enabled women discussed their ability to talk with their partners about STI and HIV infections and the influence of multiple concurrent partnerships in the acquisition of HIV/STIs. Both groups of women were concerned about men's health behaviours, and all cited the health and development of their unborn child as a key motivator for test result disclosure. CONCLUSIONS Improved counselling and support for pregnant women to disclose their STI test results to their partners may improve the impact of STI diagnostic testing during pregnancy by improving partner treatment uptake and thus reducing the risk of re-infection.
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Affiliation(s)
- Joseph Daniels
- Charles Drew University, 1731 E. 120th Street, Los Angeles, CA 90059, USA; and Corresponding author.
| | - Lindsey De Vos
- Foundation for Professional Development, 173 Mary Road, Die Wilgers, Pretoria, 0184, South Africa
| | - Winta Mogos
- Program in Public Health, 653 E. Peltason Drive, University of California Irvine, Irvine, CA 92617, USA
| | - Dawie Olivier
- Foundation for Professional Development, 173 Mary Road, Die Wilgers, Pretoria, 0184, South Africa
| | - Simukai Shamu
- Foundation for Professional Development, 173 Mary Road, Die Wilgers, Pretoria, 0184, South Africa
| | - Maanda Mudau
- Foundation for Professional Development, 173 Mary Road, Die Wilgers, Pretoria, 0184, South Africa
| | - Jeffrey Klausner
- UCLA CARE Center, 1399 S. Roxbury Drive, Suite 100, Los Angeles, CA 90035, USA
| | - Andrew Medina-Marino
- Foundation for Professional Development, 173 Mary Road, Die Wilgers, Pretoria, 0184, South Africa
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12
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Mshweshwe-Pakela N, Hansoti B, Mabuto T, Kerrigan D, Kubeka G, Hahn E, Charalambous S, Hoffmann CJ. Feasibility of implementing same-day antiretroviral therapy initiation during routine care in Ekurhuleni District, South Africa: Retention and viral load suppression. South Afr J HIV Med 2020; 21:1085. [PMID: 32934830 PMCID: PMC7479383 DOI: 10.4102/sajhivmed.v21i1.1085] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 05/07/2020] [Indexed: 11/29/2022] Open
Abstract
Background Same-day initiation (SDI) of antiretroviral therapy (ART) has been advocated as an approach to increase linkage to care and overall ART initiation. Clinical trials have demonstrated impressive benefits. However, questions regarding patient preparedness and retention in care remain for routine implementation of this approach. Objectives In this study, we sought to describe SDI of ART during routine care delivery and compare time to ART initiation on longitudinal care outcomes. Method We performed a retrospective chart review of 100 consecutive individuals, newly diagnosed with HIV, from 10 health facilities across Ekurhuleni, from January to July 2017. Records were reviewed for a period of 1 year post-diagnosis. Abstracted data included demographics, time to ART initiation, clinic visits and laboratory test results (including viral load testing). Results A total of 993 patient records were reviewed, of which 826 were included in the analysis. The majority of patients (752, 91%) had ART initiation recorded, of which 654 (79%) had ART initiated within 30 days, and 224 (27%) had SDI. Uptake of SDI of ART was higher among women (36% vs. 10.4%; p < 0.001) and in younger patients (33.7% in those < 29 years; p < 0.01). Retention in care at 6 months was achieved in 477 (58%) patients. Of those with 6-month viral loads, 350/430 (73%) had a viral load < 400 c/m. Retention in care and viral suppression were similar among those with SDI of ART and later ART initiation. Conclusion Same-day initiation of ART was successfully delivered with similar retention and viral load outcomes as subsequent initiation, providing re-assurance for scale-up of this strategy in routine care.
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Affiliation(s)
| | - Bhakti Hansoti
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, United States of America.,Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States of America
| | - Tonderai Mabuto
- Implementation Research Division, The Aurum Institute, Johannesburg, South Africa.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Deanna Kerrigan
- Department of Sociology, American University, Washington, United States of America
| | - Griffiths Kubeka
- Implementation Research Division, The Aurum Institute, Johannesburg, South Africa
| | - Elizabeth Hahn
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States of America
| | - Salome Charalambous
- Implementation Research Division, The Aurum Institute, Johannesburg, South Africa.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Christopher J Hoffmann
- Implementation Research Division, The Aurum Institute, Johannesburg, South Africa.,Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, United States of America.,Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States of America
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13
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Sakyi KS, Lartey MY, Kennedy CE, Dension JA, Mullany LC, Owusu PG, Sacks E, Hurley EA, Surkan PJ. Barriers to maternal retention in HIV care in Ghana: key differences during pregnancy and the postpartum period. BMC Pregnancy Childbirth 2020; 20:398. [PMID: 32677910 PMCID: PMC7366890 DOI: 10.1186/s12884-020-03067-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 06/18/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Maternal retention in HIV care is lower for women in the postpartum period than during pregnancy, but the reasons are poorly understood. We examined key differences in barriers to retention in HIV care during and after pregnancy. METHODS We conducted semi-structured, in-depth interviews with 30 postpartum women living with HIV. Participants were recruited from two tertiary facilities implementing Option B+ for prevention of mother-to-child HIV transmission in Accra, Ghana. We collected data from mothers who had disengaged from HIV care and those who were still engaged in care. The interviews were analyzed using principles adapted from grounded theory. RESULTS Participants' experiences and narratives showed that retention in HIV care was more challenging during the postpartum period than during pregnancy. Poor maternal physical health (from birth complications and cesarean section), socio-cultural factors (norms about newborn health and pregnancy), and economic difficulties linked to childbirth (such as unemployment, under-employment, and debt) made the costs of retention in HIV care more economically and socially expensive in the postpartum period than during pregnancy. Some participants also shared that transportation costs and resulting dependence on a partner to pay increased during the postpartum period because of a strong shift in maternal preference for private modes of transportation due to HIV stigma and the desire to protect the newborn. These factors played a larger role in the postpartum period than during pregnancy and created a significant barrier to retention. A conceptual model of how these factors interrelate, the synergy between them, and how they affect retention in the postpartum period is presented. CONCLUSIONS In Ghana, lower retention in HIV care in the postpartum period compared to in pregnancy may be primarily driven by social, economic, and newborn health factors. Multifaceted economic-based and stigma-reduction interventions are needed to increase retention in maternal HIV care after childbirth.
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Affiliation(s)
- Kwame S Sakyi
- Department of Public and Environmental Wellness, Oakland University, School of Health Sciences, 3101 Human Health Building, 433 Meadow Brook Rd, Rochester, MI, 48309-4452, USA.
- Center for Learning and Childhood Development-Ghana, AF, 3190, Adenta Flats, Accra, Ghana.
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA.
| | - Margaret Y Lartey
- Department of Medicine & Therapeutics, University of Ghana School of Medicine & Dentistry, CHS, P.O. Box GP 4236, Accra, Ghana
| | - Caitlin E Kennedy
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Julie A Dension
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Luke C Mullany
- Department of Public and Environmental Wellness, Oakland University, School of Health Sciences, 3101 Human Health Building, 433 Meadow Brook Rd, Rochester, MI, 48309-4452, USA
- Center for Learning and Childhood Development-Ghana, AF, 3190, Adenta Flats, Accra, Ghana
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Prince G Owusu
- Center for Learning and Childhood Development-Ghana, AF, 3190, Adenta Flats, Accra, Ghana
| | - Emma Sacks
- Department of Public and Environmental Wellness, Oakland University, School of Health Sciences, 3101 Human Health Building, 433 Meadow Brook Rd, Rochester, MI, 48309-4452, USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Emily A Hurley
- Health Services and Outcomes Research, Children's Mercy, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Pamela J Surkan
- Center for Learning and Childhood Development-Ghana, AF, 3190, Adenta Flats, Accra, Ghana
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
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14
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Dai L, Yu X, Shao Y, Wang Y, Li Z, Ye J, Bai S, Guo X, Wang J, Su B, Jiang T, Zhang T, Wu H, Scott SR, Liu A, Sun L. Effect of a multi-dimensional case management model on anti-retroviral therapy-related outcomes among people living with human immunodeficiency virus in Beijing, China. BMC Infect Dis 2020; 20:489. [PMID: 32646373 PMCID: PMC7350672 DOI: 10.1186/s12879-020-05219-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 07/02/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This paper introduces a comprehensive case management model uniting doctors, nurses, and non-governmental organizations (NGOs) in order to shorten the time from HIV diagnosis to initiation of antiviral therapy, improve patients' adherence, and ameliorate antiretroviral treatment (ART)-related outcomes. METHODS All newly diagnosed human immunodeficiency virus (HIV) cases at Beijing YouAn Hospital from January 2012 to December 2013 were selected as the control group, while all newly diagnosed HIV-infected patients from January 2015 to December 2016 were selected as the intervention group, receiving the comprehensive case management model. RESULTS 4906 patients were enrolled, of which 1549 were in the control group and 3357 in the intervention group. The median time from confirming HIV infection to ART initiation in the intervention group was 35 (18-133) days, much shorter than the control group (56 (26-253) days, P < 0.001). Participants in the intervention group had better ART adherence compared to those in the control group (intervention: 95.3%; control: 89.2%; p < 0.001). During the 2 years' follow-up, those receiving case management were at decreased odds of experiencing virological failure (OR: 0.27, 95%CI: 0.17-0.42, P < 0.001). Observed mortality was 0.4 deaths per 100 patient-years of follow-up for patients in the control group compared with 0.2 deaths per 100 patient-years of follow-up in the intervention group. CONCLUSIONS People living with HIV engaged in the comprehensive case management model were more likely to initiate ART sooner and maintained better treatment compliance and improved clinical outcomes compared to those who received routine care. A comprehensive case management program could be implemented in hospitals across China in order to reduce the HIV disease burden in the country.
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Affiliation(s)
- Lili Dai
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China
| | - Xiaochun Yu
- School of Public Health, Anhui Medical University, Hefei, 230032, Anhui, China
| | - Ying Shao
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China
| | - Yali Wang
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China
| | - Zaicun Li
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China
| | - Jiangzhu Ye
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China
| | - Shaoli Bai
- Lanzhou Municipality Pulmonary Hospital, Lanzhou, 730046, Gan Su, China
| | - Xiaoling Guo
- Lanzhou Municipality Pulmonary Hospital, Lanzhou, 730046, Gan Su, China
| | - Jianyun Wang
- Lanzhou Municipality Pulmonary Hospital, Lanzhou, 730046, Gan Su, China
| | - Bin Su
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China
| | - Taiyi Jiang
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China
| | - Tong Zhang
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China
| | - Hao Wu
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China
| | - Sarah Robbins Scott
- The National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, 100037, China
| | - An Liu
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China.
| | - Lijun Sun
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China.
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15
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Costs and Cost Drivers of Providing Option B+ Services to Mother-Baby Pairs for PMTCT of HIV in Health Centre IV Facilities in Jinja District, Uganda. BIOMED RESEARCH INTERNATIONAL 2020; 2020:2875864. [PMID: 32550228 PMCID: PMC7256705 DOI: 10.1155/2020/2875864] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 11/18/2019] [Accepted: 05/04/2020] [Indexed: 11/17/2022]
Abstract
Background In 2013, the World Health Organization (WHO) revised the 2012 guidelines on use of antiretroviral drugs (ARVs) for the prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV). The new guidelines recommended lifelong antiretroviral therapy (ART) for all HIV-positive pregnant and breastfeeding women irrespective of CD4 count or clinical stage (also referred to as Option B+). Uganda started implementing Option B+ in 2012 basing on the 2012 WHO guidelines. Despite the impressive benefits of the Option B+ strategy, implementation challenges, including cost burden and mother-baby pairs lost to follow-up, threatened its overall effectiveness. The researchers were unable to identify any studies conducted to assess costs and cost drivers associated with provision of Option B+ services to mother-baby pairs in HIV care in Uganda. Therefore, this study determined costs and cost drivers of providing Option B+ services to mother-baby pairs over a two-year period (2014–2015) in selected health facilities in Jinja district, Uganda. Methods The estimated costs of providing Option B+ to mother-baby pairs derived from the provider perspective were evaluated at four health centres (HC) in Jinja district. A retrospective, ingredient-based costing approach was used to collect data for 2014 as base year using a standardized cost data capture tool. All costs were valued in United States dollars (USD) using the 2014 midyear exchange rate. Costs incurred in the second year (2015) were obtained by inflating the 2014 costs by the ratio of 2015 and 2014 USA Gross Domestic Product (GDP) implicit price deflator. Results The average total cost of Option B+ services per HC was 66,512.7 (range: 32,168.2–102,831.1) USD over the 2-year period. The average unit cost of Option B+ services per mother-baby pair was USD 441.9 (range: 422.5–502.6). ART for mothers was the biggest driver of total mean costs (percent contribution: 62.6%; range: 56.0%–65.5%) followed by facility personnel (percent contribution: 8.2%; range: 7.7%–11.6%), and facility-level monitoring and quality improvement (percent contribution: 6.0%; range: 3.2%–12.3%). Conclusions and Recommendations. ART for mothers was the major cost driver. Efforts to lower the cost of ART for PMTCT would make delivery of Option B+ affordable and sustainable.
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16
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"I do all I can but I still fail them": Health system barriers to providing Option B+ to pregnant and lactating women in Malawi. PLoS One 2019; 14:e0222138. [PMID: 31513684 PMCID: PMC6742345 DOI: 10.1371/journal.pone.0222138] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 08/22/2019] [Indexed: 11/30/2022] Open
Abstract
Malawi’s Option B+ program is based on a ‘test and treat’ strategy that places all HIV-positive pregnant and lactating women on lifelong antiretroviral therapy. The steep increase in patient load placed severe pressure on a health system that has struggled for decades with inadequate supply of health care workers (HCWs) and poor infrastructure. We set out to explore health system barriers to Option B+ by asking HCWs in Malawi about their experiences treating pregnant and lactating women. We observed and conducted semi-structured interviews (SSIs) with 34 HCWs including nine expert clients (ECs) at 14 health facilities across Malawi, then coded and analyzed the data. We found that HCWs implementing Option B+ are so overburdened in Malawi that it reduces their ability to provide quality care to patients, who receive less counseling than they should, wait longer than is reasonable, and have very little privacy. Interventions that increase the number of HCWs and upgrade infrastructure to protect the privacy of HIV-infected pregnant and lactating women and their husbands could increase retention, but facilities will need to be improved to support men who accompany their partners on clinic visits.
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17
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Wanga I, Helova A, Abuogi LL, Bukusi EA, Nalwa W, Akama E, Odeny TA, Turan JM, Onono M. Acceptability of community-based mentor mothers to support HIV-positive pregnant women on antiretroviral treatment in western Kenya: a qualitative study. BMC Pregnancy Childbirth 2019; 19:288. [PMID: 31409297 PMCID: PMC6693232 DOI: 10.1186/s12884-019-2419-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 07/19/2019] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Option B+ is a comprehensive antiretroviral treatment (ART) designed for HIV-infected pregnant/ postpartum women. However, barriers to implementing Option B+ and establishing long-term ART adherence while facilitating retention in prevention of mother to child transmission of HIV (PMTCT) services remain. Community-based mentor mothers (cMMs) who can provide home-based support for PMTCT services may address some of the barriers to successful adoption and retention in Option B+. Thus, we evaluated the acceptability of using cMMs as home-based support for PMTCT services. METHODS Gender-matched in-depth interviews were conducted between September-November 2014 for HIV-infected pregnant/postpartum women and their male partners living in southwestern Kenya (n = 40); additionally, we conducted four focus groups involving 30 health workers (n = 70) within four health facilities. Audio-recordings were transcribed, translated, and then coded using a thematic analytical approach in which data were deductively and inductively coded with support from prior literature, identified themes within the interview guides, and emerging themes from the transcripts utilizing Dedoose software. RESULTS Overall, the study results suggest high acceptability of cMMs among individual participants and health workers. Stigma reduction, improvement of utilization of health care services, as well as ART adherence were most frequently discussed potential benefits of cMMs. Participants pictured a cMM as someone acting as a role model and confidant, and who was over 30 years old. Many respondents raised concerns about breaches of confidentiality and inadvertent disclosure. Respondent suggestions to overcome these issues included the cMM working in different communities than where she lives and attending home-visits with no identifying clothing as an HIV-related health worker. CONCLUSIONS The home-based cMM approach may be a beneficial and acceptable strategy for promoting ART adherence and retention within PMTCT services for pregnant/postpartum women living with HIV. Considering the risks of inadvertent disclosure of HIV-infected status and related negative consequences for pregnant/postpartum women living with HIV, similar cMM program designs may benefit from recognizing and addressing these risks. TRIAL REGISTRATION The MOTIVATE! study was registered on July 7, 2015 at the ClinicalTrials.gov ( NCT02491177 ).
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Affiliation(s)
- Iris Wanga
- Centre for Microbiology Research, Kenya Medical Research Institute, P.O. Box 19464 - 00202, Nairobi, Kenya
| | - Anna Helova
- Department of Health Care Policy and Organization, School of Public Health, University of Alabama at Birmingham, 517 RPHB 1665 University Blvd, Birmingham, AL 35294 USA
| | - Lisa L. Abuogi
- Department of Pediatrics, University of Colorado Denver, 13199 East Montview Blvd, Suite 310 Mail Stop A090, Aurora, CO 80045 USA
| | - Elizabeth A. Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, P.O. Box 19464 - 00202, Nairobi, Kenya
| | - Wafula Nalwa
- Maseno University School of Medicine, Box 3365-40100, Kisumu, Kenya
| | - Eliud Akama
- Centre for Microbiology Research, Kenya Medical Research Institute, P.O. Box 19464 - 00202, Nairobi, Kenya
| | - Thomas A. Odeny
- Centre for Microbiology Research, Kenya Medical Research Institute, P.O. Box 19464 - 00202, Nairobi, Kenya
| | - Janet M. Turan
- Department of Health Care Policy and Organization, School of Public Health, University of Alabama at Birmingham, 517 RPHB 1665 University Blvd, Birmingham, AL 35294 USA
| | - Maricianah Onono
- Centre for Microbiology Research, Kenya Medical Research Institute, P.O. Box 19464 - 00202, Nairobi, Kenya
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18
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Kawakyu N, Nduati R, Munguambe K, Coutinho J, Mburu N, DeCastro G, Inguane C, Zunt A, Abburi N, Sherr K, Gimbel S. Development and Implementation of a Mobile Phone-Based Prevention of Mother-To-Child Transmission of HIV Cascade Analysis Tool: Usability and Feasibility Testing in Kenya and Mozambique. JMIR Mhealth Uhealth 2019; 7:e13963. [PMID: 31094351 PMCID: PMC6535976 DOI: 10.2196/13963] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 04/20/2019] [Accepted: 04/23/2019] [Indexed: 12/20/2022] Open
Abstract
Background Prevention of mother-to-child HIV transmission (PMTCT) care cascade failures drive pediatric HIV infections in sub-Saharan Africa. As nurses’ clinical and management role in PMTCT expand, decision-support tools for nurses are needed to facilitate identification of cascade inefficiencies and solutions. The mobile phone–based PMTCT cascade analysis tool (mPCAT) provides health facility staff a quick summary of the number of patients and percentage drop-off at each step of the PMCTC care cascade, as well as how many women-infant pairs would be retained if a step was optimized. Objective The objective of this study was to understand and improve the mPCAT’s core usability factors and assess the health workers’ experience with using the mPCAT. Methods Overall, 2 rounds of usability testing were conducted with health workers from 4 clinics and leading experts in maternal and child health in Kenya and Mozambique using videotaped think aloud assessment techniques. Semistructured group interviews gauged the understanding of mPCAT’s core usability factors, based on the Nielsen Usability Framework, followed by development of cognitive demand tables describing the needed mPCAT updates. Post adaptation, feasibility was assessed in 3 high volume clinics over 12 weeks. Participants completed a 5-point Likert questionnaire designed to measure ease of use, convenience of integration into work, and future intention to use the mPCAT. Focus group discussions with nurse participants at each facility and in-depth interviews with nurse managers were also conducted to assess the acceptability, use, and recommendations for adaptations of the mPCAT. Results Usability testing with software engineers enabled real-time feedback to build a tool following empathic design principles. The revised mPCAT had improved navigation and simplified data entry interface, with only 1 data entry field per page. Improvements to the results page included a data visualization feature and the ability to share results through WhatsApp. Coding was simplified to enable future revisions by nontechnical staff—critical for context-specific adaptations for scale-up. Health care workers and facility managers found the tool easy to use (mean=4.3), used the tool very often (mean=4.1), and definitely intended to continue to use the tool (mean=4.8). Ease of use was the most common theme identified, with emphasis on how the tool readily informed system improvement decision making. Conclusions The mPCAT was well accepted by frontline health workers and facility managers. The collaborative process between software developer and user led to the development of a more user-friendly, context-specific tool that could be easily integrated into routine clinical practice and workflow. The mPCAT gave frontline health workers and facility managers an immediate, direct, and tangible way to use their clinical documentation and routinely reported data for decision making for their own clinical practice and facility-level improvements.
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Affiliation(s)
- Nami Kawakyu
- Center for Global Health Nursing, University of Washington, Seattle, WA, United States.,Department of Global Health, University of Washington, Seattle, WA, United States
| | - Ruth Nduati
- Network of AIDS Researchers in East and Southern Africa, Nairobi, Kenya.,Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Khátia Munguambe
- University of Eduardo Mondlane, Maputo, Mozambique.,Manhiça Health Research Centre, Manhiça, Mozambique
| | - Joana Coutinho
- Health Alliance International, Beira / Chimoio, Mozambique
| | - Nancy Mburu
- Network of AIDS Researchers in East and Southern Africa, Nairobi, Kenya
| | | | - Celso Inguane
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Andrew Zunt
- Paul G Allen School of Computer Science and Engineering, University of Washington, Seattle, WA, United States
| | - Neil Abburi
- Paul G Allen School of Computer Science and Engineering, University of Washington, Seattle, WA, United States
| | - Kenneth Sherr
- Department of Global Health, University of Washington, Seattle, WA, United States.,Health Alliance International, Seattle, WA, United States
| | - Sarah Gimbel
- Center for Global Health Nursing, University of Washington, Seattle, WA, United States.,Department of Global Health, University of Washington, Seattle, WA, United States.,Health Alliance International, Seattle, WA, United States.,Department of Family and Child Nursing, University of Washington, Seattle, WA, United States
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19
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Benzekri NA, Sambou JF, Ndong S, Tamba IT, Faye D, Diallo MB, Diatta JP, Faye K, Sall I, Sall F, Manga NM, Malomar JJ, Ndour CT, Hawes SE, Seydi M, Gottlieb GS. Prevalence, predictors, and management of advanced HIV disease among individuals initiating ART in Senegal, West Africa. BMC Infect Dis 2019; 19:261. [PMID: 30876400 PMCID: PMC6420737 DOI: 10.1186/s12879-019-3826-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 02/15/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The WHO guidelines for the management of advanced HIV disease recommend a package of care consisting of rapid initiation of antiretroviral therapy (ART), enhanced screening and diagnosis of tuberculosis (TB) and cryptococcal meningitis, co-trimoxazole prophylaxis, isoniazid preventive therapy (IPT), fluconazole pre-emptive therapy, and adherence support. The goals of this study were to determine the prevalence of advanced HIV disease among individuals initiating ART in Senegal, to identify predictors of advanced disease, and to evaluate adherence to the WHO guidelines. METHODS This study was conducted among HIV-positive individuals initiating ART in Dakar and Ziguinchor, Senegal. Clinical evaluations, laboratory analyses, questionnaires and chart review were conducted. Logistic regression was used to identify predictors of advanced disease. RESULTS A total of 198 subjects were enrolled; 70% were female. The majority of subjects (71%) had advanced HIV disease, defined by the WHO as a CD4 count < 200 cells/mm3 or clinical stage 3 or 4. The median CD4 count was 185 cells/mm3. The strongest predictors of advanced disease were age ≥ 35 (OR 5.80, 95%CI 2.35-14.30) and having sought care from a traditional healer (OR 3.86, 95%CI 1.17-12.78). Approximately one third of subjects initiated ART within 7 days of diagnosis. Co-trimoxazole prophylaxis was provided to 65% of subjects with CD4 counts ≤350 cells/mm3 or stage 3 or 4 disease. TB symptom screening was available for 166 subjects; 54% reported TB symptoms. Among those with TB symptoms, 39% underwent diagnostic evaluation. Among those eligible for IPT, one subject received isoniazid. No subjects underwent CrAg screening or received fluconazole to prevent cryptococcal meningitis. CONCLUSIONS This is the first study to report an association between seeking care from a traditional healer and presentation with WHO defined advanced disease in sub-Saharan Africa. Given the widespread use of traditional healers in sub-Saharan Africa, future studies to further explore this finding are indicated. Although the majority of individuals in this study presented with advanced disease and warranted management according to WHO guidelines, there were numerous missed opportunities to prevent HIV-associated morbidity and mortality. Programmatic evaluation is needed to identify barriers to implementation of the WHO guidelines and enhanced funding for operational research is indicated.
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Affiliation(s)
- Noelle A Benzekri
- Department of Medicine, University of Washington, Box 358061, 750 Republican St, Seattle, WA, 98109-4725, USA.
| | | | - Sanou Ndong
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier National Universitaire (CHNU) de Fann, Dakar, Senegal
| | | | | | - Mouhamadou Baïla Diallo
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier National Universitaire (CHNU) de Fann, Dakar, Senegal
| | | | - Khadim Faye
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier National Universitaire (CHNU) de Fann, Dakar, Senegal
| | | | - Fatima Sall
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier National Universitaire (CHNU) de Fann, Dakar, Senegal
| | | | | | - Cheikh T Ndour
- Division de Lutte contre le Sida et les IST, Ministère de la Santé et de l'Action Sociale, Dakar, Sénégal
| | - Stephen E Hawes
- Department of Epidemiology, University of Washington, Seattle, WA, USA.,Department of Global Health, University of Washington, Seattle, WA, USA
| | - Moussa Seydi
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier National Universitaire (CHNU) de Fann, Dakar, Senegal
| | - Geoffrey S Gottlieb
- Department of Medicine, University of Washington, Box 358061, 750 Republican St, Seattle, WA, 98109-4725, USA.,Department of Global Health, University of Washington, Seattle, WA, USA
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Kiwanuka G, Kiwanuka N, Muneza F, Nabirye J, Oporia F, Odikro MA, Castelnuovo B, Wanyenze RK. Retention of HIV infected pregnant and breastfeeding women on option B+ in Gomba District, Uganda: a retrospective cohort study. BMC Infect Dis 2018; 18:533. [PMID: 30355356 PMCID: PMC6201534 DOI: 10.1186/s12879-018-3450-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 10/16/2018] [Indexed: 12/12/2022] Open
Abstract
Background Lifelong antiretroviral therapy for HIV infected pregnant and lactating women (Option B+) has been rapidly scaled up but there are concerns about poor retention of women initiating treatment. However, facility-based data could underestimate retention in the absence of measures to account for self-transfers to other facilities. We assessed retention-in-care among women on Option B+ in Uganda, using facility data and follow-up to ascertain transfers to other facilities. Methods In a 25-month retrospective cohort analysis of routine program data, women who initiated Option B+ between March 2013 and March 2015 were tracked and interviewed quantitatively and qualitatively (in-depth interviews). Kaplan Meier survival analysis was used to estimate time to loss-to-follow-up (LTFU) while multivariable Cox proportional hazards regression was applied to estimate the adjusted predictors of LTFU, based on facility data. Thematic analysis was done for qualitative data, using MAXQDA 12. Quantitative data were analyzed with STATA® 13. Results A total of 518 records were reviewed. The mean (SD) age was 26.4 (5.5) years, 289 women (55.6%) attended primary school, and 53% (276/518) had not disclosed their HIV status to their partners. At 25 months post-ART initiation, 278 (53.7%) were LTFU based on routine facility data, with mean time to LTFU of 15.6 months. Retention was 60.2 per 1000 months of observation (pmo) (95% CI: 55.9–64.3) at 12, and 46.3/1000pmo (95% CI: 42.0–50.5) at 25 months. Overall, 237 (55%) women were successfully tracked and interviewed and 43/118 (36.4%) of those who were classified as LTFU at facility level had self-transferred to another facility. The true 25 months post-ART initiation retention after tracking was 71.3% (169/237). Women < 25 years, aHR = 1.71 (95% CI: 1.28–2.30); those with no education, aHR = 5.55 (95% CI: 3.11–9.92), and those who had not disclosed their status to their partners, aHR = 1.59 (95% CI: 1.16–2.19) were more likely to be LTFU. Facilitators for Option B+ retention based on qualitative findings were adequate counselling, disclosure, and the desire to stay alive and raise HIV-free children. Drug side effects, inadequate counselling, stigma, and unsupportive spouses, were barriers to retention in care. Conclusions Retention under Option B+ is suboptimal and is under-estimated at health facility level. There is need to institute mechanisms for tracking of women across facilities. Retention could be enhanced through strategies to enhance disclosure to partners, targeting the uneducated, and those < 25 years.
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Affiliation(s)
- George Kiwanuka
- Department of Health Policy Planning and Management, Makerere University School of Public Health, P.O Box 7072, Kampala, Uganda.
| | - Noah Kiwanuka
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Fiston Muneza
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Juliet Nabirye
- Department of Health Policy Planning and Management, Makerere University School of Public Health, P.O Box 7072, Kampala, Uganda
| | - Frederick Oporia
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda
| | - Magdalene A Odikro
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Barbara Castelnuovo
- Department of Research, Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Rhoda K Wanyenze
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda
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King EJ, Evdokimova I, Godunova J. 'If she gave birth to a healthy child, then she may forget about her own health': Postpartum engagement in HIV care and treatment among women living with HIV in Russia. Glob Public Health 2018; 14:684-695. [PMID: 30346243 DOI: 10.1080/17441692.2018.1536157] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
There is a dearth of information about the factors influencing postpartum engagement in HIV treatment and care in Russia, a country with an expanding HIV epidemic and poor treatment coverage. The goal of our community-based study was to identify and explore the factors influencing engagement in care after pregnancy. We conducted in-depth interviews with 50 women living with HIV who had recently given birth, and with 20 health care and social service providers in two locations: a large metropolitan city (St. Petersburg) and a semi-urban town near the Ural Mountains. Thematic analysis led us to identify the following themes in regard to factors influencing postpartum engagement in care: feeling overwhelmed with caring for an infant; sense of responsibility for child's health and well-being; misinformation and AIDS denialism; HIV-related stigma and fear; benefits versus side-effects of ART; professional and personal support; drug and alcohol use; and structural factors. Structural factors include poverty, continued provision of ART after pregnancy, dosage, obtaining necessary documents, and distance to clinic. These findings are important to consider in developing much-needed interventions to promote women's longer-term engagement in HIV care and treatment in Russia.
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Affiliation(s)
- Elizabeth J King
- a School of Public Health , University of Michigan , Ann Arbor , MI , USA
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22
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Rufu A, Chitimbire VTS, Nzou C, Timire C, Owiti P, Harries AD, Apollo T. Implementation of the 'Test and Treat' policy for newly diagnosed people living with HIV in Zimbabwe in 2017. Public Health Action 2018; 8:145-150. [PMID: 30271732 DOI: 10.5588/pha.18.0030] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 07/24/2018] [Indexed: 11/10/2022] Open
Abstract
Setting: Sixteen mission hospitals in Zimbabwe that are implementing the 'Test and Treat' programme for people living with the human immunodeficiency virus (HIV). Objectives: To assess linkages of HIV diagnosis to care and treatment, time taken from being diagnosed with HIV infection to initiation of antiretroviral therapy (ART) and 3-month programmatic outcomes for those starting ART. Design: Cross-sectional study using secondary data. Results: Among 972 people newly diagnosed with HIV, 915 (94%) enrolled for HIV care and 771 (79%) were initiated on ART. Enrolment in care and initiation on ART on the same day as testing occurred in respectively 864 (89%) and 628 (65%) newly diagnosed patients. Over 80% of those who underwent HIV testing in maternal and child health departments initiated ART on the same day. Of the 144 (16%) people in care who were not initiated on ART, the principal reason in 102 (71%) was being transferred out. Most patients (90%) on ART were retained in care at 3 months, with transfer out accounting for most of the remainder. Conclusion: The 'Test and Treat' approach was feasible and successful in getting newly HIV-infected people initiated early on ART. More research is needed to better understand the processes, benefits and potential risks.
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Affiliation(s)
- A Rufu
- Zimbabwe Association of Church-Related Hospitals, Harare, Zimbabwe
| | - V T S Chitimbire
- Zimbabwe Association of Church-Related Hospitals, Harare, Zimbabwe
| | - C Nzou
- Zimbabwe Association of Church-Related Hospitals, Harare, Zimbabwe
| | - C Timire
- International Union Against Tuberculosis and Lung Disease (The Union), Harare, Zimbabwe.,National TB Control Programme, Ministry of Health and Child Care Zimbabwe, Harare, Zimbabwe
| | - P Owiti
- Academic Model Providing Access to Healthcare, Eldoret, Kenya.,The Union, Paris, France
| | - A D Harries
- The Union, Paris, France.,London School of Hygiene & Tropical Medicine, London, UK
| | - T Apollo
- National AIDS Programme, Ministry of Health and Child Care Zimbabwe, Harare, Zimbabwe
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Trafford Z, Gomba Y, Colvin CJ, Iyun VO, Phillips TK, Brittain K, Myer L, Abrams EJ, Zerbe A. Experiences of HIV-positive postpartum women and health workers involved with community-based antiretroviral therapy adherence clubs in Cape Town, South Africa. BMC Public Health 2018; 18:935. [PMID: 30064405 PMCID: PMC6069812 DOI: 10.1186/s12889-018-5836-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 07/11/2018] [Indexed: 11/10/2022] Open
Abstract
Background The rollout of universal, lifelong treatment for all HIV-positive pregnant and breastfeeding women (“Option B+”) has rapidly increased the number of women initiating antiretroviral treatment (ART) and requiring ART care postpartum. In a pilot project in South Africa, eligible postpartum women were offered the choice of referral to the standard of care, a local primary health care clinic, or a community-based model of differentiated ART services, the adherence club (AC). ACs have typically enrolled only non-pregnant and non-postpartum adults; postpartum women had not previously been referred directly from antenatal care. There is little evidence regarding postpartum women’s preferences for and experiences of differentiated models of care, or the capacity of this particular model to cater to their specific needs. This qualitative paper reports on feedback from both postpartum women and health workers who care for them on their respective experiences of the AC. Methods One-on-one in-depth qualitative interviews were conducted with 19 (23%) of the 84 postpartum women who selected the AC and were retained at approximately 12 months postpartum, and 9 health workers who staff the AC. Data were transcribed and thematically analysed using NVivo 11. Results Postpartum women’s inclusion in the AC was acceptable for both participants and health workers. Health workers were welcoming of postpartum women but expressed concerns about prospects for longer term adherence and retention, and raised logistical issues they felt might compromise trust with AC members in general. Conclusions Enrolling postpartum women in mixed groups with the general adult population is feasible and acceptable. Preliminary recommendations are offered and may assist in supporting the specific needs of postpartum women transitioning from antenatal ART care. Trial registration Number NCT02417675 clinicaltrials.gov/ct2/show/record/NCT02417675 (retrospective reg.)
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Affiliation(s)
- Zara Trafford
- Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
| | - Yolanda Gomba
- Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Christopher J Colvin
- Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Victoria O Iyun
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Tamsin K Phillips
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Kirsty Brittain
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Landon Myer
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Elaine J Abrams
- Mailman School of Public Health, ICAP, Columbia University, New York, USA.,College of Physicians and Surgeons, Columbia University, New York, USA
| | - Allison Zerbe
- Mailman School of Public Health, ICAP, Columbia University, New York, USA
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Waruru A, Achia TNO, Muttai H, Ng'ang'a L, Zielinski-Gutierrez E, Ochanda B, Katana A, Young PW, Tobias JL, Juma P, De Cock KM, Tylleskär T. Spatial-temporal trend for mother-to-child transmission of HIV up to infancy and during pre-Option B+ in western Kenya, 2007-13. PeerJ 2018; 6:e4427. [PMID: 29576942 PMCID: PMC5861528 DOI: 10.7717/peerj.4427] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 02/08/2018] [Indexed: 11/20/2022] Open
Abstract
Introduction Using spatial–temporal analyses to understand coverage and trends in elimination of mother-to-child transmission of HIV (e-MTCT) efforts may be helpful in ensuring timely services are delivered to the right place. We present spatial–temporal analysis of seven years of HIV early infant diagnosis (EID) data collected from 12 districts in western Kenya from January 2007 to November 2013, during pre-Option B+ use. Methods We included in the analysis infants up to one year old. We performed trend analysis using extended Cochran–Mantel–Haenszel stratified test and logistic regression models to examine trends and associations of infant HIV status at first diagnosis with: early diagnosis (<8 weeks after birth), age at specimen collection, infant ever having breastfed, use of single dose nevirapine, and maternal antiretroviral therapy status. We examined these covariates and fitted spatial and spatial–temporal semiparametric Poisson regression models to explain HIV-infection rates using R-integrated nested Laplace approximation package. We calculated new infections per 100,000 live births and used Quantum GIS to map fitted MTCT estimates for each district in Nyanza region. Results Median age was two months, interquartile range 1.5–5.8 months. Unadjusted pooled positive rate was 11.8% in the seven-years period and declined from 19.7% in 2007 to 7.0% in 2013, p < 0.01. Uptake of testing ≤8 weeks after birth was under 50% in 2007 and increased to 64.1% by 2013, p < 0.01. By 2013, the overall standardized MTCT rate was 447 infections per 100,000 live births. Based on Bayesian deviance information criterion comparisons, the spatial–temporal model with maternal and infant covariates was best in explaining geographical variation in MTCT. Discussion Improved EID uptake and reduced MTCT rates are indicators of progress towards e-MTCT. Cojoined analysis of time and covariates in a spatial context provides a robust approach for explaining differences in programmatic impact over time. Conclusion During this pre-Option B+ period, the prevention of mother to child transmission program in this region has not achieved e-MTCT target of ≤50 infections per 100,000 live births. Geographical disparities in program achievements may signify gaps in spatial distribution of e-MTCT efforts and could indicate areas needing further resources and interventions.
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Affiliation(s)
- Anthony Waruru
- Centre for International Health, University of Bergen, Bergen, Norway.,Division of Global HIV & TB (DGHT), U.S. Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Thomas N O Achia
- Division of Global HIV & TB (DGHT), U.S. Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Hellen Muttai
- Division of Global HIV & TB (DGHT), U.S. Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Lucy Ng'ang'a
- Division of Global HIV & TB (DGHT), U.S. Centers for Disease Control and Prevention, Nairobi, Kenya
| | | | - Boniface Ochanda
- Division of Global HIV & TB (DGHT), U.S. Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Abraham Katana
- Division of Global HIV & TB (DGHT), U.S. Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Peter W Young
- Division of Global HIV & TB (DGHT), U.S. Centers for Disease Control and Prevention, Nairobi, Kenya
| | - James L Tobias
- Division of Global HIV & TB (DGHT), U.S. Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | | | - Kevin M De Cock
- Division of Global HIV & TB (DGHT), U.S. Centers for Disease Control and Prevention, Nairobi, Kenya
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Odeny TA, Onono M, Owuor K, Helova A, Wanga I, Bukusi EA, Turan JM, Abuogi LL. Maximizing adherence and retention for women living with HIV and their infants in Kenya (MOTIVATE! study): study protocol for a randomized controlled trial. Trials 2018; 19:77. [PMID: 29378622 PMCID: PMC5789594 DOI: 10.1186/s13063-018-2464-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 01/03/2018] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Successful completion and retention throughout the multi-step cascade of prevention of mother-to-child HIV transmission (PMTCT) remains difficult to achieve. The Mother and Infant Visit Adherence and Treatment Engagement study aims to evaluate the effect of mobile text messaging, community-based mentor mothers (cMMs), or both on increasing antiretroviral therapy (ART) adherence, retention in HIV care, maternal viral load suppression, and mother-to-child HIV transmission for mother-infant pairs receiving lifelong ART. METHODS/DESIGN This study is a cluster randomized, 2 × 2 factorial, controlled trial. The trial will be undertaken in the western Kenyan counties of Migori, Kisumu, and Homa Bay. Study sites will be randomized into one of four groups: six sites will implement both text messaging and cMM, six sites will implement cMM only, six sites will implement text messaging only, and six sites will implement the existing standard of care. The primary analysis will be based on the intention-to-treat principle and will compare maternal ART adherence and maternal retention in care. DISCUSSION This study will determine the impact of long-term (up to 12 months postpartum) text messaging and cMMs on retention in and adherence to ART among pregnant and breastfeeding women living with HIV in Kenya. It will address key gaps in our understanding of what interventions may successfully promote long-term retention in the PMTCT cascade of care. TRIAL REGISTRATION ClinicalTrials.gov, NCT02491177 . Registered on 11 March 2015.
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Affiliation(s)
- Thomas A. Odeny
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Medicine, University of Missouri-Kansas City, Kansas City, Missouri USA
| | - Maricianah Onono
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Kevin Owuor
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Anna Helova
- Department of Health Care Policy and Organization, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama USA
| | - Iris Wanga
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Elizabeth A. Bukusi
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Janet M. Turan
- Department of Health Care Policy and Organization, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama USA
| | - Lisa L. Abuogi
- Department of Pediatrics, University of Colorado, Denver, Colorado USA
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Abstract
Background: Recent attention has focused on the question of how quickly antiretroviral therapy (ART) should be started once HIV diagnosis is confirmed. We assessed whether rapid ART initiation improves patient outcomes. Methods: We searched five databases from inception up to August 2017. Rapid ART initiation was defined as initiation within 14 days of HIV diagnosis. Data were pooled using random effects meta-analysis. Results: Across the randomized trials, ART start on the same day increased viral suppression at 12 months [three trials: relative risk (RR) 1.17, 95% confidence interval (CI) 1.07–1.27], retention in care at 12 months (RR 1.11, 95% CI 0.99–1.26), and the likelihood of starting ART within 90 days (four trials: RR 1.35, 95% CI 1.13–1.62) and 12 months after eligibility was established (three trials: RR 1.17, 95% CI 1.07–1.27). There was a nonsignificant trend toward reduced mortality (three trials: RR 0.53, 95% CI 0.24–1.08), as well as reduced loss to follow-up at 12 months (2 trials: RR 0.66, 95% CI 0.42–1.04). In the observational studies, offering accelerated ART initiation resulted in a greater likelihood of having started ART within 3 months (two studies: RR 1.53, 95% CI 1.11–2.10). There was a trend toward an increased risk of being lost to follow-up at 6 months (three studies: RR 1.85, 95% CI 0.96–3.55). Conclusion: Accelerated ART initiation can lead to improved clinical outcomes and is likely to be of particular benefit in those settings where extensive patient preparation prior to starting ART results in long delays. These findings informed a WHO recommendation supporting accelerated ART initiation, including same day ART start.
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Differentiated models of care for postpartum women on antiretroviral therapy in Cape Town, South Africa: a cohort study. J Int AIDS Soc 2017; 20:21636. [PMID: 28770593 PMCID: PMC5577773 DOI: 10.7448/ias.20.5.21636] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background: The numbers of women initiating lifelong antiretroviral therapy (ART) during pregnancy and postpartum is increasing rapidly, presenting a burden on health systems and an urgent need for scalable models of care for this population. In a pilot project, we referred postpartum women who initiated ART during pregnancy to a community-based model of differentiated ART services. Methods: Eligible women (on ART for at least 3 months with viral load (VL)<1000 copies/mL) were offered a choice of two ART models of care: (i) referral to an existing system of community-based ‘adherence clubs’, operated by lay counsellors with medication collection every 2–4 months; or (ii) referral to local primary healthcare clinics (PHC) with services provided by clinicians and medication collection every 1–2 months (local standard of care for postpartum ART). For evaluation, women were followed through 6-months postpartum with VL testing separate from either ART service. Results: Through September 2015, n = 129 women were enrolled (median age, 28 years; median time postpartum, 10 days). Overall, 65% (n = 84) chose adherence clubs and 35% (n = 45) chose PHCs; there were no demographic or clinical predictors of this choice. Location of service delivery was commonly cited as a reason for choice by women selecting either model of care; shorter waiting times, ability to receive ART from lay counsellors and less frequent appointments were motivations for choosing adherence clubs. Among women choosing adherence clubs, 15% never attended the service and another 11% attended the service but were not retained through six months postpartum. Overall, 86% of women (n = 111) remained in the evaluation through 6 months postpartum; in this group, there were no differences in VL<1000 copies/mL at six months postpartum between women choosing PHCs (88%) vs. adherence clubs (92%; p = 0.483), but women who were not retained in adherence clubs were more likely to have VL≥1000 copies/mL compared to those who remained (p = 0.002). Discussion: Adherence clubs may be a valuable model for postpartum women initiating ART in pregnancy, with good short-term outcomes observed during this critical period. To support optimal implementation, further research is needed into patient preferences for models of care, with consideration of integration of maternal and child health services, while ART adherence and retention require ongoing consideration in this population.
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Stepped-Wedge Cluster Randomized Controlled Trial to Promote Option B+ Retention in Central Mozambique. J Acquir Immune Defic Syndr 2017; 76:273-280. [PMID: 28777263 DOI: 10.1097/qai.0000000000001515] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND This randomized trial studied performance of Option B+ in Mozambique and evaluated an enhanced retention package in public clinics. SETTING The study was conducted at 6 clinics in Manica and Sofala Provinces in central Mozambique. METHODS Seven hundred sixty-one pregnant women tested HIV+, immediately initiated antiretroviral (ARV) therapy, and were followed to track retention at 6 clinics from May 2014 to May 2015. Clinics were randomly allocated within a stepped-wedge fashion to intervention and control periods. The intervention included (1) workflow modifications and (2) active patient tracking. Retention was defined as percentage of patients returning for 30-, 60-, and 90-day medication refills within 25-35 days of previous refills. RESULTS During control periods, 52.3% of women returned for 30-day refills vs. 70.8% in intervention periods [odds ratio (OR): 1.80; 95% confidence interval (CI): 1.05 to 3.08]. At 60 days, 46.1% control vs. 57.9% intervention were retained (OR: 1.82; CI: 1.06 to 3.11), and at 90 days, 38.3% control vs. 41.0% intervention (OR: 1.04; CI: 0.60 to 1.82). In prespecified subanalyses, birth before pickups was strongly associated with failure-women giving birth before ARV pickup were 33.3 times (CI: 4.4 to 250.3), 7.5 times (CI: 3.6 to 15.9), and 3.7 times (CI: 2.2 to 6.0) as likely to not return for ARV pickups at 30, 60, and 90 days, respectively. CONCLUSIONS The intervention was effective at 30 and 60 days, but not at 90 days. Combined 90-day retention (40%) and adherence (22.5%) were low. Efforts to improve retention are particularly important for women giving birth before ARV refills.
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A group randomized trial using an appointment system to improve adherence to ART at reproductive and child health clinics implementing Option B+ in Tanzania. PLoS One 2017; 12:e0184591. [PMID: 28957381 PMCID: PMC5619716 DOI: 10.1371/journal.pone.0184591] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 08/18/2017] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION In October 2013, Tanzania adopted Option B+ under which HIV-positive pregnant women are initiated on antiretroviral therapy in reproductive and child health clinics at diagnosis. Studies have shown that adherence and retention to antiretroviral treatment can be problematic. METHODS We implemented a group randomized controlled trial in 24 reproductive and child health clinics in eight districts in Mbeya region. The trial tested the impact of implementing paper-based appointment tracking and community outreach systems on the rate of missed appointments and number of days covered by dispensed antiretroviral medications among women previously established on antiretroviral therapy. We used interrupted time series analysis to assess study outcomes. Clinic staff and patients in intervention clinics were aware of the intervention because of change in clinic procedures; data collectors knew the study group assignment. RESULTS Three months pre-intervention, we identified 1924 and 1226 patients established on antiretroviral therapy for six months or more in intervention and control clinics, respectively, of whom 83.4% and 86.9% had one or more post-intervention visits. The unadjusted rate of missed visits declined from 36.5% to 34.4% in intervention clinics and increased from 38.9% to 45.5% in control clinics following the intervention. Interrupted time series analyses demonstrated a net decrease of 13.7% (95% CI [-15.4,-12.1]) for missed visits at six months post-intervention. Similar differential changes were observed for visits missed by 3, 7, 15, or 60 days. CONCLUSION Appointment-tracking and community outreach significantly improved appointment-keeping for women on antiretroviral therapy. The facility staff controlled their workload better, identified missing patients rapidly, and worked with existing community organizations. There is now enough evidence to scale up this approach to all antiretroviral therapy and Option B+ reproductive and child health clinics in Tanzania as well as to evaluate the intervention in medical clinics that treat other chronic health conditions. TRIAL REGISTRATION Registry for International Development Impact Evaluations ID-55310280d8757.
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Naburi H, Mujinja P, Kilewo C, Orsini N, Bärnighausen T, Manji K, Biberfeld G, Sando D, Geldsetzer P, Chalamila G, Ekström AM. Job satisfaction and turnover intentions among health care staff providing services for prevention of mother-to-child transmission of HIV in Dar es Salaam, Tanzania. HUMAN RESOURCES FOR HEALTH 2017; 15:61. [PMID: 28874156 PMCID: PMC5585985 DOI: 10.1186/s12960-017-0235-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 08/25/2017] [Indexed: 05/31/2023]
Abstract
BACKGROUND Option B+ for the prevention of mother-to-child transmission (PMTCT) of HIV (i.e., lifelong antiretroviral treatment for all pregnant and breastfeeding mothers living with HIV) was initiated in Tanzania in 2013. While there is evidence that this policy has benefits for the health of the mother and the child, Option B+ may also increase the workload for health care providers in resource-constrained settings, possibly leading to job dissatisfaction and unwanted workforce turnover. METHODS From March to April 2014, a questionnaire asking about job satisfaction and turnover intentions was administered to all nurses at 36 public-sector health facilities offering antenatal and PMTCT services in Dar es Salaam, Tanzania. Multivariable logistic regression models were used to identify factors associated with job dissatisfaction and intention to quit one's job. RESULTS Slightly over half (54%, 114/213) of the providers were dissatisfied with their current job, and 35% (74/213) intended to leave their job. Most of the providers were dissatisfied with low salaries and high workload, but satisfied with workplace harmony and being able to follow their moral values. The odds of reporting to be globally dissatisfied with one's job were high if the provider was dissatisfied with salary (adjusted odds ratio (aOR) 5.6, 95% CI 1.2-26.8), availability of protective gear (aOR 4.0, 95% CI 1.5-10.6), job description (aOR 4.3, 95% CI 1.2-14.7), and working hours (aOR 3.2, 95% CI 1.3-7.6). Perceiving clients to prefer PMTCT Option B+ reduced job dissatisfaction (aOR 0.2, 95% CI 0.1-0.8). The following factors were associated with providers' intention to leave their current job: job stability dissatisfaction (aOR 3.7, 95% CI 1.3-10.5), not being recognized by one's superior (aOR 3.6, 95% CI 1.7-7.6), and poor feedback on the overall unit performance (aOR 2.7, 95% CI 1.3-5.8). CONCLUSION Job dissatisfaction and turnover intentions are comparatively high among nurses in Dar es Salaam's public-sector maternal care facilities. Providing reasonable salaries and working hours, clearer job descriptions, appropriate safety measures, job stability, and improved supervision and feedback will be key to retaining satisfied PMTCT providers and thus to sustain successful implementation of Option B+ in Tanzania.
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Affiliation(s)
- Helga Naburi
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania.
| | - Phares Mujinja
- School of Public Health, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Charles Kilewo
- Departments of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Nicola Orsini
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Till Bärnighausen
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
- Africa Health Research Institute (AHRI), Mtubatuba, South Africa
- Institute of Public Health, University of Heidelberg, Heidelberg, Germany
| | - Karim Manji
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Gunnel Biberfeld
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - David Sando
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
- Management and Development for Health (MDH) Organisation, Dar es Salaam, Tanzania
| | - Pascal Geldsetzer
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | - Guerino Chalamila
- Management and Development for Health (MDH) Organisation, Dar es Salaam, Tanzania
| | - Anna Mia Ekström
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
- Department of Infectious Diseases, Karolinska University Hospital, Huddinge, Stockholm, Sweden
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