Impact of decentralisation of antiretroviral therapy services on HIV testing and care at a population level in Agago District in rural Northern Uganda: results from the Lablite population surveys

Development and validation of an instrument for the evaluation of HIV care in Primary Health Care

OBJECTIVE

To develop and validate an instrument to evaluate the decentralization process of care for People Living with HIV in Primary Health Care.

METHOD

Methodological study, developed in four stages: elaboration of the logical model based on the triad Structure-Process-Outcomes; development of the instrument; content validation by expert judges and technical reviewers; and semantic validation. Online questionnaires were used, and the Kappa index was used for analysis.

RESULTS

The instrument with 68 items and 8 factors was submitted to validation by expert judges who recommended the exclusion of 3 items and the alteration of 2 factors. In the validation by technical reviewers, 2 items were excluded and 6 factors were highlighted; the agreement index was ≥0.75. In the semantic validation, 87.3% of the judges answered "totally agree" for the items presented.

CONCLUSION

The instrument is validated for its content, has 63 items and has the potential to assess the care provided for people living with HIV in Primary Health Care.

Construção e validação de instrumento avaliativo para atendimento ao HIV na Atenção Primária à Saúde

RESUMO Objetivo: construir e validar um instrumento de avaliação do processo de descentralização do atendimento às pessoas vivendo com HIV para Atenção Primária à Saúde. Métodos: estudo metodológico, desenvolvido em quatro etapas: elaboração do modelo lógico baseado na tríade Estrutura-Processo-Resultados; construção do instrumento; validação de conteúdo por juízes especialistas e revisores técnicos; e validação semântica. Utilizaram-se questionários on-line e, para análise, o índice de Kappa. Resultados: o instrumento, com 68 itens e 8 fatores, foi submetido à validação por juízes especialistas que recomendaram a exclusão de 3 itens e mudança de 2 fatores. Na validação por revisores técnicos, foram excluídos 2 itens e pontou-se 6 fatores, o índice de concordância foi ≥0,75. Na validação semântica 87,3% responderam “concordo totalmente” para os itens apresentados. Conclusões: O instrumento encontra-se validado quanto ao conteúdo, possui 63 itens e potencial para avaliação do atendimento às pessoas vivendo com HIV na Atenção Primária à Saúde.

Men missing from the HIV care continuum in sub-Saharan Africa: a meta-analysis and meta-synthesis

INTRODUCTION

Men are missing along the HIV care continuum. However, the estimated proportions of men in sub-Saharan Africa meeting the UNAIDS 95-95-95 goals vary substantially between studies. We sought to estimate proportions of men meeting each of the 95-95-95 goals across studies in sub-Saharan Africa, describe heterogeneity, and summarize qualitative evidence on factors influencing care engagement.

METHODS

We systematically searched PubMed and Embase for peer-reviewed articles published between 1 January 2014 and 16 October 2020. We included studies involving men ≥15 years old, with data from 2009 onward, reporting on at least one 95-95-95 goal in sub-Saharan Africa. We estimated pooled proportions of men meeting these goals using DerSimonion-Laird random effects models, stratifying by study population (e.g. studies focusing exclusively on men who have sex with men vs. studies that did not), facility setting (healthcare vs. community site), region (eastern/southern Africa vs. western/central Africa), outcome measurement (e.g. threshold for viral load suppression), median year of data collection (before vs. during or after 2017) and quality criteria. Data from qualitative studies exploring barriers to men's HIV care engagement were summarized using meta-synthesis.

RESULTS AND DISCUSSION

We screened 14,896 studies and included 129 studies in the meta-analysis, compiling data over the data collection period. Forty-seven studies reported data on knowledge of serostatus, 43 studies reported on antiretroviral therapy use and 74 studies reported on viral suppression. Approximately half of men with HIV reported not knowing their status (0.49 [95% CI, 0.41-0.58; range, 0.09-0.97]) or not being on treatment (0.58 [95% CI, 0.51-0.65; range, 0.07-0.97]), while over three-quarters of men achieved viral suppression on treatment (0.79 [95% CI, 0.77-0.81; range, 0.39-0.97]. Heterogeneity was high, with variation in estimates across study populations, settings and outcomes. The meta-synthesis of 40 studies identified three primary domains in which men described risks associated with engagement in HIV care: perceived social norms, health system challenges and poverty.

CONCLUSIONS

Psychosocial and systems-level interventions that change men's perceptions of social norms, improve trust in and accessibility of the health system, and address costs of accessing care are needed to better engage men, especially in HIV testing and treatment.

Diagnostic aspects and in-service training in the decentralization of care to people living with HIV

OBJECTIVE

To analyze the perception of nurses on the decentralization of care to people living with HIV.

METHOD

Exploratory, descriptive, qualitative study conducted with primary health care nurses based on Imogene King's Open Systems Theory (personal, interpersonal, and social). The data were obtained through interviews; a sociodemographic/professional questionnaire and a semi-structured script were employed, processed by the IRAMUTEQ software and analyzed through Descending Hierarchical Classification.

RESULTS

Study participants amounted to 32 nurses. Five classes emerged from the analysis: "diagnostic revelation process"; "professional training"; "preventive measures"; "barriers and potentials in the process of decentralization"; and "stigma and prejudice".

CONCLUSION

In the process of reorganization of the healthcare model for people living with HIV in primary health care, an important contribution by nurses in strengthening the local healthcare decentralization was identified.

"You Cannot Catch Fish Near the Shore nor Can You Sell Fish Where There Are No Customers": Rethinking Approaches for Reaching Men With HIV Testing Services in Blantyre Malawi

HIV testing is the entry point to the cascade of services within HIV care. Although Malawi has made positive strides in HIV testing, men are lagging at 65.5% while women are at 81.6%. This study explored the preferences of men on the avenues for HIV testing in Blantyre, Malawi. This was a descriptive qualitative study in the phenomenological tradition in seven public health facilities in Blantyre, Malawi, among men and health-care workers (HCWs). We conducted 20 in-depth interviews and held 14 focus group discussions among 113 men of varying HIV statuses. All our participants were purposively selected, and data were digitally recorded coded and managed through NVivo. Thematic analysis was guided by the differentiated service delivery model. Men reported a preference for formal and informal workplaces such as markets and other casual employment sites; social places like football pitches, bars, churches, and "bawo" spaces; and outreach services in the form of weekend door-to-door, mobile clinics, men-to-men group. The health facility was the least preferred avenue. The key to testing men for HIV is finding them where they are. Areas that can be leveraged in reaching men are outside the routine health system. Scaling up HIV testing among men will require targeting avenues and operations outside of the routine health system and leverage them to reach more men with services. This suggests that HIV testing and counseling (HTC) uptake among men may be increased if the services were provided at informal places.

Lessons for test and treat in an antiretroviral programme after decentralisation in Uganda: a retrospective analysis of outcomes in public healthcare facilities within the Lablite project

BACKGROUND

We describe the decentralisation of antiretroviral therapy (ART) alongside Option B+ roll-out in public healthcare facilities in the Lablite project in Uganda. Lessons learned will inform programmes now implementing universal test and treat (UTT).

METHODS

Routine data were retrospectively extracted from ART registers between October 2012 and March 2015 for all adults and children initiating ART at two primary care facilities (spokes) and their corresponding district hospitals (hubs) in northern and central Uganda. We describe ART initiation over time and retention and use of Cox models to explore risk factors for attrition due to mortality and loss to follow-up. Results from tracing of patients lost to follow-up were used to correct retention estimates.

RESULTS

Of 2100 ART initiations, 1125 were in the north, including 944 (84%) at the hub and 181 (16%) at the spokes; children comprised 95 (10%) initiations at the hubs and 14 (8%) at the spokes. Corresponding numbers were 642 (66%) at the hub and 333 (34%) at the spokes in the central region (77 [12%] and 22 [7%], respectively, in children). Children <3 y of age comprised the minority of initiations in children at all sites. Twenty-three percent of adult ART initiations at the north hub were Option B+ compared with 45% at the spokes (25% and 65%, respectively, in the central region). Proportions retained in care in the north hub at 6 and 12 mo were 92% (95% CI 90 to 93) and 89% (895% CI 7 to 91), respectively. Corresponding corrected estimates in the north spokes were 87% (95% CI 78 to 93) and 82% (95% CI 72 to 89), respectively. In the central hub, corrected estimates were 84% (95% CI 80 to 87) and 78% (95% CI 74 to 82), and were 89% (95% CI 77.9 to 95.1) and 83% (95% CI 64.1 to 92.9) at the spokes, respectively. Among adults newly initiating ART, being older was independently associated with a lower risk of attrition (adjusted hazard ratio [aHR] 0.93 per 5 y [95% CI 0.88 to 0.97]). Other independent risk factors included initiating with a tenofovir-based regimen vs zidovudine (aHR 0.60 [95% CI 0.46 to 0.77]), year of ART initiation (2013 aHR 1.55 [95% CI 1.21 to 1.97], ≥2014 aHR 1.41 [95% CI 1.06 to 1.87]) vs 2012, hub vs spoke (aHR 0.35 [95% CI 0.29 to 0.43]) and central vs north (aHR 2.28 [95% CI 1.86 to 2.81]). Independently, patient type was associated with retention.

CONCLUSIONS

After ART decentralisation, people living with human immunodeficiency virus (HIV) were willing to initiate ART in rural primary care facilities. Retention on ART was variable across facilities and attrition was higher among some groups, including younger adults and women initiating ART during pregnancy/breastfeeding. Interventions to support these groups are required to optimise benefits of expanded access to HIV services under UTT.

Acceptability of HIV testing for men attending televised football venues in Uganda

BACKGROUND

Worldwide, HIV remains a major public health challenge, especially in Sub-Saharan Africa. Literature indicates that men's involvement in HIV testing, care, and treatment services is lower compared to women, therefore novel approaches are required to engage men in the cascade of HIV care. This study aimed to explore men's perception on the provision of HIV testing services in venues where English Premier League football games are televised.

METHODS

An exploratory qualitative study was conducted between February and May 2018. Six focus group discussions were conducted with 50 conveniently selected men aged 18 years and older using a pre-tested discussion guide. All focus group discussions were audio recorded, transcribed verbatim, and analyzed thematically.

RESULTS

Overall, HIV testing at venues telecasting English Premier League football games was acceptable to men. There was a very strong preference for health workers providing testing and counseling services be external or unknown in the local community. Possible motivators for testing services provided in these settings include subsidizing or eliminating entrance fee to venues telecasting games, integrating testing and counseling with health promotion or screening for other diseases, use of local football games as mobilization tools and use of expert clients as role models.

CONCLUSIONS

This study suggests that HIV testing services at venues where EPL football games are televised is generally acceptable to men. In implementing such services, consideration should be given to preferences for external or unknown health workers and the motivating factors contributing to the use of these services. Given that HIV testing is currently not conducted in these settings, further research should be conducted to evaluate the feasibility of this approach as a means of enhancing HIV testing among Ugandan men.

Patient-level benefits associated with decentralization of antiretroviral therapy services to primary health facilities in Malawi and Uganda

Background

The Lablite project captured information on access to antiretroviral therapy (ART) at larger health facilities ('hubs') and lower-level health facilities ('spokes') in Phalombe district, Malawi and in Kalungu district, Uganda.

Methods

We conducted a cross-sectional survey among patients who had transferred to a spoke after treatment initiation (Malawi, n=54; Uganda, n=33), patients who initiated treatment at a spoke (Malawi, n=50; Uganda, n=44) and patients receiving treatment at a hub (Malawi, n=44; Uganda, n=46).

Results

In Malawi, 47% of patients mapped to the two lowest wealth quintiles (Q1-Q2); patients at spokes were poorer than at a hub (57% vs 23% in Q1-Q2; p<0.001). In Uganda, 7% of patients mapped to Q1-Q2; patients at the rural spoke were poorer than at the two peri-urban facilities (15% vs 4% in Q1-Q2; p<0.001). The median travel time one way to a current ART facility was 60 min (IQR 30-120) in Malawi and 30 min (IQR 20-60) in Uganda. Patients who had transferred to the spokes reported a median reduction in travel time of 90 min in Malawi and 30 min in Uganda, with reductions in distance and food costs.

Conclusions

Decentralizing ART improves access to treatment. Community-level access to treatment should be considered to further minimize costs and time.