1
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Psychosocial Interventions to Promote Undetectable HIV Viral Loads: A Systematic Review of Randomized Clinical Trials. AIDS Behav 2022; 26:1853-1862. [PMID: 34783938 DOI: 10.1007/s10461-021-03534-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2021] [Indexed: 10/19/2022]
Abstract
Suppressing HIV viral loads to undetectable levels is essential for ending the HIV/AIDS epidemic. We evaluated randomized controlled trials aimed to increase antiretroviral medication adherence and promote undetectable viral loads among people living with HIV through November 22, 2019. We extracted data from 51 eligible interventions and analyzed the results using random effects models to compare intervention effects between groups within each intervention and across interventions. We also evaluated the relation between publication date and treatment effects. Only five interventions increased undetectable viral loads significantly. As a whole, the analyzed interventions were superior to Standard of Care in promoting undetectable viral loads. Interventions published more recently were not more effective in promoting undetectable viral loads. No treatment category consistently produced significant increases in undetectable viral loads. To end the HIV/AIDS epidemic, we should use interventions that can suppress HIV viral loads to undetectable levels.
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2
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Sabin LL, Gifford AL, Haberer JE, Harvey K, Sarkisova N, Martin K, West RL, Stephens J, Killian C, Halim N, Berkowitz N, Jennings K, Jennings L, Orrell C. Patients' and Providers' Views on Optimal Evidence-Based and Scalable Interventions for Individuals at High Risk of HIV Treatment Failure: Sequential Explorations Among Key Stakeholders in Cape Town, South Africa. AIDS Behav 2022; 26:2783-2797. [PMID: 35190943 DOI: 10.1007/s10461-022-03623-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2022] [Indexed: 11/25/2022]
Abstract
To support translation of evidence-based interventions into practice for HIV patients at high risk of treatment failure, we conducted qualitative research in Cape Town, South Africa. After local health officials vetted interventions as potentially scalable, we held 41 in-depth interviews with patients with elevated viral load or a 3-month treatment gap at community clinics, followed by focus group discussions (FGDs) with 20 providers (physicians/nurses, counselors, and community health care workers). Interviews queried treatment barriers, solutions, and specific intervention options, including motivational text messages, data-informed counseling, individual counseling, peer support groups, check-in texts, and treatment buddies. Based on patients' preferences, motivational texts and treatment buddies were removed from consideration in subsequent FGDs. Patients most preferred peer support groups and check-in texts while individual counseling garnered the broadest support among providers. Check-in texts, peer support groups, and data-informed counseling were also endorsed by provider sub-groups. These strategies warrant attention for scale-up in South Africa and other resource-constrained settings.
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Affiliation(s)
- Lora L Sabin
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown, 3rd Floor, Boston, MA, 02118, USA.
| | - Allen L Gifford
- Section of General Internal Medicine, Boston University School of Medicine and Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA, 02118, USA
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, 02130, USA
| | - Jessica E Haberer
- Center of Global Health, Massachusetts General Hospital, Boston, MA, 02114, USA
- Department of Medicine, Harvard Medical School, Boston, MA, 02114, USA
| | - Kelsee Harvey
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown, 3rd Floor, Boston, MA, 02118, USA
| | - Natalya Sarkisova
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown, 3rd Floor, Boston, MA, 02118, USA
| | - Kyle Martin
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown, 3rd Floor, Boston, MA, 02118, USA
| | - Rebecca L West
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown, 3rd Floor, Boston, MA, 02118, USA
| | - Jessie Stephens
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown, 3rd Floor, Boston, MA, 02118, USA
| | - Clare Killian
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown, 3rd Floor, Boston, MA, 02118, USA
| | - Nafisa Halim
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown, 3rd Floor, Boston, MA, 02118, USA
| | | | - Karen Jennings
- City of Cape Town Health Department, Cape Town, South Africa
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3
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Hill LM, Saidi F, Freeborn K, Amico KR, Rosenberg NE, Maman S, Phanga T, Tsidya M, Chirwa S, Zimba C, Mutale W, Chi BH. Tonse Pamodzi: Developing a combination strategy to support adherence to antiretroviral therapy and HIV pre-exposure prophylaxis during pregnancy and breastfeeding. PLoS One 2021; 16:e0253280. [PMID: 34170913 PMCID: PMC8232532 DOI: 10.1371/journal.pone.0253280] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 06/01/2021] [Indexed: 11/19/2022] Open
Abstract
To eliminate mother-to-child transmission of HIV (EMTCT), scalable strategies to enhance antiretroviral adherence for both antiretroviral therapy (ART) and pre-exposure prophylaxis (PrEP) are needed as part of integrated HIV and maternal-child health services. We developed Tonse Pamodzi ("all of us together"), an adaptable intervention integrating biomedical and behavioral components to support HIV treatment and prevention. We describe our intervention development process, which comprised formative qualitative research, a review of the literature, and technical input from stakeholders representing the community, health systems, and policymakers. The resulting intervention, described herein, integrates patient-centered counseling and engagement of a patient-selected adherence supporter for pregnant and breastfeeding women initiating ART or PrEP. Patients receiving the intervention engage in Integrated Next Step Counseling (iNSC) sessions delivered by trained counselors to build and maintain adherence skills. Each patient also has the option of selecting an adherence supporter (partner, family member, or friend) who may participate in iNSC sessions and provide adherence support outside of these sessions. This flexible intervention is adaptable not only to ART or PrEP use, but also to the needs and preferences of each woman and the clinical context. If shown to be acceptable and feasible, the Tonse Pamodzi intervention may be an important tool in continuing efforts for EMTCT.
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Affiliation(s)
- Lauren M. Hill
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, United States of America
- * E-mail:
| | | | - Kellie Freeborn
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina, Chapel Hill, NC, United States of America
| | - K. Rivet Amico
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI, United States of America
| | - Nora E. Rosenberg
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, United States of America
| | - Suzanne Maman
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, United States of America
| | | | | | | | | | - Wilbroad Mutale
- Department of Health Policy, University of Zambia School of Public Health, Lusaka, Zambia
| | - Benjamin H. Chi
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina, Chapel Hill, NC, United States of America
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4
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Kebede HK, Gesesew HA, Mwanri L, Ward P. The Impact of Peer Educators or Community Health Workers on the Progress of the UNAIDS 90-90-90 Targets in Africa: A Systematic Review and Meta-Analysis Protocol. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18083917. [PMID: 33917917 PMCID: PMC8068227 DOI: 10.3390/ijerph18083917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 03/30/2021] [Accepted: 03/31/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Africa is far behind from achieving the Joint United Nations Program on HIV and AIDS (UNAIDS) 90-90-90 targets. Evidence shows that the participation of HIV patients as peer educators and other community health workers is substantially improving the entire HIV care continuum and subsequently the UNAIDS targets. This review aims to provide the best available evidence on the impact of peer educators and/or community health workers for the three targets in Africa. METHODS We will include cohort and experimental studies published in English between 2003 and 2020. Studies which reported interventions for HIV diagnosis, initiation of ART, or virological suppression will be included for review. Three steps searching will be conducted: (i) initial search across Google Scholar, (ii) full search strategy across five databases: MEDLINE, PubMed, CINAHL, SCOPUS and Web of Science, and (iii) screening titles and abstracts. Data will be extracted using standardized instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) and analyzed through narrative synthesis, and meta-analyses and regression. Heterogeneity among quantitative studies will be assessed using Cochran Q test and Higgins I2. Ethics: A formal ethical approval will not be required as primary data will not be collected.
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Affiliation(s)
| | - Hailay Abrha Gesesew
- Public Health, College of Medicine and Public Health, Flinders University, Adelaide 5042, Australia; (L.M.); (P.W.)
- Epidemiology, School of Health Sciences, Mekelle University, Mekelle 231, Ethiopia
- Correspondence: ; Tel.: +251-924-955-116
| | - Lillian Mwanri
- Public Health, College of Medicine and Public Health, Flinders University, Adelaide 5042, Australia; (L.M.); (P.W.)
| | - Paul Ward
- Public Health, College of Medicine and Public Health, Flinders University, Adelaide 5042, Australia; (L.M.); (P.W.)
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5
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Musa J, Mehta SD, Achenbach CJ, Evans CT, Jordan N, Magaji FA, Pam VC, Daru PH, Silas OA, Sagay AS, Anorlu R, Zheng Y, Maiga M, Adewole IF, Murphy RL, Hou L, Simon MA. HIV and development of epithelial cell abnormalities in women with prior normal cervical cytology in Nigeria. Infect Agent Cancer 2020; 15:50. [PMID: 32760435 PMCID: PMC7392708 DOI: 10.1186/s13027-020-00316-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/21/2020] [Indexed: 12/28/2022] Open
Abstract
Background HIV-associated cellular immune dysfunction has been linked to higher risk of cervical dysplasia and cancer in HIV infected women. We sought to understand the relationship between HIV and development of epithelial cell abnormalities (ECA) at follow-up in women with prior normal cervical cytology (NCC). Methods Retrospective cohort analysis of women who received a Pap test at the Operation Stop Cervical Cancer Unit in Jos, Nigeria over a 10-year period (2006-2016). We analyzed the data of women with NCC at first Pap who had at least one follow-up cytology result for time-to-detection of ECA. We determined follow-up time in years from date of first NCC to date of first ECA report or date of last NCC follow up report with censoring at last follow-up date or December 31st, 2016 whichever came first. The primary outcome was development of any ECA as defined by the Bethesda 2001 reporting system. We identified demographic and clinical factors associated with incident ECA using multivariable Cox regression. Results A total of 1599 women were eligible for this analysis. Overall, 3.7% (57/1556) of women reported being HIV infected. The median age at first Pap was 39 years (IQR; 33-45). The HIV infected women were younger (36.3 ± 8.1) compared to those uninfected (39.3 ± 6.6), p = 0.005. After an accrued follow-up time of 3809 person-years (PYs), 243 women (15%) had an ECA with an event rate of 6.38 per 100 PYs. Women ≥35 years at first Pap were more likely to have an ECA compared to those < 35 years (7.5 per 100 PYs vs 3.8 per 100 PYs, HR = 1.96; 95% CI: 1.4, 2.8). HIV status was not significantly associated with developing ECA in either unadjusted (7.4 per 100 PYs vs 6.4 per 100 PYs, HR = 1.17; 95% CI: 0.53, 2.3) or adjusted analyses (aHR = 1.78; 95% CI: 0.87, 3.65). Conclusion Women living with HIV and on successful antiretroviral treatment may not have a differential hazard in the development of ECA during follow up after a prior normal Pap. Offering a repeat CCS to women who are 35 years or older irrespective of HIV status is likely an effective strategy in resource limited settings.
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Affiliation(s)
- Jonah Musa
- Department of Obstetrics and Gynecology, College of Medical Sciences, University of Jos, Jos, Plateau State Nigeria.,Department of Preventive Medicine, Division of Cancer Epidemiology and Prevention, Feinberg School of Medicine, Northwestern University, Chicago, USA.,Center for Global Oncology, Institute for Global Health, Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - Supriya D Mehta
- Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, IL USA
| | - Chad J Achenbach
- Center for Global Oncology, Institute for Global Health, Feinberg School of Medicine, Northwestern University, Chicago, USA.,Division of Infectious Diseases, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - Charlesnika T Evans
- Department of Preventive Medicine, Center for Health Services and Outcomes Research, Global Health, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL USA.,Center of Innovation for Complex Chronic Healthcare (CINCCH), Department of Veterans Affairs, Edward Hines Jr. VA Hospital, Hines, IL USA
| | - Neil Jordan
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Department of Veterans Affairs, Edward Hines Jr. VA Hospital, Hines, IL USA.,Department of Psychiatry & Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - Francis A Magaji
- Department of Obstetrics and Gynecology, College of Medical Sciences, University of Jos, Jos, Plateau State Nigeria
| | - Victor C Pam
- Department of Obstetrics and Gynecology, College of Medical Sciences, University of Jos, Jos, Plateau State Nigeria
| | - Patrick H Daru
- Department of Obstetrics and Gynecology, College of Medical Sciences, University of Jos, Jos, Plateau State Nigeria
| | - Olugbenga A Silas
- Department of Pathology, Faculty of Medical Sciences, University of Jos, Jos, Plateau State Nigeria
| | - Atiene S Sagay
- Department of Obstetrics and Gynecology, College of Medical Sciences, University of Jos, Jos, Plateau State Nigeria
| | - Rose Anorlu
- Department of Obstetrics and Gynecology, College of Medicine, University of Lagos, Jos, Nigeria
| | - Yinan Zheng
- Center for Population Epigenetics, Robert H. Lurie Comprehensive Cancer Center and Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611 USA
| | - Mamoudou Maiga
- Center for Global Oncology, Institute for Global Health, Feinberg School of Medicine, Northwestern University, Chicago, USA.,Techniques and Technologies of Bamako, University of Sciences, Bamako, Mali
| | - Isaac F Adewole
- Department of Obstetrics and Gynecology, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Robert L Murphy
- Center for Global Oncology, Institute for Global Health, Feinberg School of Medicine, Northwestern University, Chicago, USA.,Division of Infectious Diseases, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - Lifang Hou
- Center for Global Oncology, Institute for Global Health, Feinberg School of Medicine, Northwestern University, Chicago, USA.,Center for Population Epigenetics, Robert H. Lurie Comprehensive Cancer Center and Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611 USA
| | - Melissa A Simon
- Department of Obstetrics and Gynecology, Preventive Medicine and Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, USA
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6
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Harling G, Tsai AC. Using Social Networks to Understand and Overcome Implementation Barriers in the Global HIV Response. J Acquir Immune Defic Syndr 2019; 82 Suppl 3:S244-S252. [PMID: 31764260 PMCID: PMC6923140 DOI: 10.1097/qai.0000000000002203] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Despite the development of several efficacious HIV prevention and treatment methods in the past 2 decades, HIV continues to spread globally. Uptake of interventions is nonrandomly distributed across populations. Such inequality is socially patterned and reinforced by homophily arising from both social selection (becoming friends with similar people) and influence (becoming similar to friends). METHODS We conducted a narrative review to describe how social network analysis methods-including egocentric, sociocentric, and respondent-driven sampling designs-provide tools to measure key populations, to understand how epidemics spread, and to evaluate intervention take-up. RESULTS Social network analysis-informed designs can improve intervention effectiveness by reaching otherwise inaccessible populations. They can also improve intervention efficiency by maximizing spillovers, through social ties, to at-risk but susceptible individuals. Social network analysis-informed designs thus have the potential to be both more effective and less unequal in their effects, compared with social network analysis-naïve approaches. Although social network analysis-informed designs are often resource-intensive, we believe they provide unique insights that can help reach those most in need of HIV prevention and treatment interventions. CONCLUSION Increased collection of social network data during both research and implementation work would provide important information to improve the roll-out of existing studies in the present and to inform the design of more data-efficient, social network analysis-informed interventions in the future. Doing so will improve the reach of interventions, especially to key populations, and to maximize intervention impact once delivered.
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Affiliation(s)
- Guy Harling
- Institute for Global Health, University College London, London, United Kingdom
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Department of Epidemiology and Harvard Center for Population and Development Studies, Harvard University, Cambridge MA, United States
- MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), University of the Witwatersrand, Johannesburg, South Africa
| | - Alexander C. Tsai
- Department of Epidemiology and Harvard Center for Population and Development Studies, Harvard University, Cambridge MA, United States
- Chester M. Pierce, MD Division of Global Psychiatry, Massachusetts General Hospital, Boston MA United States
- Mbarara University of Science and Technology, Mbarara, Uganda
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7
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Abah IO, Ncube NBQ, Bradley HA, AgbaJi OO, Kanki P. Antiretroviral Therapy-associated Adverse Drug Reactions and their Effects on Virologic Failure- A Retrospective Cohort Study in Nigeria. Curr HIV Res 2019; 16:436-446. [PMID: 30767743 PMCID: PMC6446442 DOI: 10.2174/1389450120666190214144609] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 02/04/2019] [Accepted: 02/11/2019] [Indexed: 01/30/2023]
Abstract
Background: Adverse drug reactions (ADRs) associated with antiretroviral therapy (ART) can rapidly reverse the gains of ART resulting in poor health outcomes. We need an improved under-standing of specific ART-related ADRs that influence virologic outcomes. Objective: To investigate the frequency of clinical ADRs and assess their effect on virologic failure in patients on ART. Method: We described the prevalence of major clinical ADRs, and the association between specific ADRs and virologic failure in a clinic cohort of HIV-1 infected Nigerians aged ≥18 years, on first-line ART between June 2004 and February 2012. Multivariable logistic regression was run to identify predictors of virologic failure at 24 and 72 weeks of ART. Results: Data of 12,115 patients with a median age of 34 (interquartile range: 29-41) years, and pre-dominantly females (67%) were evaluated. Overall, 957 (7.9%) patients experienced at least one ADR during a median follow-up period of 4 years (interquartile range: 1-7). The three most prevalent ADRs were lipodystrophy (2.6%), anemia (1.9%), and skin rash (0.7%). Virologic failure rate was 36% and 34% at 24 and 72 weeks of ART, respectively. Anemia independently predicted the odds of virologic failure at 72 weeks of ART (adjusted odds ratio, 1.74; 95% CI: 1.2-2.51); adjusted for sex, age, pre-treatment CD4+ cell count, antiretroviral regimen, and medication refill adherence. Conclusion: Antiretroviral therapy-associated anemia increases the likelihood of late virologic failure. We recommend routine monitoring of hemoglobin levels and prompt management of anemia in all pa-tients on ART as a strategy to improve virologic success rates.
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Affiliation(s)
- Isaac O Abah
- School of Public Health, University of the Western Cape, Bellville, South Africa.,Pharmacy Department, Jos University Teaching Hospital, Jos, Nigeria
| | - Nondumiso B Q Ncube
- School of Public Health, University of the Western Cape, Bellville, South Africa
| | - Hazel A Bradley
- School of Public Health, University of the Western Cape, Bellville, South Africa
| | - Oche O AgbaJi
- Department of Medicine Jos University Teaching Hospital/University of Jos, Jos, Nigeria
| | - Phyllis Kanki
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, United States
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8
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Chen YN, Coker D, Kramer MR, Johnson BA, Wall KM, Ordóñez CE, McDaniel D, Edwards A, Hare AQ, Sunpath H, Marconi VC. The Impacts of Residential Location on the Risk of HIV Virologic Failure Among ART Users in Durban, South Africa. AIDS Behav 2019; 23:2558-2575. [PMID: 31049812 DOI: 10.1007/s10461-019-02523-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Using a case-control study of patients receiving antiretroviral treatment (ART) in 2010-2012 at McCord Hospital in Durban, South Africa, we sought to understand how residential locations impact patients' risk of virologic failure (VF). Using generalized estimating equations to fit logistic regression models, we estimated the associations of VF with socioeconomic status (SES) and geographic access to care. We then determined whether neighborhood-level poverty modifies the association between individual-level SES and VF. Automobile ownership for men and having non-spouse family members pay medical care for women remained independently associated with increased odds of VF for patients dwelling in moderately and severely poor neighborhoods. Closer geographic proximity to medical care was positively associated with VF among men, while higher neighborhood-level poverty was positively associated with VF among women. The programmatic implications of our findings include developing ART adherence interventions that address the role of gender in both the socioeconomic and geographical contexts.
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Affiliation(s)
- Yi-No Chen
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
| | - Daniella Coker
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Michael R Kramer
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Brent A Johnson
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, NY, USA
| | - Kristin M Wall
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Claudia E Ordóñez
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Darius McDaniel
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Alex Edwards
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Anna Q Hare
- Department of Dermatology, Oregon Health and Sciences University, Portland, OR, USA
| | - Henry Sunpath
- Infectious Diseases Unit, Nelson Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Vincent C Marconi
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
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9
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Dave S, Peter T, Fogarty C, Karatzas N, Belinsky N, Pant Pai N. Which community-based HIV initiatives are effective in achieving UNAIDS 90-90-90 targets? A systematic review and meta-analysis of evidence (2007-2018). PLoS One 2019; 14:e0219826. [PMID: 31314764 PMCID: PMC6636761 DOI: 10.1371/journal.pone.0219826] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 07/02/2019] [Indexed: 12/21/2022] Open
Abstract
Background Reaching the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 targets to end the HIV epidemic relies on effective interventions that engage untested HIV+ individuals and retain them in care. Evidence on community-based interventions through the lens of the targets has not yet been synthesized, reflecting a knowledge gap. We conducted a systematic review and meta-analysis to shed light on successful community-based interventions that have been effective in contributing, directly or indirectly, towards the UNAIDS 90-90-90 targets: knowledge of HIV status, linkage to care/on treatment, and viral suppression. Linkage to care was also included in this review due to the limitations of studies. Methods We conducted a systematic review and meta-analysis of the period 2007–2018. Eleven databases were searched to identify community-based interventions designed to improve knowledge of HIV status (in particular HIV testing), linkage to care/on treatment, and/or viral suppression. Eligible studies were classified by intervention, population, country income level, outcomes and success. Success was defined as interventions demonstrating statistical significance between intervention and control group or that reached any target by proportion; 90% testing, 81% linked to care/on treatment and 73% viral suppression. Results Of 82 eligible studies, 51.2% (42/82) reported on HIV testing (first 90), 20.7% (17/82) on linkage to care/ on treatment (second 90), and 45.1% (37/82) on viral suppression (third 90). In all, 67.1% (55/82) of studies reported success; 21 studies on the first 90, 9 towards linkage to care/on treatment, and 25 towards the third. By strategies, 36.6% deployed community workers/peers, 22% used combined test and treat strategies, 12.2% used educational methods, 8.5% used mobile testing, 7.3% used campaigns and 13.4% used technology. For HIV testing/linkage, combined test/treat interventions were often used, for viral suppression, educational interventions and technologies were commonly deployed. Our pooled analysis suggested that deployment of community health care workers/peer workers significantly improved viral suppression (pooled OR: 1.40 95% CI 1.06–1.86). Of the studies published after 2014, 50.0% reported metrics aligned with UNAIDS targets. Conclusions Data on linkage to care/on treatment (second target) remained weak, because many studies reported successes on the first and third targets. Stratification by targets and country income levels is informative and guides adaptation of successful interventions in comparable settings. Consistent reporting of clear metrics aligned with UNAIDS targets will aid in synergy of study data with programmatic data that will help reportage. Exploration of innovative interventions, for engagement and linkage and deployment of community/ peer workers is strongly encouraged.
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Affiliation(s)
- Sailly Dave
- Division of Clinical Epidemiology, Research Institute of the McGill University Health Centre, Montreal, Canada
| | - Trevor Peter
- Clinton Health Access Initiative, Gaborone, Botswana
- * E-mail: (NPP); (TP)
| | - Clare Fogarty
- Division of Clinical Epidemiology, Research Institute of the McGill University Health Centre, Montreal, Canada
| | - Nicolaos Karatzas
- Division of Clinical Epidemiology, Research Institute of the McGill University Health Centre, Montreal, Canada
| | - Nandi Belinsky
- Division of Clinical Epidemiology, Research Institute of the McGill University Health Centre, Montreal, Canada
| | - Nitika Pant Pai
- Division of Clinical Epidemiology, Research Institute of the McGill University Health Centre, Montreal, Canada
- Department of Medicine, McGill University, Montreal, Quebec, Canada
- * E-mail: (NPP); (TP)
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10
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A Social Network Analysis of HIV Treatment Partners and Patient Viral Suppression in Botswana. J Acquir Immune Defic Syndr 2019; 78:183-192. [PMID: 29465627 DOI: 10.1097/qai.0000000000001661] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Many national HIV guidelines recommend that health care providers encourage patients to identify a treatment partner from their social network to support antiretroviral therapy adherence. This study examined associations of patient and treatment partner characteristics with patient viral suppression in Botswana. DESIGN One hundred thirty-one patients [67 (51.1%) virally suppressed and 64 (48.9%) not suppressed] and their treatment partners were recruited for cross-sectional interviews from one HIV clinic. METHODS Participants completed surveys assessing social network, sociodemographic, and psychosocial characteristics. Open-ended questions explored treatment partner relationship quality. RESULTS Multivariate logistic regressions indicated a higher likelihood of viral suppression among patients who reported greater average emotional closeness to their network members [odds ratio (95% confidence interval) = 3.8 (1.3 to 11.5), P = 0.02] and whose treatment partners were spouses/partners [odds ratio (95% confidence interval) = 2.6 (1.0 to 6.7), P = 0.04]. Qualitative analyses indicated that treatment partners of suppressed patients provided both medical and nonmedical support, whereas treatment partners of unsuppressed patients focused mainly on adherence reminders and appointment accompaniment. Treatment partners, especially of unsuppressed patients, requested ongoing training and counseling skills. CONCLUSIONS Additional research is needed to further explore effective characteristics of treatment partners to inform HIV treatment guidelines. Standard training for treatment partners could include medical-related information and counseling education.
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Martin SL, Wawire V, Ombunda H, Li T, Sklar K, Tzehaie H, Wong A, Pelto GH, Omotayo MO, Chapleau GM, Stoltzfus RJ, Dickin KL. Integrating Calcium Supplementation into Facility-Based Antenatal Care Services in Western Kenya: A Qualitative Process Evaluation to Identify Implementation Barriers and Facilitators. Curr Dev Nutr 2018; 2:nzy068. [PMID: 30402593 PMCID: PMC6215767 DOI: 10.1093/cdn/nzy068] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 07/11/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND In countries with low calcium intake, the WHO recommends integrating calcium supplementation into antenatal care (ANC) to reduce the risk of preeclampsia, a leading cause of maternal mortality. Current WHO guidelines recommend women take 3-4 calcium supplements plus 1 iron-folic acid supplement at separate times daily. There is limited evidence about implementing these guidelines through routine ANC. Through the Micronutrient Initiative-Cornell University Calcium (MICa) trial, we examined the effect of regimen on supplement consumption among ANC clients in western Kenya. A nested process evaluation examined factors that influence calcium supplementation delivery and uptake. OBJECTIVES This process evaluation assessed ANC providers', pregnant women's, and family members' experiences with calcium supplementation, and investigated the feasibility and acceptability of engaging family members to support adherence. METHODS We conducted semistructured interviews with 7 ANC providers, 32 pregnant women, and 20 adherence partners (family members who provide reminders and support), and 200 observations of ANC consultations. Interviews were transcribed, translated, and analyzed thematically. Observational data were summarized. RESULTS ANC providers reported positive feelings about calcium supplementation, the training received, and counseling materials, but reported increased workloads. Women reported that providers counseled them on supplement benefits and managing side effects, offered reminder strategies, and provided supplements and behavior change materials. Women explained that reminder materials and adherence partners improved adherence. Most adherence partners reported providing reminders and other instrumental support to help with pill taking, which women confirmed and appreciated. Some women reported that comorbidities, concerns about being perceived as HIV positive, pill burden, unfavorable organoleptic properties, and lack of food were adherence barriers. CONCLUSIONS Although integrating calcium into antenatal iron-folic acid supplementation was generally acceptable to ANC providers, pregnant women, and their families, calcium supplementation presents unique challenges that must be considered to successfully implement these guidelines.This trial was registered at clinicaltrials.gov as NCT02238704.
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Affiliation(s)
- Stephanie L Martin
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Violet Wawire
- Department of Education Foundation, Kenyatta University, Nairobi, Kenya
| | - Hedwig Ombunda
- Faculty of Education and Arts, KCA University, Nairobi, Kenya
| | - Terry Li
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY
| | - Kelsey Sklar
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY
| | - Hiwet Tzehaie
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY
| | - Athena Wong
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY
| | - Gretel H Pelto
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY
| | - Moshood O Omotayo
- Department of Epidemiology and Environmental Health, University at Buffalo, Buffalo, NY
| | - Gina M Chapleau
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY
| | - Rebecca J Stoltzfus
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY
| | - Katherine L Dickin
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY
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Zullig LL, Deschodt M, Liska J, Bosworth HB, De Geest S. Moving from the Trial to the Real World: Improving Medication Adherence Using Insights of Implementation Science. Annu Rev Pharmacol Toxicol 2018; 59:423-445. [PMID: 30125127 DOI: 10.1146/annurev-pharmtox-010818-021348] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Medication nonadherence is a serious public health concern. Although there are promising interventions that improve medication adherence, most interventions are developed and tested in tightly controlled research environments that are dissimilar from the real-world settings where the majority of patients receive health care. Implementation science methods have the potential to facilitate and accelerate the translation shift from the trial world to the real world. We demonstrate their potential by reviewing published, high-quality medication adherence studies that could potentially be translated into clinical practice yet lack essential implementation science building blocks. We further illustrate this point by describing an adherence study that demonstrates how implementation science creates a junction between research and real-world settings. This article is a call to action for researchers, clinicians, policy makers, pharmaceutical companies, and others involved in the delivery of care to adopt the implementation science paradigm in the scale-up of adherence (research) programs.
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Affiliation(s)
- Leah L Zullig
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Health Care System, Durham, North Carolina 27701, USA.,Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina 27707, USA;
| | - Mieke Deschodt
- Institute of Nursing Science, Department of Public Health, University of Basel, 4056 Basel, Switzerland; .,Division of Gerontology and Geriatrics, Department of Chronic Diseases, Metabolism, and Ageing, KU Leuven, 3000 Leuven, Belgium
| | - Jan Liska
- Patient Solutions Unit, Medical Evidence Generation Team, Sanofi, 75008 Paris, France
| | - Hayden B Bosworth
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Health Care System, Durham, North Carolina 27701, USA.,Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina 27707, USA;
| | - Sabina De Geest
- Institute of Nursing Science, Department of Public Health, University of Basel, 4056 Basel, Switzerland; .,Academic Centre for Nursing and Midwifery, Department of Public Health and Primary Care, KU Leuven, 3000 Leuven, Belgium
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HIV viral suppression and geospatial patterns of HIV antiretroviral therapy treatment facility use in Rakai, Uganda. AIDS 2018; 32:819-824. [PMID: 29369167 DOI: 10.1097/qad.0000000000001761] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess geospatial patterns of HIV antiretroviral therapy (ART) treatment facility use and whether they were impacted by viral load suppression. METHODS We extracted data on the location and type of care services utilized by HIV-positive persons accessing ART between February 2015 and September 2016 from the Rakai Community Cohort Study in Uganda. The distance from Rakai Community Cohort Study households to facilities offering ART was calculated using the open street map road network. Modified Poisson regression was used to identify predictors of distance traveled and, for those traveling beyond their nearest facility, the probability of accessing services from a tertiary care facility. RESULTS In total, 1554 HIV-positive participants were identified, of whom 68% had initiated ART. The median distance from households to the nearest ART facility was 3.10 km (interquartile range, 1.65-5.05), but the median distance traveled was 5.26 km (interquartile range, 3.00-10.03, P < 0.001) and 57% of individuals travelled further than their nearest facility for ART. Those with higher education and wealth were more likely to travel further. In total, 93% of persons on ART were virally suppressed, and there was no difference in the distance traveled to an ART facility between those with suppressed and unsuppressed viral loads (5.26 vs. 5.27 km, P = 0.650). CONCLUSION Distance traveled to HIV clinics was increased with higher socioeconomic status, suggesting that wealthier individuals exercise greater choice. However, distance traveled did not vary by those who were or were not virally suppressed.
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Amram O, Wang L, Sereda P, Shoveller JA, Barrios R, Montaner JSG, Lima VD. ASSESSING THE RELATIONSHIP BETWEEN PHYSICIAN AVAILABILITY AND VIRAL LOAD SUPPRESSION IN BRITISH COLUMBIA. THE CANADIAN GEOGRAPHER. GEOGRAPHE CANADIEN 2017; 62:120-129. [PMID: 30504965 PMCID: PMC6261522 DOI: 10.1111/cag.12433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVES In 2014, the Joint United Nations Programme HIV/AIDS (UNAIDS) set the target of dramatically reducing the burden of HIV through expansion of access to timely HIV treatment. In order to achieve this target it is necessary to expand access to care along the HIV cascade of care. This study examines the relationship between viral suppression and the availability of physicians providing HIV treatment in British Columbia, Canada. METHODS Data from the Drug Treatment Program of the British Columbia (BC) Centre for Excellence in HIV/AIDS was used for this analysis. The floating catchment method was used to assess physician availability. Multivariable Logistic Regression was used to implement a confounder selection technique to independently assess the relationship between physician availability and viral load suppression. RESULTS Individuals with more than 25 physicians within a one-hour catchment were more likely to reside in urban areas and almost twice as likely to have a suppressed viral load (adjusted odd ratio: 1.97; 95% CI 1.50 - 2.58). CONCLUSIONS This study highlights the impact of physicians' availability on viral load levels. Mapping technology was used to identify the locations in which patients were most impacted by the lack of physicians.
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Affiliation(s)
- Ofer Amram
- Spokane Health Education and Research Building Third Floor, P O Box 1495 , Spokane, WA 99210-1495. Epidemiology and Population Health Program, British Columbia Centre for Excellence in HIV/AIDS. Department of Nutrition and Exercise Physiology, Elson S. Floyd College of Medicine, Washington State University
| | - Lu Wang
- Epidemiology and Population Health Program, British Columbia Centre for Excellence in HIV/AIDS
| | - Paul Sereda
- Epidemiology and Population Health Program, British Columbia Centre for Excellence in HIV/AIDS
| | - Jean A Shoveller
- Epidemiology and Population Health Program, British Columbia Centre for Excellence in HIV/AIDS. Division of AIDS, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Rolando Barrios
- Epidemiology and Population Health Program, British Columbia Centre for Excellence in HIV/AIDS. Division of AIDS, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Julio S G Montaner
- British Columbia Centre for Excellence in HIV/AIDS. Division of AIDS, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Viviane D Lima
- Epidemiology and Population Health Program, British Columbia Centre for Excellence in HIV/AIDS. Division of AIDS, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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The Roles of Expert Mothers Engaged in Prevention of Mother-to-Child Transmission (PMTCT) Programs: A Commentary on the INSPIRE Studies in Malawi, Nigeria, and Zimbabwe. J Acquir Immune Defic Syndr 2017; 75 Suppl 2:S224-S232. [PMID: 28498193 DOI: 10.1097/qai.0000000000001375] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Several initiatives aiming to improve retention and adherence in Prevention of Mother-to-Child Transmission of HIV (PMTCT) programs include "expert mothers" (EMs) as a central tenet of their interventions. This article compares the role of EMs in 3 implementation research studies examining approaches for improving retention in care among mothers living with HIV. METHODS We compared and synthesized qualitative data and lessons learned from 3 studies (MoMent in Nigeria, PURE in Malawi, and EPAZ in Zimbabwe) with respect to the involvement of EMs in supporting PMTCT clients. The frame of reference for the comparison is the role that EMs play in PMTCT service delivery for individuals, at the health facility, within the health system, and in the community. RESULTS EMs' role was positively perceived by PMTCT clients and health care workers, as EMs provided an expanded range of services directly benefiting clients and enabling health care workers to share their workload. Common challenges included difficulties in reaching male partners and fear of stigma. The lack of structure and standardization in EM interventions in relation to eligibility criteria, training, certification, and remuneration were identified as important barriers to EMs' role development within existing health systems. CONCLUSIONS The role of EMs within PMTCT programs continues to expand rapidly. There is a need for coordinated action to develop shared standards and principles commensurate with the new roles and additional demands placed on EMs to support PMTCT services, including EM certification, mentoring and supervision standards, standardized PMTCT-specific training curricula, and, where appropriate, agreed remuneration rates.
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Abstract
Supplemental Digital Content is Available in the Text. Background: As test and treat rolls out, effective interventions are needed to address the determinants of outcomes across the HIV treatment continuum and ensure that people infected with HIV are promptly tested, initiate treatment early, adhere to treatment, and are virally suppressed. Communication approaches offer viable options for promoting relevant behaviors across the continuum. Conceptual Framework: This article introduces a conceptual framework, which can guide the development of effective health communication interventions and activities that aim to impact behaviors across the HIV treatment continuum in low- and medium-income countries. The framework includes HIV testing and counseling, linkage to care, retention in pre-antiretroviral therapy and antiretroviral therapy initiation in one single-stage linkage to care and treatment, and adherence for viral suppression. The determinants of behaviors vary across the continuum and include both facilitators and barriers with communication interventions designed to focus on specific determinants presented in the model. At each stage, relevant determinants occur at the various levels of the social–ecological model: intrapersonal, interpersonal, health services, community, and policy. Effective health communication interventions have mainly relied on mHealth, interpersonal communication through service providers and peers, community support groups, and treatment supporters. Discussion: The conceptual framework and evidence presented highlight areas across the continuum where health communication can significantly impact treatment outcomes to reach the 90-90-90 goals by strategically addressing key behavioral determinants. As test and treat rolls out, multifaceted health communication approaches will be critical.
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Hickey MD, Odeny TA, Petersen M, Neilands TB, Padian N, Ford N, Matthay Z, Hoos D, Doherty M, Beryer C, Baral S, Geng EH. Specification of implementation interventions to address the cascade of HIV care and treatment in resource-limited settings: a systematic review. Implement Sci 2017; 12:102. [PMID: 28784155 PMCID: PMC5547499 DOI: 10.1186/s13012-017-0630-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 07/17/2017] [Indexed: 01/23/2023] Open
Abstract
Background The global response to HIV has started over 18 million persons on life-saving antiretroviral therapy (ART)—the vast majority in low- and middle-income countries (LMIC)—yet substantial gaps remain: up to 40% of persons living with HIV (PLHIV) know their status, while another 30% of those who enter care are inadequately retained after starting treatment. Identifying strategies to enhance use of treatment is urgently needed, but the conceptualization and specification of implementation interventions is not always complete. We sought to assess the completeness of intervention reporting in research to advance uptake of treatment for HIV globally. Methods We carried out a systematic review to identify interventions targeting the adult HIV care cascade in LMIC dating from 1990 to 2017. We identified components of each intervention as “intervention types” to decompose interventions into common components. We grouped “intervention types” into a smaller number of more general “implementation approaches” to aid summarization. We assessed the reporting of six intervention characteristics adapted from the implementation science literature: the actor, action, action dose, action temporality, action target, and behavioral target in each study. Findings In 157 unique studies, we identified 34 intervention “types,” which were empirically grouped into six generally understandable “approaches.” Overall, 42% of interventions defined the actor, 64% reported the action, 41% specified the intervention “dose,” 43% reported action temporality, 61% defined the action target, and 69% reported a target behavior. Average completeness of reporting varied across approaches from a low of 50% to a high of 72%. Dimensions that involved conceptualization of the practices themselves (e.g., actor, dose, temporality) were in general less well specified than consequences (e.g., action target and behavioral target). Implications The conceptualization and Reporting of implementation interventions to advance treatment for HIV in LMIC is not always complete. Dissemination of standards for reporting intervention characteristics can potentially promote transparency, reproducibility, and scientific accumulation in the area of implementation science to address HIV in low- and middle-income countries. Electronic supplementary material The online version of this article (doi:10.1186/s13012-017-0630-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Matthew D Hickey
- Division of General Internal Medicine, San Francisco General Hospital, Department of Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA
| | | | - Maya Petersen
- Department of Biostatistics and Epidemiology, School of Public Health, University of California, Berkeley, CA, USA
| | - Torsten B Neilands
- Center for AIDS Prevention Studies, Department of Medicine, UCSF, San Francisco, CA, USA
| | - Nancy Padian
- Department of Biostatistics and Epidemiology, School of Public Health, University of California, Berkeley, CA, USA
| | - Nathan Ford
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | | | - David Hoos
- Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Meg Doherty
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Chris Beryer
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Stefan Baral
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Elvin H Geng
- Division of ID HIV and Global Medicine, San Francisco General Hospital, Department of Medicine, UCSF, Building 80, 6th Floor, 1001 Potrero Avenue, San Francisco, CA, 94110, USA.
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Taieb F, Madec Y, Cournil A, Delaporte E. Virological success after 12 and 24 months of antiretroviral therapy in sub-Saharan Africa: Comparing results of trials, cohorts and cross-sectional studies using a systematic review and meta-analysis. PLoS One 2017; 12:e0174767. [PMID: 28426819 PMCID: PMC5398519 DOI: 10.1371/journal.pone.0174767] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 03/15/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND UNAIDS recently defined the 90-90-90 target as a way to end the HIV epidemic. However, the proportion of virological success following antiretroviral therapy (ART) may not be as high as the anticipated 90%, and may in fact be highly heterogeneous. We aimed to describe the proportion of virological success in sub-Saharan Africa and to identify factors associated with the proportion of virological success. METHODS We performed a systematic review and meta-analysis focusing on the proportion of patients in sub-Saharan Africa who demonstrate virological success at 12 and 24 months since ART initiation, as well as at 6 and 36 months, where possible. Programme factors associated with the proportion of virological success were identified using meta-regression. Analyses were conducted using both on-treatment (OT) and intention-to-treat (ITT) approaches. RESULTS Eighty-five articles were included in the meta-analysis, corresponding to 125 independent study populations. Using an on-treatment approach, the proportions (95% confidence interval (CI)) of virological success at 12 (n = 64) and at 24 (n = 32) months since ART initiation were 87.7% (81.3-91.0) and 83.7% (79.8-87.6), respectively. Univariate analysis indicated that the proportion of virological success was not different by study design. Multivariate analysis at 24 months showed that the proportion of virological success was significantly larger in studies conducted in public sector sites than in other sites (p = 0.045). Using an ITT approach, the proportions (95% CI) of virological success at 12 (n = 50) and at 24 (n = 20) months were 65.4% (61.8-69.1) and 56.8% (51.3-62.4), respectively. At 12 months, multivariate analysis showed that the proportion of success was significantly lower in cohort studies than in trials (63.0% vs. 71.1%; p = 0.017). At 24 months, univariate analysis demonstrated that the proportion of success was also lower in cohorts. DISCUSSION Regardless of the time following ART initiation, and of the threshold, proportions of virological success were highly variable. Evidence from this review suggests that the new international target of 90% of patients controlled is not yet being achieved, and that in order to improve the virological outcome, efforts should be made to improve retention in care.
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Affiliation(s)
- Fabien Taieb
- Emerging Diseases Epidemiology Unit-Institut Pasteur, Paris, France
- IRD UMI 233 INSERM U1175 Université de Montpellier, Unité TransVIHMI, Montpellier, France
- Direction de la Recherche Clinique et du Développement-Assistance Publique des Hôpitaux de Paris-Hôpital Saint-Louis, Paris, France
- * E-mail:
| | - Yoann Madec
- Emerging Diseases Epidemiology Unit-Institut Pasteur, Paris, France
| | - Amandine Cournil
- IRD UMI 233 INSERM U1175 Université de Montpellier, Unité TransVIHMI, Montpellier, France
| | - Eric Delaporte
- IRD UMI 233 INSERM U1175 Université de Montpellier, Unité TransVIHMI, Montpellier, France
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Haberer JE, Sabin L, Amico KR, Orrell C, Galárraga O, Tsai AC, Vreeman RC, Wilson I, Sam‐Agudu NA, Blaschke TF, Vrijens B, Mellins CA, Remien RH, Weiser SD, Lowenthal E, Stirratt MJ, Sow PS, Thomas B, Ford N, Mills E, Lester R, Nachega JB, Bwana BM, Ssewamala F, Mbuagbaw L, Munderi P, Geng E, Bangsberg DR. Improving antiretroviral therapy adherence in resource-limited settings at scale: a discussion of interventions and recommendations. J Int AIDS Soc 2017; 20:21371. [PMID: 28630651 PMCID: PMC5467606 DOI: 10.7448/ias.20.1.21371] [Citation(s) in RCA: 117] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Accepted: 02/24/2017] [Indexed: 01/01/2023] Open
Abstract
Introduction: Successful population-level antiretroviral therapy (ART) adherence will be necessary to realize both the clinical and prevention benefits of antiretroviral scale-up and, ultimately, the end of AIDS. Although many people living with HIV are adhering well, others struggle and most are likely to experience challenges in adherence that may threaten virologic suppression at some point during lifelong therapy. Despite the importance of ART adherence, supportive interventions have generally not been implemented at scale. The objective of this review is to summarize the recommendations of clinical, research, and public health experts for scalable ART adherence interventions in resource-limited settings. Methods: In July 2015, the Bill and Melinda Gates Foundation convened a meeting to discuss the most promising ART adherence interventions for use at scale in resource-limited settings. This article summarizes that discussion with recent updates. It is not a systematic review, but rather provides practical considerations for programme implementation based on evidence from individual studies, systematic reviews, meta-analyses, and the World Health Organization Consolidated Guidelines for HIV, which include evidence from randomized controlled trials in low- and middle-income countries. Interventions are categorized broadly as education and counselling; information and communication technology-enhanced solutions; healthcare delivery restructuring; and economic incentives and social protection interventions. Each category is discussed, including descriptions of interventions, current evidence for effectiveness, and what appears promising for the near future. Approaches to intervention implementation and impact assessment are then described. Results and discussion: The evidence base is promising for currently available, effective, and scalable ART adherence interventions for resource-limited settings. Numerous interventions build on existing health care infrastructure and leverage available resources. Those most widely studied and implemented to date involve peer counselling, adherence clubs, and short message service (SMS). Many additional interventions could have an important impact on ART adherence with further development, including standardized counselling through multi-media technology, electronic dose monitoring, decentralized and differentiated models of care, and livelihood interventions. Optimal targeting and tailoring of interventions will require improved adherence measurement. Conclusions: The opportunity exists today to address and resolve many of the challenges to effective ART adherence, so that they do not limit the potential of ART to help bring about the end of AIDS.
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Affiliation(s)
- Jessica E. Haberer
- Massachusetts General Hospital Global Health, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Lora Sabin
- Department of Global Health, Center for Global Health and Department, Boston University School of Public Health, Boston, MA, USA
| | - K. Rivet Amico
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Catherine Orrell
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Omar Galárraga
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Alexander C. Tsai
- Chester M. Pierce, MD Division of Global Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Rachel C. Vreeman
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Ira Wilson
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Nadia A. Sam‐Agudu
- Clinical Department, Institute of Human Virology Nigeria, Abuja, Nigeria
- Institute of Human Virology and Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Terrence F. Blaschke
- Department of Medicine and Clinical Pharmacology, Stanford University School of Medicine, Stanford, CA, USA
| | - Bernard Vrijens
- Department of Biostatistics, University of Liège, Liège, Wallonia, Belgium
- WestRock Healthcare, Sion, Switzerland
| | - Claude A. Mellins
- HIV Center for Clinical and Behavioral Studies, NYSPI and Department of Psychiatry, Columbia; University, New York, NY, USA
| | - Robert H. Remien
- HIV Center for Clinical and Behavioral Studies, NYSPI and Department of Psychiatry, Columbia; University, New York, NY, USA
| | - Sheri D. Weiser
- Division of HIV, ID and Global Medicine, Department of Medicine, University of California, San Francisco, CA, USA
| | - Elizabeth Lowenthal
- Departments of Pediatrics and Epidemiology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Michael J. Stirratt
- Division of AIDS Research, National Institute of Mental Health, Bethesda, MD, USA
| | - Papa Salif Sow
- Bill and Melinda Gates Foundation, Seattle, WA, USA
- Department of Infectious diseases, University of Dakar, Dakar, Sénégal
| | | | - Nathan Ford
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Edward Mills
- Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Richard Lester
- Division of Infectious Diseases, Department of Medicine, University of British Columbia
| | - Jean B. Nachega
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Bosco Mwebesa Bwana
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Fred Ssewamala
- Columbia University School of Social Work & School of International and Public Affairs, New York, NY, USA
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Paula Munderi
- HIV Care Research Program, Medical Research Council, Uganda Virus Research Institute, Entebbe, Uganda
| | - Elvin Geng
- Division of HIV, Infectious Disease and Global Medicine, San Francisco General Hospital, Department of Medicine, University of California, San Francisco, CA, USA
| | - David R. Bangsberg
- Oregon Health & Sciences University‐Portland State University School of Public Health, Portland, OR, USA
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Use of peers to improve adherence to antiretroviral therapy: a global network meta-analysis. J Int AIDS Soc 2016; 19:21141. [PMID: 27914185 PMCID: PMC5134746 DOI: 10.7448/ias.19.1.21141] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Revised: 10/06/2016] [Accepted: 10/24/2016] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION It is unclear whether using peers can improve adherence to antiretroviral therapy (ART). To construct the World Health Organization's global guidance on adherence interventions, we conducted a systematic review and network meta-analysis to determine the effectiveness of using peers for achieving adequate adherence and viral suppression. METHODS We searched for randomized clinical trials of peer-based interventions to promote adherence to ART in HIV populations. We searched six electronic databases from inception to July 2015 and major conference abstracts within the last three years. We examined the outcomes of adherence and viral suppression among trials done worldwide and those specific to low- and middle-income countries (LMIC) using pairwise and network meta-analyses. RESULTS AND DISCUSSION Twenty-two trials met the inclusion criteria. We found similar results between pairwise and network meta-analyses, and between the global and LMIC settings. Peer supporter+Telephone was superior in improving adherence than standard-of-care in both the global network (odds-ratio [OR]=4.79, 95% credible intervals [CrI]: 1.02, 23.57) and the LMIC settings (OR=4.83, 95% CrI: 1.88, 13.55). Peer support alone, however, did not lead to improvement in ART adherence in both settings. For viral suppression, we found no difference of effects among interventions due to limited trials. CONCLUSIONS Our analysis showed that peer support leads to modest improvement in adherence. These modest effects may be due to the fact that in many settings, particularly in LMICs, programmes already include peer supporters, adherence clubs and family disclosures for treatment support. Rather than introducing new interventions, a focus on improving the quality in the delivery of existing services may be a more practical and effective way to improve adherence to ART.
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Kanters S, Park JJH, Chan K, Socias ME, Ford N, Forrest JI, Thorlund K, Nachega JB, Mills EJ. Interventions to improve adherence to antiretroviral therapy: a systematic review and network meta-analysis. Lancet HIV 2016; 4:e31-e40. [PMID: 27863996 DOI: 10.1016/s2352-3018(16)30206-5] [Citation(s) in RCA: 159] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 09/13/2016] [Accepted: 09/16/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND High adherence to antiretroviral therapy is crucial to the success of HIV treatment. We evaluated comparative effectiveness of adherence interventions with the aim of informing the WHO's global guidance on interventions to increase adherence. METHODS For this systematic review and network meta-analysis, we searched for randomised controlled trials of interventions that aimed to improve adherence to antiretroviral therapy regimens in populations with HIV. We searched Cochrane Central Register of Controlled Trials, Embase, and MEDLINE for reports published up to July 16, 2015, and searched major conference abstracts from Jan 1, 2013, to July 16, 2015. We extracted data from eligible studies for study characteristics, interventions, patients' characteristics at baseline, and outcomes for the study populations of interest. We used network meta-analyses to compare adherence and viral suppression for all study settings (global network) and for studies in low-income and middle-income countries only (LMIC network). FINDINGS We obtained data from 85 trials with 16 271 participants. Short message service (SMS; text message) interventions were superior to standard of care in improving adherence in both the global network (odds ratio [OR] 1·48, 95% credible interval [CrI] 1·00-2·16) and in the LMIC network (1·49, 1·04-2·09). Multiple interventions showed generally superior adherence to single interventions, indicating additive effects. For viral suppression, only cognitive behavioural therapy (1·46, 1·05-2·12) and supporter interventions (1·28, 1·01-1·71) were superior to standard of care in the global network; none of the interventions improved viral response in the LMIC network. For the global network, the time discrepancy (whether the study outcome was measured during or after intervention was withdrawn) was an effect modifier for both adherence to antiretroviral therapy (coefficient estimate -0·43, 95% CrI -0·75 to -0·11) and viral suppression (-0·48; -0·84 to -0·12), suggesting that the effects of interventions wane over time. INTERPRETATION Several interventions can improve adherence and viral suppression; generally, their estimated effects were modest and waned over time. FUNDING WHO.
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Affiliation(s)
- Steve Kanters
- Precision Global Health, Vancouver, BC, Canada; School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | | | - Keith Chan
- Precision Global Health, Vancouver, BC, Canada
| | - Maria Eugenia Socias
- Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada; BC Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, BC, Canada
| | - Nathan Ford
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Jamie I Forrest
- Precision Global Health, Vancouver, BC, Canada; School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | | | - Jean B Nachega
- Departments of Epidemiology and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Departments of Epidemiology, Infectious Diseases, and Microbiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
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Nachega JB, Adetokunboh O, Uthman OA, Knowlton AW, Altice FL, Schechter M, Galárraga O, Geng E, Peltzer K, Chang LW, Van Cutsem G, Jaffar SS, Ford N, Mellins CA, Remien RH, Mills EJ. Community-Based Interventions to Improve and Sustain Antiretroviral Therapy Adherence, Retention in HIV Care and Clinical Outcomes in Low- and Middle-Income Countries for Achieving the UNAIDS 90-90-90 Targets. Curr HIV/AIDS Rep 2016; 13:241-55. [PMID: 27475643 PMCID: PMC5357578 DOI: 10.1007/s11904-016-0325-9] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Little is known about the effect of community versus health facility-based interventions to improve and sustain antiretroviral therapy (ART) adherence, virologic suppression, and retention in care among HIV-infected individuals in low- and middle-income countries (LMICs). We systematically searched four electronic databases for all available randomized controlled trials (RCTs) and comparative cohort studies in LMICs comparing community versus health facility-based interventions. Relative risks (RRs) for pre-defined adherence, treatment engagement (linkage and retention in care), and relevant clinical outcomes were pooled using random effect models. Eleven cohort studies and eleven RCTs (N = 97,657) were included. Meta-analysis of the included RCTs comparing community- versus health facility-based interventions found comparable outcomes in terms of ART adherence (RR = 1.02, 95 % CI 0.99 to 1.04), virologic suppression (RR = 1.00, 95 % CI 0.98 to 1.03), and all-cause mortality (RR = 0.93, 95 % CI 0.73 to 1.18). The result of pooled analysis from the RCTs (RR = 1.03, 95 % CI 1.01 to 1.06) and cohort studies (RR = 1.09, 95 % CI 1.03 to 1.15) found that participants assigned to community-based interventions had statistically significantly higher rates of treatment engagement. Two studies found community-based ART delivery model either cost-saving or cost-effective. Community- versus facility-based models of ART delivery resulted in at least comparable outcomes for clinically stable HIV-infected patients on treatment in LMICs and are likely to be cost-effective.
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Affiliation(s)
- Jean B Nachega
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA.
- Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, South Africa.
- Johns Hopkins University, Baltimore, MD, USA.
| | - Olatunji Adetokunboh
- Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, South Africa
| | - Olalekan A Uthman
- Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, South Africa
- Warwick Medical School, The University of Warwick, Coventry, UK
| | | | | | | | - Omar Galárraga
- Brown University School of Public Health, Providence, RI, USA
| | - Elvin Geng
- University of California, San Francisco, CA, USA
| | - Karl Peltzer
- Mahidol University, Salaya, Thailand
- University of Limpopo, Polokwane, South Africa
- Human Sciences Research Council, Pretoria, South Africa
| | | | | | | | - Nathan Ford
- World Health Organization, Geneva, Switzerland
| | - Claude A Mellins
- HIV Center for Clinical and Behavioral Studies, Columbia University, New York, NY, USA
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Martin SL, Omotayo MO, Chapleau GM, Stoltzfus RJ, Birhanu Z, Ortolano SE, Pelto GH, Dickin KL. Adherence partners are an acceptable behaviour change strategy to support calcium and iron-folic acid supplementation among pregnant women in Ethiopia and Kenya. MATERNAL AND CHILD NUTRITION 2016; 13. [PMID: 27507135 DOI: 10.1111/mcn.12331] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 03/30/2016] [Accepted: 03/31/2016] [Indexed: 01/27/2023]
Abstract
Antenatal calcium and iron-folic acid (IFA) supplementation can reduce maternal mortality and morbidity. Yet, even when pregnant women have a stable supply of supplements, forgetting is often a barrier to adherence. We assessed the acceptability of adherence partners to support calcium and IFA supplementation among pregnant women in Kenya and Ethiopia. Adherence partners are a behaviour change strategy to improve adherence, where pregnant women are counselled to select a partner (e.g. spouse, relative) to remind them to take their supplements. We conducted trials of improved practices, a formative research method that follows participants over time as they try a new behaviour. We provided pregnant women in Ethiopia (n = 50) and Kenya (n = 35) with calcium and IFA supplements and counselling, and suggested selecting an adherence partner. For each participant, we conducted semi-structured interviews about acceptability and adherence during four interviews over six weeks. We analysed interview transcripts thematically and tallied numerical data. In Kenya, 28 of 35 women agreed to try an adherence partner; almost all selected their husbands. In Ethiopia, 42 of 50 women agreed to try an adherence partner; half asked their husbands, others asked children or relatives. Most women who did not select adherence partners reported not needing help or not having anyone to ask. Participants reported adherence partners reminded and encouraged them, brought supplements, provided food and helped address side-effects. Almost all women with adherence partners would recommend this strategy to others. Adherence partners are an acceptable, low-cost strategy with the potential to support antenatal micronutrient supplementation adherence.
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Affiliation(s)
- Stephanie L Martin
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, New York, USA
| | - Moshood O Omotayo
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, New York, USA
| | - Gina M Chapleau
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, New York, USA
| | - Rebecca J Stoltzfus
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, New York, USA
| | - Zewdie Birhanu
- Department of Health Education and Behavioral Sciences, College of Health Sciences, Jimma University, Jimma, Ethiopia
| | - Stephanie E Ortolano
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, New York, USA
| | - Gretel H Pelto
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, New York, USA
| | - Katherine L Dickin
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, New York, USA
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Ayer R, Kikuchi K, Ghimire M, Shibanuma A, Pant MR, Poudel KC, Jimba M. Clinic Attendance for Antiretroviral Pills Pick-Up among HIV-Positive People in Nepal: Roles of Perceived Family Support and Associated Factors. PLoS One 2016; 11:e0159382. [PMID: 27438024 PMCID: PMC4954679 DOI: 10.1371/journal.pone.0159382] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 07/03/2016] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION HIV-positive people's clinic attendance for medication pick-up is critical for successful HIV treatment. However, limited evidence exists on it especially in low-income settings such as Nepal. Moreover, the role of family support in clinic attendance remains under-explored. Therefore, this study was conducted to examine the association between perceived family support and regular clinic attendance and to assess factors associated with regular clinic attendance for antiretroviral pills pick-up among HIV-positive individuals in Nepal. METHODS A cross-sectional study was conducted among 423 HIV-positive people in three districts of Nepal. Clinic attendance was assessed retrospectively for the period of 12 months. To assess the factors associated, an interview survey was conducted using a semi-structured questionnaire from July to August, 2015. Multiple logistic regression models were used to assess the factors associated with regular clinic attendance. RESULTS Of 423 HIV-positive people, only 32.6% attended the clinics regularly. They were more likely to attend them regularly when they received high family support (AOR = 3.98, 95% CI = 2.29, 6.92), participated in support programs (AOR = 1.68, 95% CI = 1.00, 2.82), and had knowledge on the benefits of antiretroviral therapy (AOR = 2.62, 95% CI = 1.15, 5.99). In contrast, they were less likely to attend them regularly when they commuted more than 60 minutes to the clinics (AOR = 0.53, 95% CI = 0.30, 0.93), when they self-rated their health status as being very good (AOR = 0.13, 95% CI = 0.04, 0.44), good (AOR = 0.14, 95% CI = 0.04, 0.46), and fair (AOR = 0.21, 95% CI = 0.06, 0.70). CONCLUSION HIV-positive individuals are more likely to attend the clinics regularly when they receive high family support, know the benefits of antiretroviral therapy, and participate in support programs. To improve clinic attendance, family support should be incorporated with HIV care programs in resource limited settings. Service providers should also consider educating them about the benefits of antiretroviral therapy.
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Affiliation(s)
- Rakesh Ayer
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113–0033, Japan
| | - Kimiyo Kikuchi
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113–0033, Japan
- * E-mail:
| | - Mamata Ghimire
- Department of Health Care Policy and Management, Graduate School of Comprehensive Human Sciences, University of Tsukuba, 1-1-1, Tennoudai, Tsukuba, Ibaraki, 301–8577, Japan
| | - Akira Shibanuma
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113–0033, Japan
| | - Madhab Raj Pant
- Antiretroviral Therapy Clinic, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
| | - Krishna C. Poudel
- Department of Health Promotion and Policy, School of Public Health and Health Sciences, University of Massachusetts Amherst, 316 Arnold House, 715 North Pleasant St, Amherst, MA, 01003–9304, United States of America
| | - Masamine Jimba
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113–0033, Japan
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Community-Based Accompaniment Mitigates Predictors of Negative Outcomes for Adults on Antiretroviral Therapy in Rural Rwanda. AIDS Behav 2016; 20:1009-16. [PMID: 26346334 DOI: 10.1007/s10461-015-1185-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Clinical, socioeconomic, and access barriers remain a critical problem to antiretroviral (ART) programs in sub-Saharan Africa. Community-based accompaniment (CBA), including daily home visits and psychosocial and socioeconomic support, has been associated with improved patient outcomes at 1 year. We conducted a prospective observational cohort study of 578 HIV-infected adults initiating ART in 2007-2008 with or without CBA in rural Rwanda. Among patients without CBA, those with advanced HIV disease, low CD4 cell counts, lower social support, and transport costs had significantly higher odds of negative outcomes at 1 year; amongst patients who received CBA, only those with low CD4 cell counts had significantly higher odds of negative outcomes at 1 year. CBA also significantly mitigated the effect of transport costs and inaccessibility of services on the likelihood of negative outcome. CBA may be one approach to mitigating known risk factors for negative outcomes for patients on ART in resource-poor settings.
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Clinic-level factors influencing patient outcomes on antiretroviral therapy in primary health clinics in South Africa. AIDS 2016; 30:1099-109. [PMID: 26752280 DOI: 10.1097/qad.0000000000001014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To explore which clinic-level factors influence treatment outcomes in a multisite antiretroviral therapy (ART) programme in South Africa. DESIGN Retrospective cohort study using 36 clinics. METHODS We used random effects modelling to investigate clinic-level factors influencing ART outcomes, adjusting for patient-level factors and accounting for clustering at clinic level. Outcomes were unsuppressed viral load (>400 copies/ml) at 24 months after ART start and time to loss to follow-up. RESULTS At clinic level, the mean proportion of patients with unsuppressed viral load at 24 months was 16% (range 8-33%). Loss to follow-up was also highly variable across clinics ranging from 3.5 to 23.4/100 person-years. Unsuppressed viral load was associated with a lower doctor-patient ratio [for every 500 patients, compared with >2.6 doctors: <0.7 doctors: adjusted odds ratio (OR) 1.52, 95% confidence interval (CI) 1.04-2.21; 0.7-2.6 doctors, OR 1.33, CI 0.91-1.93, P trend 0.04] after adjustment for patient factors. Combinations of psychosocial support interventions were weakly associated with reduced loss to follow-up [>6 interventions vs. <4 interventions: hazard ratio 0.39 (CI 0.15 - 1.04), P = 0.11]. Flexibility of services, integration of services, staff motivation, staff leadership and location of clinic were not consistently associated with improved outcomes. CONCLUSION The dominant clinic-level influences on patient outcomes were doctor : patient ratio, and combination interventions to reduce loss to follow-up. Further research is needed to define optimum staffing levels that are required to roll out ART and the combination intervention that is most effective to reduce loss to follow-up.
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Treatment Buddies Improve Clinic Attendance among Women but Not Men on Antiretroviral Therapy in the Nyanza Region of Kenya. AIDS Res Treat 2016; 2016:9124541. [PMID: 27092271 PMCID: PMC4820594 DOI: 10.1155/2016/9124541] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Accepted: 02/28/2016] [Indexed: 11/20/2022] Open
Abstract
Background. Kenyan antiretroviral (ART) guidelines encourage treatment buddies (TBy) to maximize treatment adherence. This study examined the effect of TBys on clinic attendance in men and women on ART. Methods. This retrospective cohort study included all adult patients initiating ART from August 2007 to December 2011 at four health facilities in Kenya. Data were abstracted from electronic medical records and analyzed using Poisson regression. Results. Of 2,430 patients, 2,199 (91%) had a TBy. Relationship between TBy and clinic attendance differed in females and males (interaction p = 0.09). After demographic and clinic factor adjustment, females with a TBy were 28% more likely to adhere to all appointments than those without (adjusted aRR = 1.28; 95% CI 1.08–1.53), whereas males were no more likely to adhere (aRR = 1.01; 95% CI 0.76–1.32). Males reported partner/spouse (33%) or brother (11%) as the TBy while females reported sister (17%), partner/spouse (14%), or another family member (12%). Multivariable analysis found no association between clinic attendance and TBy relationship in either gender. Conclusion. Clinic attendance was higher among women with TBys but not men. Results support TBys to help women achieve ART success; alternate strategies to bolster TBy benefits are needed for men.
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Impact of Patient-Selected Care Buddies on Adherence to HIV Care, Disease Progression, and Conduct of Daily Life Among Pre-antiretroviral HIV-Infected Patients in Rakai, Uganda: A Randomized Controlled Trial. J Acquir Immune Defic Syndr 2015; 70:75-82. [PMID: 26039929 DOI: 10.1097/qai.0000000000000710] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Data are limited on effects of household or community support persons ("care buddies") on enrollment into and adherence to pre-antiretroviral HIV care. We assessed the impact of care buddies on adherence to HIV clinic appointments, HIV progression, and conduct of daily life among pre-antiretroviral therapy (pre-ART) HIV-infected individuals in Rakai, Uganda. METHODS A total of 1209 HIV-infected pre-ART patients aged ≥15 years were randomized to standard of care (SOC) (n = 604) or patient-selected care buddy (PSCB) (n = 605) and followed at 6 and 12 months. Outcomes were adherence to clinic visits, HIV disease progression, and self-reported conduct of daily life. Incidence and prevalence rate ratios and 95% confidence intervals (CIs) were used to assess outcomes in the intent-to-treat and as-treated analyses. RESULTS Baseline characteristics were comparable. In the intent to treat analysis, both arms were comparable with respect to adherence to CD4 monitoring visits [adjusted prevalence risk ratio (adjPRR), 0.98; 95% CI: 0.93 to 1.04; P = 0.529], and ART eligibility (adjPRR, 1.00; 95% CI: 0.77 to 1.31; P = 0.946). Good conduct of daily life was significantly higher in the PSCB than the SOC arm (adjPRR, 1.08; 95% CI: 1.03 to 1.13; P = 0.001). More men (61%) compared with women (30%) selected spouses/partners as buddies (P < 0.0001). Twenty-two percent of PSCB arm participants discontinued use of buddies. CONCLUSIONS In pre-ART persons, having care buddies improved the conduct of daily life of the HIV-infected patients but had no effect on HIV disease progression and only limited effect on clinic appointment adherence.
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Contemporary issues on the epidemiology and antiretroviral adherence of HIV-infected adolescents in sub-Saharan Africa: a narrative review. J Int AIDS Soc 2015; 18:20049. [PMID: 26385853 PMCID: PMC4575412 DOI: 10.7448/ias.18.1.20049] [Citation(s) in RCA: 150] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 07/10/2015] [Accepted: 08/12/2015] [Indexed: 12/25/2022] Open
Abstract
Introduction Adolescents are a unique and sometimes neglected group in the planning of healthcare services. This is the case in many parts of sub-Saharan Africa, where more than eight out of ten of the world's HIV-infected adolescents live. Although the last decade has seen a reduction in AIDS-related mortality worldwide, largely due to improved access to effective antiretroviral therapy (ART), AIDS remains a significant contributor to adolescent mortality in sub-Saharan Africa. Although inadequate access to ART in parts of the subcontinent may be implicated, research among youth with HIV elsewhere in the world suggests that suboptimal adherence to ART may play a significant role. In this article, we summarize the epidemiology of HIV among sub-Saharan African adolescents and review their adherence to ART, emphasizing the unique challenges and factors associated with adherence behaviour. Methods We conducted a comprehensive search of online databases for articles, relevant abstracts, and conference reports from meetings held between 2010 and 2014. Our search terms included “adherence,” “compliance,” “antiretroviral use” and “antiretroviral adherence,” in combination with “adolescents,” “youth,” “HIV,” “Africa,” “interventions” and the MeSH term “Africa South of the Sahara.” Of 19,537 articles and abstracts identified, 215 met inclusion criteria, and 148 were reviewed. Discussion Adolescents comprise a substantial portion of the population in many sub-Saharan African countries. They are at particular risk of HIV and may experience worse outcomes. Although demonstrated to have unique challenges, there is a dearth of comprehensive health services for adolescents, especially for those with HIV in sub-Saharan Africa. ART adherence is poorer among older adolescents than other age groups, and psychosocial, socio-economic, individual, and treatment-related factors influence adherence behaviour among adolescents in this region. With the exception of a few examples based on affective, cognitive, and behavioural strategies, most adherence interventions have been targeted at adults with HIV. Conclusions Although higher levels of ART adherence have been reported in sub-Saharan Africa than in other well-resourced settings, adolescents in the region may have poorer adherence patterns. There is substantial need for interventions to improve adherence in this unique population.
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Implementation and Operational Research: Pulling the Network Together: Quasiexperimental Trial of a Patient-Defined Support Network Intervention for Promoting Engagement in HIV Care and Medication Adherence on Mfangano Island, Kenya. J Acquir Immune Defic Syndr 2015; 69:e127-34. [PMID: 25984711 PMCID: PMC4485532 DOI: 10.1097/qai.0000000000000664] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Despite progress in the global scale-up of antiretroviral therapy, sustained engagement in HIV care remains challenging. Social capital is an important factor for sustained engagement, but interventions designed to harness this powerful social force are uncommon. METHODS We conducted a quasiexperimental study evaluating the impact of the Microclinic Social Network intervention on engagement in HIV care and medication adherence on Mfangano Island, Kenya. The intervention was introduced into 1 of 4 similar communities served by this clinic; comparisons were made between communities using an intention-to-treat analysis. Microclinics, composed of patient-defined support networks, participated in 10 biweekly discussion sessions covering topics ranging from HIV biology to group support and group HIV status disclosure. Nevirapine concentrations in hair were measured before and after study. RESULTS One hundred thirteen (74%) intervention community participants joined a microclinic group, 86% of whom participated in group HIV status disclosure. Over 22-month follow-up, intervention community participants experienced one-half the rate of ≥ 90-day clinic absence as those in control communities (adjusted hazard ratio: 0.48; 95% confidence interval: 0.25 to 0.92). Nevirapine hair levels declined in both study arms; in adjusted linear regression analysis, the decline was 6.7 ng/mg less severe in the intervention arm than control arm (95% confidence interval: -2.7 to 16.1). CONCLUSIONS The microclinic intervention is a promising and feasible community-based strategy to improve long-term engagement in HIV care and possibly medication adherence. Reducing treatment interruptions using a social network approach has important implications for individual patient virologic suppression, morbidity, and mortality and for broader community empowerment and engagement in healthcare.
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Holtzman CW, Brady KA, Yehia BR. Retention in care and medication adherence: current challenges to antiretroviral therapy success. Drugs 2015; 75:445-54. [PMID: 25792300 DOI: 10.1007/s40265-015-0373-2] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Health behaviors such as retention in HIV medical care and adherence to antiretroviral therapy (ART) pose major challenges to reducing new HIV infections, addressing health disparities, and improving health outcomes. Andersen's Behavioral Model of Health Service Use provides a conceptual framework for understanding how patient and environmental factors affect health behaviors and outcomes, which can inform the design of intervention strategies. Factors affecting retention and adherence among persons with HIV include patient predisposing factors (e.g., mental illness, substance abuse), patient-enabling factors (e.g., social support, reminder strategies, medication characteristics, transportation, housing, insurance), and healthcare environment factors (e.g., pharmacy services, clinic experiences, provider characteristics). Evidence-based recommendations for improving retention and adherence include (1) systematic monitoring of clinic attendance and ART adherence; (2) use of peer or paraprofessional navigators to re-engage patients in care and help them remain in care; (3) optimization of ART regimens and pharmaceutical supply chain management systems; (4) provision of reminder devices and tools; (5) general education and counseling; (6) engagement of peer, family, and community support groups; (7) case management; and (8) targeting patients with substance abuse and mental illness. Further research is needed on effective monitoring strategies and interventions that focus on improving retention and adherence, with specific attention to the healthcare environment.
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Affiliation(s)
- Carol W Holtzman
- ICAP, Columbia University Mailman School of Public Health, P.O. Box 13860, Maseru 100, Lesotho,
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Lay Social Resources for Support of Adherence to Antiretroviral Prophylaxis for HIV Prevention Among Serodiscordant Couples in sub-Saharan Africa: A Qualitative Study. AIDS Behav 2015; 19:811-20. [PMID: 25267114 PMCID: PMC4415942 DOI: 10.1007/s10461-014-0899-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Effectiveness of antiretroviral pre-exposure prophylaxis (PrEP) for HIV prevention will require high adherence. Using qualitative data, this paper identifies potential lay social resources for support of PrEP adherence by HIV serodiscordant couples in Uganda, laying the groundwork for incorporation of these resources into adherence support initiatives as part of implementation. The qualitative analysis characterizes support for PrEP adherence provided by HIV-infected spouses, children, extended family members, and the larger community. Results suggest social resources for support of PrEP adherence in Africa are plentiful outside formal health care settings and health systems and that couples will readily use them. The same shortage of health professionals that impeded scale-up of antiretroviral treatment for HIV/AIDS in Africa promises to challenge delivery of PrEP. Building on the treatment scale-up experience, implementers can address this challenge by examining the value of lay social resources for adherence support in developing strategies for delivery of PrEP.
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Mbuagbaw L, Sivaramalingam B, Navarro T, Hobson N, Keepanasseril A, Wilczynski NJ, Haynes RB. Interventions for Enhancing Adherence to Antiretroviral Therapy (ART): A Systematic Review of High Quality Studies. AIDS Patient Care STDS 2015; 29:248-66. [PMID: 25825938 DOI: 10.1089/apc.2014.0308] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
We sought to review the effectiveness of interventions designed to improve adherence to antiretroviral therapy (ART) from studies included in a recent Cochrane review that reported a clinical and an adherence outcome, with at least 80% follow-up for 6 months or more. Data were extracted independently and in duplicate, with an adjudicator for disagreements. Risk of bias was assessed using the Cochrane Risk of Bias tool. Of 182 relevant studies in the Cochrane review, 49 were related to ART. Statistical pooling was not warranted due to heterogeneity in interventions, participants, treatments, adherence measures and outcomes. Many studies had high risk of bias in elements of design and outcome ascertainment. Only 10 studies improved both adherence and clinical outcomes. These used the following interventions: adherence counselling (two studies); a once-daily regimen (compared to twice daily); text messaging; web-based cognitive behavioral intervention; face-to-face multi-session intensive behavioral interventions (two studies); contingency management; modified directly observed therapy; and nurse-delivered home visits combined with telephone calls. Patient-related adherence interventions were the most frequently tested. Uniform adherence measures and higher quality studies of younger populations are encouraged.
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Affiliation(s)
- Lawrence Mbuagbaw
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Biostatistics Unit, Father Sean O'Sullivan Research Centre, St Joseph's Healthcare–Hamilton, Ontario, Canada
- Centre for Development of Best Practices in Health, Yaoundé Central Hospital, Yaoundé, Cameroon
| | | | - Tamara Navarro
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Nicholas Hobson
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Arun Keepanasseril
- Departments of Clinical Epidemiology and Biostatistics, and Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Nancy J. Wilczynski
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - R. Brian Haynes
- Departments of Clinical Epidemiology and Biostatistics, and Medicine, McMaster University, Hamilton, Ontario, Canada
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Medley A, Bachanas P, Grillo M, Hasen N, Amanyeiwe U. Integrating prevention interventions for people living with HIV into care and treatment programs: a systematic review of the evidence. J Acquir Immune Defic Syndr 2015; 68 Suppl 3:S286-96. [PMID: 25768868 PMCID: PMC4666299 DOI: 10.1097/qai.0000000000000520] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION This review assesses the impact of prevention interventions for people living with HIV on HIV-related mortality, morbidity, retention in care, quality of life, and prevention of ongoing HIV transmission in resource-limited settings (RLSs). METHODS We conducted a systematic review of studies reporting the results of prevention interventions for people living with HIV in RLS published between January 2000 and August 2014. Standardized methods of searching and data abstraction were used. RESULTS Ninety-two studies met the eligibility criteria: 24 articles related to adherence counseling and support, 13 on risk reduction education and condom provision, 19 on partner HIV testing and counseling, 14 on provision of family planning services, and 22 on assessment and treatment of other sexually transmitted infections. Findings indicate good evidence that adherence counseling and sexually transmitted infection treatment can have a high impact on morbidity, whereas risk reduction education, partner HIV testing and counseling, and family planning counseling can prevent transmission of HIV. More limited evidence was found to support the impact of these interventions on retention in care and quality of life. Most studies did not report cost information, making it difficult to draw conclusions about the cost-effectiveness of these interventions. CONCLUSIONS This evidence suggests that these prevention interventions, if brought to sufficient scale and coverage, can help support and optimize the impact of core treatment and prevention interventions in RLS. Further operational research with more rigorous study designs, and ideally with biomarkers and costing information, is needed to determine the best model for providing these interventions in RLS.
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Affiliation(s)
- Amy Medley
- US Centers for Disease Control and Prevention, Division of Global HIV/AIDS, Atlanta, GA
| | - Pamela Bachanas
- US Centers for Disease Control and Prevention, Division of Global HIV/AIDS, Atlanta, GA
| | - Michael Grillo
- Naval Health Research Center, Department of Defense, HIV/AIDS Prevention Program, San Diego, CA
| | - Nina Hasen
- U.S. Department of State, Office of the US Global AIDS Coordinator and Health Diplomacy, Washington, DC
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Geng EH, Petersen ML. Network meta-analyses: powerful but not without perils. Lancet HIV 2014; 1:e95-e96. [PMID: 26424122 DOI: 10.1016/s2352-3018(14)00010-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 11/12/2014] [Indexed: 06/05/2023]
Affiliation(s)
- Elvin H Geng
- Division of HIV/AIDS, Department of Medicine, University of California, San Francisco, CA, USA.
| | - Maya L Petersen
- Division of Biostatistics, School of Public Health, University of California, Berkeley, CA, USA
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Interventions to promote adherence to antiretroviral therapy in Africa: a network meta-analysis. Lancet HIV 2014; 1:e104-11. [PMID: 26424119 DOI: 10.1016/s2352-3018(14)00003-4] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Accepted: 11/04/2014] [Indexed: 12/23/2022]
Abstract
BACKGROUND Adherence to antiretroviral therapy (ART) is necessary for the improvement of the health of patients and for public health. We sought to determine the comparative effectiveness of different interventions for improving ART adherence in HIV-infected people living in Africa. METHODS We searched for randomised trials of interventions to promote antiretroviral adherence within adults in Africa. We searched AMED, CINAHL, Embase, Medline (via PubMed), and ClinicalTrials.gov from inception to Oct 31, 2014, with the terms "HIV", "ART", "adherence", and "Africa". We created a network of the interventions by pooling the published and individual patients' data for comparable treatments and comparing them across the individual interventions with Bayesian network meta-analyses. The primary outcome was adherence defined as the proportion of patients meeting trial defined criteria; the secondary endpoint was viral suppression. FINDINGS We obtained data for 14 randomised controlled trials, with 7110 patients. Interventions included daily and weekly short message service (SMS; text message) messaging, calendars, peer supporters, alarms, counselling, and basic and enhanced standard of care (SOC). Compared with SOC, we found distinguishable improvement in self-reported adherence with enhanced SOC (odds ratio [OR] 1·46, 95% credibility interval [CrI] 1·06-1·98), weekly SMS messages (1·65, 1·25-2·18), counselling and SMS combined (2·07, 1·22-3·53), and treatment supporters (1·83, 1·36-2·45). We found no compelling evidence for the remaining interventions. Results were similar when using viral suppression as an outcome, although the network contained less evidence than that for adherence. Treatment supporters with enhanced SOC (1·46, 1·09-1·97) and weekly SMS messages (1·55, 1·01-2·38) were significantly better than basic SOC. INTERPRETATION Several recommendations for improving adherence are unsupported by the available evidence. These findings can inform future intervention choices for improving ART adherence in low-income settings. FUNDING None.
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Nieuwlaat R, Wilczynski N, Navarro T, Hobson N, Jeffery R, Keepanasseril A, Agoritsas T, Mistry N, Iorio A, Jack S, Sivaramalingam B, Iserman E, Mustafa RA, Jedraszewski D, Cotoi C, Haynes RB. Interventions for enhancing medication adherence. Cochrane Database Syst Rev 2014; 2014:CD000011. [PMID: 25412402 PMCID: PMC7263418 DOI: 10.1002/14651858.cd000011.pub4] [Citation(s) in RCA: 671] [Impact Index Per Article: 67.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND People who are prescribed self administered medications typically take only about half their prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications. OBJECTIVES The primary objective of this review is to assess the effects of interventions intended to enhance patient adherence to prescribed medications for medical conditions, on both medication adherence and clinical outcomes. SEARCH METHODS We updated searches of The Cochrane Library, including CENTRAL (via http://onlinelibrary.wiley.com/cochranelibrary/search/), MEDLINE, EMBASE, PsycINFO (all via Ovid), CINAHL (via EBSCO), and Sociological Abstracts (via ProQuest) on 11 January 2013 with no language restriction. We also reviewed bibliographies in articles on patient adherence, and contacted authors of relevant original and review articles. SELECTION CRITERIA We included unconfounded RCTs of interventions to improve adherence with prescribed medications, measuring both medication adherence and clinical outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive findings at earlier time points. DATA COLLECTION AND ANALYSIS Two review authors independently extracted all data and a third author resolved disagreements. The studies differed widely according to medical condition, patient population, intervention, measures of adherence, and clinical outcomes. Pooling results according to one of these characteristics still leaves highly heterogeneous groups, and we could not justify meta-analysis. Instead, we conducted a qualitative analysis with a focus on the RCTs with the lowest risk of bias for study design and the primary clinical outcome. MAIN RESULTS The present update included 109 new RCTs published since the previous update in January 2007, bringing the total number of RCTs to 182; we found five RCTs from the previous update to be ineligible and excluded them. Studies were heterogeneous for patients, medical problems, treatment regimens, adherence interventions, and adherence and clinical outcome measurements, and most had high risk of bias. The main changes in comparison with the previous update include that we now: 1) report a lack of convincing evidence also specifically among the studies with the lowest risk of bias; 2) do not try to classify studies according to intervention type any more, due to the large heterogeneity; 3) make our database available for collaboration on sub-analyses, in acknowledgement of the need to make collective advancement in this difficult field of research. Of all 182 RCTs, 17 had the lowest risk of bias for study design features and their primary clinical outcome, 11 from the present update and six from the previous update. The RCTs at lowest risk of bias generally involved complex interventions with multiple components, trying to overcome barriers to adherence by means of tailored ongoing support from allied health professionals such as pharmacists, who often delivered intense education, counseling (including motivational interviewing or cognitive behavioral therapy by professionals) or daily treatment support (or both), and sometimes additional support from family or peers. Only five of these RCTs reported improvements in both adherence and clinical outcomes, and no common intervention characteristics were apparent. Even the most effective interventions did not lead to large improvements in adherence or clinical outcomes. AUTHORS' CONCLUSIONS Across the body of evidence, effects were inconsistent from study to study, and only a minority of lowest risk of bias RCTs improved both adherence and clinical outcomes. Current methods of improving medication adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. The research in this field needs advances, including improved design of feasible long-term interventions, objective adherence measures, and sufficient study power to detect improvements in patient-important clinical outcomes. By making our comprehensive database available for sharing we hope to contribute to achieving these advances.
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Affiliation(s)
- Robby Nieuwlaat
- McMaster UniversityDepartment of Clinical Epidemiology and BiostatisticsHamilton General Hospital campus, Room C3‐107237 Barton Street EastHamiltonONCanadaL8L 2X2
| | - Nancy Wilczynski
- McMaster UniversityDepartment of Clinical Epidemiology and BiostatisticsHamilton General Hospital campus, Room C3‐107237 Barton Street EastHamiltonONCanadaL8L 2X2
| | - Tamara Navarro
- McMaster UniversityDepartment of Clinical Epidemiology and BiostatisticsHamilton General Hospital campus, Room C3‐107237 Barton Street EastHamiltonONCanadaL8L 2X2
| | - Nicholas Hobson
- McMaster UniversityDepartment of Clinical Epidemiology and BiostatisticsHamilton General Hospital campus, Room C3‐107237 Barton Street EastHamiltonONCanadaL8L 2X2
| | - Rebecca Jeffery
- McMaster UniversityDepartment of Clinical Epidemiology and BiostatisticsHamilton General Hospital campus, Room C3‐107237 Barton Street EastHamiltonONCanadaL8L 2X2
| | - Arun Keepanasseril
- McMaster UniversityDepartments of Clinical Epidemiology & Biostatistics, and Medicine, Faculty of Health Sciences1280 Main Street WestHamiltonONCanadaL8S 4L8
| | - Thomas Agoritsas
- McMaster UniversityDepartment of Clinical Epidemiology and BiostatisticsHamilton General Hospital campus, Room C3‐107237 Barton Street EastHamiltonONCanadaL8L 2X2
| | - Niraj Mistry
- St. Michael's HospitalDepartment of Pediatrics30 Bond StreetTorontoONCanadaM5B 1W8
| | - Alfonso Iorio
- McMaster UniversityDepartment of Clinical Epidemiology and BiostatisticsHamilton General Hospital campus, Room C3‐107237 Barton Street EastHamiltonONCanadaL8L 2X2
| | - Susan Jack
- McMaster UniversitySchool of Nursing, Faculty of Health SciencesHealth Sciences CentreRoom 2J32, 1280 Main Street WestHamiltonONCanadaL8S 4K1
| | | | - Emma Iserman
- McMaster UniversityDepartment of Clinical Epidemiology and BiostatisticsHamilton General Hospital campus, Room C3‐107237 Barton Street EastHamiltonONCanadaL8L 2X2
| | - Reem A Mustafa
- McMaster UniversityDepartment of Clinical Epidemiology and BiostatisticsHamilton General Hospital campus, Room C3‐107237 Barton Street EastHamiltonONCanadaL8L 2X2
| | - Dawn Jedraszewski
- McMaster UniversityDepartment of Clinical Epidemiology and BiostatisticsHamilton General Hospital campus, Room C3‐107237 Barton Street EastHamiltonONCanadaL8L 2X2
| | - Chris Cotoi
- McMaster UniversityDepartment of Clinical Epidemiology and BiostatisticsHamilton General Hospital campus, Room C3‐107237 Barton Street EastHamiltonONCanadaL8L 2X2
| | - R. Brian Haynes
- McMaster UniversityDepartments of Clinical Epidemiology & Biostatistics, and Medicine, Faculty of Health Sciences1280 Main Street WestHamiltonONCanadaL8S 4L8
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Lazarus JV, Safreed-Harmon K, Nicholson J, Jaffar S. Health service delivery models for the provision of antiretroviral therapy in sub-Saharan Africa: a systematic review. Trop Med Int Health 2014; 19:1198-215. [PMID: 25065882 DOI: 10.1111/tmi.12366] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES In response to the lack of evidence-based guidance for how to continue scaling up antiretroviral therapy (ART) in ways that make optimal use of limited resources, to assess comparative studies of ART service delivery models implemented in sub-Saharan Africa. METHODS A systematic literature search and analysis of studies that compared two or more methods of ART service delivery using either CD4 count or viral load as a primary outcome. RESULTS Most studies identified in this review were small and non-randomised, with low statistical power. Four of the 30 articles identified by this review conclude that nurse management of ART compares favourably to physician management. Seven provide evidence of the viability of managing ART at lower levels within the health system, and one indicates that vertical and integrated ART programmes can achieve similar outcomes. Five articles show that community/home-based ART management can be as effective as facility-based ART management. Five of seven articles investigating community support link it to better clinical outcomes. The results of four studies suggest that directly observed therapy may not be an important component of ART programmes. CONCLUSIONS Given that the scale-up of antiretroviral therapy represents the most sweeping change in healthcare delivery in sub-Saharan Africa in recent years, it is surprising to not find more evidence from comparative studies to inform implementation strategies. The studies reported on a wide range of service delivery models, making it difficult to draw conclusions about some models. The strongest evidence was related to the feasibility of decentralisation and task-shifting, both of which appear to be effective strategies.
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Lankowski AJ, Siedner MJ, Bangsberg DR, Tsai AC. Impact of geographic and transportation-related barriers on HIV outcomes in sub-Saharan Africa: a systematic review. AIDS Behav 2014; 18:1199-223. [PMID: 24563115 DOI: 10.1007/s10461-014-0729-8] [Citation(s) in RCA: 150] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Difficulty obtaining reliable transportation to clinic is frequently cited as a barrier to HIV care in sub-Saharan Africa (SSA). Numerous studies have sought to characterize the impact of geographic and transportation-related barriers on HIV outcomes in SSA, but to date there has been no systematic attempt to summarize these findings. In this systematic review, we summarized this body of literature. We searched for studies conducted in SSA examining the following outcomes in the HIV care continuum: (1) voluntary counseling and testing, (2) pre-antiretroviral therapy (ART) linkage to care, (3) loss to follow-up and mortality, and (4) ART adherence and/or viral suppression. We identified 34 studies containing 52 unique estimates of association between a geographic or transportation-related barrier and an HIV outcome. There was an inverse effect in 23 estimates (44 %), a null association in 26 (50 %), and a paradoxical beneficial impact in 3 (6 %). We conclude that geographic and transportation-related barriers are associated with poor outcomes across the continuum of HIV care.
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Abah IO, Ojeh VB, Musa J, Ugoagwu P, Agaba PA, Agbaji O, Okonkwo P. Clinical Utility of Pharmacy-Based Adherence Measurement in Predicting Virologic Outcomes in an Adult HIV-Infected Cohort in Jos, North Central Nigeria. J Int Assoc Provid AIDS Care 2014; 15:77-83. [PMID: 24963086 DOI: 10.1177/2325957414539197] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES We examined the association between adherence to drug-refill visits and virologic outcomes in a cohort of HIV-infected adults on combination antiretroviral therapy (cART) in North Central Nigeria. METHODS Retrospectively, 588 HIV-infected, cART-naive adults (aged ≥15 years), initiated on first-line ART between 2009 and 2010 at the Jos University Teaching Hospital, were evaluated. Association between adherence to drug-refill visits, virologic (viral load>1000 copies/mL), and immunologic failure was assessed using multivariable logistic regression. RESULTS After a median of 12 months on cART, 16% (n=94) and 10% (n=59) of patients had virologic and immunologic failures, respectively. In the final multivariable model, suboptimal adherence to drug-refill visits was a significant predictor of both virologic (adjusted odds ratio [AOR] 1.6; 95% confidence interval [CI]:1.2-2.3) and immunologic (AOR 1.92; 95% CI:1.06-3.49) failures. CONCLUSION Adherence to drug refill is a useful predictor of successful virologic control and could be utilized for routine monitoring of adherence to cART in our clinical setting.
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Affiliation(s)
- Isaac Okoh Abah
- Jos University Teaching Hospital, AIDS Prevention Initiative in Nigeria (APIN), Jos, Nigeria
| | - Victor Bazim Ojeh
- Jos University Teaching Hospital, AIDS Prevention Initiative in Nigeria (APIN), Jos, Nigeria
| | - Jonah Musa
- University of Jos/Jos University Teaching Hospital, APIN Centre, Jos, Nigeria
| | - Placid Ugoagwu
- Jos University Teaching Hospital, AIDS Prevention Initiative in Nigeria (APIN), Jos, Nigeria
| | | | - Oche Agbaji
- University of Jos/Jos University Teaching Hospital, APIN Centre, Jos, Nigeria
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Chishinga N, Godfrey-Faussett P, Fielding K, Ayles H. Effect of home-based interventions on virologic outcomes in adults receiving antiretroviral therapy in Africa: a meta-analysis. BMC Public Health 2014; 14:239. [PMID: 24606968 PMCID: PMC3974116 DOI: 10.1186/1471-2458-14-239] [Citation(s) in RCA: 10] [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: 04/08/2013] [Accepted: 02/27/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The success of adherence to combination antiretroviral therapy (ART) in sub-Saharan Africa is hampered by factors that are unique to this setting. Home based interventions have been identified as possible strategies for decentralizing ART care and improving access and adherence to ART. There is need for evidence at individual- or community-level of the benefits of home-based interventions in improving HIV suppression in African patients receiving ART. METHODS We conducted a systematic review and meta-analysis of the literature to assess the effect of home-based interventions on virologic outcomes in adults receiving ART in Africa. RESULTS A total of 260 publications were identified by the search strategy, 249 were excluded on initial screening and 11 on full review, leaving 5 publications for analysis. The overall OR of virologic suppression at 12 months after starting ART of home-based interventions to standard of care was 1.13 (95% CI: 0.51-2.52). CONCLUSIONS There was insufficient data to know whether there is a difference in HIV suppression at 12 months in the home-based arm compared with the standard of care arm in adults receiving ART in Africa. Given the few trials conducted from Africa, there is need for further research that measures the effects of home-based models on HIV suppression in African populations.
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Affiliation(s)
- Nathaniel Chishinga
- Zambia AIDS-related TB Project, School of Medicine, P.O Box 50697, Ridgeway campus, Lusaka, Zambia
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Peter Godfrey-Faussett
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Katherine Fielding
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Helen Ayles
- Zambia AIDS-related TB Project, School of Medicine, P.O Box 50697, Ridgeway campus, Lusaka, Zambia
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
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Abstract
INTRODUCTION Access to antiretroviral treatment (ART) has substantially improved over the past decade. In this new era of HIV as a chronic disease, the continued success of ART will depend critically on sustained high ART adherence. The objective of this review was to systematically review interventions that can improve adherence to ART, including individual-level interventions and changes to the structure of ART delivery, to inform the evidence base for the 2013 WHO consolidated antiretroviral guidelines. DESIGN A rapid systematic review. METHODS We conducted a rapid systematic review of the global evidence on interventions to improve adherence to ART, utilizing pre-existing systematic reviews to identify relevant research evidence complemented by screening of databases for articles published over the past 2 years on evidence from randomized controlled trials (RCTs). We searched five databases for both systematic reviews and primary RCT studies (Cochrane Library, EMBASE, MEDLINE, Web of Science, and WHO Global Health Library); we additionally searched ClinicalTrials.gov for RCT studies. We examined intervention effectiveness by different study characteristics, in particular, the specific populations who received the intervention. RESULTS A total of 124 studies met our selection criteria. Eighty-six studies were RCTs. More than 20 studies have tested the effectiveness of each of the following interventions, either singly or in combination with other interventions: cognitive-behavioural interventions, education, treatment supporters, directly observed therapy, and active adherence reminder devices (such as mobile phone text messages). Although there is strong evidence that all five of these interventions can significantly increase ART adherence in some settings, each intervention has also been found not to produce significant effects in several studies. Almost half (55) of the 124 studies investigated the effectiveness of combination interventions. Combination interventions tended to have effects that were similar to those of single interventions. The evidence base on interventions in key populations was weak, with the exception of interventions for people who inject drugs. CONCLUSION Tested and effective adherence-enhancing interventions should be increasingly moved into implementation in routine programme and care settings, accompanied by rigorous evaluation of implementation impact and performance. Major evidence gaps on adherence-enhancing interventions remain, in particular, on the cost-effectiveness of interventions in different settings, long-term effectiveness, and effectiveness of interventions in specific populations, such as pregnant and breastfeeding women.
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Impact of HIV-related stigma on treatment adherence: systematic review and meta-synthesis. J Int AIDS Soc 2013; 16:18640. [PMID: 24242258 PMCID: PMC3833107 DOI: 10.7448/ias.16.3.18640] [Citation(s) in RCA: 704] [Impact Index Per Article: 64.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 08/22/2013] [Accepted: 08/29/2013] [Indexed: 01/20/2023] Open
Abstract
Introduction Adherence to HIV antiretroviral therapy (ART) is a critical determinant of HIV-1 RNA viral suppression and health outcomes. It is generally accepted that HIV-related stigma is correlated with factors that may undermine ART adherence, but its relationship with ART adherence itself is not well established. We therefore undertook this review to systematically assess the relationship between HIV-related stigma and ART adherence. Methods We searched nine electronic databases for published and unpublished literature, with no language restrictions. First we screened the titles and abstracts for studies that potentially contained data on ART adherence. Then we reviewed the full text of these studies to identify articles that reported data on the relationship between ART adherence and either HIV-related stigma or serostatus disclosure. We used the method of meta-synthesis to summarize the findings from the qualitative studies. Results Our search protocol yielded 14,854 initial records. After eliminating duplicates and screening the titles and abstracts, we retrieved the full text of 960 journal articles, dissertations and unpublished conference abstracts for review. We included 75 studies conducted among 26,715 HIV-positive persons living in 32 countries worldwide, with less representation of work from Eastern Europe and Central Asia. Among the 34 qualitative studies, our meta-synthesis identified five distinct third-order labels through an inductive process that we categorized as themes and organized in a conceptual model spanning intrapersonal, interpersonal and structural levels. HIV-related stigma undermined ART adherence by compromising general psychological processes, such as adaptive coping and social support. We also identified psychological processes specific to HIV-positive persons driven by predominant stigmatizing attitudes and which undermined adherence, such as internalized stigma and concealment. Adaptive coping and social support were critical determinants of participants’ ability to overcome the structural and economic barriers associated with poverty in order to successfully adhere to ART. Among the 41 quantitative studies, 24 of 33 cross-sectional studies (71%) reported a positive finding between HIV stigma and ART non-adherence, while 6 of 7 longitudinal studies (86%) reported a null finding (Pearson's χ2=7.7; p=0.005). Conclusions We found that HIV-related stigma compromised participants’ abilities to successfully adhere to ART. Interventions to reduce stigma should target multiple levels of influence (intrapersonal, interpersonal and structural) in order to have maximum effectiveness on improving ART adherence.
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GPS-measured distance to clinic, but not self-reported transportation factors, are associated with missed HIV clinic visits in rural Uganda. AIDS 2013; 27:1503-8. [PMID: 23435294 DOI: 10.1097/qad.0b013e32835fd873] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Studies of the association between transportation barriers and HIV-related health outcomes have shown both positive and negative effects, possibly because a reliable, validated measure of transportation barriers has not been identified. DESIGN Prospective cohort study of HIV-infected patients in rural Uganda. METHODS Participants were enrolled from the HIV clinic at the regional referral hospital in Mbarara, Uganda as part of the Uganda AIDS Rural Treatment Outcomes (UARTO) Study. We collected the following measures of transportation barriers to HIV clinic: global positioning systems (GPS)-tracked distance measured by driving participants to their homes along their typical route; straight-line GPS distance from clinic to home, calculated with the Great Circle Formula; self-reported travel time; and self-reported travel cost. We assessed inter-measure agreement using linear regression, correlation coefficients and κ statistics (by measure quartile) and validated measures by fitting linear regression models to estimate associations with days late for clinic visits. RESULTS One hundred and eighty-eight participants were tracked with GPS. Seventy-six percent were women, with a median age of 40 years and median CD4 cell count of 193 cells/μl. We found a high correlation between GPS-based distance measures (β=0.74, P<0.001, R²=0.92, κ=0.73), but little correlation between GPS-based and self-reported measures (all R²≤0.4). GPS-based measures were associated with days late to clinic (P<0.001); but neither self-reported measure was associated (P>0.85). CONCLUSION GPS-measured distance to clinic is associated with HIV clinic absenteeism and should be prioritized over self-reported measures to optimally risk-stratify patients accessing care in rural, resource-limited settings.
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Immuno-virologic outcomes and immuno-virologic discordance among adults alive and on anti-retroviral therapy at 12 months in Nigeria. BMC Infect Dis 2013; 13:113. [PMID: 23452915 PMCID: PMC3599241 DOI: 10.1186/1471-2334-13-113] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Accepted: 02/27/2013] [Indexed: 11/21/2022] Open
Abstract
Background Predictors of immuno-virologic outcomes and discordance and their associations with clinical, demographic, socio-economic and behavioral risk factors are not well described in Nigeria since HIV viral load testing is not routinely offered in public HIV treatment programs. Methods The HACART study was a multi-center observational clinic-based cohort study of 2585 adults who started HAART between April 2008 and February 2009. A total of 628 patients were randomly selected at 12 months for immuno-virologic analyses. Results Virologic suppression rate (<400 copies/ml) was 76.7%, immunologic recovery rate (CD4 change from baseline ≥50 cells/mm3) was 77.4% and immuno-virologic discordance rate was 33%. In multivariate logistic regression, virologic failure was associated with age <30 years (OR 1.79; 95% CI: 1.17-2.67, p=0.03), anemia (Hemoglobin < 10 g/dl) (OR 1.71; 95% CI: 1.22-2.61, p=0.03), poor adherence (OR 3.82; 95% CI: 2.17-5.97, p=0.001), and post-secondary education (OR 0.60; 95% CI: 0.30-0.86, p=0.02). Immunologic failure was associated with male gender (OR 1.46; 95% CI: 1.04-2.45, p=0.04), and age <30 years (OR 1.50; 95% CI: 1.11-2.39, p=0.03). Virologic failure with immunologic success (VL-/CD4+) was associated with anemia (OR 1.80; 95% CI: 1.13-2.88, p=0.03), poor adherence (OR 3.90; 95% CI: 1.92-8.24, p=0.001), and post-secondary education (OR 0.40; 95% CI: 0.22-0.68, p=0.005). Conclusions Although favorable immuno-virologic outcomes could be achieved in this large ART program, immuno-virologic discordance was observed in a third of the patients. Focusing on intensified treatment preparation and adherence, young patients, males, persons with low educational status and most importantly baseline anemia assessment and management may help address predictors of poor immuno-virologic outcomes, and improve overall HIV program impact. Viral load testing in addition to the CD4 testing should be considered to identify, characterize and address negative immuno-virologic outcomes and discordance.
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Scanlon ML, Vreeman RC. Current strategies for improving access and adherence to antiretroviral therapies in resource-limited settings. HIV AIDS (Auckl) 2013; 5:1-17. [PMID: 23326204 PMCID: PMC3544393 DOI: 10.2147/hiv.s28912] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The rollout of antiretroviral therapy (ART) significantly reduced human immunodeficiency virus (HIV)-related morbidity and mortality, but good clinical outcomes depend on access and adherence to treatment. In resource-limited settings, where over 90% of the world's HIV-infected population resides, data on barriers to treatment are emerging that contribute to low rates of uptake in HIV testing, linkage to and retention in HIV care systems, and suboptimal adherence rates to therapy. A review of the literature reveals limited evidence to inform strategies to improve access and adherence with the majority of studies from sub-Saharan Africa. Data from observational studies and randomized controlled trials support home-based, mobile and antenatal care HIV testing, task-shifting from doctor-based to nurse-based and lower level provider care, and adherence support through education, counseling and mobile phone messaging services. Strategies with more limited evidence include targeted HIV testing for couples and family members of ART patients, decentralization of HIV care, including through home- and community-based ART programs, and adherence promotion through peer health workers, treatment supporters, and directly observed therapy. There is little evidence for improving access and adherence among vulnerable groups such as women, children and adolescents, and other high-risk populations and for addressing major barriers. Overall, studies are few in number and suffer from methodological issues. Recommendations for further research include health information technology, social-level factors like HIV stigma, and new research directions in cost-effectiveness, operations, and implementation. Findings from this review make a compelling case for more data to guide strategies to improve access and adherence to treatment in resource-limited settings.
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Affiliation(s)
- Michael L Scanlon
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- USAID, Academic Model Providing Access to Healthcare (AMPATH) Partnership, Eldoret, Kenya
| | - Rachel C Vreeman
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- USAID, Academic Model Providing Access to Healthcare (AMPATH) Partnership, Eldoret, Kenya
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Idoko J. A clinician's experience with the President's Emergency Plan for AIDS Relief in Nigeria: a transformative decade of hope. Health Aff (Millwood) 2012; 31:1422-8. [PMID: 22778331 DOI: 10.1377/hlthaff.2012.0349] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Prior to the start of the President's Emergency Plan for AIDS Relief (PEPFAR), Nigeria struggled to fight HIV/AIDS. PEPFAR changed everything. I witnessed this change firsthand by directing the response to AIDS, first in my hospital in Jos, in central Nigeria, and now as Nigeria's HIV/AIDS coordinator. When the first AIDS case was diagnosed in Nigeria in 1986, my country had one of the world's poorest health systems, and as the pandemic spread, most Nigerians with AIDS died. Eventually, effective new drugs were developed, but they were too costly for all but a few Nigerians. Then there was a miracle: PEPFAR gave us resources, direction, and expertise to treat hundreds of thousands of people around the country. Today, Nigeria is providing treatment to 500,000 people with AIDS, and 80 percent of them receive treatment supported by PEPFAR. The US effort did more than help us treat people with HIV/AIDS; it also enabled Nigeria to strengthen its health system, improve care for pregnant women and infants, increase the provision of vaccinations, build modern laboratories, and train thousands of new health care workers and technicians.
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Affiliation(s)
- John Idoko
- National Agency for the Control of AIDS, Abuja, Nigeria.
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Abstract
Treatment partnering is an adherence intervention developed in sub-Saharan Africa. This paper describes the additional social functions that treatment partners serve and shows how these functions contribute to health and survival for patients with HIV/AIDS. Ninety-eight minimally structured interviews were conducted with twenty pairs of adult HIV/AIDS patients (N = 20) and treatment partners (N = 20) treated at a public HIV-care setting in Tanzania. Four social functions were identified using inductive, category construction and interpretive methods of analysis: (1) encouraging disclosure; (2) combating stigma; (3) restoring hope; and (4) reducing social difference. These functions work to restore social connections and reverse the isolating effects of HIV/AIDS, strengthening access to essential community safety nets. Besides encouraging ARV adherence, treatment partners contribute to the social health of patients. Social health as well as HIV treatment success is essential to survival for persons living with HIV/AIDS in sub-Saharan Africa.
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Thompson MA, Mugavero MJ, Amico KR, Cargill VA, Chang LW, Gross R, Orrell C, Altice FL, Bangsberg DR, Bartlett JG, Beckwith CG, Dowshen N, Gordon CM, Horn T, Kumar P, Scott JD, Stirratt MJ, Remien RH, Simoni JM, Nachega JB. Guidelines for improving entry into and retention in care and antiretroviral adherence for persons with HIV: evidence-based recommendations from an International Association of Physicians in AIDS Care panel. Ann Intern Med 2012; 156:817-33, W-284, W-285, W-286, W-287, W-288, W-289, W-290, W-291, W-292, W-293, W-294. [PMID: 22393036 PMCID: PMC4044043 DOI: 10.7326/0003-4819-156-11-201206050-00419] [Citation(s) in RCA: 481] [Impact Index Per Article: 40.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
DESCRIPTION After HIV diagnosis, timely entry into HIV medical care and retention in that care are essential to the provision of effective antiretroviral therapy (ART). Adherence to ART is among the key determinants of successful HIV treatment outcome and is essential to minimize the emergence of drug resistance. The International Association of Physicians in AIDS Care convened a panel to develop evidence-based recommendations to optimize entry into and retention in care and ART adherence for people with HIV. METHODS A systematic literature search was conducted to produce an evidence base restricted to randomized, controlled trials and observational studies with comparators that had at least 1 measured biological or behavioral end point. A total of 325 studies met the criteria. Two reviewers independently extracted and coded data from each study using a standardized data extraction form. Panel members drafted recommendations based on the body of evidence for each method or intervention and then graded the overall quality of the body of evidence and the strength for each recommendation. RECOMMENDATIONS Recommendations are provided for monitoring entry into and retention in care, interventions to improve entry and retention, and monitoring of and interventions to improve ART adherence. Recommendations cover ART strategies, adherence tools, education and counseling, and health system and service delivery interventions. In addition, they cover specific issues pertaining to pregnant women, incarcerated individuals, homeless and marginally housed individuals, and children and adolescents, as well as substance use and mental health disorders. Recommendations for future research in all areas are also provided.
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