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Ibrahima D, Hallee W, Margeret M, Hari I, Gugulethu T, Amanda F, Jacob B, Serena P K, Kennedy O, Ingrid T K. A Risk Prediction Model to Identify People Living with HIV Who are High-risk for Disengagement from Care after HIV Diagnosis in South Africa. AIDS Behav 2024:10.1007/s10461-024-04430-y. [PMID: 38985402 DOI: 10.1007/s10461-024-04430-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2024] [Indexed: 07/11/2024]
Abstract
The provision of ART in South Africa has transformed the HIV epidemic, resulting in an increase in life expectancy by over 10 years. Despite this, nearly 2 million people living with HIV are not on treatment. The objective of this study was to develop and externally validate a practical risk assessment tool to identify people with HIV (PWH) at highest risk for attrition from care after testing. A machine learning model incorporating clinical and psychosocial factors was developed in a primary cohort of 498 PWH. LASSO regression analysis was used to optimize variable selection. Multivariable logistic regression analysis was applied to build a model using 80% of the primary cohort as a training dataset and validated using the remaining 20% of the primary cohort and data from an independent cohort of 96 participants. The risk score was developed using the Sullivan and D'Agostino point based method. Of 498 participants with mean age 35.7 years, 192 (38%) did not initiate ART after diagnosis. Controlling for site, factors associated with non-engagement in care included being < 35 years, feeling abandoned by God, maladaptive coping strategies using alcohol or other drugs, no difficulty concentrating, and having high levels of confidence in one's ability to handle personal challenges. An effective risk score can enable clinicians and implementers to focus on tailoring care for those most in need of ongoing support. Further research should focus on potential strategies to enhance the generalizability and evaluate the implementation of the proposed risk prediction model in HIV treatment programs.
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Affiliation(s)
| | | | - McNairy Margeret
- Division of General Internal Medicine, Centre for Global Health, Weill Cornell Medicine, NY, USA
| | - Iyer Hari
- Section of Cancer Epidemiology and Health Outcomes, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Tshabalala Gugulethu
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Fata Amanda
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Bor Jacob
- Department of Global Health and Epidemiology, School of Public Health, Boston University, Boston, MA, USA
| | - Koenig Serena P
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Otwombe Kennedy
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Katz Ingrid T
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
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2
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Katz IT, Ngure K, Kamolloh K, Ogello V, Okombo M, Thuo NB, Owino E, Garrison LE, Lee YS, Nardell MF, Anyacheblu C, Bukusi E, Mugo N, Baeten JM, Haberer JE. Multi-level Factors Driving Pre-exposure Prophylaxis Non-initiation Among Young Women at High Risk for HIV in Kenya. AIDS Behav 2023; 27:106-118. [PMID: 35930203 DOI: 10.1007/s10461-022-03748-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2022] [Indexed: 01/29/2023]
Abstract
Few studies have focused on understanding pre-exposure prophylaxis (PrEP) non-initiation among young, high-risk women in sub-Saharan Africa. This study aimed to qualitatively explore why young women in Kenya at high-risk for HIV chose not to enroll in a PrEP adherence trial. We performed 40 semi-structured interviews with young high-risk women assessing concerns about PrEP and/or study participation. We also assessed community-level factors influencing decision-making around PrEP through 10 focus groups involving peers, young men, caregivers, and community leaders. Our qualitative data reflect the complexity of navigating barriers preventing PrEP initiation in settings where taking PrEP may be perceived as immoral behavior. Framed within the context of risk perception, the decision to start PrEP may run counter to the potential risk of losing support from one's community. Our findings suggest that approaches addressing social norms, while de-medicalizing HIV prevention services, are needed to further increase PrEP uptake among young Kenyan women.
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Affiliation(s)
- Ingrid T Katz
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA. .,Harvard Medical School, Boston, MA, USA. .,Massachusetts General Hospital Center for Global Health, Boston, MA, USA. .,Harvard Global Health Institute, Cambridge, MA, USA. .,Division of Women's Health, Brigham and Women's Hospital, 1620 Tremont St. - 3rd Floor, Boston, MA, 02120, USA.
| | - Kenneth Ngure
- Department of Community Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | | | | | - Moses Okombo
- Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Esther Owino
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Lindsey E Garrison
- Massachusetts General Hospital Center for Global Health, Boston, MA, USA
| | - Yeonsoo S Lee
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Mayo Clinic Alix School of Medicine, Scottsdale, AZ, USA
| | - Maria F Nardell
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Chiemelie Anyacheblu
- Harvard T.H Chan School of Public Health, Boston, MA, USA.,SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Elizabeth Bukusi
- Kenya Medical Research Institute, Nairobi, Kenya.,Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - Nelly Mugo
- Kenya Medical Research Institute, Nairobi, Kenya.,Department of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, WA, USA
| | - Jared M Baeten
- Department of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, WA, USA.,Gilead Sciences, Foster City, CA, USA
| | - Jessica E Haberer
- Harvard Medical School, Boston, MA, USA.,Massachusetts General Hospital Center for Global Health, Boston, MA, USA
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3
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Denardo D, Mojola SA, Schatz E, Gómez-Olivé FX. Antiretroviral therapy and aging as resources for managing and resisting HIV-related stigma in rural South Africa. SSM. QUALITATIVE RESEARCH IN HEALTH 2022; 2:100148. [PMID: 36687383 PMCID: PMC9851406 DOI: 10.1016/j.ssmqr.2022.100148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The widespread roll-out of antiretroviral therapy (ART) in Africa has contributed to a large population of adults aging with HIV. However, little is known about how HIV-related stigma interacts with aging in the ART era. This study uses in-depth interviews with middle-aged and older South Africans living with HIV to explore stigma-related experiences and response strategies. Participants describe a persistence of stigma which requires the deployment of a range of common and age-based stigma management and resistance strategies. We find that participants minimize their exposure to stigma through selective disclosure of their HIV status; neutralize HIV-related stigma through comparisons to chronic illnesses common among older adults, and deflect stigma through asserting an ART-adherent identity and othering younger non-adherent adults. Overall, our study highlights the roles of ART and aging as resources for managing and resisting HIV-related stigma.
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Affiliation(s)
- Danielle Denardo
- Social and Behavioral Sciences, Soka University of America, Aliso Viejo, CA, USA,Corresponding author.. 1.949.480.4216, 1 University Drive, Aliso Viejo, CA, 92656, USA, (D. Denardo)
| | - Sanyu A. Mojola
- Department of Sociology, School of Public and International Affairs, Office of Population Research, Princeton University, Princeton, NJ, USA,MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, South Africa
| | - Enid Schatz
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, South Africa,Department of Public Health and Department of Women’s & Gender Studies, University of Missouri, Columbia, MO, USA
| | - F. Xavier Gómez-Olivé
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, South Africa
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4
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Macleod D, Shanaube K, Skalland T, Limbada M, Mandla N, Bwalya J, Schaap A, Yang B, Donnell D, Piwowar-Manning E, Eshleman SH, Hoddinott G, Bond V, Moore A, Griffith S, Bock P, Ayles H, Fidler S, Hayes R, Floyd S. Viral suppression and self-reported ART adherence after 3 years of universal testing and treatment in the HPTN 071 (PopART) community-randomised trial in Zambia and South Africa: a cross-sectional analysis. Lancet HIV 2022; 9:e751-e759. [PMID: 36332652 PMCID: PMC9646982 DOI: 10.1016/s2352-3018(22)00237-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 07/25/2022] [Accepted: 08/17/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND In 2014, UNAIDS set the target that 90% of individuals on antiretroviral therapy (ART) be virally suppressed. Here, we use data from the HPTN 071 (PopART) trial to report whether the introduction of universal testing and treatment has affected viral suppression or treatment adherence among individuals who self-reported they were taking ART, and identify risk factors for these outcomes. METHODS This was a cross-sectional study nested within the randomly selected population cohort of the PopART trial. The trial took place in 21 communities in Zambia and South Africa. Analyses included 3570 HIV-positive participants who were seen at the second follow-up visit in 2016-17 and who self-reported that they were currently taking ART. Viral suppression was defined as HIV RNA of less than 400 copies per mL from a blood sample collected during the cohort visit, and ART adherence was measured using self-reporting (reported as no missed pills in last 7 days). Prevalences of these outcomes were compared across three trial arms using a two-stage approach suitable for clustered data. Each arm consisted of seven communities, with one arm receiving a combination HIV prevention package including immediate ART initiation, one receiving a combination HIV prevention package excluding immediate ART initiation and one arm receving standard of care. Risk factors for each of the outcomes were assessed using logistic regression. FINDINGS Among the 3570 participants who self-reported that they were currently on ART, 416 (11·7%) of 3554 were not virally suppressed (16 were missing viral suppression status) and 345 (9·7%) of 3566 reported being non-adherent to ART (four were missing adherence status). The proportion not virally suppressed was higher in communities in South Africa (195 [16·4%] of 1191) than in Zambia (221 [9·4%] of 2363). There was no evidence that the prevalence of the outcomes differed between trial arms. There was evidence that men, younger individuals, individuals who reported participating in harmful alcohol use, and those who reported internalised stigma were more likely to be non-adherent, and not virally suppressed. INTERPRETATION The results assuaged concerns that early ART initiation in a universal testing and treatment setting could lead to reduced adherence and viral suppression. FUNDING US National Institute of Allergy and Infectious Diseases (which is a part of the National Institutes of Health), the International Initiative for Impact Evaluation with support from the Bill & Melinda Gates Foundation, US President's Emergency Plan for AIDS Relief, and Medical Research Council UK.
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Affiliation(s)
- David Macleod
- International Statistics and Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.
| | - Kwame Shanaube
- Zambart, School of Public Health, University of Zambia, Lusaka, Zambia
| | | | - Mohammed Limbada
- Zambart, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Nomtha Mandla
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Justin Bwalya
- Zambart, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Ab Schaap
- International Statistics and Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK; Zambart, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Blia Yang
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Deborah Donnell
- HPTN Statistical and Data Management Centre, Seattle, WA, USA
| | | | - Susan H Eshleman
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Graeme Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Virginia Bond
- Global Health and Development Department, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK; Zambart, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Ayana Moore
- FHI 360, HIV Prevention Trials Network, Durham, NC, USA
| | - Sam Griffith
- FHI 360, HIV Prevention Trials Network, Durham, NC, USA
| | - Peter Bock
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Helen Ayles
- Zambart, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Sarah Fidler
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Richard Hayes
- International Statistics and Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Sian Floyd
- International Statistics and Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
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5
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Nardell MF, Hedt-Gauthier B, Earnshaw VA, Bogart LM, Dietrich JJ, Courtney I, Tshabalala G, Bor J, Orrell C, Gray G, Bangsberg DR, Katz IT. Understanding Repeat Positive HIV Testing in South Africa Under Changing Treatment Guidelines. AIDS Behav 2022; 26:1366-1376. [PMID: 34705150 PMCID: PMC9007825 DOI: 10.1007/s10461-021-03493-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2021] [Indexed: 01/06/2023]
Abstract
Some people with HIV (PWH) test positive multiple times without initiating antiretroviral therapy (ART). We surveyed 496 ART-eligible PWH following routine HIV testing at three clinics in Soweto and Gugulethu, South Africa in 2014-2015. Among repeat positive testers (RPTs) in this cohort, we compared rates of treatment initiation by prior treatment eligibility and assessed psychosocial predictors of treatment initiation in logistic regression models. RPTs represented 33.8% of PWH in this cohort. Less than half of those who reported eligibility for ART on prior testing started treatment upon retesting, in contrast to two thirds of RPTs who were previously ineligible for treatment who started treatment once they learned of their eligibility. Those who reported coping through substance use were more likely to decline treatment versus those not using substances. PWH who test repeatedly represent a vulnerable population at risk for ART non-initiation who may benefit from interventions addressing individualized coping strategies.
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Affiliation(s)
- Maria F Nardell
- Division of Global Health Equity, Brigham and Women's Hospital, Thorn Building 14th Floor, Boston, MA, 02120, USA.
- Harvard Medical School, Boston, USA.
- Department of Medicine, Brigham and Women's Hospital, Boston, USA.
| | - Bethany Hedt-Gauthier
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
- Massachusetts General Hospital Center for Global Health, Boston, USA
| | - Valerie A Earnshaw
- Department of Human Development and Family Sciences, University of Delaware, Newark, USA
| | | | - Janan J Dietrich
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Health Systems Research Unit, South African Medical Research Council, Western Cape, South Africa
| | - Ingrid Courtney
- Desmond Tutu Health Foundation, University of Cape Town Medical School, Cape Town, South Africa
| | - Gugulethu Tshabalala
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Jacob Bor
- Department of Global Health, Boston University School of Public Health, Boston, USA
| | - Catherine Orrell
- Desmond Tutu Health Foundation, University of Cape Town Medical School, Cape Town, South Africa
| | - Glenda Gray
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Office of the President, South African Medical Research Council, Western Cape, South Africa
| | - David R Bangsberg
- Oregon Health & Science University-Portland State University School of Public Health, Portland, USA
| | - Ingrid T Katz
- Harvard Medical School, Boston, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, USA
- Massachusetts General Hospital Center for Global Health, Boston, USA
- Harvard Global Health Institute, Cambridge, USA
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6
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Jimu C, Govender K, Kanyemba R, Ngbesso MJO. Experiences of intimate relationships, stigma, social support and treatment adherence among HIV-positive adolescents in Chiredzi district, Zimbabwe. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2021; 20:214-223. [PMID: 34635020 DOI: 10.2989/16085906.2021.1979059] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
This study explored experiences of intimate relationships, stigma, social support and treatment adherence among HIV-positive adolescents in Chiredzi district, Zimbabwe. The study adopted an interpretive qualitative methodology to explore the intricacies of living with HIV as an adolescent. Thirty (N = 30) adolescents aged between 13 and 19 years participated in this study. They were recruited while attending social support or during their routine visits to collect antiretrovirals. In-depth interviews were conducted to generate data. Adolescents were asked about their romantic lives and the difficulties they faced while living with HIV. Findings revealed that adolescents living with HIV (ALHIV) are confronted with stigma and discrimination. They also grapple with emotional issues such as dealing with disclosure. However, social support minimises the risk of harbouring suicidal thoughts. To the various challenges ALHIV face, most of them (particularly males) adopt several coping mechanisms. These include (but are not limited to) non-disclosure of their seropositive status to sexual partners, thereby risking reinfection and exposing their partners to HIV. Non-disclosure of seropositive status contributed to either poor antiretroviral therapy (ART) adherence or defaulting on HIV medication. A life-cycle approach to HIV prevention and management is crucial to mitigating the challenges faced by ALHIV because risks of HIV infection, challenges of access to HIV services and solutions to these challenges change at different stages of someone's life. This scenario justifies the necessity of a holistic bio-psychosocial approach to managing HIV among adolescents, not only limited to the client, but also involving appropriate education programmes for the broader community.
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Affiliation(s)
- Christopher Jimu
- Psychology, School of Applied Social Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Kaymarlin Govender
- Health Economics and HIV and AIDS Research Division, University of KwaZulu-Natal, Durban, South Africa
| | - Roselyn Kanyemba
- Health Economics and HIV and AIDS Research Division, University of KwaZulu-Natal, Durban, South Africa
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7
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Leyva-Moral JM, Palmieri PA, Loayza-Enriquez BK, Vander Linden KL, Elias-Bravo UE, Guevara-Vasquez GM, Davila-Olano LY, Aguayo-Gonzalez MP. 'Staying alive' with antiretroviral therapy: a grounded theory study of people living with HIV in Peru. BMJ Glob Health 2021; 6:e006772. [PMID: 34711579 PMCID: PMC8557298 DOI: 10.1136/bmjgh-2021-006772] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/05/2021] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND To achieve an optimal quality of life through chronic disease management, people living with HIV (PLHIV) must adhere to antiretroviral therapy (ART). ART has been available throughout Peru since 2004 without cost in all regions; yet only 60% (43 200) of PLHIV receive ART and 32% are virally suppressed. Despite the low adherence, little is known about the experience of PLHIV with ART adherence in the context of Latin America. METHODS A constructivist grounded theory design was used to understand the ART adherence experiences of PLHIV in Northern Peru. Unstructured interviews were conducted with 18 participants resulting in theoretical saturation. All interviews were recorded, immediately transcribed and analysed concurrently with data collection using constant comparative analysis with Atlas.ti (V.8) software. Rigour was maintained through openness, reflexivity, audit trail, memo writing, debriefings, member checks and positionality. RESULTS The core category 'staying alive' emerged through the interaction of four categories, including: (1) overcoming barriers; (2) working with the healthcare team; (3) tailoring self-care strategies; and (4) appreciating antiretrovirals. Adherence is not a spontaneous outcome, instead, the surprise of HIV diagnosis transitions to living with HIV as a chronic disease. The healthcare team helps PLHIV realise ART is their life source by enhancing, supporting and facilitating self-care and overcoming barriers. CONCLUSION Adherence emerges from experiential learning as PLHIV recognised ART as their life source in balance with their desire to continue living a normal life. Social support and healthcare team interventions help PLHIV implement tailored self-care strategies to overcome personal, social, and structural barriers to adherence. Healthcare professionals need to recognise the challenges confronted by PLHIV as they learn how to continue living while trying to stay alive.
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Affiliation(s)
- Juan Manuel Leyva-Moral
- Grup de Recerca Infermera en Vulnerabilitat i Salut (GRIVIS), Departament d'Infermeria, Universitat Autonoma de Barcelona, Barcelona, Spain
- Qualitative Health Research, Evidence-Based Health Care South America: A JBI Affiliated Group, Lima, Peru
| | - Patrick Albert Palmieri
- South American Center for Qualitative Research, Universidad Privada Norbert Wiener, Lima, Peru
- College of Graduate Health Studies, A.T. Still University, Kirksville, Missouri, USA
| | - Blanca Katiuzca Loayza-Enriquez
- Qualitative Health Research, Evidence-Based Health Care South America: A JBI Affiliated Group, Lima, Peru
- Facultad de Medicina Humana, Universidad San Martin de Porres, Chiclayo, Peru
| | - Kara Lynette Vander Linden
- Department of Research, Saybrook University, Pasadena, California, USA
- Glaser Center for Grounded Theory, Institute for Research and Theory Methodologies, Poway, California, USA
| | - Ursula Elisa Elias-Bravo
- Escuela de Enfermería, Universidad Cientifica del Sur, Miraflores, Peru
- Estrategia Sanitaria de Prevención y Control de VIH-SIDA, Hospital Regional Lambayeque, Chiclayo, Peru
| | - Genesis Masiel Guevara-Vasquez
- Qualitative Health Research, Evidence-Based Health Care South America: A JBI Affiliated Group, Lima, Peru
- Departamento del Desarrollo de Investigación Básica Clínica, Hospital Regional Lambayeque, Chiclayo, Peru
| | | | - Mariela Patricia Aguayo-Gonzalez
- Grup de Recerca Infermera en Vulnerabilitat i Salut (GRIVIS), Departament d'Infermeria, Universitat Autonoma de Barcelona, Barcelona, Spain
- Qualitative Health Research, Evidence-Based Health Care South America: A JBI Affiliated Group, Lima, Peru
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8
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Sunpath H, Hatlen TJ, Moosa MYS, Murphy RA, Siedner M, Naidoo K. Urgent need to improve programmatic management of patients with HIV failing first-line antiretroviral therapy. Public Health Action 2020; 10:163-168. [PMID: 33437682 DOI: 10.5588/pha.20.0052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 11/04/2020] [Indexed: 11/10/2022] Open
Abstract
Introduction Delayed identification and response to virologic failure in case of first-line antiretroviral therapy (ART) in resource-limited settings is a threat to the health of HIV-infected patients. There is a need for the implementation of an effective, standardized response pathway in the public sector. Discussion We evaluated published cohorts describing virologic failure on first-line ART. We focused on gaps in the detection and management of treatment failure, and posited ways to close these gaps, keeping in mind scalability and standardization. Specific shortcomings repeatedly recorded included early loss to follow-up (>20%) after recognized first-line ART virologic failure; frequent delays in confirmatory viral load testing; and excessive time between the confirmation of first-line ART failure and initiation of second-line ART, which exceeded 1 year in some cases. Strategies emphasizing patient tracing, resistance testing, drug concentration monitoring, adherence interventions, and streamlined response pathways for those failing therapy are further discussed. Conclusion Comprehensive, evidence-based, clinical operational plans must be devised based on findings from existing research and further tested through implementation science research. Until this standard of evidence is available and implemented, high rates of losses from delays in appropriate switch to second-line ART will remain unacceptably common and a threat to the success of global HIV treatment programs.
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Affiliation(s)
- H Sunpath
- Centre for AIDS Program of Research, University of KwaZulu-Natal, Durban.,Infectious Diseases Unit, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - T J Hatlen
- Division of HIV, Lundquist Institute for Biomedical Innovation at Harbor-University of California Los Angeles Medical Center, Torrance, CA
| | - M-Y S Moosa
- Infectious Diseases Unit, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - R A Murphy
- Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-University of California Los Angeles Medical Center, Torrance, CA
| | - M Siedner
- Massachusetts General Hospital, Boston, MA, USA
| | - K Naidoo
- Centre for AIDS Program of Research, University of KwaZulu-Natal, Durban.,HIV-TB Pathogenesis and Treatment Research Unit, Medical Research Council-Centre for the AIDS Programme of Research in South Africa, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa
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9
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Dovel K, Phiri K, Mphande M, Mindry D, Sanudi E, Bellos M, Hoffman RM. Optimizing Test and Treat in Malawi: health care worker perspectives on barriers and facilitators to ART initiation among HIV-infected clients who feel healthy. Glob Health Action 2020; 13:1728830. [PMID: 32098595 PMCID: PMC7054923 DOI: 10.1080/16549716.2020.1728830] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background: Test and Treat has been widely adopted throughout sub-Saharan Africa, whereby all HIV-positive individuals initiate antiretroviral therapy (ART) immediately upon diagnosis and continue for life. However, clients who feel healthy may delay ART initiation, despite being eligible under new treatment guidelines. Objective: We examined health care worker (HCW) perceptions and experiences on how feeling healthy positively or negatively influences treatment initiation among HIV-positive clients in Malawi. Methods: We conducted 12 focus group discussions with 101 HCWs across six health facilities in Central Malawi. Data were analyzed through constant comparison methods using Atlas.ti7.5. Results: Feeling healthy influences perceptions of ART initiation among HIV-positive clients. HCWs described that healthy clients feel that there are few tangible benefits to immediate ART initiation, but numerous risks. Fear of stigma and unwanted disclosure, disruption of daily activities, fear of side effects, and limited knowledge about the benefits of early initiation were perceived by HCWs to deter healthy clients from initiating ART. Conclusion: Feeling healthy may exacerbate barriers to ART initiation. Strategies to reach healthy clients are needed, such as chronic care models, differentiated models of care that minimize disruptions to daily activities, and community sensitization on the benefits of early initiation.
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Affiliation(s)
- Kathryn Dovel
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, USA.,Partners in Hope Medical Centre, EQUIP Innovations for Health, Lilongwe, Malawi
| | - Khumbo Phiri
- Partners in Hope Medical Centre, EQUIP Innovations for Health, Lilongwe, Malawi
| | - Misheck Mphande
- Partners in Hope Medical Centre, EQUIP Innovations for Health, Lilongwe, Malawi
| | - Deborah Mindry
- UC Global Health Institute, Center for Women's Health Gender and Empowerment, Los Angeles, CA, USA
| | - Esnart Sanudi
- Partners in Hope Medical Centre, EQUIP Innovations for Health, Lilongwe, Malawi
| | - Mcdaphton Bellos
- Partners in Hope Medical Centre, EQUIP Innovations for Health, Lilongwe, Malawi
| | - Risa M Hoffman
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, USA
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10
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Ngure K, Ongolly F, Dolla A, Awour M, Mugwanya KK, Irungu E, Mugo N, Bukusi EA, Morton J, Odoyo J, Wamoni E, Barnabee G, Peebles K, O'Malley G, Baeten JM. "I just believe there is a risk" understanding of undetectable equals untransmissible (U = U) among health providers and HIV-negative partners in serodiscordant relationships in Kenya. J Int AIDS Soc 2020; 23:e25466. [PMID: 32144888 PMCID: PMC7060133 DOI: 10.1002/jia2.25466] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 02/05/2020] [Indexed: 11/11/2022] Open
Abstract
Introduction Sustained HIV viral suppression resulting from antiretroviral therapy (ART) eliminates the risk of HIV transmission, a concept popularly framed as Undetectable = Untransmittable (U = U). We explored knowledge and acceptance of information around the elimination of HIV transmission risk with ART (U = U) in Kenya. Methods Our qualitative study was conducted within a project evaluating the use of pre‐exposure prophylaxis (PrEP) integrated into ART care for HIV serodiscordant couples in public clinics in Kenya (the Partners Scale Up Project). From February 2017 to April 2019, we conducted semi‐structured key informant interviews with 83 health providers and in‐depth interviews with 61 HIV‐negative people in serodiscordant relationships receiving PrEP services. Transcripts were coded using thematic analysis. Results Health providers reported being aware of reduced risk of HIV transmission as a result of consistent ART use and used words such as “very low,” “minimal” and “like zero” to describe HIV transmission risk after viral suppression. Providers reported finding viral load results helpful when counselling clients about the risk of HIV transmission. Many lacked confidence in U = U and counselled on consistent condom use even after viral suppression while some expressed concerns that communicating this message to people living with HIV (PLHIV) would lead them to engage in multiple sexual relationships. Other providers reported that they did not counsel about the reduced risk of HIV transmission after viral suppression for fear of being blamed if HIV transmission occurred. HIV‐negative partners reported being informed about U = U by providers but they did not believe nor trust the message. Even after their partners achieved viral suppression, some HIV‐negative partners were unwilling to stop PrEP, while others indicated that they would use condoms if they stopped PrEP to be sure that they were protected from HIV. Conclusions Despite awareness that effective ART use eliminates HIV transmission risk, there is both a lack of in‐depth knowledge and conviction about the strategy among health providers and HIV‐negative partners in serodiscordant relationships. New strategies that go beyond communicating the science of U = U to consider the local social and clinical environments could maximize the effectiveness of U = U.
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Affiliation(s)
- Kenneth Ngure
- Department of Community Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya.,Department of Global Health, University of Washington, Seattle, WA, USA
| | - Fernandos Ongolly
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Annabell Dolla
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Merceline Awour
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Elizabeth Irungu
- Department of Community Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Nelly Mugo
- Department of Global Health, University of Washington, Seattle, WA, USA.,Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Elizabeth A Bukusi
- Department of Global Health, University of Washington, Seattle, WA, USA.,Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Jennifer Morton
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Josephine Odoyo
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Elizabeth Wamoni
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Gena Barnabee
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Kathryn Peebles
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | | | - Jared M Baeten
- Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
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Havlir D, Lockman S, Ayles H, Larmarange J, Chamie G, Gaolathe T, Iwuji C, Fidler S, Kamya M, Floyd S, Moore J, Hayes R, Petersen M, Dabis F. What do the Universal Test and Treat trials tell us about the path to HIV epidemic control? J Int AIDS Soc 2020; 23:e25455. [PMID: 32091179 PMCID: PMC7038879 DOI: 10.1002/jia2.25455] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 01/14/2020] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Achieving HIV epidemic control globally will require new strategies to accelerate reductions in HIV incidence and mortality. Universal test and treat (UTT) was evaluated in four randomized population-based trials (BCPP/Ya Tsie, HPTN 071/PopART, SEARCH, ANRS 12249/TasP) conducted in sub-Saharan Africa (SSA) during expanded antiretroviral treatment (ART) eligibility by World Health Organization guidelines and the UNAIDS 90-90-90 campaign. DISCUSSION These three-year studies were conducted in Botswana, Zambia, Uganda, Kenya and South Africa in settings with baseline HIV prevalence from 4% to 30%. Key observations across studies were: (1) Universal testing (implemented via a variety of home and community-based testing approaches) achieved >90% coverage in all studies. (2) When coupled with robust linkage to HIV care, rapid ART start and patient-centred care, UTT achieved among the highest reported population levels of viral suppression in SSA. Significant gains in population-level viral suppression were made in regions with both low and high baseline population viral load; however, viral suppression gains were not uniform across all sub-populations and were lower among youth. (3) UTT resulted in marked reductions in community HIV incidence when universal testing and robust linkage were present. However, HIV elimination targets were not reached. In BCPP and HPTN 071, annualized HIV incidence was approximately 20% to 30% lower in the intervention (which included universal testing) compared to control arms (no universal testing). In SEARCH (where both arms had universal testing), incidence declined 32% over three years. (4) UTT reduced HIV associated mortality by 23% in the intervention versus control communities in SEARCH, a study in which mortality was comprehensively measured. CONCLUSIONS These trials provide strong evidence that UTT inclusive of universal testing increases population-level viral suppression and decreases HIV incidence and mortality faster than the status quo in SSA and should be adapted at a sub-country level as a public health strategy. However, more is needed, including integration of new prevention interventions into UTT, in order to reach UNAIDS HIV elimination targets.
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Affiliation(s)
- Diane Havlir
- Department of MedicineUniversity of California San FranciscoSan FranciscoCAUSA
| | - Shahin Lockman
- Brigham and Women's HospitalBostonMAUSA
- Harvard School T.H. Chan School of Public HealthBostonMAUSA
- Botswana Harvard AIDS Institute PartnershipGaboroneBotswana
| | - Helen Ayles
- Clinical Research DepartmentLondon School of Hygiene & Tropical MedicineLondonUnited Kingdom
- ZambartLusakaZambia
| | - Joseph Larmarange
- Centre Population et DéveloppementInstitut de Recherche pour le DéveloppementUniversité Paris DescartesInsermParisFrance
- Africa Health Research InstituteSomkheleSouth Africa
| | - Gabriel Chamie
- Department of MedicineUniversity of California San FranciscoSan FranciscoCAUSA
| | - Tendani Gaolathe
- Botswana Harvard AIDS Institute PartnershipGaboroneBotswana
- University of BotswanaGaboroneBotswana
| | - Collins Iwuji
- Department of Global Health & InfectionBrighton and Sussex Medical SchoolBrightonUnited Kingdom
- Africa Health Research InstituteKwaZulu‐NatalSouth Africa
- Research Department of Infection and Population HealthUniversity College LondonLondonUnited Kingdom
| | - Sarah Fidler
- Imperial CollegeNational Institute for Health Research Biomedical Research CenterLondonUnited Kingdom
- Department of Infectious DiseaseImperial College LondonLondonUnited Kingdom
| | - Moses Kamya
- Department of MedicineMakerere UniversityKampalaUganda
- Infectious Diseases Research Collaboration (IDRC)KampalaUganda
| | - Sian Floyd
- Department of Infectious Disease EpidemiologyLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Janet Moore
- Division of Global HIV/AIDS and TBCenters for Disease Control and PreventionAtlantaGAUSA
| | - Richard Hayes
- Department of Infectious Disease EpidemiologyLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Maya Petersen
- School of Public HealthUniversity of California BerkeleyBerkeleyCAUSA
| | - Francois Dabis
- ISPED & Inserm Bordeaux Population Health UMR 1219Univ BordeauxBordeauxFrance
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12
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Magaço A, Dovel K, Cataldo F, Nhassengo P, Hoffman R, Nerua L, Tique J, Saide M, Couto A, Mbofana F, Gudo E, Cuco RM, Chicumbe S. 'Good health' as a barrier and facilitator to ART initiation: a qualitative study in the era of test-and-treat in Mozambique. CULTURE, HEALTH & SEXUALITY 2019; 21:1059-1073. [PMID: 30636559 DOI: 10.1080/13691058.2018.1535091] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 10/09/2018] [Indexed: 06/09/2023]
Abstract
HIV test-and-treat programmes are being implemented throughout sub-Saharan Africa, enrolling HIV-positive clients into antiretroviral treatment (ART) immediately after diagnosis, regardless of clinical stage or CD4 count. This study conducted in Mozambique examined what influenced clients who tested HIV-positive in the context of test-and-treat to make ART initiation decisions. Eighty in-depth interviews with HIV-positive clients and nine focus group discussions with health care workers were completed across 10 health facilities. 'Good health' acted simultaneously as a barrier and facilitator; clients in good health often found a positive HIV diagnosis hard to cope with since HIV was traditionally associated with ill health. Concerns about ART side effects, fear of inadvertent HIV status disclosure and discrimination, limited privacy at health facilities and long waiting times were also barriers to initiation. In contrast, being in good health also acted as a motivator to start treatment so as to remain healthy, maintain responsibilities such as work and caring for dependents and avoid unwanted disclosure. Study findings offer an in-depth understanding of the complex dynamics between individual perceptions of 'being healthy' and its influence on ART initiation within the context of test-and-treat programme implementation.
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Affiliation(s)
- Amílcar Magaço
- a Research Department , National Institute of Health , Maputo , Mozambique
| | - Kathryn Dovel
- b Division of Infectious Diseases, Department of Medicine , University of California , Los Angeles , CA , USA
- c Research Department , Partners in Hope , Lilongwe , Malawi
| | - Fabian Cataldo
- d Institute for Global Health and Development , Queen Margaret University , Edinburgh , UK
| | - Pedroso Nhassengo
- a Research Department , National Institute of Health , Maputo , Mozambique
| | - Risa Hoffman
- b Division of Infectious Diseases, Department of Medicine , University of California , Los Angeles , CA , USA
| | - Lucas Nerua
- a Research Department , National Institute of Health , Maputo , Mozambique
| | - José Tique
- e National STI, HIV/AIDS Control Program , Maputo , Mozambique
| | - Mohomed Saide
- a Research Department , National Institute of Health , Maputo , Mozambique
| | - Aleny Couto
- e National STI, HIV/AIDS Control Program , Maputo , Mozambique
| | | | - Eduardo Gudo
- a Research Department , National Institute of Health , Maputo , Mozambique
| | | | - Sérgio Chicumbe
- a Research Department , National Institute of Health , Maputo , Mozambique
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13
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Molemans M, Vernooij E, Dlamini N, Shabalala FS, Khan S, van Leth F, Gomez GB, Reis R. Changes in disclosure, adherence and healthcare interactions after the introduction of immediate ART initiation: an analysis of patient experiences in Swaziland. Trop Med Int Health 2019; 24:563-570. [PMID: 30739385 PMCID: PMC6850272 DOI: 10.1111/tmi.13214] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION There are concerns that immediate ART initiation (regardless of CD4 count) negatively affects HIV status disclosure, ART adherence and healthcare interactions. We assessed changes in these factors after the 'Early access to ART for all' intervention, a universal test-and-treat study in Swaziland. METHODS We recruited two samples of participants between 2014 and 2017. The first group was interviewed before the intervention (control); the second group at the implementation and 6 months thereafter (intervention). RESULTS High levels of disclosure to partners (controls and intervention: 94%) and family members (controls: 78%, intervention: 79%) were reported, and high levels of adherence (85% did not miss a dose among the controls, 84% in the intervention group). There were no changes in patients reporting feeling pressured to initiate ART (controls: 10%, intervention: 11%). The quality of interaction with healthcare workers improved after the intervention; healthcare workers explained more often the choice of ART initiation (controls: 88%, intervention: 93%) and the meaning of both CD4 and viral load test results (controls: 15%, intervention: 47%). More patients in the intervention group reported receiving test results (controls: 13%, intervention: 46%). We observed no changes in disclosure, adherence or patient experiences 6 months into the intervention compared to its start. CONCLUSION Our results suggest that both reported adherence and disclosure levels remain high after the introduction of immediate ART in Swaziland. We observed an improvement in the healthcare interactions, possibly due to training at participating facilities, which will be an important element for a successful roll-out of immediate ART.
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Affiliation(s)
- Marjan Molemans
- Department of Global HealthAcademic Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
- Amsterdam Institute for Global Health and DevelopmentAmsterdamThe Netherlands
| | - Eva Vernooij
- Amsterdam Institute for Social Science ResearchDepartment of AnthropologyUniversity of AmsterdamAmsterdamThe Netherlands
- Social AnthropologySchool of Social and Political ScienceThe University of EdinburghEdinburghUK
| | - Njabuliso Dlamini
- Amsterdam Institute for Social Science ResearchDepartment of AnthropologyUniversity of AmsterdamAmsterdamThe Netherlands
| | - Fortunate S. Shabalala
- Amsterdam Institute for Social Science ResearchDepartment of AnthropologyUniversity of AmsterdamAmsterdamThe Netherlands
- Department of Community Health Nursing SciencesFaculty of Health SciencesUniversity of SwazilandMbabaneSwaziland
| | - Shaukat Khan
- Clinton Health Access InitiativeMbabaneSwaziland
| | - Frank van Leth
- Department of Global HealthAcademic Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
- Amsterdam Institute for Global Health and DevelopmentAmsterdamThe Netherlands
| | - Gabriela B. Gomez
- Amsterdam Institute for Global Health and DevelopmentAmsterdamThe Netherlands
- Department of Global Health and DevelopmentLondon School of Hygiene and Tropical MedicineLondonUK
| | - Ria Reis
- Amsterdam Institute for Global Health and DevelopmentAmsterdamThe Netherlands
- Amsterdam Institute for Social Science ResearchDepartment of AnthropologyUniversity of AmsterdamAmsterdamThe Netherlands
- Department of Public Health and Primary CareLeiden University Medical CentreLeidenThe Netherlands
- The Children's InstituteSchool of Child and Adolescent HealthUniversity of Cape TownCape TownSouth Africa
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14
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Seeley J, Bond V, Yang B, Floyd S, MacLeod D, Viljoen L, Phiri M, Simuyaba M, Hoddinott G, Shanaube K, Bwalya C, de Villiers L, Jennings K, Mwanza M, Schaap A, Dunbar R, Sabapathy K, Ayles H, Bock P, Hayes R, Fidler S. Understanding the Time Needed to Link to Care and Start ART in Seven HPTN 071 (PopART) Study Communities in Zambia and South Africa. AIDS Behav 2019; 23:929-946. [PMID: 30415432 PMCID: PMC6458981 DOI: 10.1007/s10461-018-2335-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
To achieve UNAIDS 90:90:90 targets at population-level, knowledge of HIV status must be followed by timely linkage to care, initiation and maintenance of antiretroviral therapy (ART) for all people living with HIV (PLHIV). Interpreting quantitative patterns using qualitative data, we investigate time taken to link to care and initiate ART amongst individuals aware of their HIV-status in high HIV-prevalence urban communities in the HPTN 071 (PopART) study, a community-randomised trial of a combination HIV prevention package, including universal testing and treatment, in 21 communities in Zambia and South Africa. Data are drawn from the seven intervention communities where immediate ART irrespective if CD4 count was offered from the trial-start in 2014. Median time from HIV-diagnosis to ART initiation reduced after 2 years of delivering the intervention from 10 to 6 months in both countries but varied by gender and community of residence. Social and health system realities impact decisions made by PLHIV about ART initiation.
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Affiliation(s)
- Janet Seeley
- London School of Hygiene and Tropical Medicine, London, UK.
| | - Virginia Bond
- London School of Hygiene and Tropical Medicine, London, UK
- Zambart, School of Medicine, University of Zambia, Ridgeway Campus, Lusaka, Zambia
| | - Blia Yang
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Stellenbosch University, K-Floor, Clinical Building, Tygerberg Medical Campus, Francie van Zyl Drive, Tygerberg, 7505, South Africa
| | - Sian Floyd
- London School of Hygiene and Tropical Medicine, London, UK
| | - David MacLeod
- London School of Hygiene and Tropical Medicine, London, UK
| | - Lario Viljoen
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Stellenbosch University, K-Floor, Clinical Building, Tygerberg Medical Campus, Francie van Zyl Drive, Tygerberg, 7505, South Africa
| | - Mwelwa Phiri
- Zambart, School of Medicine, University of Zambia, Ridgeway Campus, Lusaka, Zambia
| | - Melvin Simuyaba
- Zambart, School of Medicine, University of Zambia, Ridgeway Campus, Lusaka, Zambia
| | - Graeme Hoddinott
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Stellenbosch University, K-Floor, Clinical Building, Tygerberg Medical Campus, Francie van Zyl Drive, Tygerberg, 7505, South Africa
| | - Kwame Shanaube
- Zambart, School of Medicine, University of Zambia, Ridgeway Campus, Lusaka, Zambia
| | - Chiti Bwalya
- Zambart, School of Medicine, University of Zambia, Ridgeway Campus, Lusaka, Zambia
| | - Laing de Villiers
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Stellenbosch University, K-Floor, Clinical Building, Tygerberg Medical Campus, Francie van Zyl Drive, Tygerberg, 7505, South Africa
| | - Karen Jennings
- City of Cape Town Health Directorate, Cape Town, South Africa
| | - Margaret Mwanza
- Zambia Prevention Care and Treatment partnership (ZPCT), Lusaka, Zambia
| | - Ab Schaap
- Zambart, School of Medicine, University of Zambia, Ridgeway Campus, Lusaka, Zambia
| | - Rory Dunbar
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Stellenbosch University, K-Floor, Clinical Building, Tygerberg Medical Campus, Francie van Zyl Drive, Tygerberg, 7505, South Africa
| | | | - Helen Ayles
- London School of Hygiene and Tropical Medicine, London, UK
- Zambart, School of Medicine, University of Zambia, Ridgeway Campus, Lusaka, Zambia
| | - Peter Bock
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Stellenbosch University, K-Floor, Clinical Building, Tygerberg Medical Campus, Francie van Zyl Drive, Tygerberg, 7505, South Africa
| | - Richard Hayes
- London School of Hygiene and Tropical Medicine, London, UK
| | - Sarah Fidler
- Department of Medicine, Imperial College, London, UK
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15
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Kawuma R, Seeley J, Mupambireyi Z, Cowan F, Bernays S. "Treatment is not yet necessary": delays in seeking access to HIV treatment in Uganda and Zimbabwe. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2018; 17:217-225. [PMID: 30132397 DOI: 10.2989/16085906.2018.1490785] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We examined the logic that individuals use to account for delaying HIV testing and/or initiating HIV treatment. Our qualitative study, situated within the REALITY trial (Reduction of EArly mortaLITY in HIV infected adults and children starting antiretroviral therapy), was conducted in Uganda and Zimbabwe in 2015. Forty-eight participants (different age groups, sex and viral load/WHO disease stage) were included. Each participant had 2 interviews (1 after 4 weeks of participation in the trial the other after 12 weeks). If a person could manage presenting symptoms, they felt they had "more time" before starting antiretroviral therapy (ART). Their reluctance to have an HIV test (despite deteriorating health) arose from a belief that they were not "sick", that treatment was "not yet necessary". People in our study did not consider themselves as presenting "late", and treatment was not considered urgent as long as they considered their health to be "good enough".
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Affiliation(s)
- Rachel Kawuma
- a Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine (MRC/UVRI and LSHTM) , Uganda Research Unit , Entebbe , Uganda
| | - Janet Seeley
- a Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine (MRC/UVRI and LSHTM) , Uganda Research Unit , Entebbe , Uganda.,b Global Health and Development Department , London School of Hygiene and Tropical Medicine , London , UK
| | - Zivai Mupambireyi
- c Centre for Sexual Health and HIV/AIDS Research , Harare , Zimbabwe
| | - Frances Cowan
- d International Public Health Department , Liverpool School of Tropical Medicine , Liverpool , UK.,e Centre for Sexual Health and HIV/AIDS Research , Harare , Zimbabwe
| | - Sarah Bernays
- f School of Public Health , University of Sydney , Sydney , Australia
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- a Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine (MRC/UVRI and LSHTM) , Uganda Research Unit , Entebbe , Uganda
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16
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Meyers K, Wu Y, Brill A, Sandfort T, Golub SA. To switch or not to switch: Intentions to switch to injectable PrEP among gay and bisexual men with at least twelve months oral PrEP experience. PLoS One 2018; 13:e0200296. [PMID: 30024903 PMCID: PMC6053164 DOI: 10.1371/journal.pone.0200296] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 06/22/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Phase III trials of long-acting injectable (LAI) PrEP, currently underway, have great potential for expanding the menu of HIV prevention options. Imagining a future in which multiple PrEP modalities are available to potential users of biomedical HIV prevention, we investigated which factors might help direct a patient-physician shared-decision making process to optimize the choice of biomedical HIV prevention method. METHODS Participants (n = 105; ages 19-63; 46.7% men of color) were former participants in a PrEP demonstration project and had taken daily oral PrEP for ≥ 12 months. Participants were given information about LAI PrEP and asked whether they would be interested in switching from oral to LAI PrEP. Participants were also asked about specific pros/cons of LAI PrEP, PrEP attitudes and experiences, and personality factors. RESULTS Two-thirds (66.7%) of current oral PrEP users would switch to LAI PrEP. Intention to switch was associated with product-level and psychosocial factors. Attitudes towards logistical factors (i.e. getting to regular clinic visits for recurring shots) featured more prominently than factors related to the physical experience of PrEP modality (i.e., concerns about injection pain) as motivators for switching. In a multivariate regression model, psychosocial factors including the emotional burden of daily pill taking, deriving a sense of responsibility from PrEP use, and self-identifying as an early adopter, were the strongest predictors of switching. CONCLUSIONS These data underscore the importance of attending not only to product-level factors, but also to the logistical and psychological experience of prevention methods for users. Findings have significant implications for the development of patient education materials and patient-provider shared decision aids.
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Affiliation(s)
- Kathrine Meyers
- Aaron Diamond AIDS Research Center, The Rockefeller University, New York, New York, United States of America
| | - Yumeng Wu
- Aaron Diamond AIDS Research Center, The Rockefeller University, New York, New York, United States of America
| | - Atrina Brill
- Department of Psychology, Hunter College of the City University of New York, New York, New York, United States of America
| | - Theodorus Sandfort
- HIV Center for Clinical and Behavioral Studies, Columbia University, New York, New York, United States of America
| | - Sarit A. Golub
- Department of Psychology, Hunter College of the City University of New York, New York, New York, United States of America
- Department of Psychology, the Graduate Center of the City University of New York, New York, New York, United States of America
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17
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Ware NC, Pisarski EE, Nakku‐Joloba E, Wyatt MA, Muwonge TR, Turyameeba B, Asiimwe SB, Heffron RA, Baeten JM, Celum CL, Katabira ET. Integrated delivery of antiretroviral treatment and pre-exposure prophylaxis to HIV-1 serodiscordant couples in East Africa: a qualitative evaluation study in Uganda. J Int AIDS Soc 2018; 21:e25113. [PMID: 29851436 PMCID: PMC5980503 DOI: 10.1002/jia2.25113] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 05/04/2018] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION Serodiscordant couples are a priority population for delivery of new HIV prevention interventions in Africa. An integrated strategy of delivering time-limited, oral pre-exposure prophylaxis (PrEP) to uninfected partners in serodiscordant couples as a bridge to long-term antiretroviral treatment (ART) for infected partners has been implemented in East Africa, nearly eliminating new infections. We conducted a qualitative evaluation of the integrated strategy in Uganda, to better understand its success. METHODS Data collection consisted of 274 in-depth interviews with 93 participating couples, and 55 observations of clinical encounters between couples and healthcare providers. An inductive content analytic approach aimed at understanding and interpreting couples' experiences of the integrated strategy was used to examine the data. Analysis sought to characterize: (1) key aspects of services provided; (2) what the services meant to recipients; and (3) how couples managed the integrated strategy. Themes were identified in each domain, and represented as descriptive categories. Categories were grouped inductively into more general propositions based on shared content. Propositions were linked and interpreted to explain "why the integrated strategy worked." RESULTS Couples found "couples-focused" services provided through the integrated strategy strengthened partnered relationships threatened by the discovery of serodiscordance. They saw in services hope for "getting help" to stay together, turned joint visits to clinic into opportunities for mutual support, and experienced counselling as bringing them closer together. Couples adopted a "couples orientation" to the integrated strategy, considering the health of partners as they made decisions about initiating ART or accepting PrEP, and devising joint approaches to adherence. A couples orientation to services, grounded in strengthened partnerships, may have translated to greater success in using antiretrovirals to prevent HIV transmission. CONCLUSIONS Various strategies for delivering antiretrovirals for HIV prevention are being evaluated. Understanding how and why these strategies work will improve evaluation processes and strengthen implementation platforms. We highlight the role of service organization in shaping couples' experiences of and responses to ART and PrEP in the context of the integrated strategy. Organizing services to promote positive care experiences will strengthen delivery and contribute to positive outcomes as antiretrovirals for prevention are rolled out.
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Affiliation(s)
- Norma C Ware
- Department of MedicineBrigham and Women's HospitalBostonMAUSA
- Department of Global Health and Social MedicineHarvard Medical SchoolBostonMAUSA
| | - Emily E Pisarski
- Department of Global Health and Social MedicineHarvard Medical SchoolBostonMAUSA
| | - Edith Nakku‐Joloba
- Department of Epidemiology and BiostatisticsMakerere University College of Health SciencesKampalaUganda
- STD Clinic/Ward 12Mulago HospitalKampalaUganda
| | - Monique A Wyatt
- Department of Global Health and Social MedicineHarvard Medical SchoolBostonMAUSA
- Harvard GlobalCambridgeMAUSA
| | | | | | | | - Renee A Heffron
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | - Jared M Baeten
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | - Connie L Celum
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
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18
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Kim HY, Hanrahan CF, Dowdy DW, Martinson N, Golub J, Bridges JFP. The effect of partner HIV status on motivation to take antiretroviral and isoniazid preventive therapies: a conjoint analysis. AIDS Care 2018; 30:1298-1305. [PMID: 29595060 DOI: 10.1080/09540121.2018.1455958] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Antiretroviral therapy (ART) and isoniazid preventive therapy (IPT) are important to reduce morbidity and mortality among people newly diagnosed of HIV. The successful uptake of ART and IPT requires a comprehensive understanding of patients' motivation to take such therapies. Partners also play an important role in the decision to be initiated and retained in care. We quantified patients' motivation to take preventive therapies (ART and IPT) and compared by partner HIV status among people newly diagnosed of HIV. We enrolled and surveyed adults (≥18 years) with a recent HIV diagnosis (<6 months) from 14 public primary care clinics in Matlosana, South Africa. Participants received eight forced-choice tasks comparing two mutually exclusive sub-sets of seven possible benefits related to preventive therapies. A linear probability model was fitted to estimate the probability of prioritizing each benefit. Tests of concordance were conducted across partner HIV status (no partner, HIV- or unknown, or HIV+). A total of 424 people completed surveys. At the time of interview, 272 (64%) were on ART and 334 (79%) had a partner or spouse. Keeping themselves healthy for their family was the most important motivator to take preventive therapies (p < 0.001). Preventing HIV transmission to partners was also highly prioritized among participants with current partners independent of partner's HIV status (p < 0.001), but it was least prioritized among those without current partners (p = 0.72). Keeping themselves healthy was less prioritized. We demonstrate that social responsibility such as supporting family and preventing HIV transmission to partners may pose greater motivation for ART and IPT initiation and adherence compared to individual health benefits. These messages should be emphasized to provide effective patient-centered care and counseling.
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Affiliation(s)
- Hae-Young Kim
- a Department of Epidemiology , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | - Colleen F Hanrahan
- a Department of Epidemiology , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | - David W Dowdy
- a Department of Epidemiology , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA.,b Department of International Health , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | - Neil Martinson
- c Perinatal HIV Research Unit , University of Witwatersrand , Johannesburg , South Africa.,d Center for Tuberculosis Research , Johns Hopkins University , Baltimore , MD , USA
| | - Jonathan Golub
- a Department of Epidemiology , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA.,b Department of International Health , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA.,d Center for Tuberculosis Research , Johns Hopkins University , Baltimore , MD , USA
| | - John F P Bridges
- b Department of International Health , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA.,e Department of Health Policy and Management , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA.,f Department of Health Behavior and Society , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
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Mujugira A, Baeten J, Kidoguchi L, Haberer J, Celum C, Donnell D, Ngure K, Bukusi E, Mugo N, Asiimwe S, Odoyo J, Tindimwebwa E, Bulya N, Katabira E, Heffron R. High levels of viral suppression among East African HIV-infected women and men in serodiscordant partnerships initiating antiretroviral therapy with high CD4 counts and during pregnancy. AIDS Res Hum Retroviruses 2018; 34:140-147. [PMID: 28899162 PMCID: PMC5806074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2024] Open
Abstract
BACKGROUND People who are asymptomatic and feel healthy, including pregnant women, may be less motivated to initiate ART or achieve high adherence. We assessed whether ART initiation, and viral suppression 6, 12 and 24-months after ART initiation, were lower in HIV-infected members of serodiscordant couples who initiated during pregnancy or with higher CD4 counts. METHODS We used data from the Partners Demonstration Project, an open-label study of the delivery of integrated PrEP and ART (at any CD4 count) for HIV prevention among high-risk HIV serodiscordant couples in Kenya and Uganda. Differences in viral suppression (HIV RNA <400 copies/ml) among people initiating ART at different CD4 count levels (≤350, 351-500, and >500 cells/mm3) and during pregnancy were estimated using Poisson regression. RESULTS Of 865 HIV-infected participants retained after becoming eligible for ART during study follow-up, 95% initiated ART. Viral suppression 24-months after ART initiation was high overall (97%), and comparable among those initiating ART at CD4 counts >500, 351-500 and ≤350 cells/mm3 (96% vs 97% vs 97%; relative risk [RR] 0.98; 95% CI: 0.93-1.03 for CD4 >500 vs <350 and RR 0.99; 95% CI: (0.93-1.06) for CD4 351-500 vs ≤350). Viral suppression was as likely among women initiating ART primarily to prevent perinatal transmission as ART initiation for other reasons (p=0.9 at 6 months and p=0.5 at 12 months). CONCLUSIONS Nearly all HIV-infected partners initiating ART were virally suppressed by 24 months, irrespective of CD4 count or pregnancy status. These findings suggest that people initiating ART at high CD4 counts or due to pregnancy can adhere to ART as well as those starting treatment with symptomatic HIV disease or low CD4 counts.
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Affiliation(s)
- Andrew Mujugira
- University of Washington, Department of Global Health , 901 Boren Ave , Suite 1300 , Seattle, Washington, United States , 98104 ;
| | | | | | | | | | - Deborah Donnell
- Fred Hutchinson Cancer Research Center, SCHARP/VIDI/PHS , 1100 Fairview Ave N , Seattle, Washington, United States , 98109 ;
| | | | | | - Nelly Mugo
- Kenya Medical Research Institute, Nairobi, Kenya ;
| | | | | | | | | | - Elly Katabira
- Makerere University, Infectious Disease Institute, Kampala, Uganda ;
| | - Renee Heffron
- University of Washington, Department of Epidemiology, Seattle, United States ;
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20
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Mujugira A, Baeten JM, Kidoguchi L, Haberer J, Celum C, Donnell D, Ngure K, Bukusi EA, Mugo N, Asiimwe S, Odoyo J, Tindimwebwa E, Bulya N, Katabira E, Heffron R, for the Partners Demonstration Proj. High levels of viral suppression among East African HIV-infected women and men in serodiscordant partnerships initiating antiretroviral therapy with high CD4 counts and during pregnancy. AIDS Res Hum Retroviruses 2017. [PMID: 28899162 DOI: 10.1089/aid.2017.0020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND People who are asymptomatic and feel healthy, including pregnant women, may be less motivated to initiate ART or achieve high adherence. We assessed whether ART initiation, and viral suppression 6, 12 and 24-months after ART initiation, were lower in HIV-infected members of serodiscordant couples who initiated during pregnancy or with higher CD4 counts. METHODS We used data from the Partners Demonstration Project, an open-label study of the delivery of integrated PrEP and ART (at any CD4 count) for HIV prevention among high-risk HIV serodiscordant couples in Kenya and Uganda. Differences in viral suppression (HIV RNA <400 copies/ml) among people initiating ART at different CD4 count levels (≤350, 351-500, and >500 cells/mm3) and during pregnancy were estimated using Poisson regression. RESULTS Of 865 HIV-infected participants retained after becoming eligible for ART during study follow-up, 95% initiated ART. Viral suppression 24-months after ART initiation was high overall (97%), and comparable among those initiating ART at CD4 counts >500, 351-500 and ≤350 cells/mm3 (96% vs 97% vs 97%; relative risk [RR] 0.98; 95% CI: 0.93-1.03 for CD4 >500 vs <350 and RR 0.99; 95% CI: (0.93-1.06) for CD4 351-500 vs ≤350). Viral suppression was as likely among women initiating ART primarily to prevent perinatal transmission as ART initiation for other reasons (p=0.9 at 6 months and p=0.5 at 12 months). CONCLUSIONS Nearly all HIV-infected partners initiating ART were virally suppressed by 24 months, irrespective of CD4 count or pregnancy status. These findings suggest that people initiating ART at high CD4 counts or due to pregnancy can adhere to ART as well as those starting treatment with symptomatic HIV disease or low CD4 counts.
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Affiliation(s)
- Andrew Mujugira
- Department of Global Health, University of Washington, Seattle, Washington
| | - Jared M. Baeten
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
- Department of Medicine, University of Washington, Seattle, Washington
| | - Lara Kidoguchi
- Department of Global Health, University of Washington, Seattle, Washington
| | | | - Connie Celum
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
- Department of Medicine, University of Washington, Seattle, Washington
| | - Deborah Donnell
- Department of Global Health, University of Washington, Seattle, Washington
| | - Kenneth Ngure
- Department of Global Health, University of Washington, Seattle, Washington
- School of Public Health, Jomo Kenyatta University of Agriculture and Technology, Juja, Kenya
| | - Elizabeth A. Bukusi
- Department of Global Health, University of Washington, Seattle, Washington
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Nelly Mugo
- Department of Global Health, University of Washington, Seattle, Washington
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Josephine Odoyo
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Nulu Bulya
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Elly Katabira
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Renee Heffron
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
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Counseling Framework for HIV-Serodiscordant Couples on the Integrated Use of Antiretroviral Therapy and Pre-exposure Prophylaxis for HIV Prevention. J Acquir Immune Defic Syndr 2017; 74 Suppl 1:S15-S22. [PMID: 27930607 PMCID: PMC5147040 DOI: 10.1097/qai.0000000000001210] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background: For HIV-serodiscordant couples, integrated delivery of antiretroviral therapy (ART) for HIV-positive partners and time-limited pre-exposure prophylaxis (PrEP) for negative partners virtually eliminates HIV transmission. Standardized messaging, sensitive to the barriers and motivators to HIV treatment and prevention, is needed for widespread scale-up of this approach. Methods: Within the Partners Demonstration Project, a prospective interventional project among 1013 serodiscordant couples in Kenya and Uganda, we offered ART to eligible HIV-positive partners and PrEP to HIV-negative partners before ART initiation and through the HIV-positive partner's first 6 months of ART use. We conducted individual and group discussions with counseling staff to elicit the health communication framework and key messages about ART and PrEP that were delivered to couples. Results: Counseling sessions for serodiscordant couples about PrEP and ART included discussions of HIV serodiscordance, PrEP and ART initiation and integrated use, and PrEP discontinuation. ART messages emphasized daily, lifelong use for treatment and prevention, adherence, viral suppression, resistance, side effects, and safety of ART during pregnancy. PrEP messages emphasized daily dosing, time-limited PrEP use until the HIV-positive partner sustained 6 months of high adherence to ART, adherence, safety during conception, side effects, and other risks for HIV. Conclusions: Counseling messages for HIV-serodiscordant couples are integral to the delivery of time-limited PrEP as a “bridge” to ART-driven viral suppression. Their incorporation into programmatic scale-up will maximize intervention impact on the global epidemic.
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Hughes SD, Truong HHM. Sero-discovering versus sero-cognisant: initial challenges and needs of HIV-serodiscordant couples in Porto Alegre, Brazil. CULTURE, HEALTH & SEXUALITY 2017; 19:888-902. [PMID: 28074680 DOI: 10.1080/13691058.2016.1269366] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
This paper focuses on challenges faced by heterosexual couples of mixed HIV status in Porto Alegre, Brazil, and argues for more conceptual nuance in our understanding of 'serodiscordance'. Couples' stories, collected over 11 months of qualitative research, demonstrate how profoundly serodiscordance involves both partners and suggest that the timing of relationship formation relative to HIV diagnosis influenced the particular challenges they confronted. In recognition of this variation, we propose the distinction of 'sero-discovering' from 'sero-cognisant' couples. Though Brazilian health policy strives to address the needs of individuals diagnosed with HIV, the needs of seronegative partners in this cohort received relatively little attention. In addition, the transformation of HIV from a death sentence to a chronic condition both facilitated the formation of serodiscordant unions and raised special challenges for such couples. Conceiving of any person receiving an HIV diagnosis as 'potentially partnered' may help address some of these lacunae while promoting primary prevention within mixed-status couples, and HIV testing more generally. More research with this population is needed.
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Affiliation(s)
- Shana D Hughes
- a Department of Anthropology , University of South Florida , Tampa , USA
| | - Hong-Ha M Truong
- b Center for AIDS Prevention Studies , University of California-San Francisco , San Francisco , USA
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23
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Katz IT, Bangsberg DR. Cascade of Refusal-What Does It Mean for the Future of Treatment as Prevention in Sub-Saharan Africa? Curr HIV/AIDS Rep 2016; 13:125-30. [PMID: 26894487 DOI: 10.1007/s11904-016-0309-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Recent recommendations by the World Health Organization support treatment for all people living with HIV (PLWH) globally to be initiated at the point of testing. While there has been marked success in efforts to identify and expand treatment for PLWH throughout sub-Saharan Africa, the goal of universal treatment may prove challenging to achieve. The pre-ART phase of the care cascade from HIV testing to HIV treatment initiation includes several social and structural barriers. One such barrier is antiretroviral therapy (ART) treatment refusal, a phenomenon in which HIV-infected individuals choose not to start treatment upon learning their ART eligibility. Our goal is to provide further understanding of why treatment-eligible adults may choose to present for HIV testing but not initiate ART when indicated. In this article, we will discuss factors driving pre-ART loss and present a framework for understanding the impact of decision-making on early losses in the care cascade, with a focus on ART refusal.
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Affiliation(s)
- Ingrid T Katz
- Division of Women's Health, Department of Medicine, Brigham and Women's Hospital, 1620 Tremont St, Boston, MA, 02120, USA. .,Harvard Medical School, Boston, MA, USA. .,Massachusetts General Hospital Center for Global Health, Boston, MA, USA.
| | - David R Bangsberg
- Harvard Medical School, Boston, MA, USA.,Massachusetts General Hospital Center for Global Health, Boston, MA, USA
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A One-Size-Fits-All HIV Prevention and Education Approach?: Interpreting Divergent HIV Risk Perceptions Between African American and East African Immigrant Women in Washington, DC Using the Proximate-Determinants Conceptual Framework. Sex Transm Dis 2016; 43:78-83. [PMID: 26766523 DOI: 10.1097/olq.0000000000000386] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND To date, there are very few comparative US studies and none in DC that distinguish between US-born and foreign-born black women to examine and compare their perceptions of HIV risk. This qualitative study, therefore, analyzes African American and East African women's perceptions of HIV risk in the Washington DC Metropolitan area, which has the highest AIDS rate in the United States. METHODS Forty in-depth, semistructured interviews and 10 cognitive interviews were conducted among a sample of 25 African American women and 25 East African born women between October 2012 and March 2013 to examine perceptions regarding HIV risk. The in-depth semistructured interviews were preceded by the cognitive interviews and accompanying survey. Study protocol was reviewed and approved by the American University Institutional Review Board. RESULTS Adopting Boerma and Weir's Proximate Determinants conceptual framework to interpret the data, the results of the study demonstrate that African American and East African immigrant women have divergent perceptions of HIV risk. Although African American women ascribe HIV risk to individual-level behaviors and choices such as unprotected sex, East African women attribute HIV risk to conditions of poverty and survival. CONCLUSIONS Study findings suggest that addressing HIV prevention and education among black women in DC will require distinct and targeted strategies that are culturally and community-centered to resonate with these different audiences.
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Patel RC, Odoyo J, Anand K, Stanford-Moore G, Wakhungu I, Bukusi EA, Baeten JM, Brown JM. Facilitators and Barriers of Antiretroviral Therapy Initiation among HIV Discordant Couples in Kenya: Qualitative Insights from a Pre-Exposure Prophylaxis Implementation Study. PLoS One 2016; 11:e0168057. [PMID: 27930740 PMCID: PMC5145201 DOI: 10.1371/journal.pone.0168057] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 11/25/2016] [Indexed: 12/28/2022] Open
Abstract
Introduction The World Health Organization now recommends antiretroviral therapy (ART) initiation for all HIV-infected individuals regardless of CD4 cell count or disease status. Understanding the facilitators and barriers to initiation of and adherence to ART is essential to successful scale-up of “universal” ART. Methods To investigate facilitators and barriers to ART initiation, we conducted 44 in-depth individual or couple interviews with 63 participants (33 participants with HIV and 30 without HIV) already enrolled in a prospective implementation study of oral antiretroviral-based prevention in Kisumu, Kenya between August and September 2014. A semi-structured interview guided discussions on: 1) perceived advantages and disadvantages of ART; 2) reasons for accepting or declining ART initiation; and 3) influence of prevention of transmission to partner or infant influencing ART use. Transcripts from the interviews were iteratively analyzed using inductive content analysis. Results HIV-infected participants indicated that living a healthier life, preventing HIV transmission to others, and appearing “normal” or “healthy” again facilitated their initiation of ART. While appearing “normal” allowed these individuals to interact with their communities without stigmatization, they also perceived community opposition to their initiating ART, because appearing “normal” again prevented community members from easily identifying infected individuals in their community. Denial of diagnosis, disclosure stigma, perceived side-effects, and challenges in obtaining refills were additional barriers to ART initiation. Conclusions Community perceptions play an important role in both facilitating and inhibiting ART initiation. Perceived stigma, including perceived community opposition to widespread ART use, is an important barrier to ART initiation. Addressing such barriers, while capitalizing on facilitators, to ART initiation should be central to universal ART scale-up efforts.
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Affiliation(s)
- Rena C Patel
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Josephine Odoyo
- Centre for Microbiologic Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Keerthana Anand
- Northwestern University, Chicago, IL, United States of America
| | - Gaelen Stanford-Moore
- School of Medicine, University of California, San Francisco, CA, United States of America
| | - Imeldah Wakhungu
- Centre for Microbiologic Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Elizabeth A Bukusi
- Centre for Microbiologic Research, Kenya Medical Research Institute, Kisumu, Kenya
- Departments of Obstetrics and Gynecology and Global Health, University of Washington, Seattle, WA, United States of America
| | - Jared M Baeten
- Departments of Epidemiology, Global Health, and Medicine, University of Washington, Seattle, WA, United States of America
| | - Joelle M Brown
- Departments of Epidemiology and Biostatistics and Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, CA, United States of America
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Katirayi L, Chouraya C, Kudiabor K, Mahdi MA, Kieffer MP, Moland KM, Tylleskar T. Lessons learned from the PMTCT program in Swaziland: challenges with accepting lifelong ART for pregnant and lactating women - a qualitative study. BMC Public Health 2016; 16:1119. [PMID: 27776495 PMCID: PMC5078916 DOI: 10.1186/s12889-016-3767-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 10/13/2016] [Indexed: 11/25/2022] Open
Abstract
Background Swaziland has one of the highest HIV prevalence rates in sub-Saharan Africa, 26 % of the adult population is infected with HIV. The prevalence is highest among pregnant women, at 41.1 %. According to Swaziland’s prevention of mother-to-child transmission (PMTCT) guidelines, approximately 50 % of pregnant women are eligible for antiretroviral therapy (ART) by CD4 criteria (<350 cells/ml). Studies have shown that most mother-to-child transmission and postnatal deaths occur among women who are eligible for ART. Therefore, ensuring that ART eligible women are initiated on ART is critical for PMTCT and for mother and baby survival. This study provides insight into the challenges of lifelong ART initiation among pregnant women under Option A in Swaziland. We believe that these challenges and lessons learned from initiating women on lifelong ART under Option A are relevant and important to consider during implementation of Option B+. Methods HIV-positive, treatment-eligible, postpartum women and nurses were recruited within maternal and child health (MCH) units using convenience and purposive sampling. Participants came from both urban and rural areas. Focus group discussions (FGDs) and structured interviews using a short answer questionnaire were conducted to gain an understanding of the challenges experienced when initiating lifelong ART. Seven FGDs (of 5–11 participants) were conducted, four FGDs with nurses, two FGDs with women who initiated ART, and one FGD with women who did not initiate ART. A total of 83 interviews were conducted; 50 with women who initiated ART and 33 with women who did not initiate. Data collection with the women was conducted in the local language of SiSwati and data collection with the nurses was done in English. FGDs were audio-recorded and simultaneously transcribed and translated into English. Analysis was conducted using thematic analysis. Transcripts were coded by two researchers in the qualitative software program MAXqda v.10. Thematic findings were illustrated using verbatim quotes which were selected on the basis of being representative of a specific theme. The short-answer interview questionnaire included specific questions about the different steps in the woman’s experience initiating ART; therefore the responses for each question were analyzed separately. Results Findings from the study highlight women feeling overwhelmed by the lifetime commitment of ART, feeling “healthy” when asked to initiate ART, preference for short-course prophylaxis and fear of side effects (body changes). Also, the preference for nurses to determine on an individual basis the number of counseling appointments a woman needs before initiating ART, more information about HIV and ART needed at the community level, and the need to educate men about HIV and ART. Conclusion Women face a myriad of challenges initiating lifelong ART. Understanding women’s concerns will aid in developing effective counseling messages, designing appropriate counseling structures, understanding where additional support is needed in the process of initiating ART, and knowing who to target for community level messages.
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Affiliation(s)
- Leila Katirayi
- Elizabeth Glaser Pediatric AIDS Foundation, 1140 Connecticut Ave NW, Suite 200, Washington DC, 20036, USA. .,Center for International Health, University of Bergen, Bergen, Norway.
| | | | | | - Mohammed Ali Mahdi
- Elizabeth Glaser Pediatric AIDS Foundation, 1140 Connecticut Ave NW, Suite 200, Washington DC, 20036, USA
| | - Mary Pat Kieffer
- Elizabeth Glaser Pediatric AIDS Foundation, 1140 Connecticut Ave NW, Suite 200, Washington DC, 20036, USA
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Test site predicts HIV care linkage and antiretroviral therapy initiation: a prospective 3.5 year cohort study of HIV-positive testers in northern Tanzania. BMC Infect Dis 2016; 16:497. [PMID: 27646635 PMCID: PMC5028933 DOI: 10.1186/s12879-016-1804-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Accepted: 08/23/2016] [Indexed: 01/08/2023] Open
Abstract
Background Linkage to HIV care is crucial to the success of antiretroviral therapy (ART) programs worldwide, loss to follow up at all stages of the care continuum is frequent, and long-term prospective studies of care linkage are currently lacking. Methods Consecutive clients who tested HIV-positive were enrolled from four HIV testing centers (1 health facility and 3 community-based centers) in the Kilimanjaro region of Tanzania as part of the larger Coping with HIV/AIDS in Tanzania (CHAT) prospective observational study. Biannual interviews were conducted over 3.5 years, assessing care linkage, retention, and mental health. Bivariable and multivariate logistic regression analyses were conducted to determine associations with early death (prior to the second follow up interview) and delayed (>6 months post-test) or failed care linkage. Results A total of 263 participants were enrolled between November, 2008 and August, 2009 and 240 participants not already linked to care were retained in the final dataset. By 6 months after enrollment, 169 (70.4 %) of 240 participants had presented to an HIV care and treatment facility; 41 (17.1 %) delayed more than 6 months, 15 (6.3 %) died, and 15 (6.3 %) were lost to follow up. Twenty-six patients died before their second follow up visit and were analyzed in the early death group (10.8 %). Just 15 (9.6 %) of those linked to care had started ART within 6 months, but 123 (89.1 %) of patients documented to be ART eligible by local guidelines had started ART by the end of 3.5 years. On multivariate analysis, male gender (OR 1.72; 95 % CI 1.08, 2.75), testing due to illness (OR 1.63; 95 % CI 1.01, 2.63), and higher mean depression scale scores (4 % increased risk per increase in depression score; 95 % CI 1 %, 8 %) were associated with early death. Testing at a community versus a hospital-based site (OR 2.89; 95 % CI 1.79, 4.66) was strongly associated with delaying or never entering care. Conclusions Nearly 30 % of the cohort did not have timely care linkage, ART initiation was frequently delayed, and testing at a hospital outpatient department versus community-based testing centers was strongly associated with successful care linkage.
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Kruk ME, Riley PL, Palma AM, Adhikari S, Ahoua L, Arnaldo C, Belo DF, Brusamento S, Cumba LIG, Dziuban EJ, El-Sadr WM, Gutema Y, Habtamu Z, Heller T, Kidanu A, Langa J, Mahagaja E, McCarthy CF, Melaku Z, Shodell D, Tsiouris F, Young PR, Rabkin M. How Can the Health System Retain Women in HIV Treatment for a Lifetime? A Discrete Choice Experiment in Ethiopia and Mozambique. PLoS One 2016; 11:e0160764. [PMID: 27551785 PMCID: PMC4994936 DOI: 10.1371/journal.pone.0160764] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 07/25/2016] [Indexed: 01/12/2023] Open
Abstract
INTRODUCTION Option B+, an approach that involves provision of antiretroviral therapy (ART) to all HIV-infected pregnant women for life, is the preferred strategy for prevention of mother to child transmission of HIV. Lifelong retention in care is essential to its success. We conducted a discrete choice experiment in Ethiopia and Mozambique to identify health system characteristics preferred by HIV-infected women to promote continuity of care. METHODS Women living with HIV and receiving care at hospitals in Oromia Region, Ethiopia and Zambézia Province, Mozambique were shown nine choice cards and asked to select one of two hypothetical health facilities, each with six varying characteristics related to the delivery of HIV services for long term treatment. Mixed logit models were used to estimate the influence of six health service attributes on choice of clinics. RESULTS 2,033 women participated in the study (response rate 97.8% in Ethiopia and 94.7% in Mozambique). Among the various attributes of structure and content of lifelong ART services, the most important attributes identified in both countries were respectful provider attitude and ability to obtain non-HIV health services during HIV-related visits. Availability of counseling support services was also a driver of choice. Facility type, i.e., hospital versus health center, was substantially less important. CONCLUSIONS Efforts to enhance retention in HIV care and treatment for pregnant women should focus on promoting respectful care by providers and integrating access to non-HIV health services in the same visit, as well as continuing to strengthen counseling.
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Affiliation(s)
- Margaret E. Kruk
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Patricia L. Riley
- Division of Global HIV/AIDS, US Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Anton M. Palma
- Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Sweta Adhikari
- Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Laurence Ahoua
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Carlos Arnaldo
- Center for Population and Health Research, Maputo, Mozambique
| | | | - Serena Brusamento
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | | | - Eric J. Dziuban
- Division of Global HIV/AIDS, US Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Wafaa M. El-Sadr
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Yoseph Gutema
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Zelalem Habtamu
- Oromio Regional Health Bureau, Ethiopia Ministry of Health, Addis Ababa, Ethiopia
| | - Thomas Heller
- Centers for Disease Control and Prevention, Addis Ababa, Ethiopia
| | | | - Judite Langa
- Centers for Disease Control and Prevention, Maputo, Mozambique
| | | | - Carey F. McCarthy
- Division of Global HIV/AIDS, US Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Zenebe Melaku
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Daniel Shodell
- Centers for Disease Control and Prevention, Maputo, Mozambique
| | - Fatima Tsiouris
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Paul R. Young
- Division of Global HIV/AIDS, US Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Miriam Rabkin
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, New York, United States of America
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Winchester MS, McGrath JW, Kaawa-Mafigiri D, Namutiibwa F, Ssendegye G, Nalwoga A, Kyarikunda E, Birungi J, Kisakye S, Ayebazibwe N, Walakira EJ, Rwabukwali C. Routines, Hope, and Antiretroviral Treatment among Men and Women in Uganda. Med Anthropol Q 2016; 31:237-256. [PMID: 27159357 DOI: 10.1111/maq.12301] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 04/28/2016] [Accepted: 05/04/2016] [Indexed: 11/25/2022]
Abstract
Antiretroviral treatment programs, despite biomedical emphases, require social understanding and transformations to be successful. In this article, we draw from a qualitative study of HIV treatment seeking to examine the drug-taking routines and health-related subjectivities of men and women on antiretroviral treatment (ART) at two sites in Uganda. We show that while not all participants in ART programs understand clinical protocols in biomedical terms, they adopt treatment-taking strategies to integrate medication into daily practices and social spaces. In turn, these embedded practices and understandings shape long-term hopes and fears for living with HIV, including the possibility of a cure. More significant than new forms of citizenship or sociality, we suggest that quotidian dimensions of treatment normalization shape the long-term experience of medication and outlook for the future.
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Affiliation(s)
- Margaret S Winchester
- Department of Health Policy and Administration, Pennsylvania State University.,Center for Social Science Research on AIDS (CeSSRA), Makerere University, Kampala, Uganda and Case Western Reserve University
| | - Janet W McGrath
- Department of Anthropology, Case Western Reserve University.,Center for Social Science Research on AIDS (CeSSRA), Makerere University, Kampala, Uganda
| | - David Kaawa-Mafigiri
- Department of Anthropology, Case Western Reserve University.,Center for Social Science Research on AIDS (CeSSRA), Makerere University, Kampala, Uganda
| | - Florence Namutiibwa
- Center for Social Science Research on AIDS (CeSSRA), Makerere University, Kampala, Uganda.,Case Western Reserve University
| | - George Ssendegye
- Center for Social Science Research on AIDS (CeSSRA), Makerere University, Kampala, Uganda.,Case Western Reserve University
| | - Amina Nalwoga
- Center for Social Science Research on AIDS (CeSSRA), Makerere University, Kampala, Uganda.,Case Western Reserve University
| | - Emily Kyarikunda
- Center for Social Science Research on AIDS (CeSSRA), Makerere University, Kampala, Uganda.,Case Western Reserve University
| | - Judith Birungi
- Center for Social Science Research on AIDS (CeSSRA), Makerere University, Kampala, Uganda.,Case Western Reserve University
| | - Sheila Kisakye
- Center for Social Science Research on AIDS (CeSSRA), Makerere University, Kampala, Uganda.,Case Western Reserve University
| | - Nicholas Ayebazibwe
- Center for Social Science Research on AIDS (CeSSRA), Makerere University, Kampala, Uganda.,Case Western Reserve University
| | - Eddy J Walakira
- Department of Social Work and Social Administration, Makerere University, Kampala.,Center for Social Science Research on AIDS (CeSSRA), Makerere University, Kampala, Uganda
| | - Charles Rwabukwali
- Center for Social Science Research on AIDS (CeSSRA), Makerere University, Kampala, Uganda.,Department of Sociology and Anthropology, Makerere University, Kampala, Uganda
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30
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Iwuji CC, Orne-Gliemann J, Larmarange J, Okesola N, Tanser F, Thiebaut R, Rekacewicz C, Newell ML, Dabis F. Uptake of Home-Based HIV Testing, Linkage to Care, and Community Attitudes about ART in Rural KwaZulu-Natal, South Africa: Descriptive Results from the First Phase of the ANRS 12249 TasP Cluster-Randomised Trial. PLoS Med 2016; 13:e1002107. [PMID: 27504637 PMCID: PMC4978506 DOI: 10.1371/journal.pmed.1002107] [Citation(s) in RCA: 127] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 06/28/2016] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The 2015 WHO recommendation of antiretroviral therapy (ART) for all immediately following HIV diagnosis is partially based on the anticipated impact on HIV incidence in the surrounding population. We investigated this approach in a cluster-randomised trial in a high HIV prevalence setting in rural KwaZulu-Natal. We present findings from the first phase of the trial and report on uptake of home-based HIV testing, linkage to care, uptake of ART, and community attitudes about ART. METHODS AND FINDINGS Between 9 March 2012 and 22 May 2014, five clusters in the intervention arm (immediate ART offered to all HIV-positive adults) and five clusters in the control arm (ART offered according to national guidelines, i.e., CD4 count ≤ 350 cells/μl) contributed to the first phase of the trial. Households were visited every 6 mo. Following informed consent and administration of a study questionnaire, each resident adult (≥16 y) was asked for a finger-prick blood sample, which was used to estimate HIV prevalence, and offered a rapid HIV test using a serial HIV testing algorithm. All HIV-positive adults were referred to the trial clinic in their cluster. Those not linked to care 3 mo after identification were contacted by a linkage-to-care team. Study procedures were not blinded. In all, 12,894 adults were registered as eligible for participation (5,790 in intervention arm; 7,104 in control arm), of whom 9,927 (77.0%) were contacted at least once during household visits. HIV status was ever ascertained for a total of 8,233/9,927 (82.9%), including 2,569 ascertained as HIV-positive (942 tested HIV-positive and 1,627 reported a known HIV-positive status). Of the 1,177 HIV-positive individuals not previously in care and followed for at least 6 mo in the trial, 559 (47.5%) visited their cluster trial clinic within 6 mo. In the intervention arm, 89% (194/218) initiated ART within 3 mo of their first clinic visit. In the control arm, 42.3% (83/196) had a CD4 count ≤ 350 cells/μl at first visit, of whom 92.8% initiated ART within 3 mo. Regarding attitudes about ART, 93% (8,802/9,460) of participants agreed with the statement that they would want to start ART as soon as possible if HIV-positive. Estimated baseline HIV prevalence was 30.5% (2,028/6,656) (95% CI 25.0%, 37.0%). HIV prevalence, uptake of home-based HIV testing, linkage to care within 6 mo, and initiation of ART within 3 mo in those with CD4 count ≤ 350 cells/μl did not differ significantly between the intervention and control clusters. Selection bias related to noncontact could not be entirely excluded. CONCLUSIONS Home-based HIV testing was well received in this rural population, although men were less easily contactable at home; immediate ART was acceptable, with good viral suppression and retention. However, only about half of HIV-positive people accessed care within 6 mo of being identified, with nearly two-thirds accessing care by 12 mo. The observed delay in linkage to care would limit the individual and public health ART benefits of universal testing and treatment in this population. TRIAL REGISTRATION ClinicalTrials.gov NCT01509508.
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Affiliation(s)
- Collins C. Iwuji
- Africa Centre for Population Health, University of KwaZulu-Natal, Durban, South Africa
- Research Department of Infection and Population Health, University College London, London, United Kingdom
- * E-mail:
| | - Joanna Orne-Gliemann
- Centre INSERM U1219 Bordeaux Population Health, Université de Bordeaux, Bordeaux, France
- Institut de Santé Publique, d’Epidémiologie et de Développement, Centre INSERM U1219 Bordeaux Population Health, Université de Bordeaux, Bordeaux, France
| | - Joseph Larmarange
- Africa Centre for Population Health, University of KwaZulu-Natal, Durban, South Africa
- Centre Population & Développement UMR 196, Université Paris Descartes, Institut de Recherche pour le Développement, Paris, France
| | - Nonhlanhla Okesola
- Africa Centre for Population Health, University of KwaZulu-Natal, Durban, South Africa
| | - Frank Tanser
- Africa Centre for Population Health, University of KwaZulu-Natal, Durban, South Africa
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Rodolphe Thiebaut
- Centre INSERM U1219 Bordeaux Population Health, Université de Bordeaux, Bordeaux, France
- Institut de Santé Publique, d’Epidémiologie et de Développement, Centre INSERM U1219 Bordeaux Population Health, Université de Bordeaux, Bordeaux, France
| | - Claire Rekacewicz
- Agence Nationale de Recherches sur le Sida et les Hépatites Virales, Paris, France
| | - Marie-Louise Newell
- Africa Centre for Population Health, University of KwaZulu-Natal, Durban, South Africa
- Human Health and Development and Global Health Research Institute, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Francois Dabis
- Centre INSERM U1219 Bordeaux Population Health, Université de Bordeaux, Bordeaux, France
- Institut de Santé Publique, d’Epidémiologie et de Développement, Centre INSERM U1219 Bordeaux Population Health, Université de Bordeaux, Bordeaux, France
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HIV-positive pregnant and postpartum women's perspectives about Option B+ in Malawi: a qualitative study. J Int AIDS Soc 2016; 19:20919. [PMID: 27312984 PMCID: PMC4911420 DOI: 10.7448/ias.19.1.20919] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 04/28/2016] [Accepted: 05/12/2016] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION The implementation of lifelong antiretroviral treatment (ART) for all pregnant women (Option B+) in Malawi has resulted in a significant increase in the number of HIV-positive pregnant women initiating treatment. However, research has highlighted the challenge of retaining newly initiated women in care. This study explores barriers and facilitators that affect a woman's decision to initiate and to adhere to Option B+. METHODS A total of 39 in-depth interviews and 16 focus group discussions were conducted. Eligible women were ≥18 years old, living with HIV and either pregnant and receiving antenatal care from a study site or had delivered a child within the last 18 months, breastfed their child and received services at one of the study sites. Eligible women were identified by healthcare workers (HCWs) in the antenatal clinic and ART unit. Focus groups were also conducted with HCWs employed in these departments. Qualitative data were analyzed using Maxqda version 10 (VERBI Software, Berlin, Germany). RESULTS The general perception towards the drug regimen used in Option B+ was positive; women reported fewer side effects and acknowledged the positive benefits of ART. Women felt hopeful about prolonging their life and having an HIV-uninfected baby, yet grappled with the fact that ART is a lifelong commitment. Women and HCWs discussed challenges with the counselling services for prevention of mother-to-child HIV transmission under the new Option B+ guidelines, and many women struggled with initiating ART on the same day as learning their HIV status. Women wanted to discuss their circumstances with their husbands first, receive a CD4 count and obtain an HIV test at another facility to confirm their HIV status. HCWs expressed concern that women might just agree to take the drugs to please them. HCWs also discussed concerns around loss to follow-up and drug resistance. CONCLUSIONS Although Option B+ has significantly increased the number of women initiating ART, there are still challenges that need to be addressed to strengthen initiation, adherence and retention in care. Strategies to strengthen the counselling services upon diagnosis need to be developed to improve same-day initiation of ART and long-term adherence.
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Culbert GJ, Bazazi AR, Waluyo A, Murni A, Muchransyah AP, Iriyanti M, Finnahari, Polonsky M, Levy J, Altice FL. The Influence of Medication Attitudes on Utilization of Antiretroviral Therapy (ART) in Indonesian Prisons. AIDS Behav 2016; 20:1026-38. [PMID: 26400080 PMCID: PMC4805506 DOI: 10.1007/s10461-015-1198-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Negative attitudes toward HIV medications may restrict utilization of antiretroviral therapy (ART) in Indonesian prisons where many people living with HIV (PLH) are diagnosed and first offered ART. This mixed-method study examines the influence of medication attitudes on ART utilization among HIV-infected Indonesian prisoners. Randomly-selected HIV-infected male prisoners (n = 102) completed face-to-face in-depth interviews and structured surveys assessing ART attitudes. Results show that although half of participants utilized ART, a quarter of those meeting ART eligibility guidelines did not. Participants not utilizing ART endorsed greater concerns about ART efficacy, safety, and adverse effects, and more certainty that ART should be deferred in PLH who feel healthy. In multivariate analyses, ART utilization was independently associated with more positive ART attitudes (AOR = 1.09, 95 % CI 1.03-1.16, p = 0.002) and higher internalized HIV stigma (AOR = 1.03, 95 % CI 1.00-1.07, p = 0.016). Social marketing of ART is needed to counteract negative ART attitudes that limit ART utilization among Indonesian prisoners.
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Affiliation(s)
- Gabriel J Culbert
- Department of Health Systems Science, University of Illinois at Chicago, College of Nursing, 845 S. Damen Ave., Chicago, IL, 60612, USA.
- Center for HIV/AIDS Nursing Research, Faculty of Nursing, Universitas Indonesia, Depok, Indonesia.
- Section of Infectious Diseases, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA.
- Centre of Excellence for Research in AIDS (CERiA), University of Malaya, Kuala Lumpur, Malaysia.
| | - Alexander R Bazazi
- Section of Infectious Diseases, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
- Centre of Excellence for Research in AIDS (CERiA), University of Malaya, Kuala Lumpur, Malaysia
| | - Agung Waluyo
- Center for HIV/AIDS Nursing Research, Faculty of Nursing, Universitas Indonesia, Depok, Indonesia
| | - Astia Murni
- Directorate General of Corrections, Indonesian Ministry of Law and Human Rights, Jakarta, Indonesia
| | | | - Mariska Iriyanti
- Center for HIV/AIDS Nursing Research, Faculty of Nursing, Universitas Indonesia, Depok, Indonesia
| | - Finnahari
- Directorate General of Corrections, Indonesian Ministry of Law and Human Rights, Jakarta, Indonesia
| | - Maxim Polonsky
- Section of Infectious Diseases, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Judith Levy
- Department of Health Policy & Administration, University of Illinois at Chicago School of Public Health, Chicago, IL, USA
| | - Frederick L Altice
- Section of Infectious Diseases, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
- Centre of Excellence for Research in AIDS (CERiA), University of Malaya, Kuala Lumpur, Malaysia
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Mujugira A, Celum C, Tappero JW, Ronald A, Mugo N, Baeten JM. Younger Age Predicts Failure to Achieve Viral Suppression and Virologic Rebound Among HIV-1-Infected Persons in Serodiscordant Partnerships. AIDS Res Hum Retroviruses 2016; 32:148-54. [PMID: 26670218 DOI: 10.1089/aid.2015.0296] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Antiretroviral therapy (ART) markedly reduces the risk of HIV-1 transmission in serodiscordant partnerships. We previously found that younger age and higher CD4 counts were associated with delayed initiation of ART by HIV-1-infected partners in serodiscordant partnerships. Among those initiating ART, we sought to explore whether those same factors were associated with failure to achieve viral suppression. METHODS In a prospective study of HIV-1-infected persons who had a known heterosexual HIV-1-uninfected partner in Kenya and Uganda [Partners Pre-Exposure Prophylaxis (PrEP) Study], we used Cox proportional hazards regression to evaluate correlates of viral nonsuppression (HIV-1 RNA >80 copies/ml). RESULTS Of 1,035 HIV-1-infected participants initiating ART, 867 (84%) achieved viral suppression: 77% by 6 months and 86% by 12 months. Younger age [adjusted hazard ratio (aHR) 1.05 for every 5 years younger; p = .006], lower pretreatment CD4 count (aHR 1.26; p = .009 for ≤250 compared with >250 cells/μl), and higher pretreatment HIV-1 RNA quantity (aHR 1.21 per log10; p < .001) independently predicted failure to achieve viral suppression. Following initial viral suppression, 8.8% (76/867) experienced virologic rebound (HIV-1 RNA >200 copies/ml): 6.3% and 11.5% by 6 and 12 months after initial suppression, respectively. Age was the only factor associated with increased risk of virologic rebound (aHR 1.33 for every 5 years younger; p = .005). CONCLUSIONS For HIV-1-infected persons in serodiscordant couples, younger age was associated with delayed ART initiation, failure to achieve viral suppression, and increased risk of virologic rebound. Motivating ART initiation and early adherence is a key to achieving and sustaining viral suppression.
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Affiliation(s)
- Andrew Mujugira
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
| | - Connie Celum
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
- Department of Medicine, University of Washington, Seattle, Washington
| | - Jordan W. Tappero
- Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Allan Ronald
- Departments of Medicine and Medical Microbiology, University of Manitoba, Winnipeg, Canada
| | - Nelly Mugo
- Department of Global Health, University of Washington, Seattle, Washington
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Jared M. Baeten
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
- Department of Medicine, University of Washington, Seattle, Washington
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Ngure K, Heffron R, Curran K, Vusha S, Ngutu M, Mugo N, Celum C, Baeten JM. I Knew I Would Be Safer. Experiences of Kenyan HIV Serodiscordant Couples Soon After Pre-Exposure Prophylaxis (PrEP) Initiation. AIDS Patient Care STDS 2016; 30:78-83. [PMID: 26836236 DOI: 10.1089/apc.2015.0259] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Pre-exposure prophylaxis (PrEP) for HIV-uninfected persons is highly efficacious for HIV prevention. Understanding how people at risk for HIV will use PrEP is important to inform PrEP scale-up and implementation. We used qualitative methods to gather insights into couples' early experiences with PrEP use within the Partners Demonstration Project, an open-label implementation study evaluating integrated delivery of PrEP and antiretroviral therapy (ART). PrEP is offered to HIV uninfected partners until the HIV-infected partner initiates and sustains ART use (i.e., PrEP as a "bridge" to ART initiation and viral suppression). From August 2013 to March 2014 we conducted 20 in-depth dyadic interviews (n = 40) with heterosexual HIV serodiscordant couples participating at the Thika, Kenya study site, exploring how couples make decisions about using PrEP for HIV prevention. We developed and applied deductive and inductive codes to identify key themes related to experiences of PrEP initiation and use of time-limited PrEP. Couples reported that PrEP offered them an additional strategy to reduce the risk of HIV transmission, meet their fertility desires, and cope with HIV serodiscordance. Remaining HIV negative at follow-up visits reinforced couples' decisions and motivated continued adherence to PrEP. In addition, confidence in their provider's advice and client-friendly services were critical to their decisions to initiate and continue use of PrEP. Strategies for wide-scale PrEP delivery for HIV serodiscordant couples in low resource settings may include building capacity of health providers to counsel on PrEP adoption while addressing couples' concerns and barriers to adoption and continued use.
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Affiliation(s)
- Kenneth Ngure
- School of Public Health, Jomo Kenyatta University of Agriculture and Technology, Kenya
- Department of Global Health, University of Washington, Seattle, Washington
| | - Renee Heffron
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
| | - Kathryn Curran
- Department of Global Health, University of Washington, Seattle, Washington
| | - Sophie Vusha
- Center for Clinical Research, Kenya Medical Research Institute, Kenya
| | - Mariah Ngutu
- Center for Clinical Research, Kenya Medical Research Institute, Kenya
| | - Nelly Mugo
- Department of Global Health, University of Washington, Seattle, Washington
- Center for Clinical Research, Kenya Medical Research Institute, Kenya
| | - Connie Celum
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
- Department of Medicine, University of Washington, Seattle, Washington
| | - Jared M. Baeten
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
- Department of Medicine, University of Washington, Seattle, Washington
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Carroll JJ, Ngure K, Heffron R, Curran K, Mugo NR, Baeten JM. Gendered differences in the perceived risks and benefits of oral PrEP among HIV-serodiscordant couples in Kenya. AIDS Care 2016; 28:1000-6. [PMID: 26754017 DOI: 10.1080/09540121.2015.1131972] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Pre-exposure prophylaxis (PrEP) is effective for preventing HIV among HIV-serodiscordant heterosexual couples. Gender roles may influence perceived personal and social risks related to HIV-prevention behaviors and may affect use of PrEP. In this study, interviews and focus groups were conducted with 68 individuals from 34 mutually disclosed serodiscordant heterosexual partnerships in Thika, Kenya. Sociocultural factors that affect adherence to PrEP were explored using grounded analysis. Three factors were identified, which shape perceptions of PrEP: gendered power dynamics and control over decision-making in the household; conflicts between risk-reduction strategies and male sexual desire; culture-bound definitions of women's work. Adherence to PrEP in the Partners PrEP Study was high; however, participants articulated conflicting interests related to PrEP in connection with traditional gender roles. The successful delivery of PrEP will require understanding of key social factors, particularly related to gender and dyadic dynamics around HIV serostatus.
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Affiliation(s)
- Jennifer J Carroll
- a Department of Epidemiology , University of Washington , Seattle , Washington , USA.,b Department of Anthropology , University of Washington , Seattle , Washington , USA
| | - Kenneth Ngure
- c Department of Global Health , University of Washington , Seattle , Washington , USA.,e Jomo Kenyatta University of Agriculture and Technology , Nairobi , Kenya
| | - Renee Heffron
- a Department of Epidemiology , University of Washington , Seattle , Washington , USA.,c Department of Global Health , University of Washington , Seattle , Washington , USA
| | - Kathryn Curran
- a Department of Epidemiology , University of Washington , Seattle , Washington , USA
| | - Nelly R Mugo
- f Kenya Medical Research Institute , Nairobi , Kenya
| | - Jared M Baeten
- a Department of Epidemiology , University of Washington , Seattle , Washington , USA.,c Department of Global Health , University of Washington , Seattle , Washington , USA.,d Department of Medicine , University of Washington , Seattle , Washington , USA
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Kaplan RL, Khoury CE, Field ERS, Mokhbat J. Living Day by Day: The Meaning of Living With HIV/AIDS Among Women in Lebanon. Glob Qual Nurs Res 2016; 3:2333393616650082. [PMID: 28462340 PMCID: PMC5342635 DOI: 10.1177/2333393616650082] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 04/18/2016] [Accepted: 04/19/2016] [Indexed: 11/16/2022] Open
Abstract
We examined the meaning of living with HIV/AIDS among women in Lebanon. Ten women living with HIV/AIDS (WLWHA) described their experiences via semistructured in-depth interviews. They navigated a process of HIV diagnosis acceptance that incorporated six overlapping elements: receiving the news, accessing care, starting treatment, navigating disclosure decisions, negotiating stigma, and maintaining stability. Through these elements, we provide a framework for understanding three major themes that were constructed during data analysis: Stand by my side: Decisions of disclosure; Being "sick" and feeling "normal": Interacting with self, others, and society; and Living day by day: focusing on the present. We contribute to the existing literature by providing a theoretical framework for understanding the process of diagnosis and sero-status acceptance among WLWHA. This was the first study of its kind to examine the meaning of living with HIV/AIDS among women in a Middle Eastern country.
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Narasimhan M, Loutfy M, Khosla R, Bras M. Sexual and reproductive health and human rights of women living with HIV. J Int AIDS Soc 2015; 18:20834. [PMID: 28326129 PMCID: PMC4813610 DOI: 10.7448/ias.18.6.20834] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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38
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Mmeje O, Njoroge B, Cohen CR, Temmerman M, Vermund SH, van der Poel S. Achieving Pregnancy Safely in HIV-Affected Individuals and Couples: An Important Strategy to Eliminate HIV Transmission From Mother-To-Child and Between Sexual Partners. J Acquir Immune Defic Syndr 2015; 70:e155-9. [PMID: 26334740 PMCID: PMC10767706 DOI: 10.1097/qai.0000000000000814] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Okeoma Mmeje
- *Department of Obstetrics and Gynecology, University of Michigan School of Medicine, Ann Arbor, MI †Kenya Medical Research Institute (KEMRI), Centre for Microbiology Research (CMR) Nairobi, Kenya ‡Department of Obstetrics, Gynecology and Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California, San Francisco, CA §Division of Reproductive Health and Research, World Health Organization, Geneva, Switzerland ‖Vanderbilt Institute for Global Health and Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
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A discussion of key values to inform the design and delivery of services for HIV-affected women and couples attempting pregnancy in resource-constrained settings. J Int AIDS Soc 2015; 18:20272. [PMID: 26643454 PMCID: PMC4672397 DOI: 10.7448/ias.18.6.20272] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 08/28/2015] [Accepted: 09/22/2015] [Indexed: 12/18/2022] Open
Abstract
Introduction HIV-affected women and couples often desire children and many accept HIV risk in order to attempt pregnancy and satisfy goals for a family. Risk reduction strategies to mitigate sexual and perinatal HIV transmission include biomedical and behavioural approaches. Current efforts to integrate HIV and reproductive health services offer prime opportunities to incorporate strategies for HIV risk reduction during pregnancy attempts. Key client and provider values about services to optimize pregnancy in the context of HIV risk provide insights for the design and implementation of large-scale “safer conception” programmes. Discussion Through our collective experience and discussions at a multi-disciplinary international World Health Organization–convened workshop to initiate the development of guidelines and an algorithm of care to support the delivery of services for HIV-affected women and couples attempting pregnancy, we identified four values that are key to the implementation of these programmes: (1) understanding fertility care and an ability to identify potential fertility problems; (2) providing equity of access to resources enabling informed decision-making about reproductive choices; (3) creating enabling environments that reduce stigma associated with HIV and infertility; and (4) creating enabling environments that encourage disclosure of HIV status and fertility status to partners. Based on these values, recommendations for programmes serving HIV-affected women and couples attempting pregnancy include the following: incorporation of comprehensive reproductive health counselling; training to support the transfer and exchange of knowledge between providers and clients; care environments that reduce the stigma of childbearing among HIV-affected women and couples; support for safe and voluntary disclosure of HIV and fertility status; and increased efforts to engage men in reproductive decision-making at times that align with women's desires. Conclusions Programmes, policies and guidelines that integrate HIV treatment and prevention, sexual and reproductive health and fertility care services in a manner responsive to user values and preferences offer opportunities to maximize demand for and use of these services. For HIV-affected women and couples attempting pregnancy, the provision of comprehensive services using available tools – and the development of new tools that are adaptable to many settings and follow consensus recommendations – is a public health imperative. The impetus now is to design and deliver value-driven inclusive programming to achieve the greatest coverage and impact to reduce HIV transmission during pregnancy attempts.
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Factors Associated with Retention to Care in an HIV Clinic in Gabon, Central Africa. PLoS One 2015; 10:e0140746. [PMID: 26473965 PMCID: PMC4608719 DOI: 10.1371/journal.pone.0140746] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Accepted: 09/30/2015] [Indexed: 01/30/2023] Open
Abstract
Background Retention to HIV care is vital for patients’ survival, to prevent onward transmission and emergence of drug resistance. Travelling to receive care might influence adherence. Data on the functioning of and retention to HIV care in the Central African region are limited. Methods This retrospective study reports outcomes and factors associated with retention to HIV care at a primary HIV clinic in Lambaréné, Gabon. Adult patients who presented to this clinic between January 2010 and January 2012 were included. Outcomes were retention in care (defined as documented show-up for clinical visits, regardless of delay) or LTFU (defined as a patient not retained in care; on ART or ART naïve, not returning to care during the study period with a patient delay for scheduled visits of more than 6 months), and mortality. Cox regression analysis was used to assess factors associated with respective outcomes. Qualitative data on reasons for LTFU were obtained from focus-group discussions. Results Of 223 patients included, 67.3% were female. The mean age was 40.5 (standard deviation 11.4) years and the median CD4 count 275 (interquartile range 100.5–449.5) cells/μL. In total, 34.1% were lost to follow up and 8.1% died. Documented tuberculosis was associated with increased risk of being LTFU (adjusted hazard ratio (aHR) 1.80, 95% confidence interval (95% CI) 1.05–3.11, P = 0.03), whereas early starting anti-retroviral therapy (ART) was associated with a decreased risk of LTFU (aHR 0.43, 95%CI 0.24–0.76, P = 0.004), as was confirmed by qualitative data. Conclusions Retention to HIV care in a primary clinic in Gabon is relatively poor and interventions to address this should be prioritized in the HIV program. Early initiation of ART might improve retention in care.
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Schwartz SR, West N, Phofa R, Yende N, Sanne I, Bassett J, Van Rie A. Acceptability and preferences for safer conception HIV prevention strategies: a qualitative study. Int J STD AIDS 2015; 27:984-92. [PMID: 26384950 DOI: 10.1177/0956462415604091] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 08/11/2015] [Indexed: 11/16/2022]
Abstract
Safer conception strategies to reduce the HIV transmission risk include antiretroviral therapy for HIV-positive partners, pre-exposure prophylaxis for HIV-negative partners, condomless sex limited to fertile periods, and home-based self-insemination. Resistance to taking treatment or cultural concerns may limit uptake of strategies and intervention success. Understanding the acceptability and preferences between different approaches is important to optimise service delivery. Between February and July 2013, 42 adults (21 HIV-positive and 21 HIV-negative) receiving primary care at Witkoppen Health and Welfare Centre in Johannesburg, South Africa, participated in focus group discussions or in-depth interviews. Themes were analysed using a grounded theory approach. Acceptability of antiretroviral-based strategies varied. Concerns over side effects, antiretroviral treatment duration and beliefs that treatment is only for the sick were common barriers; however, desperation for a child was noted as a facilitator for uptake. HIV-negative men and HIV-positive women had favourable attitudes towards self-insemination, though paternity and safety concerns were raised. Self-insemination was generally preferred over pre-exposure prophylaxis by HIV-negative men, and antiretroviral-based strategies were preferred by couples with HIV-negative female partners, despite concerns raised about condomless sex while virally suppressed. Knowledge about the fertile window was low. A strong counselling component will be required for effective uptake and adherence to safer conception services.
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Affiliation(s)
- Sheree R Schwartz
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Nora West
- Witkoppen Health and Welfare Centre, Johannesburg, South Africa
| | - Rebecca Phofa
- Witkoppen Health and Welfare Centre, Johannesburg, South Africa
| | | | - Ian Sanne
- Clinical HIV Research Unit, Department of Medicine, University of the Witwatersrand, Johannesburg, South Africa Right to Care, Johannesburg, South Africa
| | - Jean Bassett
- Witkoppen Health and Welfare Centre, Johannesburg, South Africa
| | - Annelies Van Rie
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Saleem HT, Surkan PJ, Kerrigan D, Kennedy CE. Application of an ecological framework to examine barriers to the adoption of safer conception strategies by HIV-affected couples. AIDS Care 2015; 28:197-204. [PMID: 26288153 DOI: 10.1080/09540121.2015.1074652] [Citation(s) in RCA: 10] [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
Safer conception interventions can significantly reduce the risk of horizontal HIV transmission between HIV-serodiscordant partners. However, prior to implementing safer conception interventions, it is essential to understand potential barriers to their adoption so that strategies can be developed to overcome these barriers. This paper examines potential barriers to the adoption of safer conception strategies by HIV-affected couples in Iringa, Tanzania using an ecological framework. We interviewed 30 HIV-positive women, 30 HIV-positive men and 30 health providers engaged in delivering HIV-related services. We also conducted direct observations at five health facilities. Findings suggest that there are multiple barriers to safer conception that operate at the individual, relational, environmental, structural, and super-structural levels. The barriers to safer conception identified are complex and interact across these levels. Barriers at the individual level included antiretroviral adherence, knowledge of HIV status, knowledge and acceptability of safer conception strategies, and poor nutrition. At the relational level, unplanned pregnancies, non-disclosure of status, gendered power dynamics within relationships, and patient-provider interactions posed a threat to safer conception. HIV stigma and distance to health facilities were environmental barriers to safer conception. At the structural level there were multiple barriers to safer conception, including limited safer conception policy guidelines for people living with HIV (PLHIV), lack of health provider training in safer conception strategies and preconception counseling for PLHIV, limited resources, and lack of integration of HIV and sexual and reproductive health services. Poverty and gender norms were super-structural factors that influenced and reinforced barriers to safer conception, which influenced and operated across different levels of the framework. Multi-level interventions are needed to ensure adoption of safer conception strategies and reduce the risk of HIV transmission between partners within HIV-serodiscordant couples.
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Affiliation(s)
- Haneefa T Saleem
- a Department of International Health , Bloomberg School of Public Health, Johns Hopkins University , 615 N. Wolfe Street, Baltimore , MD 21205 , USA
| | - Pamela J Surkan
- a Department of International Health , Bloomberg School of Public Health, Johns Hopkins University , 615 N. Wolfe Street, Baltimore , MD 21205 , USA
| | - Deanna Kerrigan
- b Department of Health , Behavior and Society, Bloomberg School of Public Health, Johns Hopkins University , 624 North Broadway, Hampton House, 257, Baltimore , MD 21205 , USA
| | - Caitlin E Kennedy
- a Department of International Health , Bloomberg School of Public Health, Johns Hopkins University , 615 N. Wolfe Street, Baltimore , MD 21205 , USA
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Growing-up just like everyone else: key components of a successful pediatric HIV disclosure intervention in Namibia. AIDS 2015; 29 Suppl 1:S81-9. [PMID: 26049542 DOI: 10.1097/qad.0000000000000667] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To facilitate replication and adaptation of pediatric HIV disclosure interventions, we identified key components of a child-friendly cartoon book used to guide Namibian caregivers and healthcare workers (HCWs) through a gradual, structured disclosure process. DESIGN Qualitative interviews were conducted with caregivers and HCWs from four high-volume pediatric HIV clinics in Namibia. METHODS Semi-structured in-depth interviews with 35 HCWs and 64 caregivers of HIV+ children aged 7-15 were analyzed using constant comparative and modified grounded theory analysis. Major barriers to disclosure were compared to accounts of intervention success, and themes related to key components were identified. RESULTS The disclosure book overcomes barriers to disclosure by reducing caregiver resistance, increasing HIV and disclosure knowledge, and providing a gradual, structured framework for disclosure. The delayed mention of HIV-specific terminology overcomes caregiver fears associated with HIV stigma, thus encouraging earlier uptake of disclosure initiation. Caregivers value the book's focus on staying healthy, keeping the body strong, and having a future 'like other kids', thus capitalizing on evidence of the positive benefits of resilience and hopefulness rather than the negative consequences of HIV. The book's concepts and images resonate with children who readily adopt the language of 'body soldiers' and 'bad guys' in describing how important it is for them to take their medicine. Discussion cues ease communication between HCWs, caregivers, and pediatric patients. CONCLUSION Given the urgent need for available pediatric HIV disclosure interventions, easily implementable tools like the Namibian disclosure book should be evaluated for utility in similar settings.
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Katz IT, Dietrich J, Tshabalala G, Essien T, Rough K, Wright AA, Bangsberg DR, Gray GE, Ware NC. Understanding treatment refusal among adults presenting for HIV-testing in Soweto, South Africa: a qualitative study. AIDS Behav 2015; 19:704-14. [PMID: 25304330 DOI: 10.1007/s10461-014-0920-y] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
HIV treatment initiatives have focused on increasing access to antiretroviral therapy (ART). There is growing evidence, however, that treatment availability alone is insufficient to stop the epidemic. In South Africa, only one third of individuals living with HIV are actually on treatment. Treatment refusal has been identified as a phenomenon among people who are asymptomatic, however, factors driving refusal remain poorly understood. We interviewed 50 purposively sampled participants who presented for voluntary counseling and testing in Soweto to elicit a broad range of detailed perspectives on ART refusal. We then integrated our core findings into an explanatory framework. Participants described feeling "too healthy" to start treatment, despite often having a diagnosis of AIDS. This subjective view of wellness was framed within the context of treatment being reserved for the sick. Taking ART could also lead to unintended disclosure and social isolation. These data provide a novel explanatory model of treatment refusal, recognizing perceived risks and social costs incurred when disclosing one's status through treatment initiation. Our findings suggest that improving engagement in care for people living with HIV in South Africa will require optimizing social integration and connectivity for those who test positive.
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Mayer KH. Antiretroviral chemoprophylaxis: state of evidence and the research agenda. Clin Infect Dis 2015; 59 Suppl 1:S47-51. [PMID: 24926034 DOI: 10.1093/cid/ciu322] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Oral antiretroviral preexposure prophylaxis (PrEP) has been shown to decrease human immunodeficiency virus (HIV) incidence in studies of men who have sex with men, heterosexual men and women, and injecting drug users. One study of pericoital tenofovir gel demonstrated that it reduced HIV incidence in South African women. However, other studies of African women failed to demonstrate protection with either oral tenofovir or tenofovir-emtricitabine, or daily tenofovir gel. The magnitude of PrEP protection appears to be highly correlated with medication adherence. New studies are evaluating whether different antiretrovirals, including dapivirine, rilpivirine, maraviroc, and new integrase inhibitors. Different formulations are also being evaluated, including gels, films, vaginal rings, and injectable medication. Although PrEP efficacy has been demonstrated, and several normative bodies (eg, the US Food and Drug Administration) have approved PrEP for clinical use, uptake has been slow. Reasons may include lack of sufficient provider and consumer education, residual concerns about costs, potential long-term toxicities, and behavioral disinhibition. Additional work is under way to determine how to best educate consumers and providers about optimal adherence and to use PrEP in conjunction with risk mitigation.
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Affiliation(s)
- Kenneth H Mayer
- Fenway Institute, Fenway Health Harvard Medical School Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Successful antiretroviral therapy delivery and retention in care among asymptomatic individuals with high CD4+ T-cell counts above 350 cells/μl in rural Uganda. AIDS 2014; 28:2241-9. [PMID: 25022596 DOI: 10.1097/qad.0000000000000401] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND HIV antiretroviral therapy (ART) is being rapidly scaled up in sub-Saharan Africa, including recently patients with CD4 T-cell counts above 350 cells/μl. However, concerns persist about adherence and virologic suppression among these asymptomatic, high CD4 cell count individuals. OBJECTIVE To determine the virologic efficacy and safety of ART among asymptomatic HIV-positive Ugandan adults with high CD4 cell counts above 350 cells/μl via a streamlined model of care. DESIGN Prospective nonrandomized clinical study (EARLI Study: clinicaltrials.gov NCT#01479634). SETTING Prototypic rural Ugandan HIV clinic. PATIENTS/PARTICIPANTS Asymptomatic, ART-naive adults (aged >18 years, N = 197) with CD4 at least 350 cells/μl, without pregnancy or WHO stage 3/4 illness. INTERVENTIONS ART included tenofovir/emtricitabine/efavirenz, with ritonavir/lopinavir substitution for efavirenz available. Streamlined ART model included nurse-driven visits with physician back-up, basic safety laboratory monitoring with HIV viral load, clinician telephone contact, and defaulter tracking. No incentives were provided. OUTCOMES Undetectable viral load (≤400 copies/ml) at 24 and 48 weeks [intention to treat (ITT); missing = detectable), self-reported ART adherence, retention in care, and laboratory/clinical ART toxicities. RESULTS Of the 197 patients with CD4 above 350 cells/μl, median CD4 cell count was 569 cells/μl (interquartile range 451-716). Undetectable viral load was achieved in 189 of 197 (95.9%, ITT) and 189 of 195 (96.9%, ITT) of participants at weeks 24 and 48, respectively. Self-reported adherence was 98% and 192 of 197 (97%) of the patients were retained at week 48. Laboratory adverse events and hospitalizations were rare. CONCLUSIONS We demonstrate high virologic suppression, retention, and safety among asymptomatic individuals with CD4 above 350 cells/μl in a prototypic Ugandan clinic. Our results challenge current concerns that individuals with high CD4 cell count lack motivation for ART, and may not achieve sustained virologic suppression.
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Preferences for daily or intermittent pre-exposure prophylaxis regimens and ability to anticipate sex among HIV uninfected members of Kenyan HIV serodiscordant couples. AIDS Behav 2014; 18:1701-11. [PMID: 24871870 DOI: 10.1007/s10461-014-0804-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Intermittent dosing for pre-exposure prophylaxis (PrEP) has been proposed as an alternative to daily PrEP to reduce cost and patient drug exposure and to improve adherence. One possible dosing regimen is pre-intercourse PrEP, which requires anticipating sex in advance. We examined preferences for daily versus pre-intercourse PrEP and ability to anticipate sex among 310 HIV uninfected members of HIV serodiscordant heterosexual couples in Thika, Kenya, with high HIV knowledge and experience with daily PrEP use in a clinical trial setting. Preferences were evenly split between daily PrEP (47.4 %) and pre-intercourse PrEP (50.7 %). Participants were more likely to prefer daily PrEP if they reported unprotected sex during the prior month (adjusted prevalence ratio [aPR] 1.48, 95 % CI 1.20-1.81) or <80 % adherence to study drug (aPR 1.50, 95 % CI 1.25-1.79), and were less likely to prefer daily PrEP if sex was usually planned, versus spontaneous (aPR 0.76, 95 % CI 0.61-0.96). A minority (24.2 %) reported anticipating sex >3 h in advance, with younger participants being less likely to do so (aPR 0.43, 95 % CI 0.23-0.83 for ages 18-29 vs. ≥40). Findings suggest that intermittent PrEP could be a popular option in this population, but that optimal adherence and sufficient drug levels might be challenging with a pre-intercourse regimen.
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Cairns G, Baker AC, Dedes N, Zakowicz A, West B. Treatment as Prevention: Arriving at Community Consensus. Clin Infect Dis 2014; 59 Suppl 1:S35-40. [DOI: 10.1093/cid/ciu268] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Heffron R, Donnell D, Kiarie J, Rees H, Ngure K, Mugo N, Were E, Celum C, Baeten JM. A prospective study of the effect of pregnancy on CD4 counts and plasma HIV-1 RNA concentrations of antiretroviral-naive HIV-1-infected women. J Acquir Immune Defic Syndr 2014; 65:231-6. [PMID: 24442226 PMCID: PMC3898601 DOI: 10.1097/qai.0000000000000013] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND In HIV-1-infected women, CD4 count declines occur during pregnancy, which has been attributed to hemodilution. However, for women who have not initiated antiretroviral therapy, it is unclear if CD4 declines are sustained beyond pregnancy and accompanied by increased viral levels, which could indicate an effect of pregnancy on accelerating HIV-1 disease progression. METHODS In a prospective study among 2269 HIV-1-infected antiretroviral therapy-naive women from 7 African countries, we examined the effect of pregnancy on HIV-1 disease progression. We used linear mixed models to compare CD4 counts and plasma HIV-1 RNA concentrations between pregnant, postpartum, and nonpregnant periods. RESULTS Women contributed 3270 person-years of follow-up, during which time 476 women became pregnant. In adjusted analysis, CD4 counts were an average of 56 (95% confidence interval: 39 to 73) cells/mm lower during pregnant compared with nonpregnant periods and 70 (95% confidence interval: 53 to 88) cells/mm lower during pregnant compared with postpartum periods; these results were consistent when restricted to the subgroup of women who became pregnant. Plasma HIV-1 RNA concentrations were not different between pregnant and nonpregnant periods (P = 0.9) or pregnant and postpartum periods (P = 0.3). Neither CD4 counts nor plasma HIV-1 RNA levels were significantly different in postpartum compared with nonpregnant periods. CONCLUSIONS CD4 count declines among HIV-1-infected women during pregnancy are temporary and not sustained in postpartum periods. Pregnancy does not have a short-term impact on plasma HIV-1 RNA concentrations.
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Affiliation(s)
- Renee Heffron
- Department of Global Health, University of Washington, Seattle, USA
| | - Deborah Donnell
- Department of Global Health, University of Washington, Seattle, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, USA
| | - James Kiarie
- Department of Obstetrics & Gynaecology, University of Nairobi, Nairobi, Kenya
| | - Helen Rees
- Wits Reproductive Health and HIV Institute (WRHI), University of the Witwatersrand, Johannesburg, South Africa
| | - Kenneth Ngure
- Department of Global Health, University of Washington, Seattle, USA
- Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Nelly Mugo
- Department of Global Health, University of Washington, Seattle, USA
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Edwin Were
- Department of Reproductive Health, Moi University, Eldoret, Kenya
| | - Connie Celum
- Department of Global Health, University of Washington, Seattle, USA
- Department of Epidemiology, University of Washington, Seattle, USA
- Department of Medicine, University of Washington, Seattle, USA
| | - Jared M. Baeten
- Department of Global Health, University of Washington, Seattle, USA
- Department of Epidemiology, University of Washington, Seattle, USA
- Department of Medicine, University of Washington, Seattle, USA
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