Facilitators and barriers in HIV linkage to care interventions: a qualitative evidence review

An exploration of multi-level factors affecting routine linkage to HIV care in Zambia's PEPFAR-supported treatment program in the treat all era

Multiple steps from HIV diagnosis to treatment initiation and confirmed engagement with the health system are required for people living with HIV to establish full linkage to care in the modern treat all era. We undertook a qualitative study to gain an in-depth understanding of the impeding and enabling factors at each step of this linkage pathway. In-depth interviews were conducted with fifty-eight people living with HIV recruited from ten routine HIV care settings supported by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) in Lusaka, Zambia. Using a semi-structured interview guide informed by an established conceptual framework for linkage to care, questions explored the reasons behind late, missed, and early linkage into HIV treatment, as well as factors influencing the decision to silently transfer to a different clinic after an HIV diagnosis. We identified previously established and intersecting barriers of internal and external HIV-related stigma, concerns about ART side effects, substance use, uncertainties for the future, and a perceived lack of partner and social support that impeded linkage to care at every step of the linkage pathway. However, we also uncovered newer themes specific to the current test and treat era related to the rapidity of ART initiation and insufficient patient-centered post-test counseling that appeared to exacerbate these well-known barriers, including callous health workers and limited time to process a new HIV diagnosis before treatment. Long travel distance to the clinic where they were diagnosed was the most common reason for silently transferring to another clinic for treatment. On the other hand, individual resilience, quality counseling, patient-centered health workers, and a supportive and empathetic social network mitigated these barriers. These findings highlight potential areas for strengthening linkage to care and addressing early treatment interruption and silent transfer in the test and treat era in Zambia.

Social and structural barriers and facilitators to HIV healthcare and harm reduction services for people experiencing syndemics in Manitoba: study protocol

INTRODUCTION

In Manitoba, Canada, there has been an increase in the number of people newly diagnosed with HIV and those not returning for regular HIV care. The COVID-19 pandemic resulted in increased sex and gender disparities in disease risk and mortalities, decreased harm reduction services and reduced access to healthcare. These health crises intersect with increased drug use and drug poisoning deaths, houselessness and other structural and social factors most acutely among historically underserved groups. We aim to explore the social and structural barriers and facilitators to HIV care and harm reduction services experienced by people living with HIV (PLHIV) in Manitoba.

METHODS AND ANALYSIS

Our study draws on participatory action research design. Guiding the methodological design are the lived experiences of PLHIV. In-depth semi-structured face-to-face interviews and quantitative questionnaires will be conducted with two groups: (1) persons aged ≥18 years living or newly diagnosed with HIV and (2) service providers who work with PLHIV. Data collection will include sex, gender, sociodemographic information, income and housing, experiences with the criminal justice system, sexual practices, substance use practices and harm reduction access, experiences with violence and support, HIV care journey (since diagnosis until present), childhood trauma and a decision-making questionnaire. Data will be analysed intersectionally, employing grounded theory for thematic analysis, sex-based and gender-based analysis and social determinants of health and syndemic framework to understand the experiences of PLHIV in Manitoba.

ETHICS AND DISSEMINATION

We received approval from the University of Manitoba Health Ethics Research Board (HS25572; H2022:218), First Nations Health and Social Secretariat of Manitoba, Nine Circles Community Health Centre, Shared Health Manitoba (SH2022:194) and 7th Street Health Access Centre. Findings will be disseminated using community-focused knowledge translation strategies identified by participants, peers, community members and organisations, and reported in conferences, peer-reviewed journals and a website (www.alltogether4ideas.org).

Internet-based peer support interventions for people living with HIV: A scoping review

Peer support interventions for people living with HIV and AIDS (PLWHA) are effective, but their associated time and material costs for the recipient and the health system make them reachable for only a small proportion of PLWHA. Internet-based interventions are an effective alternative for delivering psychosocial interventions for PLWHA as they are more accessible. Currently, no reviews are focusing on internet-based interventions with peer support components. This scoping review aims to map the existing literature on psychosocial interventions for PLWHA based on peer support and delivered through the internet. We conducted a systematic scoping review of academic literature following methodological guidelines for scoping reviews, and 28 articles met our criteria. We summarized the main characteristics of the digital peer support interventions for PLWHA and how they implemented peer support in a virtual environment. Overall the reported outcomes appeared promising, but more robust evidence is needed.

Traditional Human Immunodeficiency Virus treatment and family and social influence as barriers to accessing HIV care services in Belu, Indonesia

Access to HIV care services, including antiretroviral therapy (ART), is essential for improving health outcomes of people living with HIV (PLHIV) and reducing HIV transmission and AIDS-related deaths. As a part of a qualitative study in Belu, this paper describes the use of traditional medicines for HIV treatment and family and social influence as barriers to access to HIV care services among PLHIV. One-on-one in-depth interviews were employed to collect data from 46 PLHIV (26 women and 20 men) and 10 healthcare professionals. They were recruited using the snowball sampling technique. The study information sheets were initially posted on information boards in healthcare facilities. Potential participants who contacted to confirm their participation were recruited for an interview and then asked for help to distribute the information sheets to their eligible colleagues who might be willing to participate. Data analysis was performed using NVivo 12 software and guided by a qualitative data analysis framework. The findings showed that the use of traditional medicines, a well-known cultural practice in Belu, was a barrier to access to HIV care services among PLHIV. The influence of family in determining the use of traditional medicines for HIV treatment, supported by the lack of knowledge of ART, effectiveness of traditional medicines in treating other health issues, and social influence of relatives, neighbours, and friends, were also significant barriers to PLHIV’s access to HIV care services. The findings indicate the need for dissemination of HIV care-related information for PLHIV, family, and community members to increase their knowledge of the service, ART and its function, and to support and improve access to HIV care services especially ART by PLHIV.

Risk Behaviors Associated with Patterns of Sexualized Stimulant and Alcohol Use among Men Who Have Sex with Men: a Latent Class Analysis

Substance use during sexual encounters (sexualized substance use) is an important driver of HIV and sexually transmitted infection (STI) disparities that are experienced by men who have sex with men (MSM). This analysis aimed to identify patterns of sexualized substance use and their associations with HIV risk behaviors. We utilized visit-level data from a longitudinal cohort of predominantly Black/Latinx MSM, half with HIV and half with substance use in Los Angeles, California. Every 6 months from 8/2014 to 3/2020, participants underwent STI testing and completed surveys on demographics, sexualized substance use (stimulant and/or alcohol intoxication during oral sex, receptive anal intercourse [RAI] and/or insertive anal intercourse [IAI]), transactional sex, biomedical HIV prevention (pre-/post-exposure prophylaxis use or undetectable viral load), and depressive symptoms. Latent class analysis was used to identify patterns of sexualized substance use. Multinomial logit models evaluated risk behaviors associated with latent classes. Among 2386 study visits from 540 participants, 5 classes were identified: no substance use, sexualized stimulant use, sexualized alcohol use, sexualized stimulant and alcohol use, and stimulant/alcohol use during oral sex and RAI. Compared to the no sexualized substance use class, sexualized stimulant use was associated with transactional sex, current diagnosis of STIs, not using HIV biomedical prevention, and depressive symptoms. Sexualized alcohol use had fewer associations with HIV risk behaviors. Patterns of sexual activities, and the substances that are used during those activities, confer different risk behavior profiles for HIV/STI transmission and demonstrate the potential utility of interventions that combine substance use treatment with HIV prevention.

HIV Prevention and Treatment Behavior Change and the Situated Information Motivation Behavioral Skills (sIMB) Model: A Qualitative Evaluation of a Community Health Worker Intervention in Rakai, Uganda

A community health worker (CHW) model can promote HIV prevention and treatment behaviors, especially in highly mobile populations. In a fishing community in Rakai, Uganda, the Rakai Health Sciences Program implemented a CHW HIV intervention called Health Scouts. The situated Information, Motivation, and Behavioral Skills (sIMB) framework informed the design and a qualitative evaluation of the intervention. We interviewed 51 intervention clients and coded transcripts informed by sIMB framework dimensions. Clients reported that Health Scouts provided information about HIV prevention and treatment behaviors and helped them manage personal and social motivations to carry out health-promoting behavior. Prominent barriers which moved clients away from behavior change included daily pill burdens, anticipated stigma, serostatus disclosure, substance use at social gatherings, and anticipated reactions of partners. Our study adds to the evidence establishing CHWs as facilitators of behavior change, positioned to offer supportive encouragement and navigate contextualized circumstances.

A community approach to promote healthcare services for people living with HIV who use drugs in Vietnam

BACKGROUND

People living with HIV who use drugs (PLHWUD) face enormous challenges to access antiretroviral therapy (ART), addiction treatment, and other healthcare services. This study evaluated the effect of a community capacity-building approach on PLHWUD's access to healthcare services.

METHODS

A cluster randomized controlled trial was conducted in four provinces of Vietnam. Trained commune health workers in the intervention condition were encouraged to provide services to PLHWUD in the community and engage them in HIV/addiction treatment and care using learned knowledge and skills. A total of 241 PLHWUD participated in surveys at the baseline and every three months for one year. The primary outcome was PLHWUD's reported barriers to seeking healthcare. A linear mixed-effects regression model with a difference in difference approach was used to estimate the intervention effect on the primary outcome.

RESULTS

Adjusted analyses indicated that significant intervention effects were observed at the Sixth and ninth month follow-ups for those on ART at the baseline and increased motivation to engage in treatment at the 3-month follow-up (60.2% vs 34.4% for the intervention and control groups, respectively).

CONCLUSIONS

The community capacity-building intervention had shown promising yet limited outcomes among a subset of PLHWUD in the community, that is, PLHWUD who had already initiated ART.

Factors influencing the performance of community health volunteers working within urban informal settlements in low- and middle-income countries: a qualitative meta-synthesis review

BACKGROUND

There is limited information on community health volunteer (CHV) programmes in urban informal settlements in low- and middle-income countries (LMICs). This is despite such settings accounting for a high burden of disease. Many factors intersect to influence the performance of CHVs working in urban informal settlements in LMICs. This review was conducted to identify both the programme level and contextual factors influencing performance of CHVs working in urban informal settlements in LMICs.

METHODS

Four databases were searched for qualitative and mixed method studies focusing on CHVs working in urban and peri-urban informal settlements in LMICs. We focused on CHV programme outcome measures at CHV individual level. A total of 13 studies met the inclusion criteria and were double read to extract relevant data. Thematic coding was conducted, and data synthesized across ten categories of both programme and contextual factors influencing CHV performance. Quality was assessed using both the Critical Appraisal Skills Programme (CASP) and the Mixed Methods Assessment Tool (MMAST); and certainty of evidence evaluated using the Confidence in the Evidence from Reviews of Qualitative research (CERQual) approach.

RESULTS

Key programme-level factors reported to enhance CHV performance in urban informal settlements in LMICs included both financial and non-financial incentives, training, the availability of supplies and resources, health system linkage, family support, and supportive supervision. At the broad contextual level, factors found to negatively influence the performance of CHVs included insecurity in terms of personal safety and the demand for financial and material support by households within the community. These factors interacted to shape CHV performance and impacted on implementation of CHV programmes in urban informal settlements.

CONCLUSION

This review identified the influence of both programme-level and contextual factors on CHVs working in both urban and peri-urban informal settlements in LMICs. The findings suggest that programmes working in such settings should consider adequate remuneration for CHVs, integrated and holistic training, adequate supplies and resources, adequate health system linkages, family support and supportive supervision. In addition, programmes should also consider CHV personal safety issues and the community expectations.

Patient-reported Reasons for Stopping Care or Switching Clinics in Zambia: A Multisite, Regionally Representative Estimate Using a Multistage Sampling-based Approach in Zambia

BACKGROUND

Understanding patient-reported reasons for lapses of retention in human immunodeficiency virus (HIV) treatment can drive improvements in the care cascade. A systematic assessment of outcomes among a random sample of patients lost to follow-up (LTFU) from 32 clinics in Zambia to understand the reasons for silent transfers and disengagement from care was undertaken.

METHODS

We traced a simple random sample of LTFU patients (>90 days from last scheduled visit) as determined from clinic-based electronic medical records from a probability sample of facilities. Among patients found in person, we solicited reasons for either stopping or switching care and predictors for re-engagement. We coded reasons into structural, psychosocial, and clinic-based barriers.

RESULTS

Among 1751 LTFU patients traced and found alive, 31% of patients starting antiretroviral therapy (ART) between 1 July 2013 and 31 July 2015 silently transferred or were disengaged (40% male; median age, 35 years; median CD4 level, 239 cells/μL); median time on ART at LTFU was 480 days (interquartile range, 110-1295). Among the 544 patients not in care, median prevalences for patient-reported structural, psychosocial, and clinic-level barriers were 27.3%, 13.9%, and 13.4%, respectively, and were highly variable across facilities. Structural reasons, including, "relocated to a new place" were mostly cited among 289 patients who silently transferred (35.5%). We found that men were less likely to re-engage in care than women (odds ratio, .39; 95% confidence interval, .22-.67; P = .001).

CONCLUSIONS

Efforts to improve retention of patients on ART may need to be tailored at the facility level to address patient-reported barriers.

An Integrated Primary Care Initiative for Child Health in Northern Togo

OBJECTIVES

To determine if the Integrated Community-Based Health Systems-Strengthening (ICBHSS) initiative was effective in expanding health coverage, improving care quality, and reducing child mortality in Togo.

METHODS

Population-representative cross-sectional household surveys adapted from the Demographic Household Survey and Multiple Indicator Cluster Surveys were conducted at baseline (2015) and then annually (2016-2020) in 4 ICBHSS catchment sites in Kara, Togo. The primary outcome was under-5 mortality, with health service coverage and health-seeking behavior as secondary outcomes. Costing analyses were calculated by using "top-down" methodology with audited financial statements and programmatic data.

RESULTS

There were 10 022 household surveys completed from 2015 to 2020. At baseline (2015), under-5 mortality was 51.1 per 1000 live births (95% confidence interval [CI]: 35.5-66.8), and at the study end period (2020), under-5 mortality was 35.8 (95% CI: 23.4-48.2). From 2015 to 2020, home-based treatment by a community health worker increased from 24.1% (95% CI: 21.9%-26.4%) to 45.7% (95% CI: 43.3%-48.2%), and respondents reporting prenatal care in the first trimester likewise increased (37.5% to 50.1%). Among respondents who sought care for a child with fever, presenting for care within 1 day increased from 51.9% (95% CI: 47.1%-56.6%) in 2015 to 80.3% (95% CI: 74.6%-85.0%) in 2020. The estimated annual additional intervention cost was $8.84 per person.

CONCLUSIONS

Our findings suggest that the ICBHSS initiative, a bundle of evidence-based interventions implemented with a community-based strategy, improves care access and quality and was associated with reduction in child mortality.

Comprehensive approach to HIV/AIDS testing and linkage to treatment among men who have sex with men in Curitiba, Brazil

Introduction

The Curitiba (Brazil)-based Project, A Hora é Agora (AHA), evaluated a comprehensive HIV control strategy among men who have sex with men (MSM) aimed at expanding access to HIV rapid testing and linking HIV-positive MSM to health services and treatment. AHA’s approach included rapid HIV Testing Services (HTC) in one mobile testing unit (MTU); a local, gay-led, non-governmental organization (NGO); an existing government-run health facility (COA); and Internet-based HIV self-testing. The objectives of the paper were to compare a) number of MSM tested in each strategy, its positivity and linkage; b) social, demographic and behavioral characteristics of MSM accessing the different HTC and linkage services; and c) the costs of the individual strategies to diagnose and link MSM to services.

Methods

We used data for 2,681 MSM tested at COA, MTU and NGO from March 2015 to March 2017. This is a cross sectional comparison of the demographics and behavioral factors (age group, race/ethnicity, education, sexually transmitted diseases, knowledge of AHA services and previous HIV test). Absolute frequencies, percentage distributions and confidence intervals for the percentages were used, as well as unilateral statistical tests.

Results and discussion

AHA performed 2,681 HIV tests among MSM across three in-person strategies: MTU, NGO, and COA; and distributed 4,752 HIV oral fluid tests through the self-testing platform. MTU, NGO and COA reported 365 (13.6%) HIV positive diagnoses among MSM, including 28 users with previous HIV diagnosis or on antiretroviral treatment for HIV. Of these, 89% of MSM were eligible for linkage-to-care services. Linkage support was accepted by 86% of positive MSM, of which 66.7% were linked to services in less than 90 days. The MTU resulted in the lowest cost per MSM tested ($137 per test), followed by self-testing ($247).

Conclusions

AHA offered MSM access to HTC through innovative strategies operating in alternative sites and schedules. It presented the Curitiba HIV/AIDS community the opportunity to monitor HIV-positive MSM from diagnosis to treatment uptake. Self-testing emerged as a feasible strategy to increase MSM access to HIV-testing through virtual tools and anonymous test kit delivery and pick-up. Cost per test findings in both the MTU and self-testing support expansion to other regions with similar epidemiological contexts.

Barriers and Facilitators to Effective Implementation of the NAMWEZA Intervention in Dar es Salaam, Tanzania

The NAMWEZA intervention was implemented, using a ten-session group format, to build skills targeting psychosocial vulnerabilities and enhancing HIV prevention among people living with HIV (PLH) and their social networks. The overall goal of this intervention is to improve psychological wellbeing and reduce HIV risk behaviours. These analyses aim to describe the barriers and facilitators of implementing the NAMWEZA intervention from the perspective of participants and trained peer group facilitators. Twenty-four in-depth interviews were conducted with NAMWEZA participants, and 50 pooled peer facilitator self-assessment reports were obtained from 16 trained peers. Participants identified personal and structural barriers, including fear of inadvertent HIV status disclosure, time constraints, level of participant reimbursements, and limited space available for group sessions. Factors facilitating effective implementation included perceived benefits of the program, such as reduction in HIV-related risk behaviours, increased self-esteem, and improvement in confidence in HIV prevention communications. Scaling up the NAMWEZA intervention to other areas of Tanzania or regionally should take into account these facilitators and barriers to implementation.

Travel time to health-care facilities, mode of transportation, and HIV elimination in Malawi: a geospatial modelling analysis

BACKGROUND

UNAIDS has prioritised Malawi and 21 other countries in sub-Saharan Africa for fast-tracking the end of their HIV epidemics. UNAIDS' elimination strategy requires achieving a treatment coverage of 90% by 2030. However, many individuals in the prioritised countries have to travel long distances to access HIV treatment and few have access to motorised transportation. Using data-based geospatial modelling, we investigated whether these two factors are barriers to achieving HIV elimination in Malawi and assessed the effect of increasing bicycle availability on expanding treatment coverage.

METHODS

We built a data-based geospatial model that we used to estimate the minimum travel time needed to access treatment, for every person living with HIV in Malawi. We constructed our model by combining a spatial map of health-care facilities, a map that showed the number of HIV-infected individuals per km², and an impedance map. We quantified impedance using data on road and river networks, land cover, and topography. We estimated travel times for the existing coverage of 70%, and the time that HIV-infected individuals would need to spend travelling in order to achieve a coverage of 90%, whether driving, bicycling, or walking.

FINDINGS

We identified a quantitative relationship between the maximum achievable coverage of treatment and the minimum travel time to the nearest health-care facility. At 70% coverage, health-care facilities can be reached within approximately 45 min if driving, 65 min if bicycling, and 85 min if walking. Increasing coverage above 70% will become progressively more difficult. To reach 90% coverage, many HIV-infected individuals (who have yet to initiate treatment) will need to travel for almost twice as long as those already on treatment. Bicycling, rather than walking, in rural areas would substantially increase the maximum achievable coverage.

INTERPRETATION

The long travel times needed to reach health-care facilities coupled with little motorised transportation in rural areas are substantial barriers to reaching 90% coverage in Malawi. Increased bicycle availability could help eliminate HIV.

FUNDING

US National Institute of Allergy and Infectious Diseases.

Barriers and motivators to participation and retention in HIV/HCV cohort studies among people who inject drugs: a community consultation in Iran

BACKGROUND

The lack of robust estimates of HIV/HCV incidence among people who inject drugs (PWID) in Iran calls for well-designed prospective cohort studies. Successful recruitment and follow-up of PWID in cohort studies may require formative assessment of barriers PWID are faced with in participation and retention in cohort studies and factors they think may facilitate their engagement in such studies. Using a focus group discussion (FGD) format, we conducted a consultation with PWID in southeast Iran to recognize those barriers and motivators.

METHODS

Using targeted sampling and through snowball referrals, we recruited PWID (aged≥18, injected in last 6 months) from community-based drop-in centers (DICs), homeless shelters, and through outreach efforts to participate in four FGDs (one women-only). Socio-demographic characteristics, injection behaviors and self-reported HCV/HIV testing and diagnosis history were obtained. Then, a semi-structured FGD guide was applied to explore barriers and motivators to participation and retention in cohort studies among study participants. All FGD sessions were recorded and transcribed verbatim, removing any identifying information. The content of FGDs were analyzed by thematic analysis using an inductive approach.

RESULTS

In total, 30 individuals (10 women) participated in the study. The median age of participants was 35 (IQR 31-40), with majority (73.3%) reporting injecting drug use within the last month. Only 40.0% reported ever being tested for HCV whereas a larger proportion (63.4%) reported ever being tested for HIV. While the majority were willing to participate in cohort studies, breach of confidentiality, fear of positive test results, perceived required commitment, and marginalization were reported as barriers to participation and retention in such studies. Monetary incentive, the thought of a better life, protection from police interventions and trust between health workers and PWID were addressed as motivators of engagement in cohort studies among PWID.

CONCLUSIONS

Strategies to enhance data security and reduce stigma associated with injecting drug use along with involving peer workers in research, providing pre and post-test counselling and education and addressing the needs of more marginalized groups potentially through integrated healthcare programs and housing support are among few approaches that may help address barriers and strengthen the motivators for successful cohort studies among this population.

Patient-reported reasons for declining same-day antiretroviral therapy initiation in routine HIV care settings in Lusaka, Zambia: results from a mixed-effects regression analysis

INTRODUCTION

In the current "test and treat" era, HIV programmes are increasingly focusing resources on linkage to care and same-day antiretroviral therapy (ART) initiation to meet UNAIDS 95-95-95 targets. After observing sub-optimal treatment indicators in health facilities supported by the Centre for Infectious Disease Research in Zambia (CIDRZ), we piloted a "linkage assessment" tool in facility-based HIV testing settings to uncover barriers to same-day linkage to care and ART initiation among newly identified people living with HIV (PLHIV) and to guide HIV programme quality improvement efforts.

METHODS

The one-page, structured linkage assessment tool was developed to capture patient-reported barriers to same-day linkage and ART initiation using three empirically supported categories of barriers: social, personal and structural. The tool was implemented in three health facilities, two urban and one rural, in Lusaka, Zambia from 1 November 2017 to 31 January 2018, and administered to all newly identified PLHIV declining same-day linkage and ART. Individuals selected as many reasons as relevant. We used mixed-effects logistic regression modelling to evaluate predictors of citing specific barriers to same-day linkage and ART, and Fisher's Exact tests to assess differences in barrier citation by socio-demographics and HIV testing entry point.

RESULTS

A total of 1278 people tested HIV positive, of whom 126 (9.9%) declined same-day linkage and ART, reporting a median of three barriers per respondent. Of these 126, 71.4% were female. Females declining same-day ART were younger, on average, (median 28.5 years, interquartile range (IQR): 21 to 37 years) than males (median 34.5 years, IQR: 26 to 44 years). The most commonly reported barrier category was structural, "clinics were too crowded" (n = 33), followed by a social reason, "friends and family will condemn me" (n = 30). The frequency of citing personal barriers differed significantly across HIV testing point (χ2 p = 0.03). Significant predictors for citing ≥1 barrier to same-day ART were >50 years of age (OR: 12.59, 95% CI: 6.00 to 26.41) and testing at a rural facility (OR: 9.92, 95% CI: 4.98 to 19.79).

CONCLUSIONS

Given differences observed in barriers to same-day ART initiation reported across sex, age, testing point, and facility type, new, tailored counselling and linkage to care approaches are needed, which should be rigorously evaluated in routine programme settings.

Households in HIV Care: Designing an Intervention to Stimulate HIV Competency in Households in South Africa

Despite the Universal Test and Treat program and widespread antiretroviral treatment rollout, South Africa is still facing HIV prevention and treatment challenges, which are aggravated by human resource shortages in the healthcare sector. Individual- and community-level responses to these HIV-related challenges are increasingly being explored, for example, in community and home-based care. The role of the household as a crucial mediating social level has, however, largely been omitted. This paper outlines the design of an intervention to stimulate the involvement of the household in support for people living with HIV in South Africa. The 6SQuID model guided the intervention development process in four phases: (1) formative research, theory formulation, and a review of the existing literature, (2) integration of the results from the formative research into the "Positive Communication Process" (P2CP model) as a mechanism of change, (3) design of a community-health-worker-led intervention as the way to deliver the change mechanism, and (4) testing and revision of the developed intervention material-called Sinako-in a small-scale pilot study. The Sinako intervention anticipates that the future of chronic HIV care in resource-constrained settings will need to integrate the patient's household into the fight against HIV.

"Our Tradition Our Enemy": A Qualitative Study of Barriers to Women's HIV Care in Jimma, Southwest Ethiopia

Evidence exists that suggests that women are vulnerable to negative HIV treatment outcomes worldwide. This study explored barriers to treatment outcomes of women in Jimma, Southwest Ethiopia. We interviewed 11 HIV patients, 9 health workers, 10 community advocates and 5 HIV program managers from 10 institutions using an in-depth interview guide designed to probe barriers to HIV care at individual, community, healthcare provider, and government policy levels. To systematically analyze the data, we applied a thematic framework analysis using NVivo. In total, 35 participants were involved in the study and provided the following interrelated barriers: (i) Availability— most women living in rural areas who accessed HIV cared less often than men; (ii) free antiretroviral therapy (ART) is expensive—most women who have low income and who live in urban areas sold ART drugs illegally to cover ART associated costs; (iii) fear of being seen by others—negative consequences of HIV related stigma was higher in women than men; (iv) the role of tradition—the dominance of patriarchy was found to be the primary barrier to women’s HIV care and treatment outcomes. In conclusion, barriers related to culture or tradition constrain women’s access to HIV care. Therefore, policies and strategies should focus on these contextual constrains.

Improving Timely Linkage to Care among Newly Diagnosed HIV-Infected Youth: Results of SMILE

Delayed linkage to care deprives youth living with HIV of the benefits of HIV treatment and risks increased HIV transmission. Developing and testing linkage-to-care models that are capable of simultaneously addressing structural and individual obstacles are necessary to attain national goals for timely linkage of newly diagnosed youth to care. We assessed an integrated, multi-pronged strategy for improving youth's timely linkage to care carried out in eight adolescent medicine clinical trials units (AMTUs) in the USA. In phase I, the intervention strategy paired intensive medical case management with formalized relationships to local health departments, including granting of public health authority (PHA) to four of the AMTUs. In phase II, local coalitions run by the AMTUs to address structural changes to meet youth's HIV prevention and HIV testing needs began to advocate for local structural changes to improve timely access to care. Results of an ARIMA model demonstrated sustained decline in the average number of days to link to care over a 6-year period (ARIMA (1,2,1) AIC = 245.74, BIC = 248.70, p < .01)). By the end of the study, approximately 90% of youth linked to care had an initial medical visit in 42 or fewer days post-diagnosis. PHA improved the timeliness of linkage to care (b = - 69.56, p < .05). A piecewise regression suggested the addition of structural change initiatives during phase II made a statistically significant contribution to reducing time to linkage over and above achievements attained via case management alone (F (3,19) = 5.48, p < .01; Adj. R² = .3794). Multi-level linkage-to-care interventions show promise for improving youth's timely access to HIV medical care.

Tobacco, Alcohol, Drug Use, and Intimate Partner Violence Among MSM Living With HIV

Men who have sex with men (MSM) and are living with HIV have reported high rates of intimate partner violence (IPV) and substance use. We examined relationships between accumulative IPV, incidents of IPV, and numbers of substances used. One hundred twenty Taiwanese MSM living with HIV completed a cross-sectional survey. Accumulative IPV was assessed by summing the number of 15 types of IPV experienced in the previous year; substance use was measured by any use of alcohol, tobacco, or other drugs during the previous week. In multivariate analysis, IPV was not associated with tobacco use but was positively associated with alcohol and other drug use and significantly associated with the probability of using multiple substances. MSM living with HIV who experienced greater IPV were more likely to use alcohol and other drugs and were more likely to use more than one substance. Health care providers screening for IPV should also screen for substance use.

Assessing the Integrated Community-Based Health Systems Strengthening initiative in northern Togo: a pragmatic effectiveness-implementation study protocol

BACKGROUND

Over the past decade, prevalence of maternal and child morbidity and mortality in Togo, particularly in the northern regions, has remained high despite global progress. The causes of under-five child mortality in Togo are diseases with effective and low-cost prevention and/or treatment strategies, including malaria, acute lower respiratory infections, and diarrheal diseases. While Togo has a national strategy for implementing the integrated management of childhood illness (IMCI) guidelines, including a policy on integrated community case management (iCCM), challenges in implementation and low public sector health service utilization persist. There are critical gaps to access and quality of community health systems throughout the country. An integrated facility- and community-based initiative, the Integrated Community-Based Health Systems Strengthening (ICBHSS) initiative, seeks to address these gaps while strengthening the public sector health system in northern Togo. This study aims to evaluate the effect and implementation strategy of the ICBHSS initiative over 48 months in the catchment areas of 21 public sector health facilities.

METHODS

The ICBHSS model comprises a bundle of evidence-based interventions targeting children under five, women of reproductive age, and people living with HIV through (1) community engagement and feedback; (2) elimination of point-of-care costs; (3) proactive community-based IMCI using community health workers (CHWs) with additional services including family planning, HIV testing, and referrals; (4) clinical mentoring and enhanced supervision; and (5) improved supply chain management and facility structures. Using a pragmatic type II hybrid effectiveness-implementation study, we will evaluate the ICBHSS initiative with two primary aims: (1) determine effectiveness through changes in under-five mortality rates and (2) assess the implementation strategy through measures of reach, adoption, implementation, and maintenance. We will conduct a mixed-methods assessment using the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework. This assessment consists of four components: (1) a stepped-wedge cluster randomized control trial using a community-based household survey, (2) annual health facility assessments, (3) key informant interviews, and (4) costing and return-on-investment assessments for each randomized cluster.

DISCUSSION

Our research is expected to contribute to continuous quality improvement initiatives, optimize implementation factors, provide knowledge regarding health service delivery, and accelerate health systems improvements in Togo and more broadly.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT03694366 , registered 3 October 2018.

Re-thinking Linkage to Care in the Era of Universal Test and Treat: Insights from Implementation and Behavioral Science for Achieving the Second 90

To successfully link to care, persons living with HIV must negotiate a complex series of processes from HIV diagnosis through initial engagement with HIV care systems and providers. Despite the complexity involved, linkage to care is often oversimplified and portrayed as a single referral step. In this article, we offer a new conceptual framework for linkage to care, tailored to the current universal test and treat era that presents linkage to care as its own nuanced pathway within the larger HIV care cascade. Conceptualizing linkage to care in this way may help better identify and specify processes posing a barrier to linkage, and allow for the development of targeted implementation and behavioral science-based approaches to address them. Such approaches are likely to be most relevant to programmatic and clinical settings with limited resources and high HIV burden.

Barriers and facilitators to linkage to care and ART initiation in the setting of high ART coverage in Botswana

We conducted a qualitative study using focus groups and in-depth interviews to explore barriers to and facilitators of linkage-to-care and antiretroviral treatment (ART) initiation in Botswana. Participants were selected from communities receiving interventions through the Ya Tsie Study. Fifteen healthcare providers and 49 HIV-positive individuals participated. HIV-positive participants identified barriers including stigma, discrimination and overcrowded clinics, and negative staff attitudes; personal factors, such as a lack of acceptance of one's HIV status, non-disclosure, and gender differences; along with lack of social/family support, and certain religious beliefs. Healthcare providers cited delayed test results, poverty, and transport difficulties as additional barriers. Major facilitators were support from healthcare providers, including home visits, social support, and knowing the benefits of ART. Participants were highly supportive of universal ART as a personal health measure. Our results highlighted a persistent structural health facility barrier: HIV-positive patients expressed strong discontent with HIV care/treatment being delivered differently than routine healthcare, feeling inconvenienced and stigmatized by separately designated locations and days of service. This barrier was particularly problematic for highly mobile persons. Addressing this structural barrier, which persists even in the context of high ART uptake, could bring gains in willingness to initiate ART and improved adherence in Botswana and elsewhere.

Feasibility of community-based HIV self-screening in South Africa: a demonstration project

Background

HIV diagnosis is a critical step in linking HIV-infected individuals to care and treatment and linking HIV-uninfected persons to prevention services. However, the uptake of HIV testing remains low in many countries. HIV self-screening (HIVSS) is acceptable to adults, but there is limited data on HIVSS feasibility in community programmes. This study aimed to evaluate the feasibility of HIVSS in South Africa.

Methods

We conducted a prospective study that enrolled participants through mobile site, homebased, workplace and sex worker programmes in two townships from May to November 2017. Following an information session on HIVSS, interested participants were offered one of three methods of HIVSS testing: supervised, semi-supervised, and unsupervised. Participants who opted for unsupervised testing and those who tested HIV positive after semi- or supervised HIVSS were followed up telephonically or with a home visit one week after receipt of the test kit to confirm results and linkages to care. Follow-up visits were concluded when the participant indicated that they had used the kit or had accessed a confirmatory HIV test.

Results

Of the 2061 people approached, 88.2% (1818/2061) received HIV testing information. Of this group, 89% (1618/1818) were enrolled in the study and 70.0% (1133/1618) were tested for HIV with the kit. The median age was 28 (IQR:23–33) years with an even gender distribution. Of those enrolled, 43.0% (696/1618) were identified through homebased outreach, 42.5% (687/1618) through mobile sites, 7.3% (118/1618) at their workplace and 7.2% (117/1618) from sex worker programmes. A total of 68.7% (1110/1616) selected unsupervised HIVSS, whereas 6.3% (101/1616) opted for semi-supervised and 25.0% ((405/1616) chose supervised HIVSS. Overall, the HIV prevalence using the HIVSS test was 8.2% (93/1129). Of those newly diagnosed with HIV, 16% (12/75) were initiated on ART. Almost half (48.0%; 543/1131) of those tested were linked to a primary HIV test as follows: supervised (85.2%; 336/394); semi-supervised (93.8%; 91/97) and unsupervised (18.1%; 116/640).

Conclusion

Unsupervised HIVSS was by far the most selected and utilised HIVSS method. Linkages to primary and confirmatory testing for the unsupervised HIVSS and further care were low, despite home visits and telephonic reminders.

Being HIV positive and staying on antiretroviral therapy in Africa: A qualitative systematic review and theoretical model

BACKGROUND

Adherence to antiretroviral therapy (ART) and long-term uninterrupted engagement in HIV care is difficult for HIV-positive people, and randomized trials of specific techniques to promote adherence often show small or negligible effects. Understanding what influences decision-making in HIV-positive people in Africa may help researchers and policy makers in the development of broader, more effective interventions and policies.

METHODS

We used thematic synthesis and a grounded theory approach to generate a detailed narrative and theoretical model reflecting life with HIV in Africa, and how this influences ART adherence and engagement decisions. We included qualitative primary studies that explored perspectives, perceptions and experiences of HIV-positive people, caregivers and healthcare service providers. We searched databases from 1 January 2013 to 9 December 2016, screened all studies, and selected those for inclusion using purposeful sampling methods. Included studies were coded with Atlas.ti, and we assessed methodological quality across five domains.

RESULTS

We included 59 studies from Africa in the synthesis. Nine themes emerged which we grouped under three main headings. First, people who are HIV-positive live in a complicated world where they must navigate the challenges presented by poverty, competing priorities, unpredictable life events, social identity, gender norms, stigma, and medical pluralism-these influences can make initiating and maintaining ART difficult. Second, the health system is generally seen as punishing and uninviting and this can drive HIV-positive people out of care. Third, long-term engagement and adherence requires adaptation and incorporation of ART into daily life, a process which is facilitated by: inherent self-efficacy, social responsibilities, previous HIV-related illnesses and emotional, practical or financial support. These factors together can lead to a "tipping point", a point in time when patients choose to either engage or disengage from care. HIV-positive people may cycle in and out of these care states in response to fluctuations in influences over time.

CONCLUSION

This analysis provides a practical theory, arising from thematic synthesis of research, to help understand the dynamics of adherence to ART and engagement in HIV care. This can contribute to the design of service delivery approaches, and informed thinking and action on the part of policy makers, providers, and society: to understand what it is to be HIV-positive in Africa and how attitudes and the health service need to shift to help those with HIV lead 'normal' lives.

Being HIV positive and staying on antiretroviral therapy in Africa: A qualitative systematic review and theoretical model

BACKGROUND

Adherence to antiretroviral therapy (ART) and long-term uninterrupted engagement in HIV care is difficult for HIV-positive people, and randomized trials of specific techniques to promote adherence often show small or negligible effects. Understanding what influences decision-making in HIV-positive people in Africa may help researchers and policy makers in the development of broader, more effective interventions and policies.

METHODS

We used thematic synthesis and a grounded theory approach to generate a detailed narrative and theoretical model reflecting life with HIV in Africa, and how this influences ART adherence and engagement decisions. We included qualitative primary studies that explored perspectives, perceptions and experiences of HIV-positive people, caregivers and healthcare service providers. We searched databases from 1 January 2013 to 9 December 2016, screened all studies, and selected those for inclusion using purposeful sampling methods. Included studies were coded with Atlas.ti, and we assessed methodological quality across five domains.

RESULTS

We included 59 studies from Africa in the synthesis. Nine themes emerged which we grouped under three main headings. First, people who are HIV-positive live in a complicated world where they must navigate the challenges presented by poverty, competing priorities, unpredictable life events, social identity, gender norms, stigma, and medical pluralism-these influences can make initiating and maintaining ART difficult. Second, the health system is generally seen as punishing and uninviting and this can drive HIV-positive people out of care. Third, long-term engagement and adherence requires adaptation and incorporation of ART into daily life, a process which is facilitated by: inherent self-efficacy, social responsibilities, previous HIV-related illnesses and emotional, practical or financial support. These factors together can lead to a "tipping point", a point in time when patients choose to either engage or disengage from care. HIV-positive people may cycle in and out of these care states in response to fluctuations in influences over time.

CONCLUSION

This analysis provides a practical theory, arising from thematic synthesis of research, to help understand the dynamics of adherence to ART and engagement in HIV care. This can contribute to the design of service delivery approaches, and informed thinking and action on the part of policy makers, providers, and society: to understand what it is to be HIV-positive in Africa and how attitudes and the health service need to shift to help those with HIV lead 'normal' lives.

Preferences for linkage to HIV care services following a reactive self-test: discrete choice experiments in Malawi and Zambia

OBJECTIVES

The current research identifies key drivers of demand for linkage into care following a reactive HIV self-test result in Malawi and Zambia. Preferences are explored among the general population and key groups such as HIV-positive individuals and adolescents.

DESIGN

We used discrete choice experiments (DCEs) embedded in representative household surveys to quantify the relative strength of preferences for various HIV services characteristics.

METHODS

The DCE was designed on the basis of a literature review and qualitative studies. Data were collected within a survey (Malawi n = 553, Zambia n = 388), pooled across country and analysed using mixed logit models. Preference heterogeneity was explored by country, age, sex, wealth, HIV status and belief that HIV treatment is effective.

RESULTS

DCE results were largely consistent across countries. Major barriers for linkage were fee-based testing and long wait for testing. Community-based confirmatory testing, that is at the participant's or counsellor's home, was preferred to facility-based confirmation. Providing separated waiting areas for HIV services at health facilities and mobile clinics was positively viewed in Malawi but not in Zambia. Active support for linkage was less important to respondents than other attributes. Preference heterogeneity was identified: overall, adolescents were more willing to seek care than adults, whereas HIV-positive participants were more likely to link at health facilities with separate HIV services.

CONCLUSION

Populations in Malawi and in Zambia were responsive to low-cost, HIV care services with short waiting time provided either at the community or privately at health facilities. Hard-to-reach groups could be encouraged to link to care with targeted support.

What do we know about community-based health worker programs? A systematic review of existing reviews on community health workers

OBJECTIVE

To synthesize current understanding of how community-based health worker (CHW) programs can best be designed and operated in health systems.

METHODS

We searched 11 databases for review articles published between 1 January 2005 and 15 June 2017. Review articles on CHWs, defined as non-professional paid or volunteer health workers based in communities, with less than 2 years of training, were included. We assessed the methodological quality of the reviews according to AMSTAR criteria, and we report our findings based on PRISMA standards.

FINDINGS

We identified 122 reviews (75 systematic reviews, of which 34 are meta-analyses, and 47 non-systematic reviews). Eighty-three of the included reviews were from low- and middle-income countries, 29 were from high-income countries, and 10 were global. CHW programs included in these reviews are diverse in interventions provided, selection and training of CHWs, supervision, remuneration, and integration into the health system. Features that enable positive CHW program outcomes include community embeddedness (whereby community members have a sense of ownership of the program and positive relationships with the CHW), supportive supervision, continuous education, and adequate logistical support and supplies. Effective integration of CHW programs into health systems can bolster program sustainability and credibility, clarify CHW roles, and foster collaboration between CHWs and higher-level health system actors. We found gaps in the review evidence, including on the rights and needs of CHWs, on effective approaches to training and supervision, on CHWs as community change agents, and on the influence of health system decentralization, social accountability, and governance.

CONCLUSION

Evidence concerning CHW program effectiveness can help policymakers identify a range of options to consider. However, this evidence needs to be contextualized and adapted in different contexts to inform policy and practice. Advancing the evidence base with context-specific elements will be vital to helping these programs achieve their full potential.

Enhancing value and lowering costs of care: a qualitative exploration of a randomized linkage to care intervention in South Africa

While interventions to improve HIV linkage and retention in care exist, none have demonstrated results sufficient to reach UNAIDS 90-90-90 goals. We explored values and costs of seeking clinical care through testing three strategies to improve linkage to care: Point of care CD4 testing alone (POC-CD4), POC-CD4 combined with transportation support and combined with care facilitation. We conducted in-depth interviews with participants and transcribed audio-recordings of care facilitation sessions. Participants described values and costs enhanced or addressed by the three interventions. Psychosocial support provided through the care facilitation intervention appeared salient. Participants named other values and costs of seeking care unrelated to the intervention, such as encouragement from healthcare workers and aversion to lifelong treatment. Combined with the quantitative results of this trial, these findings may point to why the care facilitation arm was successful but not the POC-CD4 only or transportation arms. It also provides guidance for future interventions.

Experiences using and organizing HIV self-testing

OBJECTIVE

HIV self-testing (HIVST) is now officially recommended by the WHO, yet much of HIVST evidence to date has focused on quantitative data and hypothetical concerns. Effective scale-up of HIVST in diverse local contexts requires qualitative data from experiences using and organizing HIVST. This qualitative systematic review aims to appraise and synthesize research evidence on experiences using and organizing HIVST.

METHODS

We conducted a systematic search of seven primary literature databases, four gray literature sources, and reference lists reporting qualitative evidence on HIVST. Data extraction and thematic analysis were used to synthesize findings. Quality of studies was assessed using the Critical Appraisal Skills Programme tool. Confidence in review findings was evaluated using the Confidence in the Evidence from Reviews of Qualitative Research approach. The review protocol was registered (CRD42015027607).

RESULTS

From 1266 potential articles, we included 18. Four studies were conducted in low-income countries, three in middle-income countries, 10 in high-income countries, and one in multiple countries. Generally, HIVST increased capacity to reach priority populations and expanded opportunities for service delivery. Self-testing was preferred to facility-based testing due to increased convenience and confidentiality, especially among stigmatized populations. HIVST decreased test-associated stigma compared with facility-based testing. HIVST generally empowered people because it provided greater control over individual testing needs. At the same time, HIVST rarely allowed husbands to coerce their wives to test.

CONCLUSIONS

This review suggests that HIVST should be offered as an additional HIV testing option to expand testing and empower testers. Adapting national policies to incorporate HIVST will be necessary to guide scale-up.

Use of expenditure analysis to enhance returns on investments in HIV services

PURPOSE OF REVIEW

Globally, the response to the HIV epidemic is at a crisis point. International investments in the HIV response have been essentially flat for 8 years and domestic budgets in low and middle-income countries - still recovering from the global recession - have not been able to fill the resource gap to drive a full-fledged HIV response. Still, efficiencies and prioritization of evidence-based interventions enable a significant scale-up of treatment, but millions more people remain without treatment. This review looks at recent data and research to evaluate interventions that may help close gaps in service provision that undermine testing and treatment programs.

RECENT FINDINGS

The President's Emergency Plan for AIDS Relief recently began publicly releasing vast programmatic and expenditure data. These data reveal potential efficiency gaps in testing and treatment programs, particularly in the area of linkage and retention. Interventions such as HIV self-testing have been proposed to help, but whether they can deliver better results remains unclear. Same-day initiation on treatment improves initiation, retention, and viral suppression rates.

SUMMARY

Near real-time analysis of data and active response is critical in improving efficiencies in programs. More investment in implementation research is necessary to improve linkage to care and treatment to reach 90-90-90 goals.

Linkage between HIV diagnosis and care: Understanding the role of gender in a Northern Province in Vietnam

Early linkage to HIV care is associated significantly with improved patient outcomes and reduced the risk of HIV transmission. However, delays between HIV diagnosis and registering for care have prevailed in Vietnam. The aim of researchers in this study is to examine linkages to care for individuals newly diagnosed with HIV in 2014, especially to highlight the impact of gender upon these linkages in a Northern Province of Ninh Binh. We collected secondary data of all 125 eligible HIV positive people diagnosed in 2014 and conducted a gender-based descriptive analysis of their registration to care within 6 months. Nineteen in-depth interviews and two focus group discussions were completed. We found that women accounted for one-third of newly diagnosed cases (42/125), but initiated HIV treatment at an earlier stage of HIV disease than men (65% women at stage 1, 2 versus 31% in men). Stigma and discrimination was greater among women while inadequate awareness of treatment was greater for men. Dissatisfaction with HIV testing and counseling and no or passive referral to treatment were other barriers for both the genders for enrolling in care services after diagnosis.

The scope and impact of mobile health clinics in the United States: a literature review

As the U.S. healthcare system transforms its care delivery model to increase healthcare accessibility and improve health outcomes, it is undergoing changes in the context of ever-increasing chronic disease burdens and healthcare costs. Many illnesses disproportionately affect certain populations, due to disparities in healthcare access and social determinants of health. These disparities represent a key area to target in order to better our nation's overall health and decrease healthcare expenditures. It is thus imperative for policymakers and health professionals to develop innovative interventions that sustainably manage chronic diseases, promote preventative health, and improve outcomes among communities disenfranchised from traditional healthcare as well as among the general population. This article examines the available literature on Mobile Health Clinics (MHCs) and the role that they currently play in the U.S. healthcare system. Based on a search in the PubMed database and data from the online collaborative research network of mobile clinics MobileHealthMap.org , the authors evaluated 51 articles with evidence on the strengths and weaknesses of the mobile health sector in the United States. Current literature supports that MHCs are successful in reaching vulnerable populations, by delivering services directly at the curbside in communities of need and flexibly adapting their services based on the changing needs of the target community. As a link between clinical and community settings, MHCs address both medical and social determinants of health, tackling health issues on a community-wide level. Furthermore, evidence suggest that MHCs produce significant cost savings and represent a cost-effective care delivery model that improves health outcomes in underserved groups. Even though MHCs can fulfill many goals and mandates in alignment with our national priorities and have the potential to help combat some of the largest healthcare challenges of this era, there are limitations and challenges to this healthcare delivery model that must be addressed and overcome before they can be more broadly integrated into our healthcare system.

Optimizing linkage to care and initiation and retention on treatment of adolescents with newly diagnosed HIV infection

OBJECTIVE

Unsuccessful linkage to care and treatment increases adolescent HIV-related morbidity and mortality. This study evaluated the effect of a novel adolescent and youth Red Carpet Program (RCP) on the timing and outcomes of linkage to care.

DESIGN

A prepost implementation evaluation of the pilot RCP program.

SETTINGS

Healthcare facilities (HCFs) and schools in Homa Bay County, Kenya.

STUDY PARTICIPANTS

HIV-infected adolescents (15-19 years) and youth (20-21 years).

INTERVENTIONS

RCP provided fast-track peer-navigated services, peer counseling, and psychosocial support at HCFs and schools in six Homa Bay subcounties in 2016. RCP training and sensitization was implemented in 50 HCFs and 25 boarding schools.

MAIN OUTCOME MEASURES

New adolescent and youth HIV diagnosis, linkage to and retention in care and treatment.

RESULTS

Within 6 months of program rollout, 559 adolescents and youths (481 women; 78 men) were newly diagnosed with HIV (15-19 years n = 277; 20-21 years, n = 282). The majority (n = 544; 97.3%) were linked to care, compared to 56.5% at preimplementation (P < 0.001). All (100.0%; n = 559) adolescents and youths received peer counseling and psychosocial support, and the majority (n = 430; 79.0%) were initiated on treatment. Compared to preimplementation, the proportion of adolescents and youths who were retained on treatment increased from 66.0 to 90.0% at 3 months (P < 0.001), and from 54.4 to 98.6% at 6 months (P < 0.001).

CONCLUSION

Implementation of RCP was associated with significant improvement in linkage to and early retention in care among adolescent and youth. The ongoing study will fully assess the efficacy of this linkage-to-care approach.

Integrated opioid substitution therapy and HIV care: a qualitative systematic review and synthesis of client and provider experiences

People who use drugs in many contexts have limited access to opioid substitution therapy and HIV care. Service integration is one strategy identified to support increased access. We reviewed and synthesized literature exploring client and provider experiences of integrated opioid substitution therapy and HIV care to identify acceptable approaches to care delivery. We systematically reviewed qualitative literature. We searched nine bibliographic databases, supplemented by manual searches of reference lists of articles from the database search, relevant journals, conferences, key organizations and consultation with experts. Thematic synthesis was used to develop descriptive themes in client and provider experiences. The search yielded 11 articles for inclusion, along with 8 expert and policy reports. We identify five descriptive themes: the convenience and comprehensive nature of co-located care, contrasting care philosophies and their role in shaping integration, the limits to disclosure and communication between clients and providers, opioid substitution therapy enabling HIV care access and engagement, and health system challenges to delivering integrated services. The discussion explores how integrated opioid substitution therapy and HIV care needs to adapt to specific social conditions, rather than following universal approaches. We identify priorities for future research. Acceptable integrated opioid substitution therapy and HIV care for people who use drugs and providers is most likely through co-located care and relies upon attention to stigma, supportive relationships and client centred cultures of delivery. Further research is needed to understand experiences of integrated care, particularly delivery in low and middle income settings and models of care focused on community and non-clinic based delivery.

Enhancing Public Health HIV Interventions: A Qualitative Meta-Synthesis and Systematic Review of Studies to Improve Linkage to Care, Adherence, and Retention

Although HIV services are expanding, few have reached the scale necessary to support universal viral suppression of individuals living with HIV. The purpose of this systematic review was to summarize the qualitative evidence evaluating public health HIV interventions to enhance linkage to care, antiretroviral drug (ARV) adherence, and retention in care. We searched 19 databases without language restrictions. The review collated data from three separate qualitative evidence reviews addressing each of the three outcomes along the care continuum. 21,738 citations were identified and 24 studies were included in the evidence review. Among low and middle-income countries in Africa, men living with HIV had decreased engagement in interventions compared to women and this lack of engagement among men also influenced the willingness of their partners to engage in services. Four structural issues (poverty, unstable housing, food insecurity, lack of transportation) mediated the feasibility and acceptability of public health HIV interventions. Individuals living with HIV identified unmet mental health needs that interfered with their ability to access HIV services. Persistent social and cultural factors contribute to disparities in HIV outcomes across the continuum of care, shaping the context of service delivery among important subpopulations.

Traditional health practitioners' management of HIV/AIDS in rural South Africa in the era of widespread antiretroviral therapy

BACKGROUND

Traditional health practitioners (THPs) have been identified as a key local resource in the fight against human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) in South Africa. However, their approaches to the treatment of people living with HIV (PLHIV) have been met with scepticism by some biomedical practitioners amid increasing access to antiretroviral therapy (ART).

OBJECTIVE

In light of this ambivalence, this study aims to document and identify treatment approaches of THPs to the management of illness among PLHIV in the current era of widespread access to ART.

METHODS

The study was conducted as part of a larger trial of Treatment as Prevention (TasP) in rural northern Kwa-Zulu Natal, intended to treat PLHIV regardless of CD4 count. Nine THPs were enrolled using purposive and snowballing techniques. Repeat group discussions, triangulated with community walks and photovoice techniques, were conducted. A thematic analysis approach was used to analyse the data.

RESULTS

Eight of the nine THPs had received training in biomedical aspects of HIV. THPs showed a multilayered decision-making process in managing illness among PLHIV, influenced by the attributes and choices of the THPs. THPs assessed and managed illness among PLHIV based on THP training in HIV/AIDS, THP type, as well as knowledge and experience in the traditional healing practice. Management of illness depended on the patients' report of their HIV status or willingness to test for HIV.

CONCLUSIONS

THPs' approaches to illness in PLHIV appear to be shifting in light of increasing exposure to HIV/AIDS-related information. Importantly, disclosure of HIV status plays a major role in THPs' management of illness among PLHIV, as well as linkage to HIV testing and care for their patients. Therefore, THPs can potentially enhance the success of ART for PLHIV when HIV status is known.

Barriers and facilitators of interventions for improving antiretroviral therapy adherence: a systematic review of global qualitative evidence

INTRODUCTION

Qualitative research on antiretroviral therapy (ART) adherence interventions can provide a deeper understanding of intervention facilitators and barriers. This systematic review aims to synthesize qualitative evidence of interventions for improving ART adherence and to inform patient-centred policymaking.

METHODS

We searched 19 databases to identify studies presenting primary qualitative data on the experiences, attitudes and acceptability of interventions to improve ART adherence among PLHIV and treatment providers. We used thematic synthesis to synthesize qualitative evidence and the CERQual (Confidence in the Evidence from Reviews of Qualitative Research) approach to assess the confidence of review findings.

RESULTS

Of 2982 references identified, a total of 31 studies from 17 countries were included. Twelve studies were conducted in high-income countries, 13 in middle-income countries and six in low-income countries. Study populations focused on adults living with HIV (21 studies, n=1025), children living with HIV (two studies, n=46), adolescents living with HIV (four studies, n=70) and pregnant women living with HIV (one study, n=79). Twenty-three studies examined PLHIV perspectives and 13 studies examined healthcare provider perspectives. We identified six themes related to types of interventions, including task shifting, education, mobile phone text messaging, directly observed therapy, medical professional outreach and complex interventions. We also identified five cross-cutting themes, including strengthening social relationships, ensuring confidentiality, empowerment of PLHIV, compensation and integrating religious beliefs into interventions. Our qualitative evidence suggests that strengthening PLHIV social relationships, PLHIV empowerment and developing culturally appropriate interventions may facilitate adherence interventions. Our study indicates that potential barriers are inadequate training and compensation for lay health workers and inadvertent disclosure of serostatus by participating in the intervention.

CONCLUSIONS

Our study evaluated adherence interventions based on qualitative data from PLHIV and health providers. The study underlines the importance of incorporating social and cultural factors into the design and implementation of interventions. Further qualitative research is needed to evaluate ART adherence interventions.