What are the essential components of HIV treatment and care services in low and middle-income countries: an overview by settings and levels of the health system?

"If it weren't for my traditional healer, I would be dead": Engaging traditional healers to support people living with HIV in rural Mozambique

Across rural sub-Saharan Africa, people living with HIV (PLHIV) commonly seek out treatment from traditional healers. We report on the clinical outcomes of a community health worker intervention adapted for traditional healers with insight into our results from qualitative interviews. We employed a pre-post intervention study design and used sequential mixed methods to assess the impact of a traditional healer support worker intervention in Zambézia province, Mozambique. After receiving a positive test result, 276 participants who were newly enrolled in HIV treatment and were interested in receiving home-based support from a traditional healer were recruited into the study. Those who enrolled from February 2016 to August 2016 received standard of care services, while those who enrolled from June 2017 to May 2018 received support from a traditional healer. We conducted interviews among healers and participants to gain insight into fidelity of study activities, barriers to support, and program improvement. Medication possession ratio at home (based on pharmacy pick-up dates) was not significantly different between pre- and post-intervention participants (0.80 in the pre-intervention group compared to 0.79 in the post-intervention group; p = 0.96). Participants reported receiving educational and psychosocial support from healers. Healers adapted their support protocol to initiate directly observed therapy among participants with poor adherence. Traditional healers can provide community-based psychosocial support, education, directly observed therapy, and disclosure assistance for PLHIV. Multiple factors may hinder patients' desire and ability to remain adherent to treatment, including poverty, confusion about medication side effects, and frustration with wait times at the health facility.

Differences in prevalence and risk factors of non-communicable diseases between young people living with HIV (YLWH) and young general population in Cambodia

Understanding non-communicable diseases (NCDs) among young people living with HIV (YLWH) is critical given the potential for aging-associated comorbidities resulting from HIV, especially in Cambodia where such data are limited. Therefore, we examined the prevalence and correlates of NCDs in YLWH and compared it to a nationally representative sample of young people not otherwise infected. We collected data from a sample of 370 YLWH aged 18-29 years attending three HIV clinics in Cambodia between 2019 and 2020. Our comparison group were 486 young people who participated in the Ministry of Health/WHO 2016 Noncommunicable Disease Risk Factor Surveillance (STEP survey). Both surveys used a standardized questionnaire to collect information on lifestyle factors and World Health Organization protocols for physical and biochemical measurements. We compared the prevalence of diabetes, hypertension, and high cholesterolemia between the two groups and examined the relationship between these conditions and HIV. We found 16 (4%), 22 (6%), and 72 (20%) had diabetes, hypertension, and high cholesterolemia, respectively, among YLWH, compared to 4 (1%), 22 (4%), and 49 (11%) among the general population. In logistic regression, YLWH were at higher odds of diabetes/prediabetes and high cholesterolemia compared with the young general population, aOR = 6.64 (95% CI 3.62-12.19) and aOR = 7.95 (95% CI 3.98-15.87), respectively. Our findings demonstrate that YLWH in Cambodia face multiple metabolic disorders and NCDs despite their young age and that accessible screening measures and treatment for these conditions are needed in order to combat NCDs in the future.

"I don't know when he will be back": life-changing events challenge the community ART Group model- a qualitative research study, Tete, Mozambique

Background

Since 2008 in Mozambique, patients stable on antiretroviral therapy (ART) can join Community ART Groups (CAG), peer groups in which members are involved in adherence support and community ART delivery. More than 10 years after the implementation of the first CAGs, we study how changes in circumstance and daily life events of CAG members have affected the CAG dynamic.

Methods

A qualitative study using individual in-depth interviews (27) and focus group discussions (8) with CAG members and health care providers was carried out in Tete province, rural Mozambique. Purposive sampling was used to select participants. Data were transcribed and translated, and manual thematic analysis carried out to identify codes, which were then categorized in sub-themes and themes.

Results

Data were collected from 61 CAG members and 18 health-care providers in 2017. The CAG dynamic was affected by life events and changing circumstances including a loss of geographical proximity or a change in social relationships. Family CAGs facilitated reporting and ART distribution, but conflict between CAG members meant some CAGs ceased to function. In some CAGs, the dynamic changed as pill counts were not carried out, members met less frequently or stopped meeting entirely. Some members did not collect ART at the facility when it was their turn, and others stopped taking ART completely. Health care providers were reported to push people living with HIV to join CAGs, instead of allowing voluntary participation. Some CAGs responded to adherence challenges by strengthening peer support through counselling and observed pill intake. Health-care providers agreed that strengthening CAG rules and membership criteria could help to overcome the identified problems.

Conclusions

Changing life circumstances, changes in relationships and a lack of participation by CAG members altered the CAG dynamic, which sometimes affected adherence. Some CAGs responded to challenges by intensifying peer support, including to those diagnosed with virological failure. To ensure flexible implementation and modification of CAGs to the inevitable changes in life circumstances of its members, feedback mechanisms should be implemented between CAG members and the health-care providers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12087-8.

A comparative analysis of cervical cancer prevention between Nigeria and Nordic countries that have experienced a decline in cervical cancer incidence

BACKGROUND

A modelling analysis carried out in 2014 suggested that, without cervical cancer screening programmes, the incidence of cervical cancer in Denmark, Finland, Norway and Sweden would have been as high as that in some low- and middle-income countries. We compare programme strategies between Nigeria and these Nordic countries and develop translatable recommendations.

METHODS

A literature review using a systematic approach through Medline, Popline, Global Health, CINAHL PLUS, Cochrane Library, EMBASE, Google Scholar, Africa Wide and WHO databases was conducted.

RESULTS

Fifteen journal articles and two grey literature reports met our criteria. Six descriptive studies from Nigeria noted that services in Nigeria were mainly provided in urban secondary/tertiary facilities and that uptake was low even where screening was free. Trials in Nigeria and Sweden noted that subsidies and free programmes alone did not improve uptake; a Danish trial demonstrated that reminders and invitations issued by general practitioners improved participation.

CONCLUSION

Free screening programmes are important but should also consider incentivisation of treatment when needed and demand creation among health workers. Additionally, effective monitoring and evaluation of programme data are key to improving and maintaining quality. More broadly, we suggest that Nigeria can build success through stakeholder-led implementation of well-defined policies with national consensus to ensure coordination and sustainability.

Growing up HIV-positive in Uganda: "psychological immunodeficiency"? A qualitative study

BACKGROUND

This study is part of a longitudinal study among children and adolescents with HIV in both urban and rural Uganda: 'Mental health among HIV infected CHildren and Adolescents in KAmpala and Masaka, Uganda (CHAKA)'.

METHOD

The study is constructed of both quantitative and qualitative components. In this article we report a qualitative study on the experiences of 21 adolescents (twelve to seventeen years) living with HIV in Uganda. The purpose of the study was to investigate both the protective and the risk factors in HIV-infected adolescents' care environment in order to understand what might contribute to negative outcomes and what might provide a protective buffer against harmful life events. Semi-structured interviews with vignettes about mental disorders were employed and a phenomenological analysis was done.

RESULTS

The findings uncovered that the adolescents' families were mostly characterized by instability and diffuse relationships that provided an insecure basis for secure attachment and emotional support. Even in stable and secure family environments, there was no guarantee for getting sufficient emotional support in order to develop a positive self-concept due to the fate being the only infected child in the family. Both secure attachment and positive self-concept are known psychological protective mechanisms that provide the individual with resilience. The adolescents in this study seemed hampered in the development of protective mechanisms and consequently seemed psychologically vulnerable and badly equipped for coping with challenges, which paves the way for the possible development of mental disorders.

CONCLUSION

To change the focus towards strengthening the children and adolescents' development of psychological protective mechanisms implicates a change in focus from illness to health and has consequences for both treatment and prevention. Psychological health promotion must be systemic and aim at strengthening the family environment, but also to establish peer group support.

Trends in task shifting in HIV treatment in Africa: Effectiveness, challenges and acceptability to the health professions

BACKGROUND

Task shifting has been suggested to meet the demand for initiating and managing more patients on antiretroviral therapy. Although the idea of task shifting is not new, it acquires new relevance in the context of current healthcare delivery.

AIM

To appraise current trends in task shifting related to HIV treatment programmes in order to evaluate evidence related to the effectiveness of this strategy in addressing human resource constraints and improving patient outcomes, challenges identified in practice and the acceptability of this strategy to the health professions.

METHOD

Electronic databases were searched for studies published in English between January 2009 and December 2014. Keywords such as 'task shifting', 'HIV treatment', 'human resources' and 'health professions' were used.

RESULTS

Evidence suggests that task shifting is an effective strategy for addressing human resource constraints in healthcare systems in many countries and provides a cost-effective approach without compromising patient outcomes. Challenges include inadequate supervision support and mentoring, absent regulatory frameworks, a lack of general health system strengthening and the need for monitoring and evaluation. The strategy generally seems to be accepted by the health professions although several arguments against task shifting as a long-term approach have been raised.

CONCLUSION

Task shifting occurs in many settings other than HIV treatment programmes and is viewed as a key strategy for governing human resources for healthcare. It may be an opportune time to review current task shifting recommendations to include a wider range of programmes and incorporate initiatives to address current challenges.

Severe morbidity after antiretroviral (ART) initiation: active surveillance in HIV care programs, the IeDEA West Africa collaboration

Background

The causes of severe morbidity in health facilities implementing Antiretroviral Treatment (ART) programmes are poorly documented in sub-Saharan Africa. We aimed to describe severe morbidity among HIV-infected patients after ART initiation, based on data from an active surveillance system established within a network of specialized care facilities in West African cities.

Methods

Within the International epidemiological Database to Evaluate AIDS (IeDEA) - West Africa collaboration, we conducted a prospective, multicenter data collection that involved two facilities in Abidjan, Côte d’Ivoire and one in Cotonou, Benin. Among HIV-infected adults receiving ART, events were recorded using a standardized form. A simple case-definition of severe morbidity (death, hospitalization, fever > 38°5C, Karnofsky index < 70%) was used at any patient contact point. Then a physician confirmed and classified the event as WHO stage 3 or 4 according to the WHO clinical classification or as degree 3 or 4 of the ANRS scale.

Results

From December 2009 to December 2011, 978 adults (71% women, median age 39 years) presented with 1449 severe events. The main diagnoses were: non-AIDS-defining infections (33%), AIDS-defining illnesses (33%), suspected adverse drug reactions (7%), other illnesses (4%) and syndromic diagnoses (16%). The most common specific diagnoses were: malaria (25%), pneumonia (13%) and tuberculosis (8%). The diagnoses were reported as syndromic in one out of five events recorded during this study.

Conclusions

This study highlights the ongoing importance of conventional infectious diseases among severe morbid events occurring in patients on ART in ambulatory HIV care facilities in West Africa. Meanwhile, additional studies are needed due to the undiagnosed aspect of severe morbidity in substantial proportion.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-015-0910-3) contains supplementary material, which is available to authorized users.

Review of the Umthombo Youth Development Foundation scholarship scheme, 1999-2013

Introduction

Staffing of rural and remote facilities is a challenge throughout the world. Umthombo Youth Development Foundation (UYDF) has been running a rurally based scholarship scheme since 1999. The aim of this review is to present data on the number of students selected, their progress, graduation and work placement from inception of the scheme until 2013.

Methods

Data were extracted from the UYDF data base using a data collection template to ensure all important information was captured.

Results

Since 1999, 430 rural students across 15 health disciplines have been supported by UYDF. The annual pass rate has been greater than 89%, and less than 10% of students have been excluded from university. All graduates have spent time working in rural areas (excluding the 32 currently doing internships) and 72% (52/73) of those with no work-back obligation continue to work in rural areas.

Discussion and conclusion

The UYDF model is built around local selection, compulsory academic and peer mentoring and social support, comprehensive financial support and experiential holiday work. The results are encouraging and highlight the fact that rural students can succeed at university and will come back and work in rural areas. With 46% of the South African population situated rurally, greater thought and effort must be put into the recruitment and training of rural scholars as a possible solution to the staffing of rural healthcare facilities. The UYDF provides a model which could be replicated in other parts of South Africa.

Commonization of HIV/AIDS services in Nigeria: the need, the processes and the prospects

INTRODUCTION

With the first case of Human Immunodeficiency Virus infection/Acquired Immunodeficiency Syndrome (HIV/AIDS) identified in 1986, the management of HIV/AIDS in Nigeria has evolved through the years. The emergency phase of the HIV/AIDS program, aimed at containing the HIV/AIDS epidemic within a short time frame, was carried out by international agencies that built structures separate from hospitals' programs. It is imperative that Nigeria shifts from the previous paradigm to the concept of Commonization of HIV to achieve sustainability. Commonization ensures that HIV/AIDS is seen as a health condition like others. It involves making HIV services available at all levels of healthcare.

METHODS

Excellence & Friends Management Consult (EFMC) undertook this process by conducting HIV tests in people's homes and work places, referring infected persons for treatment and follow up, establishing multiple HIV testing points and HIV services in private and public primary healthcare facilities. EFMC integrated HIV services within existing hospital care structures and trained all healthcare workers at all supported sites on HIV/AIDS prevention, care and treatment modalities.

RESULTS

Commonization has improved the uptake of HIV testing and counseling and enrolment into HIV care as more people are aware that HIV services are available. It has integrated HIV services into general hospital services and minimized the cost of HIV programming as the existing structures and personnel in healthcare facilities are utilized for HIV services.

CONCLUSION

Commonization of HIV services i.e. integrating HIV care into the existing fabric of the healthcare system, is highly recommended for a sustainable and efficient healthcare system as it makes HIV services acceptable by all.

Survival of AIDS patients in Sao Paulo-Brazil in the pre- and post-HAART eras: a cohort study

BACKGROUND

Brazil was the first middle-income country to provide free and universal access to AIDS treatment. Understanding the impact of this policy is key to promote ongoing improvement of current intervention strategies. The aim of this study was to compare mortality rates and survival in a cohort of AIDS patients before and after the introduction of antiretrovirals (ARV) and to investigate predictors of survival.

METHODS

A retrospective cohort study of AIDS patients aged 13 years or more living in the city of Sao Paulo was conducted. All patients were recruited from an STD/HIV outpatient clinic between 1988 and 2003 and followed up until 2005. We estimated AIDS mortality rates in person-years (py) and carried out a survival analysis using the Kaplan-Meier method. The Cox proportional hazards model was used to assess predictors of survival in AIDS patients.

RESULTS

The study cohort comprised 6,594 patients. The yearly mean mortality rates were 17.6, 23.2, and 7.8 per 1,000 py for the study periods 1988-1993, 1994-1996, and 1997-2003, respectively. Median survival time was 13.4 and 22.3 months for patients entering the study in the first and second study periods and survival time was 108 months or more in 72% of those entering the study during 1997-2003. Factors independently associated with shorter survival included: AIDS diagnosis during the 1994-1996 (HR 2.0) and 1988-1993 (HR 3.2) periods; 50 years of age or more (HR 2.0); exposure category of injection drug users (IDU) (HR 1.5); 8 years of schooling or less (HR 1.4); no schooling (HR 2.1); and CD4+ counts between 350 and 500 cells/mm(3) (HR 1.2) and less than 350 cells/mm(3) at AIDS diagnosis (HR 1.3).

CONCLUSIONS

The study showed a strong impact following the introduction of HAART in 1996 with decreased AIDS mortality, increased survival rates, and benefits with early introduction of HAART. However, some groups of patients were less likely to benefit from the new drug regimens. Public policies promoting health equity create an enabling environment helping AIDS control programs in developing countries to achieve their goals as effectively as in developed countries.

HIV, tuberculosis, and noncommunicable diseases: what is known about the costs, effects, and cost-effectiveness of integrated care?

Unprecedented investments in health systems in low- and middle-income countries (LMICs) have resulted in more than 8 million individuals on antiretroviral therapy. Such individuals experience dramatically increased survival but are increasingly at risk of developing common noncommunicable diseases (NCDs). Integrating clinical care for HIV, other infectious diseases, and NCDs could make health services more effective and provide greater value. Cost-effectiveness analysis is a method to evaluate the clinical benefits and costs associated with different health care interventions and offers guidance for prioritization of investments and scale-up, especially as resources are increasingly constrained. We first examine tuberculosis and HIV as 1 example of integrated care already successfully implemented in several LMICs; we then review the published literature regarding cervical cancer and depression as 2 examples of NCDs for which integrating care with HIV services could offer excellent value. Direct evidence of the benefits of integrated services generally remains scarce; however, data suggest that improved effectiveness and reduced costs may be attained by integrating additional services with existing HIV clinical care. Further investigation into clinical outcomes and costs of care for NCDs among people living with HIV in LMICs will help to prioritize specific health care services by contributing to an understanding of the affordability and implementation of an integrated approach.

Integrating HIV care and treatment into primary healthcare: are clinics equipped?

BACKGROUND

The demand for HIV care and treatment services is increasing rapidly and strategies to sustain long-term care should be employed. The decentralisation and integration of HIV care and treatment services into primary healthcare (PHC) is vitally important in order to ensure optimal access to life-saving antiretroviral therapy and ongoing chronic care. Conversely, the PHC system is fraught with the current burden of disease.

SETTING

The study was conducted in PHC clinics in the uMgungundlovu district, Kwa-Zulu Natal.

AIM

The objectives of the study were to assess whether PHC clinics were equipped to deliver integrated HIV services and to evaluate the availability of resources as well as support systems for HIV care and treatment in PHC clinics.

METHODS

A quantitative, cross-sectional descriptive study was undertaken in 20 randomly-selected, eligible clinics in the uMgungundlovu district, KwaZulu-Natal, South Africa. An evaluation instrument was completed through observations and review of the clinic data records. Criteria were based on the World Health Organization's guide to indicators for antiretroviral programmes as well as South African HIV standards for PHC facilities.

RESULTS

None of the clinics were equipped adequately. Clinics with a higher patient load had poorer scores, whilst clinics providing antiretroviral therapy were better equipped in terms of human resources and infrastructure.

CONCLUSION

HIV services are an essential part of primary healthcare and clinics need to be equipped adequately in order to render this service. It is unlikely that the over-burdened health system would be able to cope with an increased number of patients on antiretroviral therapy in the long term, whilst maintaining quality of services, without support being given to PHC clinics.

Clinical evaluation of a low cost, in-house developed real-time RT-PCR human immunodeficiency virus type 1 (HIV-1) quantitation assay for HIV-1 infected patients

OBJECTIVES

HIV-1 viral quantitation is essential for treatment monitoring. An in-house assay would decrease financial barriers to access.

MATERIALS AND METHODS

A real-time competitive RT-PCR in house assay (Sing-IH) was developed in Singapore. Using HXB2 as reference, the assay's primers and probes were designed to generate a 183-bp product that overlaps a portion of the LTR region and gag region. A competitive internal control (IC) was included in each assay to monitor false negative results due to inhibition or human error. Clinical evaluation was performed on 249 HIV-1 positive patient samples in comparison with the commercially available Generic HIV Viral Load assay. Correlation and agreement of results were assessed for plasma HIV-1 quantification with both assays.

RESULTS

The assay has a lower limit of detection equivalent to 126 copies/mL of HIV-1 RNA and a linear range of detection from 100-1000000 copies/mL. Comparative analysis with reference to the Generic assay demonstrated good agreement between both assays with a mean difference of 0.22 log10 copies/mL and 98.8% of values within 1 log10 copies/mL range. Furthermore, the Sing-IH assay can quantify HIV-1 group M subtypes A-H and group N isolates adequately, making it highly suitable for our region, where subtype B and CRF01_AE predominate.

CONCLUSIONS

With a significantly lower running cost compared to commercially available assays, the broadly sensitive Sing-IH assay could help to overcome the cost barriers and serve as a useful addition to the currently limited HIV viral load assay options for resource-limited settings.

An expanded behavioral paradigm for prevention and treatment of HIV-1 infection

This article addresses behavioral and social research priorities for prevention and treatment of HIV-1 infection. The approach used to define these priorities is based on 3 premises: (1) Behavioral interventions for prevention and treatment are necessary but not sufficient for producing reductions in transmission or advances in treatment; the same is true of biomedical interventions, and by themselves, they cannot maximally impact the health of communities. (2) Combination prevention and treatment strategies should include optimal combinations of behavioral and biomedical strategies but also must include the varieties of the behaviors of individuals, communities, and systems needed to ensure effective treatment and prevention. (3) And it is no longer useful, given scientific advances in understanding how treatment contributes to prevention, to discuss prevention without incorporating treatment and vice versa. This redefinition of behavioral approaches in combination prevention and treatment provides a new paradigm for defining behavioral research in HIV-1 disease. No longer is it sufficient to focus on single behavior (eg, high-risk sexual behavior, adherence to antiretroviral medications) of individuals in a vertical way. Rather, the behavioral agenda not only need to expand to encompass traditional investigations of single behaviors but also need to include the behavior of many actors and systems that are essential in facilitating reductions in transmission and improvements in treatment outcomes. In addition, there is the need for expanded implementation research agenda to encompass the study of methods to achieve high coverage, acceptability, and effectiveness of available menu of interventions.

Financing HIV programming: how much should low- and middle-income countries and their donors pay?

Global HIV control funding falls short of need. To maximize health outcomes, it is critical that national governments sustain reasonable commitments, and that international donor assistance be distributed according to country needs and funding gaps. We develop a country classification framework in terms of actual versus expected national domestic funding, considering resource needs and donor financing. With UNAIDS and World Bank data, we examine domestic and donor HIV program funding in relation to need in 84 low- and middle-income countries. We estimate expected domestic contributions per person living with HIV (PLWH) as a function of per capita income, relative size of the health sector, and per capita foreign debt service. Countries are categorized according to levels of actual versus expected domestic contributions, and resource gap. Compared to national resource needs (UNAIDS Investment Framework), we identify imbalances among countries in actual versus expected domestic and donor contributions: 17 countries, with relatively high HIV prevalence and GNI per capita, have domestic funding below expected (median per PLWH $143 and $376, respectively), yet total available funding including from donors would exceed the need ($368 and $305, respectively) if domestic contribution equaled expected. Conversely, 27 countries have actual domestic funding above the expected (medians $294 and $149) but total (domestic+donor) funding does not meet estimated need ($685 and $1,173). Across the 84 countries, in 2009, estimated resource need totaled $10.3 billion, actual domestic contributions $5.1 billion and actual donor contributions $3.7 billion. If domestic contributions would increase to the expected level in countries where the actual was below expected, total domestic contributions would increase to $7.4 billion, turning a funding gap of $1.5 billion into a surplus of $0.8 billion. Even with imperfect funding and resource-need data, the proposed country classification could help improve coherence and efficiency in domestic and international allocations.