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Font H, Rollins N, Essajee S, Becquet R, Foster G, Mangwiro AZ, Mwapasa V, Oyeledun B, Phiri S, Sam-Agudu NA, Bellare NB, Orne-Gliemann J. Retention-in-care in the PMTCT cascade: definitions matter! Analyses from the INSPIRE projects in Malawi, Nigeria and Zimbabwe. J Int AIDS Soc 2021; 23:e25609. [PMID: 33030306 PMCID: PMC7543052 DOI: 10.1002/jia2.25609] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 07/08/2020] [Accepted: 07/15/2020] [Indexed: 11/30/2022] Open
Abstract
Introduction Definitions of retention‐in‐care in Prevention of Mother‐to‐Child Transmission of HIV (PMTCT) vary substantially between studies and programmes. Some definitions are based on visits missed/made, others on a minimum total number of visits, or attendance at a final clinic visit at a specific time. An agreed definition could contribute to developing evidence‐based interventions for improving retention‐in‐care. In this paper, we estimated retention‐in‐care rates according to different definitions, and we quantified and visualized the degree of agreement between definitions. Methods We calculated retention in care rates using nine definitions in the six INSPIRE PMTCT intervention studies, conducted in three sub‐Saharan African countries between 2013 and 2017. With data from one of the studies (E4E), we estimated the agreement between definitions using Gwet’s agreement coefficient (AC1) and concordance. We calculated positive predictive values (PPV) and negative predictive values (NPV) for all definitions considering successively each definition as the reference standard. Finally, we used a Multiple Correspondence Analysis (MCA) to examine clustering of the way different definitions handle retention‐in‐care. Results Retention‐in‐care rates among 5107 women ranged from 30% to 76% in the complete dataset with Gwet’s AC1 being 0.56 [0.53; 0.59] indicating a moderate agreement between all definitions together. Two pairs of definitions with high inner concordance and agreement had either very high PPV or very high NPV, and appeared distinct from the other five definitions on the MCA figures. These pairs of definitions were also the ones resulting in the lowest and highest estimates of retention‐in‐care. The simplest definition, that only required a final clinic visit to classify women as retained in care, and classified 55% of women as retained in care, had a PPV ranging from 0.7 to 1 and a NPV ranging from 0.69 to 0.98 when excluding the two pairs afore‐mentioned; it resulted in a moderate to substantial agreement and a 70% to 90% concordance with all other definitions. Conclusions Our study highlights the variability of definitions in estimating retention‐in‐care. Some definitions are very stringent which may be required in some instances. A simple indicator such as attendance at a single time point may be sufficient for programme planning and evaluation.
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Affiliation(s)
- Helene Font
- ISPED, Inserm, Bordeaux Population Health Research Center, UMR 1219, University of Bordeaux, Bordeaux, France
| | - Nigel Rollins
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | | | - Renaud Becquet
- ISPED, Inserm, Bordeaux Population Health Research Center, UMR 1219, University of Bordeaux, Bordeaux, France
| | - Geoff Foster
- Family AIDS Caring Trust, World Health Organization, Mutare, Zimbabwe
| | | | - Victor Mwapasa
- Department of Public Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | | | - Sam Phiri
- Lighthouse Trust, Lilongwe, Malawi.,Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA.,Department of Public Health, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Lilongwe, Malawi
| | - Nadia A Sam-Agudu
- International Research Center of Excellence, Institute of Human Virology Nigeria, Abuja, Nigeria.,Division of Epidemiology and Prevention, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nita B Bellare
- Strategic Information Department, UNAIDS, Geneva, Switzerland
| | - Joanna Orne-Gliemann
- ISPED, Inserm, Bordeaux Population Health Research Center, UMR 1219, University of Bordeaux, Bordeaux, France
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Courtenay-Quirk C, Geller AL, Duran D, Honwana N. Tracking linkage to care in an anonymous HIV testing context: A field assessment in Mozambique. J Eval Clin Pract 2020; 26:1005-1012. [PMID: 31414555 DOI: 10.1111/jep.13262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 07/26/2019] [Accepted: 07/29/2019] [Indexed: 11/29/2022]
Abstract
RATIONALE Effective human immunodeficiency virus (HIV) prevention requires a coordinated continuum of services to foster early diagnosis and treatment. Early linkage to care (LTC) is critical, yet programmes differ in strategies to monitor LTC. METHODS In 2014, we visited 23 HIV testing and care service delivery points in Mozambique to assess programme strategies for monitoring LTC. We interviewed key informants, reviewed forms, and matched records across service points to identify successful models and challenges. RESULTS Forms most useful for tracking LTC included individual identifiers, eg, patient name, unique identifier (ie, National Health Identification Number [NID]), sex, and date of birth. The majority (67%) of records matched occurred in the presence of a unique NID. Key informants described challenges related to processes, staffing, and communication between service delivery points to confirm LTC. CONCLUSIONS While tracking clients from HIV testing to care is possible, programmes with insufficient tracking procedures are likely to underreport LTC. Adoption of additional patient identifiers in testing registers and standardized protocols may improve LTC programme monitoring and reduce underreporting.
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Affiliation(s)
- Cari Courtenay-Quirk
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Amanda L Geller
- Division of Global HIV & TB, Centers for Disease Control and Prevention, Atlanta, GA
| | - Denise Duran
- Division of Global HIV & TB, Centers for Disease Control and Prevention, Atlanta, GA
| | - Nely Honwana
- Division of Global HIV & TB, Centers for Disease Control and Prevention, Maputo, Mozambique
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Continuum of HIV Care in Rural Mozambique: The Implications of HIV Testing Modality on Linkage and Retention. J Acquir Immune Defic Syndr 2019; 78:527-535. [PMID: 29771786 PMCID: PMC6075879 DOI: 10.1097/qai.0000000000001720] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Supplemental Digital Content is Available in the Text. Introduction: Context-specific improvements in the continuum of HIV care are needed to achieve the UNAIDS target of 90-90-90. This study aimed to assess the linkage to and retention in HIV care according to different testing modalities in rural southern Mozambique. Methods: Adults newly diagnosed with HIV from voluntary counseling and testing, provider-initiated counseling and testing, and home-based HIV testing services were prospectively enrolled between 2014 and 2015 at the Manhiça District. Patients were passively followed up through chart examination. Tracing was performed at 12 months to ascertain causes of loss to follow-up. Fine and Gray competing risk analysis was performed to determine factors associated with the each step of the cascade. Results: Overall linkage to care as defined by having a CD4 count at 3 months was 43.7% [95% confidence interval (CI): 40.8 to 46.6] and 25.2% of all participants initiated antiretroviral therapy. Factors associated with increased linkage in multivariable analysis included testing at voluntary counseling and testing, older age, having been previously tested for HIV, owning a cell phone, presenting with WHO clinical stages III/IV, self-reported illness-associated disability in the previous month, and later calendar month of participant recruitment. Ascertaining deaths and transfers allowed for adjustment of the rate of 12-month retention in treatment from 75.6% (95% CI: 70.2 to 80.5) to 84.2% (95% CI: 79.2 to 88.5). Conclusions: Home-based HIV testing reached a sociodemographically distinct population from that of clinic-based testing modalities but low linkage to care points to a need for facilitated linkage interventions. Distinguishing between true treatment defaulting and other causes of loss to follow-up can significantly change indicators of retention in care.
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Sanga ES, Mukumbang FC, Mushi AK, Lerebo W, Zarowsky C. Understanding factors influencing linkage to HIV care in a rural setting, Mbeya, Tanzania: qualitative findings of a mixed methods study. BMC Public Health 2019; 19:383. [PMID: 30953503 PMCID: PMC6451278 DOI: 10.1186/s12889-019-6691-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 03/21/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND In remote rural Tanzania, the rate of linkage into HIV care was estimated at 28% in 2014. This study explored facilitators and barriers to linkage to HIV care at individual/patient, health care provider, health system, and contextual levels to inform eventual design of interventions to improve linkage to HIV care. METHODS We conducted a descriptive qualitative study nested in a cohort study of 1012 newly diagnosed HIV-positive individuals in Mbeya region between August 2014 and July 2015. We conducted 8 focus group discussions and 10 in-depth interviews with recently diagnosed HIV-positive individuals and 20 individual interviews with healthcare providers. Transcripts were analyzed inductively using thematic content analysis. The emergent themes were then deductively fitted into the four level ecological model. RESULTS We identified multiple factors influencing linkage to care. HIV status disclosure, support from family/relatives and having symptoms of disease were reported to facilitate linkage at the individual level. Fear of stigma, lack of disclosure, denial and being asymptomatic, belief in witchcraft and spiritual beliefs were barriers identified at individual's level. At providers' level; support and good patient-staff relationship facilitated linkage, while negative attitudes and abusive language were reported barriers to successful linkage. Clear referral procedures and well-organized clinic procedures were system-level facilitators, whereas poorly organized clinic procedures and visit schedules, overcrowding, long waiting times and lack of resources were reported barriers. Distance and transport costs to HIV care centers were important contextual factors influencing linkage to care. CONCLUSION Linkage to HIV care is an important step towards proper management of HIV. We found that access and linkage to care are influenced positively and negatively at all levels, however, the individual-level and health system-level factors were most prominent in this setting. Interventions must address issues around stigma, denial and inadequate awareness of the value of early linkage to care, and improve the capacity of HIV treatment/care clinics to implement quality care, particularly in light of adopting the 'Test and Treat' model of HIV treatment and care recommended by the World Health Organization.
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Affiliation(s)
- Erica S Sanga
- NIMR-Mwanza Medical Research Centre, P.O Box 1462, Mwanza, Tanzania. .,School of Public Health- University of Western Cape, Cape Town, South Africa. .,NIMR-Mwanza Medical Research Centre (MMRC), Mbeya, Tanzania.
| | - Ferdinand C Mukumbang
- School of Public Health- University of Western Cape, Cape Town, South Africa.,Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Adiel K Mushi
- National Institute for Medical Research (NIMR), London, England
| | - Wondwossen Lerebo
- School of Public Health- University of Western Cape, Cape Town, South Africa.,School of Public Health, Mekelle University, Makelle, Ethiopia
| | - Christina Zarowsky
- School of Public Health- University of Western Cape, Cape Town, South Africa.,University of Montreal Hospital Research Centre and School of Public Health, Universite de Montreal, Montreal, Canada
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Sanga ES, Mukumbang FC, Mushi AK, Olomi W, Lerebo W, Zarowsky C. Processes and dynamics of linkage to care from mobile/outreach and facility-based HIV testing models in hard-to-reach settings in rural Tanzania. Qualitative findings of a mixed methods study. AIDS Res Ther 2018; 15:21. [PMID: 30458874 DOI: 10.1186/s12981-018-0209-8n.pag-n.pag] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 11/08/2018] [Indexed: 05/22/2023] Open
Abstract
BACKGROUND Like other countries, Tanzania instituted mobile and outreach testing approaches to address low HIV testing rates at health facilities and enhance linkage to care. Available evidence from hard-to-reach rural settings of Mbeya region, Tanzania suggests that clients testing HIV+ at facility-based sites are more likely to link to care, and to link sooner, than those testing at mobile sites. This paper (1) describes the populations accessing HIV testing at mobile/outreach and facility-based testing sites, and (2) compares processes and dynamics from testing to linkage to care between these two testing models from the same study context. METHODS An explanatory sequential mixed-method study (a) reviewed records of all clients (n = 11,773) testing at 8 mobile and 8 facility-based testing sites over 6 months; (b), reviewed guidelines; (c) observed HIV testing sites (n = 10) and Care and Treatment Centers (CTCs) (n = 8); (d) applied questionnaires at 0, 3 and 6 months to a cohort of 1012 HIV newly-diagnosed clients from the 16 sites; and (e) conducted focus group discussions (n = 8) and in-depth qualitative interviews with cohort members (n = 10) and health care providers (n = 20). RESULTS More clients tested at mobile/outreach than facility-based sites (56% vs 44% of 11,733, p < 0.001). Mobile site clients were more likely to be younger and male (p < 0.001). More clients testing at facility sites were HIV positive (21.5% vs. 7.9% of 11,733, p < 0.001). All sites in both testing models adhered to national HIV testing and care guidelines. Staff at mobile sites showed more proactive efforts to support linkage to care, and clients report favouring the confidentiality of mobile sites to avoid stigma. Clients who tested at mobile/outreach sites faced longer delays and waiting times at treatment sites (CTCs). CONCLUSIONS Rural mobile/outreach HIV testing sites reach more people than facility based sites but they reach a different clientèle which is less likely to be HIV +ve and appears to be less "linkage-ready". Despite more proactive care and confidentiality at mobile sites, linkage to care is worse than for clients who tested at facility-based sites. Our findings highlight a combination of (a) patient-level factors, including stigma; and (b) well-established procedures and routines for each step between testing and initiation of treatment in facility-based sites. Long waiting times at treatment sites are a further barrier that must be addressed.
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Affiliation(s)
- Erica S Sanga
- NIMR-Mwanza Medical Research Centre (MMRC), Mwanza, Tanzania.
- School of Public Health, University of Western Cape, Cape Town, South Africa.
- NIMR-Mbeya Medical Research Centre (MMRC), Mbeya, Tanzania.
| | - Ferdinand C Mukumbang
- School of Public Health, University of Western Cape, Cape Town, South Africa
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Adiel K Mushi
- National Institute for Medical Research (NIMR), Dar-es-Salaam, Tanzania
| | | | - Wondwossen Lerebo
- School of Public Health, University of Western Cape, Cape Town, South Africa
- School of Public Health, Mekelle University, Mekelle, Ethiopia
| | - Christina Zarowsky
- School of Public Health, University of Western Cape, Cape Town, South Africa
- University of Montreal Hospital Research Centre and School of Public Health, Université de Montréal, Montreal, Canada
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Processes and dynamics of linkage to care from mobile/outreach and facility-based HIV testing models in hard-to-reach settings in rural Tanzania. Qualitative findings of a mixed methods study. AIDS Res Ther 2018; 15:21. [PMID: 30458874 PMCID: PMC6247671 DOI: 10.1186/s12981-018-0209-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 11/08/2018] [Indexed: 12/23/2022] Open
Abstract
Background Like other countries, Tanzania instituted mobile and outreach testing approaches to address low HIV testing rates at health facilities and enhance linkage to care. Available evidence from hard-to-reach rural settings of Mbeya region, Tanzania suggests that clients testing HIV+ at facility-based sites are more likely to link to care, and to link sooner, than those testing at mobile sites. This paper (1) describes the populations accessing HIV testing at mobile/outreach and facility-based testing sites, and (2) compares processes and dynamics from testing to linkage to care between these two testing models from the same study context. Methods An explanatory sequential mixed-method study (a) reviewed records of all clients (n = 11,773) testing at 8 mobile and 8 facility-based testing sites over 6 months; (b), reviewed guidelines; (c) observed HIV testing sites (n = 10) and Care and Treatment Centers (CTCs) (n = 8); (d) applied questionnaires at 0, 3 and 6 months to a cohort of 1012 HIV newly-diagnosed clients from the 16 sites; and (e) conducted focus group discussions (n = 8) and in-depth qualitative interviews with cohort members (n = 10) and health care providers (n = 20). Results More clients tested at mobile/outreach than facility-based sites (56% vs 44% of 11,733, p < 0.001). Mobile site clients were more likely to be younger and male (p < 0.001). More clients testing at facility sites were HIV positive (21.5% vs. 7.9% of 11,733, p < 0.001). All sites in both testing models adhered to national HIV testing and care guidelines. Staff at mobile sites showed more proactive efforts to support linkage to care, and clients report favouring the confidentiality of mobile sites to avoid stigma. Clients who tested at mobile/outreach sites faced longer delays and waiting times at treatment sites (CTCs). Conclusions Rural mobile/outreach HIV testing sites reach more people than facility based sites but they reach a different clientèle which is less likely to be HIV +ve and appears to be less “linkage-ready”. Despite more proactive care and confidentiality at mobile sites, linkage to care is worse than for clients who tested at facility-based sites. Our findings highlight a combination of (a) patient-level factors, including stigma; and (b) well-established procedures and routines for each step between testing and initiation of treatment in facility-based sites. Long waiting times at treatment sites are a further barrier that must be addressed.
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Time taken to link newly identified HIV positive clients to care following a home-base index case HIV testing: Experience from two provinces in Zimbabwe. PLoS One 2018; 13:e0201018. [PMID: 30133526 PMCID: PMC6104920 DOI: 10.1371/journal.pone.0201018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Accepted: 07/07/2018] [Indexed: 12/21/2022] Open
Abstract
Background Homebased index case HIV testing (HHTC) has shown higher uptake and good yield than traditional HIV testing methods. World Health Organization has called for increased operational research to evaluate HIV care processes particularly linkage to care. In this paper, we present project results of the time taken to link newly identified PLHIV to care after HHTC in the Manicaland and Midlands provinces of Zimbabwe. Methods We retrospectively reviewed community-facility referral data from the Zimbabwe HIV Care and Treatment project for newly diagnosed PLHIV for the period March–September 2016. A referral slip was given to a client after receiving a positive HIV results and was presented and filed upon reaching a health facility. In July 2016, the project started working with trained expert clients to assist with linkage to care. Data was entered in a spreadsheet and then imported for descriptive statistical analysis with EpiInfoTM Version 7.2.0.1. Odd ratios were used to identify factors associated with linkage to care within seven days. Results Out of 1004 newly identified PLHIV between March and September 2016, 650 (64.7%) were linked to care. The median time taken to be linked to care was four days (Interquartile range 19 days). Overall, 63.1% (410) of PLHIV were linked to care within seven days of diagnosis and 85% within 30 days. PLHIV were more likely to be linked to care within seven days of diagnosis between July and September 2016 (OR = 4.1; p< 0.001), a period when ZHCT started working with expert clients to support linkage to care. Conclusion HHTC resulted in almost 63% of newly diagnosed PLHIV being linked into care within seven days, and 85% within 30 days. Linkage to care within seven days was significantly associated with the period of engaging expert clients in the project. We recommend community based HIV testing programs to work with expert clients to ensure timely linkages of new PLHIV.
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TB Presenting as Recurrent Pneumonia in a HIV-Infected Infant in Central Viet Nam. REPORTS 2018. [DOI: 10.3390/reports1020012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We report on a six-month-old infant admitted to our intensive care unit (ICU) with recurrent severe pneumonia. The mother was infected with human immunodeficiency virus (HIV)-infected, but initially failed to disclose this to doctors. Neither did she report the grandmother of the child’s chronic coughing, likely due to tuberculosis (TB). The infant was diagnosed with X-pert MTB/RIF® confirmed TB and tested positive for HIV infection. Once a correct diagnosis was established, the child demonstrated good recovery with appropriate TB and antiretroviral treatment (ART). The case demonstrates the importance of including TB in the differential diagnosis for young children not responding to first-line pneumonia treatment, especially in TB endemic areas. Taking a meticulous TB and HIV exposure history, with careful consideration of potential social stigma, is essential. It also demonstrates how the inaccessibility of HIV results and the absence of a continuous patient record may jeopardize patient care.
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Bor J, Fox MP, Rosen S, Venkataramani A, Tanser F, Pillay D, Bärnighausen T. Treatment eligibility and retention in clinical HIV care: A regression discontinuity study in South Africa. PLoS Med 2017; 14:e1002463. [PMID: 29182641 PMCID: PMC5705070 DOI: 10.1371/journal.pmed.1002463] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 10/25/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Loss to follow-up is high among HIV patients not yet receiving antiretroviral therapy (ART). Clinical trials have demonstrated the clinical efficacy of early ART; however, these trials may miss an important real-world consequence of providing ART at diagnosis: its impact on retention in care. METHODS AND FINDINGS We examined the effect of immediate (versus deferred) ART on retention in care using a regression discontinuity design. The analysis included all patients (N = 11,306) entering clinical HIV care with a first CD4 count between 12 August 2011 and 31 December 2012 in a public-sector HIV care and treatment program in rural South Africa. Patients were assigned to immediate versus deferred ART eligibility, as determined by a CD4 count < 350 cells/μl, per South African national guidelines. Patients referred to pre-ART care were instructed to return every 6 months for CD4 monitoring. Patients initiated on ART were instructed to return at 6 and 12 months post-initiation and annually thereafter for CD4 and viral load monitoring. We assessed retention in HIV care at 12 months, as measured by the presence of a clinic visit, lab test, or ART initiation 6 to 18 months after initial CD4 test. Differences in retention between patients presenting with CD4 counts just above versus just below the 350-cells/μl threshold were estimated using local linear regression models with a data-driven bandwidth and with the algorithm for selecting the bandwidth chosen ex ante. Among patients with CD4 counts close to the 350-cells/μl threshold, having an ART-eligible CD4 count (<350 cells/μl) was associated with higher 12-month retention than not having an ART-eligible CD4 count (50% versus 32%), an intention-to-treat risk difference of 18 percentage points (95% CI 11 to 23; p < 0.001). The decision to start ART was determined by CD4 count for one in four patients (25%) presenting close to the eligibility threshold (95% CI 20% to 31%; p < 0.001). In this subpopulation, having an ART-eligible CD4 count was associated with higher 12-month retention than not having an ART-eligible CD4 count (91% versus 21%), a complier causal risk difference of 70 percentage points (95% CI 42 to 98; p < 0.001). The major limitations of the study are the potential for limited generalizability, the potential for outcome misclassification, and the absence of data on longer-term health outcomes. CONCLUSIONS Patients who were eligible for immediate ART had dramatically higher retention in HIV care than patients who just missed the CD4-count eligibility cutoff. The clinical and population health benefits of offering immediate ART regardless of CD4 count may be larger than suggested by clinical trials.
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Affiliation(s)
- Jacob Bor
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Africa Health Research Institute, Somkhele, South Africa
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Matthew P. Fox
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Atheendar Venkataramani
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Frank Tanser
- Africa Health Research Institute, Somkhele, South Africa
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, South Africa
- Research Department of Infection & Population Health, University College London, London, United Kingdom
| | - Deenan Pillay
- Africa Health Research Institute, Somkhele, South Africa
- Department of Virology, University College London, London, United Kingdom
| | - Till Bärnighausen
- Africa Health Research Institute, Somkhele, South Africa
- Research Department of Infection & Population Health, University College London, London, United Kingdom
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Institute of Public Health, University of Heidelberg, Heidelberg, Germany
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Option B+ in Mozambique: Formative Research Findings for the Design of a Facility-Level Clustered Randomized Controlled Trial to Improve ART Retention in Antenatal Care. J Acquir Immune Defic Syndr 2017; 72 Suppl 2:S181-8. [PMID: 27355507 PMCID: PMC5113244 DOI: 10.1097/qai.0000000000001061] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION With the rollout of "Option B+" in Mozambique in 2013, initial data indicated major challenges to early retention in antiretroviral therapy (ART) among HIV-positive pregnant women. We sought to develop and test a pilot intervention in 6 large public clinics in central Mozambique to improve retention of mothers starting ART in antenatal care. The results from the formative research from this study described here were used to design the intervention. METHODS The research was initiated in early 2013 and completed in early 2014 in each of the 6 study clinics and consisted of (1) patient flow mapping and measurement of retention through collection of health systems data from antenatal care registries, pharmacy registries, ART clinic databases, (2) workforce assessment and measurement of patient waiting times, and (3) patient and worker individual interviews and focus groups. RESULTS Coverage of HIV testing and ART initiation were over 90% at all sites, but retention at 30-, 60-, and 90-day pharmacy refill visits was very low ranging from only 5% at 1 site to 30% returning at 90 days. These data revealed major systemic bottlenecks that contributed to poor adherence and retention in the first month after ART initiation. Long wait times, short consultations, and poor counseling were identified as barriers. CONCLUSIONS Based on these findings, we designed an intervention with these components: (1) workflow modification to redefine nurse tasks, shift tasks to community health workers, and enhance patient tracking and (2) an adherence and retention package to systematize active patient follow-up, ensure home visits by community health workers, use text messaging, and intensify counseling by health staff. This intervention is currently under evaluation using a stepped wedge design.
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Sanga ES, Lerebo W, Mushi AK, Clowes P, Olomi W, Maboko L, Zarowsky C. Linkage into care among newly diagnosed HIV-positive individuals tested through outreach and facility-based HIV testing models in Mbeya, Tanzania: a prospective mixed-method cohort study. BMJ Open 2017; 7:e013733. [PMID: 28404611 PMCID: PMC5541440 DOI: 10.1136/bmjopen-2016-013733] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Revised: 02/18/2017] [Accepted: 02/27/2017] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE Linkage to care is the bridge between HIV testing and HIV treatment, care and support. In Tanzania, mobile testing aims to address historically low testing rates. Linkage to care was reported at 14% in 2009 and 28% in 2014. The study compares linkage to care of HIV-positive individuals tested at mobile/outreach versus public health facility-based services within the first 6 months of HIV diagnosis. SETTING Rural communities in four districts of Mbeya Region, Tanzania. PARTICIPANTS A total of 1012 newly diagnosed HIV-positive adults from 16 testing facilities were enrolled into a two-armed cohort and followed for 6 months between August 2014 and July 2015. 840 (83%) participants completed the study. MAIN OUTCOME MEASURES We compared the ratios and time variance in linkage to care using the Kaplan-Meier estimator and Log rank tests. Cox proportional hazards regression models to evaluate factors associated with time variance in linkage. RESULTS At the end of 6 months, 78% of all respondents had linked into care, with differences across testing models. 84% (CI 81% to 87%, n=512) of individuals tested at facility-based site were linked to care compared to 69% (CI 65% to 74%, n=281) of individuals tested at mobile/outreach. The median time to linkage was 1 day (IQR: 1-7.5) for facility-based site and 6 days (IQR: 3-11) for mobile/outreach sites. Participants tested at facility-based site were 78% more likely to link than those tested at mobile/outreach when other variables were controlled (AHR=1.78; 95% CI 1.52 to 2.07). HIV status disclosure to family/relatives was significantly associated with linkage to care (AHR=2.64; 95% CI 2.05 to 3.39). CONCLUSIONS Linkage to care after testing HIV positive in rural Tanzania has increased markedly since 2014, across testing models. Individuals tested at facility-based sites linked in significantly higher proportion and modestly sooner than mobile/outreach tested individuals. Mobile/outreach testing models bring HIV testing services closer to people. Strategies to improve linkage from mobile/outreach models are needed.
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Affiliation(s)
- Erica Samson Sanga
- NIMR-Mbeya Medical Research Centre (MMRC), Mbeya, Tanzania
- School of Public Health, University of Western Cape, Cape Town, South Africa
| | - Wondwossen Lerebo
- School of Public Health, University of Western Cape, Cape Town, South Africa
- School of Public Health, Mekelle University, Mekelle, Ethiopia
| | - Adiel K Mushi
- National Institute for Medical Research (NIMR), Dar es Salaam, Tanzania
| | - Petra Clowes
- NIMR-Mbeya Medical Research Centre (MMRC), Mbeya, Tanzania
- Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich (LMU), Munich, Germany
| | | | - Leonard Maboko
- NIMR-Mbeya Medical Research Centre (MMRC), Mbeya, Tanzania
| | - Christina Zarowsky
- School of Public Health, University of Western Cape, Cape Town, South Africa
- University of Montreal Hospital Research Centre and School of Public Health, Université de Montréal, Montreal, Quebec, Canada
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Horter S, Thabede Z, Dlamini V, Bernays S, Stringer B, Mazibuko S, Dube L, Rusch B, Jobanputra K. "Life is so easy on ART, once you accept it": Acceptance, denial and linkage to HIV care in Shiselweni, Swaziland. Soc Sci Med 2017; 176:52-59. [PMID: 28129547 DOI: 10.1016/j.socscimed.2017.01.006] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 12/15/2016] [Accepted: 01/04/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Timely uptake of antiretroviral therapy, adherence and retention in care for people living with HIV (PLHIV) can improve health outcomes and reduce transmission. Médecins Sans Frontières and the Swaziland Ministry of Health provide community-based HIV testing services (HTS) in Shiselweni, Swaziland, with high HTS coverage but sub-optimal linkage to HIV care. This qualitative study examined factors influencing linkage to HIV care for PLHIV diagnosed by community-based HTS. METHODS Participants were sampled purposively, exploring linkage experiences among both genders and different age groups. Interviews were conducted with 28 PLHIV (linked and not linked) and 11 health practitioners. Data were thematically analysed to identify emergent patterns and categories using NVivo 10. Principles of grounded theory were applied, including constant comparison of findings, raising codes to a conceptual level, and inductively generating theory from participant accounts. RESULTS The process of HIV status acceptance or denial influenced the accounts of patients' health seeking and linkage to care. This process was non-linear and varied temporally, with some experiencing non-acceptance for an extended period of time. Non-acceptance was linked to perceptions of HIV risk, with those not identifying as at risk less likely to expect and therefore be prepared for a positive result. Status disclosure was seen to support linkage, reportedly occurring after the acceptance of HIV status. HIV status acceptance motivated health seeking and tended to be accompanied by a perceived need for, and positive value placed on, HIV health care. CONCLUSIONS The manner in which PLHIV process a positive result can influence their engagement with HIV treatment and care. Thus, there is a need for individually tailored approaches to HTS, including the potential for counselling over multiple sessions if required, supporting status acceptance, and disclosure. This is particularly relevant considering 90-90-90 targets and the need to better support PLHIV to engage with HIV treatment and care following diagnosis.
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Affiliation(s)
- Shona Horter
- Médecins Sans Frontières (MSF), London, UK; London School of Hygiene and Tropical Medicine, London, UK.
| | | | | | - Sarah Bernays
- London School of Hygiene and Tropical Medicine, London, UK.
| | | | - Sikhathele Mazibuko
- Swaziland National AIDS Programme, Ministry of Health of Swaziland, Mbabane, Swaziland.
| | - Lenhle Dube
- Swaziland National AIDS Programme, Ministry of Health of Swaziland, Mbabane, Swaziland.
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Labhardt ND, Ringera I, Lejone TI, Masethothi P, Thaanyane T, Kamele M, Gupta RS, Thin K, Cerutti B, Klimkait T, Fritz C, Glass TR. Same day ART initiation versus clinic-based pre-ART assessment and counselling for individuals newly tested HIV-positive during community-based HIV testing in rural Lesotho - a randomized controlled trial (CASCADE trial). BMC Public Health 2016; 16:329. [PMID: 27080120 PMCID: PMC4832467 DOI: 10.1186/s12889-016-2972-6] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 03/19/2016] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Achievement of the UNAIDS 90-90-90 targets in Sub-Sahara Africa is challenged by a weak care-cascade with poor linkage to care and retention in care. Community-based HIV testing and counselling (HTC) is widely used in African countries. However, rates of linkage to care and initiation of antiretroviral therapy (ART) in individuals who tested HIV-positive are often very low. A frequently cited reason for non-linkage to care is the time-consuming pre-ART assessment often requiring several clinic visits before ART-initiation. METHODS This two-armed open-label randomized controlled trial compares in individuals tested HIV-positive during community-based HTC the proposition of same-day community-based ART-initiation to the standard of care pre-ART assessment at the clinic. Home-based HTC campaigns will be conducted in catchment areas of six clinics in rural Lesotho. Households where at least one individual tested HIV positive will be randomized. In the standard of care group individuals receive post-test counselling and referral to the nearest clinic for pre-ART assessment and counselling. Once they have started ART the follow-up schedule foresees monthly clinic visits. Individuals randomized to the intervention group receive on the spot point-of-care pre-ART assessment and adherence counselling with the proposition to start ART that same day. Once they have started ART, follow-up clinic visits will be less frequent. First primary outcome is linkage to care (individual presents at the clinic at least once within 3 months after the HIV test). The second primary outcome is viral suppression 12 months after enrolment in the study. We plan to enrol a minimum of 260 households with 1:1 allocation and parallel assignment into both arms. DISCUSSION This trial will show if in individuals tested HIV-positive during community-based HTC campaigns the proposition of same-day ART initiation in the community, combined with less frequent follow-up visits at the clinic could be a pragmatic approach to improve the care cascade in similar settings. TRIAL REGISTRATION NCT02692027 , registered February 21, 2016.
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Affiliation(s)
- Niklaus Daniel Labhardt
- />Clinical Research Unit, Medical Services and Diagnostics, Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051 Basel, Switzerland
- />University of Basel, Basel, Switzerland
| | - Isaac Ringera
- />SolidarMed, Swiss Organization for Health in Africa, Premium House #224, Kingsway, P.O.Box 0254, Maseru West, 105 Lesotho
| | - Thabo Ishmael Lejone
- />SolidarMed, Swiss Organization for Health in Africa, Premium House #224, Kingsway, P.O.Box 0254, Maseru West, 105 Lesotho
| | - Phofu Masethothi
- />SolidarMed, Swiss Organization for Health in Africa, Premium House #224, Kingsway, P.O.Box 0254, Maseru West, 105 Lesotho
| | - T’sepang Thaanyane
- />SolidarMed, Swiss Organization for Health in Africa, Premium House #224, Kingsway, P.O.Box 0254, Maseru West, 105 Lesotho
| | - Mashaete Kamele
- />SolidarMed, Swiss Organization for Health in Africa, Premium House #224, Kingsway, P.O.Box 0254, Maseru West, 105 Lesotho
| | - Ravi Shankar Gupta
- />District Health Management Team Butha-Buthe, Ministry of Health of Lesotho, Butha-Buthe, Lesotho
| | - Kyaw Thin
- />Research Coordination Unit, Room Number 326, Ministry of Health of Lesotho, Maseru, Lesotho
| | - Bernard Cerutti
- />Faculty of Medicine, UDREM, University of Geneva, 1 Rue Michel Servet, 1211 Geneva, Switzerland
| | - Thomas Klimkait
- />Department of Biomedicine – Petersplatz, Molecular Virology, University of Basel, Basel, Switzerland
| | - Christiane Fritz
- />SolidarMed, Swiss Organization for Health in Africa, Premium House #224, Kingsway, P.O.Box 0254, Maseru West, 105 Lesotho
| | - Tracy Renée Glass
- />Clinical Research Unit, Medical Services and Diagnostics, Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051 Basel, Switzerland
- />University of Basel, Basel, Switzerland
- />Biostatistics Department, Epidemiology and Public Health Unit, Swiss Tropical and Public Health Institute, Socinstrasse 57, P.O. Box 4002, Basel, Switzerland
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